Prolonged Jaundice Screening Research Articles

Three-year experience with prolonged neonatal jaundice screening in a district general hospital

Background: Investigations for prolonged jaundice vary in complexity, especially in well neonates. The aim was to ascertain the causes of prolonged jaundice in well neonates and to analyse the extent and consistency of investigations performed. Methods: We performed a retrospective review of nurse-led prolonged jaundice screening in our children’s assessment unit from 2013 to 2016. The proforma included clinical assessment and recommended investigations. Data from electronic records and laboratory findings were compiled for analysis. Results: A total of 116 infants aged 14-73 days were referred for screening, with 100% utilization of the screening proforma. All patients had unconjugated hyperbilirubinaemia with normal urine and stool colour. Of the 113 with a full blood count performed, 74 (65.5%) were normal, with neutropenia in 32 (28.3%) and 1 blood film showing spherocytosis with haemolysis. Urine culture was performed in 106 infants, yielding 2 pure-growth cultures in infants subsequently treated for urinary tract infection (UTI) (1%). Seventy-four infants had one or more additional tests. The causes of prolonged jaundice identified were breast-milk jaundice (97), feeding difficulties (7), UTI (2) and hereditary spherocytosis (1). Conclusions: The most common cause of prolonged jaundice identified was breast-milk jaundice. The eldest referred infant was 73 days old, demonstrating a need for increased community awareness of guidelines to facilitate prompt referral. Additional investigations yielded little diagnostic value and we propose that in well neonates, following clinical evaluation, investigations may safely be reduced to full blood count and split bilirubin.

PS-057 Analysis Of Prolonged Jaundice In Newborns: A Study Looking At The Investigations Performed And Outcomes In A District General Hospital

<h3>Background and aims</h3> Prolonged neonatal jaundice is a common presentation in newborns and rarely requires intervention; however it is important to rule out sinister causes such as biliary atresia. The outcome of this study was to analyse the demographics of infants presenting with prolonged jaundice, investigations undertaken and results of these tests in relation to NICE guidelines. <h3>Methods</h3> We retrospectively identified infants over 2 years (January 2012 to December 2013) coded to have a prolonged jaundice screen. Analysing the case notes, 90 infants had a screen performed, from age 14 to 71 days of life, with an average of 21 days of life. <h3>Results</h3> Of the infants screened, 18 (20%) patients were found to have abnormal initial results, with significant abnormalities in 3 (3.3%) patients. One infant who presented at day 71 of life was identified to have biliary atresia, one infant had a urinary tract infection, and one infant had a positive reducing sugar and confirmed to be lactose intolerant. Four patients had ABO incompatibility but were otherwise well. <h3>Conclusion</h3> In our study, we found only one baby with conjugated hyperbilirubinaemia who presented late. The remainder of the babies investigated for prolonged jaundice were benign. Majority of the infants (72%) were breastfed, which is a well-recognised cause for prolonged jaundice. As such, the authors propose that in well babies with pigmented stools, performing the prolonged jaundice screen at 21 rather than 14 days could reduce the burden of carrying out unnecessary tests without causing significant detriment to these patients.

Rationalized assessment of prolonged jaundice is safe and cost-effective

Prolonged jaundice (PJ) in healthy term neonates is common and frequently benign. It can, however, be the earliest manifestation of underlying liver disease. Its management requires a balanced approach, avoiding over-investigation of well babies while ensuring the early identification of those with pathology. Currently marked heterogeneity exists in the assessment of PJ. Over a two-year period we prospectively audited the management of PJ in two Level 3 neonatal units prior to and after the introduction of a rationalized investigation algorithm in keeping with the recently published British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) guidelines (i.e. clinical examination and stool inspection combined with measurement of split bilirubin). In this study we reviewed initial practice and then evaluated the impact of our change in practice. A total of 197 babies, 1.5% of live births, were referred with PJ. Of these, 105 babies were included in the first part of the study and 92 babies were included in the second part. No pathology relating to PJ, such as infection, hepatitis or liver disease, was identified. Following the introduction of our rationalized algorithm, we demonstrated a statistically significant reduction in the number of return appointments (28 versus 7; P < 0.0009) and repeat investigations (37 versus 7; P < 0.0001). This represented a saving of £1575-2625 per year in laboratory costs alone. Contemporaneously, three infants presented with biliary atresia, none of whom were identified by PJ screening and all of whom were over seven weeks old at diagnosis. A rationalized approach to the assessment of PJ reduces workload and is cost-effective; however, the limitations of selective screening, irrespective of how streamlined it is, remain--if babies are not identified and referred, they cannot be screened. Population-based methodologies offer an alternative approach to the identification of cholestatic liver disease and are worthy of further consideration.

782 Prolonged Jaundice Screen Audit- Rational Approach to Investigations

Background: Extensive laboratory investigations are routinely performed to exclude rare but potentially catastrophic causes of prolonged jaundice. Aims: This study aims to review the investigations and outcomes of Prolonged Jaundice Screening (PJS) and considers whether it is poβible to safely reduce the number of unneceβary blood tests. Methods: Retrospective analysis of all babies for PJS, between June 2008 and March 2010. Data from the Prolonged Jaundice Proforma was collated in Excel and was analysed using simple statistical methods and percentage calculations. Results: 100 babies reviewed, age of presentation were between 2 to >8weeks. 97% were fully or partially breast fed and 97.3% showed adequate growth. 90.4% term and 9.6% pre-term. Stool colour and clinical examination was normal in all cases. 8% had conjugated bilirubin above 20% of the total, 19% were noted to have >200mmol/L unconjugated bilirubin levels. All were subsequently found to have normal second line investigations. 55% of babies had abnormal blood results requiring repeat testing. All results normalised on subsequent testing (up to five repeats). Urine was positive in 25 cases with poβible contamination in 20 cases and E.coli in five cases. 2 babies had positive reducing substances, however, Galactosaemia was ruled out in both cases. No cases of cholestasis were identified. Conclusions: Good clinical history and examination along with split bilirubin is sufficient as first line investigation for PJ screen. Second line investigations are indicated only if there are any concerns on initial screen.

A study of prolonged jaundice screen in healthy term babies

Prolonged jaundice in most of the term babies is associated with breast milk but in some cases it can be a marker for a range of hepatobiliary, hematological, metabolic, endocrine, infectious and genetic disorders that are associated with significant mortality and morbidity if not diagnosed in time. A diagnosis of conjugated hyperbilirubinaemia warrants urgent investigation. Protocols for investigating prolonged jaundice screen vary in complexity and the yield from screen has not been assessed. In order to address these issues, we carried out a study on healthy term babies referred to our day unit with prolonged jaundice. Infants were examined by pediatrician and investigations done as per unit protocol. Prolonged jaundice screen was found to be helpful in excluding biliary atresia and to support the diagnosis of breast milk jaundice. Present study concluded that negative prolonged jaundice screen is reassuring in healthy term babies and further investigations are unwarranted unless otherwise specified.

Iatrogenic iodine as a cause of hypothyroidism in infants with end-stage renal failure

Between 1996 and 2005, two of seven infants in our unit on overnight continuous-cycle peritoneal dialysis (CCPD) acquired hypothyroidism following normal thyroid function on neonatal screening. Case 1 had posterior urethral valves, commenced CCPD at day 29, and developed hypothyroidism requiring treatment at 3 months: TSH 258 micro/l (ref.: 0.3-3.8), total thyroxine 74 nmol/l (ref.: 77-159). Plasma iodine concentration was 7.44 micromol/l (ref.: 0.23-0.68). Iodine concentrations in peritoneal dialysis (PD) fluid were found to be higher at the end of the first cycle (11.4 micromol/l) than at the end of the twelfth cycle (1.55 micromol/l). Case 2 had posterior urethral valves, commenced CCPD on day 4 and was diagnosed with hypothyroidism following a prolonged jaundice screen. Thyroxine replacement was stopped 2 months after a renal transplant. A third child commenced CCPD on day 2 and had high plasma iodine concentrations at 8 weeks (5.79 micromol/l). He had borderline thyroid function, not requiring replacement. Our hypothesis is that these infants developed hypothyroidism as a consequence of iodine exposure via the Wolff-Chaikoff effect. Iodine levels were higher in the PD fluid than in plasma. This suggests that povidine-iodine 10% in the PD cap may be the source of the high plasma iodine levels.

Investigation of prolonged neonatal jaundice

Jaundice persisting beyond 14 d of age (prolonged jaundice) can be a sign of serious underlying liver disease. Protocols for investigating prolonged jaundice vary in complexity and the yield from screening has not been assessed. In order to address these issues, we carried out a prospective study of term infants referred to our neonatal unit with prolonged jaundice over an 18 mo period. Infants were examined by a paediatrician and had the following investigations: a total and conjugated serum bilirubin, liver function tests, full blood count, packed cell volume, group and Coombs' test, thyroid function tests, glucose‐6‐phosphate dehydrogenase levels and urine for culture. One‐hundred‐and‐fifty‐four infants were referred with prolonged jaundice out of 7139 live births during the study period. Nine infants were referred to other paediatric specialties. One infant had a conjugated hyperbilirubinaemia, giving an incidence of conjugated hyperbilirubinaemia of 0.14 per 1000 live births. Diagnoses included: giant cell hepatitis (n= 1), hepatoblastoma (n= 1), trisomy 9p (n= 1), urinary tract infections (n= 2), glucose‐6‐phosphate dehydrogenase deficiency (n= 3) and failure to regain birthweight (n= 1).Conclusions: In conclusion, a large number of infants referred to hospital for prolonged jaundice screening had detectable problems. The number of investigations may safely be reduced to: a total and conjugated bilirubin, packed cell volume, glucose‐6‐phosphate dehydrogenase level (where appropriate), a urine for culture and inspection of a recent stool sample for bile pigmentation. Clinical examination by a paediatrician has a vital role in the screening process.

Investigation of prolonged neonatal jaundice.

Jaundice persisting beyond 14 d of age (prolonged jaundice) can be a sign of serious underlying liver disease. Protocols for investigating prolonged jaundice vary in complexity and the yield from screening has not been assessed. In order to address these issues, we carried out a prospective study of term infants referred to our neonatal unit with prolonged jaundice over an 18 mo period. Infants were examined by a paediatrician and had the following investigations: a total and conjugated serum bilirubin, liver function tests, full blood count, packed cell volume, group and Coombs' test, thyroid function tests, glucose-6-phosphate dehydrogenase levels and urine for culture. One-hundred-and-fifty-four infants were referred with prolonged jaundice out of 7,139 live births during the study period. Nine infants were referred to other paediatric specialties. One infant had a conjugated hyperbilirubinaemia, giving an incidence of conjugated hyperbilirubinaemia of 0.14 per 1,000 live births. Diagnoses included: giant cell hepatitis (n = 1), hepatoblastoma (n = 1), trisomy 9p (n = 1), urinary tract infections (n = 2), glucose-6-phosphate dehydrogenase deficiency (n = 3) and failure to regain birthweight (n = 1). In conclusion, a large number of infants referred to hospital for prolonged jaundice screening had detectable problems. The number of investigations may safely be reduced to: a total and conjugated bilirubin, packed cell volume, glucose-6-phosphate dehydrogenase level (where appropriate), a urine for culture and inspection of a recent stool sample for bile pigmentation. Clinical examination by a paediatrician has a vital role in the screening process.