Clinical assessment of neonatal hyperbilirubinaemia

hyperbilirubinaemia The study by Keren and colleagues is a retrospective study, using infants in whom preand post-discharge TSB has been carried out, hence causing an inherent bias towards the same group. The data for clinical risk have been collected from documents such as admission, intrapartum, and discharge forms. This retrospective collection can result in missing or ambiguous data, as has been accepted by the authors. Ideally, a study should be prospective using both methods on all neonates in a study group, and then the sensitivity and specificity (that is, false positives and false negatives) should be compared using actual data on follow up. The clinical risk factor score includes factors that are interrelated such as vacuum and cephalhematoma. In cases where the cephalhematoma is caused by the use of vacuum the neonate gets a double rating. Obviously, authors have not found clinical risk factors more specific than pre-discharge TSB. Contrary to this study, the AAP guidelines promote and support breast feeding and state that effective breast feeding can reduce substantially the risk for hyperbilirubinaemia. It is known that inadequate feeds increase the level of neonatal jaundice; hence the emphasis on ‘‘effective’’ breast feeds. The study subjects date from 1993–97 and the feeding habits (that is, breast/bottle/combination feeds) have been given a considerable amount of significance, which contradicts the AAP guidelines by the subcommittee on hyperbilirubinaemia. Newman et al state that, compared to early TSB levels (,48 hours of life), clinical risk factors combined with TSB significantly improve prediction of subsequent hyperbilirubinaemia. Suresh et al have studied the cost effectiveness of strategies to prevent kernicterus, and concluded that to prevent one case of kernicterus, the cost was $10 321 463 for universal follow up of early newborn discharge, $5 743 905 for routine predischarge TSB, and $9 191 352 routine predischarge transcutaneous bilirubin with selective follow up. They concluded that widespread implementation of these strategies would result in significantly increased healthcare costs with uncertain benefits. The AAP guidelines also focus on the rarity of kernicterus and aim to reduce the incidence of kernicterus, while minimising the risks of unintended harm such as maternal anxiety, decreased breast feeding, and unnecessary costs or treatments. They recommend a systematic clinical assessment before discharge and an early and focused follow up based on the risk assessment. Finally we must remember that we are all clinicians and we should use the lab report as an adjunct to our clinical knowledge.