Predischarge Bilirubin Research Articles

Hyperbilirubinemia in African American neonates: clinical issues and current challenges

African American neonates evidence a low incidence of hyperbilirubinemia yet account for more than 25% of the reported kernicterus cases in the USA. Glucose-6-phosphate dehydrogenase (G6PD) deficiency accounts for approximately 60%, and late preterm gestation and ABO hemolytic disease approximately 40% of these cases. Females heterozygous for G6PD A- harbor a population of G6PD-deficient red blood cells and are at risk for hyperbilirubinemia. Pre-discharge bilirubin measurement coupled with gestational age enhances the identification of neonates at hyperbilirubinemia risk. Parental education at the time of birth hospitalization discharge combined with timely follow-up may help to reduce the risk of developing hazardous hyperbilirubinemia.

Bilirubin Screening for Normal Newborns: A Critique of the Hour-Specific Bilirubin Nomogram

Kernicterus is a devastating but rare disease with an incidence that ranges from 0.4 to 2.9 per 100000 live births.1–6 Recently, a preventive strategy of measuring predischarge bilirubin levels in all infants discharged from the newborn nursery was proposed and included as an option in the American Academy of Pediatrics guidelines.7 The percentile location of these levels on an hour-specific “nomogram” of total serum bilirubin (TSB) levels first described by Bhutani et al8 is thought to predict the risk of severe hyperbilirubinemia. In this commentary we highlight the methodologic flaws in the development of the nomogram, the lack of evidence for efficacy of screening, and the potential undesirable consequences of such an approach. Multiple flaws in the methods used to create the nomogram8 and assess its accuracy generate serious questions about its validity. Some of these issues were emphasized previously by experts on hyperbilirubinemia who stated that “the study biases and interlaboratory variability in TSB measurements preclude general extrapolation of the quantitative results of this study… ”9 First, the applicability of these percentile curves to the overall US or international population is suspect, because they were developed in a retrospective study that used a small sample of infants from a single urban Philadelphia, Pennsylvania, hospital, the demographics of which (43% white, 41% black, 4% Hispanic, and 4% … Address correspondence to David L. Fay, MD, Waukesha Family Medicine Residency Program, 210 NW Barstow, Suite 201, Waukesha, WI 53188. E-mail: david.fay{at}phci.org

Hyperbilirubinemia in the Newborn Infant ≥35 Weeks’ Gestation: An Update With Clarifications

In July 2004, the Subcommittee on Hyperbilirubinemia of the American Academy of Pediatrics (AAP) published its clinical practice guideline on the management of hyperbilirubinemia in the newborn infant ≥35 weeks of gestation,1 and a similar guideline was published in 2007 by the Canadian Paediatric Society.2 Experience with implementation of the AAP guideline suggests that some areas require clarification. The 2004 AAP guideline also expressed hope that its implementation would “reduce the incidence of severe hyperbilirubinemia and bilirubin encephalopathy… .” We do not know how many practitioners are following the guideline, nor do we know the current incidence of bilirubin encephalopathy in the United States. We do know, however, that kernicterus is still occurring in the United States, Canada, and Western Europe.3–7 In 2002, the National Quality Forum suggested that kernicterus should be classified as a “serious reportable event,”8 sometimes termed a “never event,”9 implying that with appropriate monitoring, surveillance, and intervention, this devastating condition can, or should, be eliminated. Although this is certainly a desirable objective, it is highly unlikely that it can be achieved given our current state of knowledge and practice.10 In certain circumstances (notably, glucose-6-phosphate dehydrogenase [G6PD] deficiency, sepsis, genetic predisposition, or other unknown stressors), acute, severe hyperbilirubinemia can occur and can produce brain damage despite appropriate monitoring and intervention. In addition to clarifying certain items in the 2004 AAP guideline, we recommend universal predischarge bilirubin screening using total serum bilirubin (TSB) or transcutaneous bilirubin (TcB) measurements, which help to assess the risk of subsequent severe hyperbilirubinemia. We also recommend a more structured approach to management and follow-up according to the predischarge TSB/TcB, gestational age, and other risk factors for hyperbilirubinemia. These recommendations represent a consensus of expert opinion based on the available evidence, and they are supported by … Address correspondence to M. Jeffrey Maisels, MB, BCh, DSc, Beaumont Children's Hospital, 3601 W. 13 Mile Rd, Royal Oak, MI 48073. E-mail: JMaisels{at}beaumont.edu

Delayed pediatric office follow-up of newborns after birth hospitalization.

Key recommendations of the American Academy of Pediatrics guideline on management of severe hyperbilirubinemia in healthy infants of >or=35 weeks' gestation include predischarge screening for risk of subsequent hyperbilirubinemia, follow-up at 3 to 5 days of age, and lactation support. Little information is available on contemporary compliance with follow-up recommendations. To assess timing and content of the first newborn office visit after birth hospitalization in urban and suburban pediatric practices in Houston, Texas. We reviewed office records for the first visit within 4 weeks of birth during January through July 2006 for apparently healthy newborns with a gestational age of >or=35 weeks or birth weight of >or=2500 g seen within a pediatric provider network. For each pediatrician, we selected every fifth patient up to a total of 6. Of 845 records abstracted, 698 (83%) were eligible for analysis. Infants were seen by 136 pediatricians in 39 practices. They had vaginal (64%) or cesarean (36%) deliveries at 20 local hospitals, of which 17 had routine predischarge bilirubin screening policies. Only 37% of all infants, 44% of vaginally delivered infants, and 41% of exclusively breastfed infants were seen before 6 days of age. Thirty-five percent of the infants were seen after 10 days of age. Among 636 infants seen at <or=15 days, jaundice was noted on examination in 33%; of these, 44% had bilirubin measured. Nine infants had phototherapy documented after birth hospitalization. Among a large group of urban and suburban pediatricians, implementation of the American Academy of Pediatrics recommendation for follow-up was inconsistent, and delayed follow-up was common. Understanding reasons for delayed follow-up and providing guidance for jaundice management may promote a safer first week of life.

False-negative results of pre-discharge neonatal bilirubin screening to predict severe hyperbilirubinemia: a need for caution

Routine bilirubin screening prior to newborn hospital discharge, using an hour-specific bilirubin nomogram, has been advocated to assess risk for subsequent severe hyperbilirubinemia. However, the false-negative rate has never been adequately studied. Our objective was to determine false-negative results of pre-discharge bilirubin screening. After routine pre-discharge, bilirubin screening was in place for over 4 years, we performed a retrospective chart review to identify infants readmitted for total bilirubin levels > 17 mg/dl (>290.7 micromol/l). We documented each infant's pre-discharge bilirubin level, risk-zone assignment by nomogram, the presence or absence of risk factors for severe hyperbilirubinemia, co-morbidities upon readmission, treatment received, and ultimate disposition. Readmitted infants whose pre-discharge bilirubin was in the low-risk (<40th percentile) and low-intermediate (40-75th percentile) risk zones of the nomogram, were considered false-negatives. Of the 6,220 infants discharged from the newborn nursery during the 51-month study period, 28 (0.45%) were readmitted for treatment of serum bilirubin levels > 17 mg/dl (>290.7 micromol/l). All received phototherapy and none required exchange transfusion. Pre-discharge bilirubin values were <40th percentile (low-risk zone) in one infant (3.6%), and between 40-75th percentiles (low-intermediate risk zone) in twelve infants (43%). Risk factors for the development of severe hyperbilirubinemia were present in 27 (96%) readmitted infants. In conclusion, nearly half of readmitted infants had pre-discharge bilirubin values in zones considered at lower risk. The use of pre-discharge bilirubin screening alone to assign future risk for severe hyperbilirubinemia may provide false reassurance. Rigorous research is required to determine the test characteristics of pre-discharge bilirubin screening before widespread acceptance and implementation. Universal early post-discharge follow-up should remain the cornerstone of preventing severe hyperbilirubinemia.

Neonatal Hyperbilirubinemia: Don't Let Glucose-6-phosphate Dehydrogenase Deficiency off the Hook: In Reply

We agree with Kaplan and Hammerman: there is substantial evidence that glucose-6-phosphate dehydrogenase (G6PD) deficiency is associated with neonatal hyperbilirubinemia.1–4 And, our results do not contest that association. Rather, our findings raise questions about the utility of a particular DNA-based G6PD screening test5 as a predictor of neonatal hyperbilirubinemia. As we pointed out in our article,6 there are several reasons why a positive G6PD mutation analysis did not correlate with hyperbilirubinemia in our study sample: (1) some mutations may not result in inadequate G6PD enzyme levels; (2) some mutations may result in low enzyme activity levels but not hyperbilirubinemia; and (3) some mutations that result in low enzyme activity and hyperbilirubinemia may not be detected by this screening test.Studies are needed to further evaluate the predictive accuracy of and relationship between alternative methods of G6PD-deficiency screening. Infants enrolled onto these studies should have the following tests performed: G6PD mutation analysis, G6PD enzyme level, UDPGT1 polymorphism analysis, and daily bilirubin levels. Investigators can then compare the predictive value of alternative screening tests for G6PD deficiency, determine reasons for divergent screening test results, and evaluate the contribution of glucuronidation defects to hyperbilirubinemia. Even more important is that these studies can inform us about the incremental predictive value of G6PD screening tests above and beyond the predictive information provided by the predischarge bilirubin level (expressed as a risk zone on the hour-specific bilirubin nomogram) and the infant's gestational age, the 2 factors shown to be most predictive of significant hyperbilirubinemia.

Is the hour-specific bilirubin nomogram suitable for predicting hyperbilirubinemia

To demonstrate the effectiveness of the hour-specific serum bilirubin nomogram, described by Bhutani et al, in predicting significant hyperbilirubinemia in term Turkish newborns. A total of 217 healthy term newborns without signs of hemolysis were enrolled. Serum bilirubin levels were obtained at discharge and whenever visible jaundice was observed. According to the percentile-based hour specific bilirubin nomogram the babies were grouped into four categories (high, high/low, intermediate or low risk zone). All babies were followed up for hyperbilirubinemia and examined between 7 to 10 days of life and a bilirubin level was obtained when jaundice was observed. The mean predischarge bilirubin of cases was 9.71+/-3.4mg/dl. Thirty six patients (16.6%) received phototherapy while none of the cases had an exchange transfusion. The distribution of cases according to the high risk, intermediate, low/high, and low zones and the percentage of babies who received phototherapy were, 21(63.6%), 10(38.5%), 3(4.5%) and 2(2.2%), respectively. The risk of phototherapy decreased to 0.35 times for every increasing week of gestational age. Babies in the high intermediate and high risk zones were more likely to receive phototherapy (OR:24.5 and OR:83.6) The hour-specific serum bilirubin nomogram described by Bhutani et al. predicted clinically significant hyperbilirubinemia in Turkish term newborns.

A Comparison of Alternative Risk-Assessment Strategies for Predicting Significant Neonatal Hyperbilirubinemia in Term and Near-Term Infants

The purpose of this work was to compare the predictive accuracy of alternative risk-assessment strategies used to screen for the risk of significant neonatal hyperbilirubinemia. We conducted a prospective cohort study of 823 term and near-term newborns admitted to the well-infant nursery at the Hospital of the University of Pennsylvania. Maternal, infant, and delivery risk factors for significant hyperbilirubinemia were obtained from chart review, structured interviews with parents, and nurse assessments before discharge. Transcutaneous bilirubin measurement was performed daily until discharge and once by a visiting home nurse between 3 and 8 days of life. We used the c statistic to compare the predictive accuracy of 3 risk-assessment strategies for estimating the risk of significant neonatal hyperbilirubinemia, defined as a bilirubin level that at any time after birth exceeded or was within 1 mg/dL (17 micromol/L) of the hour-specific phototherapy treatment threshold recommended by the American Academy of Pediatrics in 2004. The compared strategies included those that use (1) a predischarge bilirubin level (obtained before 52 hours) expressed as a risk zone on an hour-specific bilirubin nomogram, (2) clinical risk factors other than the predischarge bilirubin level, and (3) a combination of the predischarge bilirubin risk zone and additional clinical risk factors. Forty-eight patients (6%) developed significant neonatal hyperbilirubinemia. The predischarge (<52 hours) bilirubin level expressed as a risk zone on the bilirubin nomogram and a prediction model that combined multiple other clinical risk factors had similar accuracy for predicting significant hyperbilirubinemia. The only clinical risk factor that could be added to the predischarge risk zone to improve overall predictive accuracy was gestational age. The predischarge bilirubin risk zone and gestational age could be used to stratify patients into a large group (n = 523 [70%]) of infants with a very low (0.2%) risk of developing significant hyperbilirubinemia, a small group of infants (n = 127 [17%]) with a low (4%) risk of developing significant hyperbilirubinemia, and an even smaller group of infants (n = 100 [13%]) with a high (42%) risk of developing significant hyperbilirubinemia. An infant's risk of developing significant hyperbilirubinemia can be simply and accurately assessed by using just the infant's predischarge bilirubin level and gestational age.

Evaluation of Discharge Management in the Prediction of Hyperbilirubinemia: The Jerusalem Experience

We evaluated our program for prediction and follow-up of hyperbilirubinemia in preventing plasma total bilirubin (PTB) > or = 25 mg/dL and in limiting readmission for hyperbilirubinemia. Term and near-term neonates were screened before discharge for risk factors for hyperbilirubinemia. A PTB test was performed when visible jaundice was apparent. Formal postdischarge follow-up was integrated with a possibly unique religious/cultural support system complemented by ritual circumciser (mohel) home visits and a high rate of jaundice awareness in the community. During 2001-2002, 18,079 term and near-term healthy neonates were cared for in our well baby nurseries. Three hundred forty-two (1.9%) were treated with phototherapy, and 4 with exchange transfusion. Seventy-four (21.6%) of these (0.41% of total) were readmitted for hyperbilirubinemia. Forty-two percent of those readmitted had not been regarded as sufficiently jaundiced to warrant a predischarge bilirubin determination. In only 1 neonate did the PTB exceed > or = 25.0 mg/dL (0.006%). No infant had signs of bilirubin encephalopathy. Our practice was successful in keeping the number of readmitted neonates low and limiting those with extreme hyperbilirubinemia to the minimum. Local customs, rituals, and practices may be successfully adapted as adjuncts in the detection and prevention of hyperbilirubinemia.

Predischarge Risk Assessment for Severe Neonatal Hyperbilirubinemia

Current approaches to identifying infants at risk of developing severe neonatal hyperbilirubinemia include use of an hour-specific bilirubin nomogram that employs predischarge bilirubin measurements and clinical risk factor assessment that employs multiple factors in clinical prediction rules. Determining the hour-specific total serum bilirubin before discharge has been shown to be the most accurate method for assessing risk of severe hyperbilirubinemia. Combining clinical risk factors and predischarge bilirubin values may offer additional predictive performance above either approach used alone. Current risk assessment strategies need to be validated prospectively in a large and diverse newborn population, and the risk assessment strategies should be paired with recommended actions. Finally, transcutaneous bilirubin and end-tidal carbon monoxide measurements and screening for specific genetic markers of neonatal hyperbilirubinemia have the potential to refine risk assessment strategies further.

Effect of Predischarge Bilirubin Screening on Subsequent Hyperbilirubinemia: In Reply

We appreciate the comments by Drs Maisels, Newman, and Watchko on our recently published experience1 with newborn prehospital discharge bilirubin screening. Our result of reducing the number of neonates whose serum bilirubin levels exceeded 20 mg/dL was achieved as described in “Methods.” Education of caregivers was completed before institution of the program, and the newborn order set for Intermountain Health Care hospitals was changed to provide for the predischarge bilirubin test. Physicians could opt out by crossing through the bilirubin order. We obtained at least 1 predischarge bilirubin level from >99% of the infants, so this was rarely an …

Effect of Predischarge Bilirubin Screening on Subsequent Hyperbilirubinemia

To the Editor .— Although Eggert et al1 showed that the use of universal predischarge bilirubin screening seems to reduce the number of neonates whose serum bilirubin levels exceed 20 mg/dL and the rate of hospital readmission for phototherapy, they provide no information on how this result was achieved. They also note that a predischarge risk assessment allows health care providers to “have the opportunity to target surveillance and provide a more selective approach to the …

Neonatal hyperbilirubinemia in African American males: The importance of glucose-6-phosphate dehydrogenase deficiency

To perform risk factor analysis for the prediction of hyperbilirubinemia in an African American male neonatal cohort. A database of 500 previously published term and near-term African American male neonates was further analyzed to determine the role of risk factors for hyperbilirubinemia. Factors studied included birth weight >/=4.0 kg, gestational age </=37 weeks, breast-feeding, glucose-6-phosphate dehydrogenase (G-6-PD) deficiency, and predischarge bilirubin >/=75(th) percentile. Hyperbilirubinemia was defined as any bilirubin value >/=95(th) percentile on the hour-of-life-specific bilirubin nomogram. Forty-three (8.6%) neonates developed hyperbilirubinemia. At 48 +/- 12 hours, median transcutaneous bilirubin was 8.3 mg/dL, 75(th) percentile 10.0 mg/dL, and 95(th) percentile 12.6 mg/dL. Of the risk factors, only exclusive breast-feeding, G-6-PD deficiency and predischarge bilirubin >/=75(th) percentile were significant (Adjusted Odds Ratios [95% Confidence Intervals; CI] 3.15 [1.39-7.14], P = .006; 4.96 [2.28-10.80], P = .001; and 7.47 [3.50-15.94], P < .0001, respectively). G-6-PD-deficient neonates who were also premature and breast-feeding had the highest incidence of hyperbilirubinemia (60%). African American male neonates may be at higher risk for hyperbilirubinemia than previously thought. Screening for G-6-PD deficiency and predischarge bilirubin determination may be useful adjuncts in hyperbilirubinemia prediction in these newborns.

The Effect of Instituting a Prehospital-Discharge Newborn Bilirubin Screening Program in an 18-Hospital Health System

Kernicterus is a rare but devastating condition. The prevention of bilirubin-induced brain injury is based on the detection of infants at risk for developing severe hyperbilirubinemia. In an 18-hospital health system, Intermountain Health Care (IHC), we initiated a program of predischarge bilirubin screening of all neonates and coupled this with a results assessment using a percentile-based nomogram. Data during 2 periods of time, before versus after initiating the program, were compared to assess the effect of the program on significant hyperbilirubinemia and rehospitalization. We conducted a historic cohort study involving all neonates delivered at > or =35 weeks' gestation, within IHC's 18-hospital system, during 2 periods of time: March 1, 2001, to December 31, 2002, versus January 1, 2003, to December 31, 2004. A bilirubin screening program, instituted in December 2002, called for a total serum bilirubin (TSB) or transcutaneous bilirubin measurement to be performed on every neonate either at the recognition of clinical jaundice or before discharge regardless of whether jaundice was observed. For nonjaundiced neonates, the nursery staff was encouraged to obtain the screening TSB at the same time they obtained the state-mandated newborn screen for inborn errors of metabolism. Bilirubin values were plotted on an hour-specific nomogram and the corresponding percentile was used to guide evaluation, therapy, and follow-up. This study compared TSB data and readmission data for a 2-year period before versus a 2-year period after implementing the program. The study involved 101272 neonates: 48789 in period 1 and 52483 in period 2. Before the program, 1 in every 77 neonates born at an IHC hospital had 1 or more serum bilirubin levels >20 mg/dL. After initiating the program, the incidence fell to 1 in 142 and the number of neonates with a level >25 mg/dL fell from 1 in 1522 before to 1 in 4037 after. The rate of hospital readmission with a primary diagnosis of jaundice fell from 0.55% in period 1 to 0.43% in period 2. Initiating a program of bilirubin screening in a multihospital health system, coupled with evaluating the results using a percentile-based nomogram, reduced the proportion of neonates with significant hyperbilirubinemia and reduced the rate of hospital readmissions with jaundice.

Identifying newborns at risk of significant hyperbilirubinaemia: a comparison of two recommended approaches

Aims: To compare the predictive performance of clinical risk factor assessment and pre-discharge bilirubin measurement as screening tools for identifying infants at risk of developing significant neonatal hyperbilirubinaemia (post-discharge total...

Hyperbilirubinemia Guidelines in Newborn Infants

To the Editor .— We read with interest the recent hyperbilirubinemia guidelines by the American Academy of Pediatrics1 (AAP). We found them to be very informative, but we believe these guidelines can be adapted further to become more “user friendly.” To follow the guidelines, the practicing pediatrician needs to use information from 1 algorithm, 3 nomograms, and 4 tables that are spread over several pages. In our experience, using a 1-page practice guideline is a feasible solution to this problem (see Fig 1). Fig 1. Hyperbilirubinemia guidelines for infants ≥34 weeks' gestation. The AAP allows 2 options for predischarge assessment of newborns: (1) predischarge bilirubin measurement, …

Hyperbilirubinemia among African American, glucose-6-phosphate dehydrogenase-deficient neonates.

Although glucose-6-phosphate dehydrogenase (G-6-PD) deficiency is prevalent in African Americans, their risk of associated neonatal hyperbilirubinemia has not been prospectively studied. To compare hemolysis and the risk of hyperbilirubinemia among African American, G-6-PD-deficient neonates (study group) and G-6-PD-normal control subjects. Consecutive, healthy, term and near-term, male neonates born to African American mothers comprised the patient cohort. G-6-PD testing was performed with umbilical cord blood samples. Routine management included measurement of the end tidal carbon monoxide level corrected for ambient carbon monoxide level (ETCOc) within 4 hours after delivery (assessment of hemolysis), > or =1 predischarge bilirubin determination, and additional bilirubin testing as clinically indicated. Indications for phototherapy were identical for study patients and control subjects. Neonates were monitored for the first 1 week of life. ETCOc results, the incidence of hyperbilirubinemia (defined as a transcutaneous or plasma total bilirubin concentration of > or =95th percentile for the hour of life), and the need for phototherapy were compared between the G-6-PD-deficient and G-6-PD-normal groups. Five hundred male patients were enrolled, of whom 64 (12.8%) were G-6-PD-deficient. ETCOc values (median and interquartile range) were higher among G-6-PD-deficient neonates than among control neonates (2.4 ppm [2.0-2.9 ppm] vs 2.1 ppm [1.7-2.5 ppm]). More G-6-PD-deficient neonates developed hyperbilirubinemia than did control subjects (14 of 64, 21.9%, vs 29 of 436, 6.7%; relative risk: 3.27; 95% confidence interval: 1.83-5.86), whereas 13 (20.3%) met the criteria for phototherapy, compared with 25 control subjects (5.7%) (relative risk: 3.53; 95% confidence interval: 1.91-6.56). No cases of kernicterus were observed. Within the African American neonatal population, there is a subgroup of G-6-PD-deficient infants with elevated rates of hemolysis, a higher incidence of hyperbilirubinemia, and a greater requirement for phototherapy, compared with G-6-PD-normal control subjects. These newborns should be monitored vigilantly for the development of hyperbilirubinemia.

Preventing kernicterus: Almost there

Preventing kernicterus: Almost there

Managing the assessment of neonatal jaundice: importance of timing.

In view of the limitations in the accurate visual assessment of jaundice and its potential role as a predictive vector for serious neurologic sequelae, we propose that a universal screening of bilirubin be considered concurrent to the routine pre-discharge metabolic screening. Universal bilirubin screening in the term and near-term newborns when plotted on "Hour-specific Bilirubin Nomogram" in lieu of the usual "day-specific" value will predict the high-risk and the low-risk groups and facilitate cost-effective and individualized follow-up of those babies at risk. A percentile based bilirubin nomogram for the first week of age was constructed from hour-specific pre- and post-discharge bilirubin values of 2840 healthy term and near-term babies. The accuracy of the pre-discharge bilirubin values was determined as a predictive vector. Pre-discharge (18-72 hours age), 6.1% of the study population had bilirubin values in the high-risk zone (> 95th percentile). Of these, 39.5% remained in that zone (likelihood ratio ¿LR¿ = 14.08). Pre-discharge, 32.1% of the study population had bilirubin values in the intermediate risk zone (40-75th percentiles). In a clinically significant minority of these babies (6.4%), the post-discharge values moved to the high-risk zone (L-R = 3.2 for the move from the upper-intermediate zone and 0.48 from the lower-intermediate zone). In the remainder 61.8% of the population who were identified to be at low risk, there was no measurable risk for significant hyperbilirubinemia (L-R = 0). The bilirubin nomogram can predict which infant is at high, intermediate, and low risk for subsequent excessive hyperbilirubinemia and allows for the individualized follow-up of these high-risk babies with particular attention to those who may need evaluation and intervention. Whereas, identification of the low risk group allows for a less intense bilirubin follow-up and in whom a visual check by an experienced care-provider may suffice.

Guidelines for Management of the Jaundiced Term and Near-Term Infant

Factors believed to have contributed to the reemergence of kernicterus in the United States during the 1990's are discussed: these include decreased concern about toxicity of bilirubin in term and near-term infants, increased prevalence of breastfeeding, and increasingly shortened postnatal hospital stays. The rationale for a universal predischarge bilirubin measurement at the time of the routine predischarge metabolic screen is presented: the hour-specific level of bilirubin at discharge, plotted on an Hour-Specific Bilirubin Nomogram, improves prediction of risk of excessive jaundice postdischarge and facilitates safe, cost-effective follow-up. This minimizes repeat bilirubin measurements and maximizes recognition of confounding variables and risk of hyperbilirubinemia so that timely, minimally invasive, preventive therapy can be instituted if needed.