Management Of Neonatal Hyperbilirubinemia Research Articles

Comparison of Intermittent Versus Continuous Phototherapy in Neonatal Hyperbilirubinaemia

Background: Neonatal jaundice is a common condition characterized by elevated bilirubin levels, which, if untreated, can lead to severe complications such as kernicterus. Phototherapy is a widely used treatment modality, with two primary approaches: continuous and intermittent phototherapy. While both methods aim to reduce bilirubin levels, there is ongoing debate about their relative efficacy and safety. Objective: This study aimed to compare the efficacy and safety of intermittent versus continuous phototherapy in the management of neonatal hyperbilirubinaemia in terms of bilirubin reduction, treatment duration, and associated complications. Methods: A quasi-experimental study was conducted at the Department of Paediatrics, Combined Military Hospital, Rawalpindi, from January 2022 to December 2023. The study included 62 full-term neonates with indirect bilirubin levels >15.0 mg/dL but ≤20 mg/dL. Neonates were randomly assigned to receive either intermittent phototherapy (two hours on, two hours off) or continuous phototherapy. Serum indirect bilirubin levels were measured at 24 and 48 hours post-initiation of phototherapy. The total duration of phototherapy, volume of milk consumed, and complications such as hyperthermia and hypocalcaemia were recorded. Data were analyzed using SPSS version 25, with a p-value ≤ 0.05 considered statistically significant. Results: At 24 hours post-treatment, the median indirect bilirubin level was 12.70 mg/dL (IQR: 1.20) in the intermittent group versus 12.50 mg/dL (IQR: 1.90) in the continuous group (p=0.893). At 48 hours, the levels were 6.40 mg/dL (IQR: 1.10) and 6.50 mg/dL (IQR: 1.10), respectively (p=0.821). The median total duration of phototherapy was significantly shorter in the intermittent group (22.0 hours, IQR: 2.0) compared to the continuous group (45.0 hours, IQR: 3.0; p<0.001). Neonates in the intermittent group consumed more milk (420.0 mL, IQR: 93.0) than those in the continuous group (397.0 mL, IQR: 57.0; p=0.014). Hyperthermia was less frequent in the intermittent group (3.2% vs. 25.8%, p=0.026), as was hypocalcaemia (16.1% vs. 45.2%, p=0.013). Conclusion: Intermittent phototherapy is as effective as continuous phototherapy in reducing bilirubin levels and offers additional benefits, including a shorter treatment duration, improved feeding, and fewer complications. Intermittent phototherapy should be considered a preferred option for managing neonatal hyperbilirubinaemia in clinical practice.

Bilirubin measurements in neonates: uniform neonatal treatment can only be achieved by improved standardization.

Measurement of total bilirubin (TBil) concentration in serum is the gold standard approach for diagnosing neonatal unconjugated hyperbilirubinemia. It is of utmost importance that the measured TBil concentration is sufficiently accurate to prevent under treatment, unnecessary escalation of care, or overtreatment. However, it is widely recognized that TBil measurements urgently require improvement in neonatal clinical chemistry. External quality assessment (EQA) programs for TBil assess for differences between laboratories and provide supporting evidence of significant differences between various methods, manufacturers and measurement platforms. At the same time, many countries have adopted or only slightly adapted the neonatal hyperbilirubinemia management guidelines from the USA or UK, often without addressing differences in the methodology of TBil measurements. In this report, we provide an overview of the components of bilirubin that are measured by laboratory platforms, the availability of current reference measurement procedures and reference materials, and therole of EQA surveys in this context. Furthermore, the current status of agreement in neonatal bilirubin against clinical decision thresholds is reviewed. We advocate for enhancements in accuracy and comparability of neonatal TBil measurements, propose a path forward to accomplish this, and reflect on the position of the International Federation for Clinical Chemistry and Laboratory Medicine (IFCC) Working Group Neonatal Bilirubin (WG-NB) in this matter.

Management of Neonatal Hyperbilirubinemia: Shedding Light on the American Academy of Pediatrics 2022 Clinical Practice Guideline Revision.

Neonatal hyperbilirubinemia is one of the most common conditions managed by pediatricians. Although many infants are affected, most will experience complete resolution without complication. Acute bilirubin encephalopathy and kernicterus are rare yet debilitating sequelae of severe hyperbilirubinemia that can be avoided through careful monitoring and treatment with phototherapy. Appropriate management of neonatal hyperbilirubinemia must balance the risks of these severe conditions with the effects of overtreatment. Released in 2022, the American Academy of Pediatrics revised the clinical practice guideline for the management of hyperbilirubinemia, which aims to provide that balance through updates to the previous guideline. This article will provide the reader with (1) an evidence-based harm and benefit analysis of the guideline, (2) an overview of key changes and clarifications made in the new guideline, and (3) a practical summary of guideline updates. [Pediatr Ann. 2024;53(6):e208-e216.].

Comparing Outcomes Between Direct and ED Admissions for Neonatal Hyperbilirubinemia.

Pediatric direct admissions (DA) have multiple benefits including reduced emergency department (ED) volumes, greater patient and provider satisfaction, and decreased costs without compromising patient safety. We sought to compare resource utilization and outcomes between patients with a primary diagnosis of neonatal hyperbilirubinemia directly admitted with those admitted from the ED. Single-center, retrospective study at a large, academic, free-standing children's hospital (2017-2021). Patients were between 24 hours and 14 days old with a gestational age of ≥35 weeks, admitted with a primary diagnosis of neonatal hyperbilirubinemia. Outcomes included length of stay (LOS), time to clinical care, resource utilization, NICU transfer, and 7-day readmission for phototherapy. A total of 1098 patients were included, with 276 (25.1%) ED admissions and 822 (74.9%) DAs. DAs experienced a shorter median time to bilirubin level collection (1.9 vs 2.1 hours, P = .003), received less intravenous fluids (8.9% vs 51.4%, P < .001), had less bilirubin levels collected (median of 3.0 vs 4.0, P < .001), received phototherapy sooner (median of 0.8 vs 4.2 hours, P < .001), and had a shorter LOS (median of 21 vs 23 hours, P = .002). One patient who was directly admitted required transfer to the NICU. No differences were observed in the 7-day readmission rates for phototherapy. Directly admitting patients for the management of neonatal hyperbilirubinemia is a preferred alternative to ED admission as our study demonstrated that DAs had a shorter time to clinical care, shorter LOS, and less unnecessary resource utilization with no difference in 7-day readmissions for phototherapy.

Effect of phototherapy on haematologic indices in neonatal hyperbilirubinemia

Objective: The purpose of this study was to investigate the clinical significance of the platelet to lymphocyte ratio (PLR) and the neutrophil to lymphocyte ratio (NLR) in term neonates and its impact on management of neonatal hyperbilirubinemia on phototherapy Materials and Methods: This observational study was conducted with 20 term neonates diagnosed with neonatal hyperbilirubinemia, and recieved phototherapy. Exclusion criteria were prematurity, post- maturity, small or large for gestational age according to week of pregnancy, babies born to mothers with GDM or pre-eclampsia and congenital defects. Results: We observed that there was an increase in the lymphocyte counts from 12650 cells/mm3 before phototherapy to 10360 cells/mm3 after phototherapy with a p-value 0.03*. The mean platelet count also decreased from 209×103 cells/mm 3 to 258×103 cells/mm 3 with a p-value of 0.045 which was significant. Rest of the blood cell counts seem to be unaltered by phototherapy. Conclusions: NLRs and PLRs were reduced due to phototherapy in term neonates, and these ratios can be used to aid in management in term neonates with hyperbilirubinemia on phototherapy.

Is it time for a precision health approach to the management of newborn hyperbilirubinemia?

Newborn hyperbilirubinemia during the first two weeks of lifeis one of most common problems requiring management decisions by a pediatrician. However, high bilirubin levels in the circulation have been associated with neurologic injury under a variety of conditions encountered in the newborn infant, such as hemolysis. The risk for developing dangerous hyperbilirubinemia is multifactorial and is determined by a complex set of factors related to a newborn infant's genetic capacities as well as intra- and extrauterine exposures. To this end, a precision health approach based on the integration of prenatal genetic and postnatal diagnostic measures might improve the management of neonatal hyperbilirubinemia.

Bilirubin Measurement and Phototherapy Use After the AAP 2022 Newborn Hyperbilirubinemia Guideline.

Guidelines for the management of neonatal hyperbilirubinemia have helped to reduce rates of significant hyperbilirubinemia. However, recent evidence suggesting overtreatment and potential harms of phototherapy have informed the American Academy of Pediatrics clinical practice guideline revision and the accompanying increase in phototherapy thresholds. These changes are predicted to safely reduce overuse; however, to date, the exact effect of these guidelines has not been established. We conducted a retrospective study of newborns born at ≥35 weeks' gestation across a network of 8 hospitals between January 2022 and June 2023. Outcomes included rates of phototherapy and total serum bilirubin (TSB) measurements before and after guideline publication, as well as clinical outcomes, including length of stay, readmissions, and duration of phototherapy. In our cohort of >22 000 newborns, we observed a 47% decrease in phototherapy utilization, from 3.9% to 2.1% (P < .001). TSB measurements were reduced by 23%, from 712 to 551 measurements per 1000 newborns (P < .001), without an increase in outpatient TSB measurements. We did not observe an increase in readmissions receiving phototherapy, and length of stay increased by only 1 hour (P < .001). Our study reveals that the publication of the updated American Academy of Pediatrics 2022 hyperbilirubinemia guidelines has likely yielded a significant reduction in phototherapy use and serum bilirubin measurement. Dedicated quality improvement initiatives may help determine which implementation strategies are most effective. Further population-level studies are needed to confirm safety with ongoing guideline uptake.

Clinical study to determine the predictability of significant rebound hyperbilirubinemia in neonates after phototherapy and conditions likely to be associated with it: Prospective observational study in a teaching hospital in Eastern India.

Neonatal hyperbilirubinemia is defined as yellowish discoloration of the skin, conjunctive, and sclera from the elevated serum or plasma bilirubin in the newborn. The standard of care for the management of neonatal hyperbilirubinemia is phototherapy to prevent long-term neurological sequelae. The aim of this study was to ascertain the predictability of significant rebound hyperbilirubinemia (SRH) in neonates after phototherapy and the factors associated with it. Neonates ≥ 35 weeks of gestation, who received treatment for hyperbilirubinemia and admitted in our hospital from 15th of March 2019 to 15th of September 2020 were enrolled after taking parental consent. SRH was defined as bilirubin levels crossing the treatment threshold within 72 hours of phototherapy termination. Logistic regression analysis was used to identify the predictability of SRH. Out of 400 neonates treated with phototherapy, 10% developed SRH. Prematurity (Gestational age < 37 weeks), low birth weight (Birth weight < 2000 gram), ABO and Rh incompatibility, Glucose-6-phophate dehydrogenase deficiency (G6PD) deficiency, sepsis, and longer duration of primary phototherapy were found to be significantly associated with rebound hyperbilirubinemia. The probability of SRH increases for all American Academy of Paediatrics (AAP) risk categories as the gestational age decreases and total serum bilirubin at the stoppage of phototherapy increases. The presence of risk factors should be taken into account while planning discharge and follow-up of neonates admitted for neonatal hyperbilirubinemia to prevent long-term complication of bilirubin neurotoxicity.

Does strengths of a positive direct antiglobulin test predicts the need for phototherapy and duration of phototherapy? – a single center, retrospective study

Background Use of Direct Antiglobulin test (DAT) in management of neonatal hyperbilirubinemia is conflicting. Objective whether strength of positive DAT predicts the need for phototherapy, duration of phototherapy and need for major interventions. Methods We retrospectively collected data on all DAT positive neonates with birth gestational age ≥32 weeks over six years (2014–2019). Data regarding blood group, DAT and clinical details were obtained from a hospital database. We also collected data on serial hemoglobin and other relevant laboratory parameters. We also collected data on infants receiving major interventions such as exchange transfusion, in-utero transfusion, immunoglobulins, and postnatal transfusion for the duration of the study period. All of these infants were electronically followed up for a period of 6 weeks. This study was approved by institutional audit authority. All the statistics were performed using SPSS software. Results Out of 1285 DAT tests performed, only 91 infants were positive (7%), and 78 DAT positive infants were available for analysis. There were 54 infants with DAT (1+), 15 infants with DAT (2+), 7 infants with DAT (3+) and 2 infants with DAT (4+). There was no significant statistical difference in terms of need for phototherapy, duration of phototherapy, need for major interventions and hemoglobin levels at different time points between the groups (DAT 1+ Vs DAT ≥2+; DAT ≤2+ Vs DAT >2). A Total of 10 infants received major intervention, with one infant receiving all three interventions (DAT 3+ with significant maternal antibodies), 2 additional infants (both DAT1+) received exchange transfusion, 6 additional infants received immunoglobulin (2 infants: DAT 2+; 4 infants: DAT 1+) and one additional infant (DAT 1+) with significant maternal antibodies received a postnatal transfusion. Conclusion Strength of a DAT did not predict the need for phototherapy, duration of phototherapy, and the need for major hemolysis related intervention in the first 6 weeks of life.

Management of Indirect Hyperbilirubinemia; Comparison of Complications of Light Emitting Diode (LED) and Fluorescent Phototherapy

Objective: To compare the frequency of complications (hyperthermia, skin eruption, dehydration) of LED phototherapy and fluorescent phototherapy in management of indirect hyperbilirubinemia in neonates Material and methods: This randomized control study was carried out from 1st June 2015 to 31 December 2016 at NNU of The Children`s Hospital Lahore using Non probability consecutive sampling technique after getting informed consent from parents. All basic demographic information of each variable (name, age) was noted and entered on Performa. SPSS-18 was used to interpret the data. Results: In our study the mean age was 1.98±0.83 days. Skin rash complication was observed in 43(13%) cases, dehydration was found in 48(14.5%) cases and hyperthermia was noted in 65(19.70%) patients. Practical Implication: Many setups in Pakistan are still using conventional fluorescent phototherapy machines. LED has lesser side effects as compared to conventional one so by using LED light source we can lessen the adverse effects of phototherapy that will be beneficial to the babies Conclusion: LED light source is effective for phototherapy with significantly lesser complication rate (hyperthermia, skin eruption, and dehydration) compared to fluorescent phototherapy in management of indirect hyperbilirubinemia in neonates. In this study LED phototherapy significantly showed fewer complications as compared to fluorescent phototherapy cases. Keywords: LED, Fluorescent, Hyperthermia, Skin, Rash, Dehydration, Neonates, Hyperbilirubinemia

Community health worker-led household screening and management of neonatal hyperbilirubinemia in rural Bangladesh: a cluster randomized control trial protocol

Background: Extreme hyperbilirubinemia leading to neurologic disability and death is disproportionately high in low to middle income countries (LMIC) such as Bangladesh, and is largely preventable through timely treatment. Of the estimated 50% of newborns born in LMICs born at home, few receive screening or treatment for hyperbilirubinemia, leading to 6 million newborns per year who need phototherapy treatment for hyperbilirubinemia but are untreated. Household screening and treatment for neonatal hyperbilirubinemia with phototherapy administered by a trained community health worker (CHW) may increase indicated treatment for neonatal hyperbilirubinemia in comparison to the existing care system in Bangladesh. Methods: 530 Bangladeshi women in their 2nd or 3rd trimester of pregnancy from the rural community of Sakhipur, Bangladesh will be recruited for a cluster randomized trial and randomized to the intervention arm — home screening and treatment for neonatal hyperbilirubinemia — or the comparison arm to receive usual care. In the intervention arm, CHWs will provide mothers with two prenatal visits, visit newborns by 2 days of age and then daily for 3 days to measure transcutaneous bilirubin (TcB) and monitor clinical danger signs. Newborns without danger signs but with a TcB above the treatment threshold &lt;15 mg/dL will be treated with light-emitting diode (LED) phototherapy at home. Newborns with danger signs or TcB &gt;15 mg/dL will be referred to a hospital for treatment. Treatment rates for neonatal hyperbilirubinemia in each arm will be compared. Conclusion: This study will evaluate the effectiveness of CHW-led home phototherapy to increase neonatal hyperbilirubinemia treatment rates in rural Bangladesh. LMICs are expanding access to postnatal care by using CHWs, and our work will give CHWs a curative treatment option for neonatal hyperbilirubinemia. Similar projects in other LMICs can be pursued to dramatically extend healthcare access to vulnerable newborns with hyperbilirubinemia.

Feasibility and acceptability of home-based neonatal hyperbilirubinemia screening by community health workers using transcutaneous bilimeters in Bangladesh

BackgroundUniversal screening for neonatal hyperbilirubinemia risk assessment is recommended by the American Academy of Pediatrics to reduce related morbidity. In Bangladesh and in many low- and middle-income countries, there is no screening for neonatal hyperbilirubinemia. Furthermore, neonatal hyperbilirubinemia may not be recognized as a medically significant condition by caregivers and community members. We aimed to evaluate the acceptability and operational feasibility of community health worker (CHW)-led, home-based, non-invasive neonatal hyperbilirubinemia screening using a transcutaneous bilimeter in Shakhipur, a rural subdistrict in Bangladesh.MethodsWe employed a two-step process. In the formative phase, we conducted eight focus group discussions with parents and grandparents of infants and eight key informant interviews with public and private healthcare providers and managers to explore their current knowledge, perceptions, practices, and challenges regarding identification and management of neonatal hyperbilirubinemia. Next, we piloted a prenatal sensitization intervention and home-based screening by CHWs using transcutaneous bilimeters and evaluated the acceptability and operational feasibility of this approach through focus group discussions and key informant interviews with parents, grandparents and CHWs.ResultsFormative findings identified misconceptions regarding neonatal hyperbilirubinemia causes and health risks among caregivers in rural Bangladesh. CHWs were comfortable with adoption, maintenance and use of the device in routine home visits. Transcutaneous bilimeter-based screening was also widely accepted by caregivers and family members due to its noninvasive technique and immediate display of findings at home. Prenatal sensitization of caregivers and family members helped to create a supportive environment in the family and empowered mothers as primary caregivers.ConclusionAdopting household neonatal hyperbilirubinemia screening in the postnatal period by CHWs using a transcutaneous bilimeter is an acceptable approach by both CHWs and families and may increase rates of screening to prevent morbidity and mortality.

You Code It! Management of Hyperbilirubinemia (Online Exclusive)

Management of neonatal hyperbilirubinemia may require low to highly complex medical decision-making. The correct diagnosis code(s) must be reported to support the level of service provided. Can you identify the appropriate procedure and diagnosis codes for the following examples? Answers are elsewhere in this issue.

Clinical progress note: Revisions to the management of neonatal hyperbilirubinemia.

The authors declare no conflict of interest.

Phototherapy services for newborns with jaundice: Availability and practices in Southeast Nigeria

Severe neonatal hyperbilirubinemia remains a cause of neurologic damage in children in low-income countries. Phototherapy, which is the standard of care for neonatal hyperbilirubinemia is not only necessary but an essential neonatal service that should be readily available in all health facilities with maternal and newborn services. The study describes the availability and distribution of phototherapy service in secondary health facilities in Southeast Nigeria. This was a cross-sectional descriptive study carried out in four of the largest cities in Southeast Nigeria using purposive and convenient sampling methods. A questionnaire was administered and information regarding the availability of phototherapy machines, its use and availability of personnel was obtained. A total of 77 facilities were surveyed. Fifty-five (71.4%) of the studied facilities manage jaundice in their facility. Of these, 45/55 (81.8%) use phototherapy in the management of jaundice in newborns. The most used phototherapy is Light-Emitting Diode (LED) (42.2%). Others were fluorescent (26.6%), fabricated LED (11.1%) and fabricated fluorescent (20%). Routine serum bilirubin assay was done in 60 (77.9%) facilities even though majority was done in laboratories outside the facility. Non-invasive serum bilirubin monitoring was available in only two facilities. Only 21 (47.7%) had a servicing protocol for their phototherapy machines, and just 12 (27.7%) of these services were offered by a biomedical engineer. Phototherapy use in secondary health facilities is suboptimal. There is urgent need for states health authorities to collaborate with private health facilities especially those offering maternal and child services in provision of phototherapy machines and help in the training health workers for optimal management of neonatal hyperbilirubinemia.

Community health worker led household screening and management of neonatal hyperbilirubinemia in rural Bangladesh: a cluster randomized control trial protocol Spirit 2013 Checklist, Consort 2010 Checklist, and Consent forms

Community health worker led household screening and management of neonatal hyperbilirubinemia in rural Bangladesh: a cluster randomized control trial protocol Spirit 2013 Checklist, Consort 2010 Checklist, and Consent forms

Intensive phototherapy as the initial management of severe hyperbilirubinemia in neonates

Hyperbilirubinemia is one of the most common clinical phenomena found in newborns, which is about 60% of term infants and 80% of preterm infants in the first week of life. Severe hyperbilirubinemia can cause encephalopathy and permanent neurodevelopmental damage with an incidence that varies between 4% - 60.3% and mortality rate of 13% to 56.8% worldwide. Phototherapy and exchange transfusion are therapeutic modalities for infants with severe hyperbilirubinemia. Intensive phototherapy has fewer side effects and can reduce the need for exchange transfusion. This treatment is rarely needed if intensive phototherapy is effective, current guidelines for the management of hyperbilirubinemia focus on the use of intensive phototherapy as initial treatment. This literature review aims to discuss intensive phototherapy as the initial management of severe hyperbilirubinemia in neonates.

EFFECT OF PHOTOTHERAPY ON SERUM ELECTROLYTE LEVELS IN NEONATAL HYPERBILIRUBINEMIA

Introduction: Neonatal hyperbilirubinemia is the most common clinical morbidity noted during the first seven days following birth. Amongst all the modalities available for management of neonatal hyperbilirubinemia, phototherapy is proven to be the safest. However, like any other intervention, phototherapy too has some of its own side effects. Aims &amp; objective: This study aimed to investigate the effect of phototherapy on serum electrolyte levels in neonates admitted to neonatal intensive care unit with the diagnosis of neonatal hyperbilirubinemia. DemographicMaterial and methods: profiles, laboratory findings, and electrolyte levels before phototherapy and 48-72 hours after phototherapy of 290 patients hospitalized with neonatal hyperbilirubinemia between Sep 2020 and March 2022 were compared in this retrospective study. The mean sodium level significantly decreased from 141.3 mg/dL to 140.1 mg/dL afterResults: phototherapy. The decrease in potassium level was not statistically significant. The mean calcium level significantly decreased from 10.02 mg/dL to 9.68 mg/dL after receiving phototherapy. The level of serum electrolytesConclusion: in newborns may change with phototherapy. Serum sodium and calcium levels may decrease after phototherapy. For prevention of possible adverse effects, the changes in electrolyte levels should be considered in the clinical course of newborns receiving phototherapy and appropriate fluid-electrolyte treatments should be given

Accuracy and Reliability of Whole Blood Bilirubin Measurements Using a Roche Blood Gas Analyzer for Neonatal Hyperbilirubinemia Screening and Risk Stratification.

BackgroundAccurate bilirubin measurements are essential for appropriate management of neonatal hyperbilirubinemia. This study aimed to evaluate the accuracy and reliability of whole blood bilirubin measurements obtained using a Roche blood gas analyzer (Roche TBiL), with total serum bilirubin (TSB) measurements determined by the Ortho VITROS 4600 chemistry system (Ortho TSB) serving as a reference.Materials and MethodsMedical records of hospitalized neonates that underwent simultaneous Roche TBiL and Ortho TSB measurements were reviewed for eligibility selection and data collection. The correlations and differences between two sets of results were determined using Passing–Bablok regression analysis and a Bland–Altman plot, respectively. For eligible newborns, the risk of developing severe hyperbilirubinemia was assessed using the Bhutani nomogram. Weighted kappa analysis was used to evaluate the agreement between risk prediction by the two methods.ResultsWe obtained 618 paired Roche TBiL and Ortho TSB results from 309 neonates. Roche TBiL and Ortho TSB measurements showed a good correlation (r = 0.923; 95% CI: 0.905–0.938). Passing–Bablok regression analysis yielded the following equation: Roche TBiL = 0.794 × Ortho TSB + 1.255 mg/dL, with a slope of 0.794 (95% CI: 0.763–0.825) and intercept of 1.255 (95% CI: 1.042–1.417). The average difference between the two methods was 0.1 ± 1.448 mg/dL. A total of 207 neonates were eligible for evaluation of the agreement between the risk-grading methods. Although kappa analysis showed good agreement between the methods, with a weighted kappa of 0.681 (95% CI: 0.610–0.751) across all populations, the values for approximately half of the neonates at intermediate and high risk of hyperbilirubinemia (33/72) were underestimated by Roche TBiL.ConclusionOur results indicate that Roche TBiL and Ortho TSB measurements in the neonatal population are not consistent. As a point-of-care and trace blood assay, Roche blood gas bilirubin measurements can facilitate primary screening of neonatal hyperbilirubinemia, but it seems to lack accuracy regarding risk stratification, particularly for high-risk newborn individuals.

Effect of Phototherapy on Serum Electrolytes and Alkaline Phosphatase During Management of Neonatal Hyperbilirubinemia

Effect of Phototherapy on Serum Electrolytes and Alkaline Phosphatase During Management of Neonatal Hyperbilirubinemia