Evaluation of Early Transcutaneous Bilirubinometry to Predict Subsequent Hyperbilirubinemia in Neonates Admitted to a Well-Baby Nursery.

OBJECTIVE: The aim of this study is to determine whether a transcutaneous bilirubin (TcB) value obtained within 6 hours of birth (early transcutaneous bilirubin [ETcB]) either alone, or used to calculate an early rate of rise (E-ROR) in TcB, will identify those neonates who are at a higher risk for subsequent jaundice. STUDY DESIGN: ETcB values were obtained from a convenience sample of neonates admitted to the newborn nursery. E-ROR was calculated as the average hourly increase between ETcB and subsequent TcB obtained at 18 to 36 hours of age. TcB percentile values at various ages were obtained from a previously published and cross-validated nomogram. The predictive values relating ETcB, E-ROR, and TcB at 18 to 36 hours of age to TcB at 42 to 66 hours of age were determined, and receiver-operator characteristic curves were compared. RESULTS: A total of 516 late preterm and term neonates were studied. ETcB was higher (p = 0.003) in those neonates who subsequently received phototherapy (n = 15), and negative predictive value was always ≥ 0.96; positive predictive value (PPV) ranged from 0.04 to 0.06. Compared with ETcB, TcB at 18 to 36 hours was more likely to predict significant jaundice at 42 to 66 hours of age. CONCLUSION: Given the observed low PPV, ETcB is not useful in identifying infants who develop subsequent hyperbilirubinemia. However, it may be helpful in identifying those neonates at a low risk of subsequent hyperbilirubinemia.

Transcutaneous bilirubinometry.

Although the modern era of transcutaneous bilirubin monitoring (TcB) began only about 35 years ago, this screening tool is now widely used in newborn nurseries and outpatient clinics, offices, and emergency departments to obtain a rapid and non-invasive estimate of the degree of hyperbilirubinemia. TcB devices have become more sophisticated, and major breakthroughs include the following: (a) ability to report a bilirubin value rather than an index value, (b) enhanced correction for chromophores other than bilirubin, and (c) technologic improvements including interface with electronic medical records. Good agreement with laboratory bilirubin measurement has been demonstrated, and the ability of TcB screening to predict and decrease the incidence of subsequent hyperbilirubinemia has been well-documented. To date, it has not been shown that this screening results in improved long-term outcomes.

Prevention of mother-to-infant transmission of influenza during the postpartum period.

OBJECTIVES: The optimal management of infants born to mothers with peripartum influenza infection is not known. The objective of this study is to describe our experience with a practice guideline that promotes rooming-in and breast-feeding and to determine whether infants managed in this way acquire influenza infection. STUDY DESIGN: All mothers diagnosed with influenza infection within 8 days of delivery and their infants were included. Demographics, clinical characteristics, and outcome data were collected. Mothers were contacted at ~1 month after giving birth to determine if their infants had developed any signs suggestive of influenza infection. RESULTS: Forty-two women were diagnosed with peripartum influenza over the 2003 to 2005 and 2009 to 2010 seasons. Median onset of symptoms was 3 days before delivery, and median day of diagnosis was 1 day before delivery. The 42 infants had a median gestational age of 39 weeks; none were born earlier than 35 weeks. Ninety-five percent of the infants roomed-in with their mothers. Follow-up information was available on 95% of infants by 1 month; no infants had illness suggestive of influenza through the follow-up period. CONCLUSION: A guideline for the management of infants born to mothers with peripartum influenza infection, based on attention to hand hygiene, antiviral treatment for mothers, and encouragement of rooming-in and breast-feeding, was not associated with mother-to-infant influenza transmission over three separate influenza seasons.

Circulating blasts and associated hematologic disorders in neonates with Down syndrome.

We analyzed complete blood count (CBC) data obtained from neonates with Down syndrome (DS) in a primarily Hispanic population over a 10-year period to determine the incidence of hematologic abnormalities and the relationship of abnormalities to the presence of circulating blasts (CB). Hematologic values obtained during the first 10 days were analyzed. Definitions were: CB, ≥ 1% blasts manually counted on peripheral smear; elevated white blood cell count (WBC), >30,000 cells/mm(3); thrombocytopenia, platelet count < 150,000/mm(3); polycythemia, hematocrit >65%. Two hundred thirty-two neonates (88% Hispanic) with DS had 692 CBCs available for analysis. The presence of CB (11.6%) and the incidence of thrombocytopenia (60.2%) were significantly higher in DS neonates than in the reference group. Elevated WBC (33.3%) and thrombocytopenia (84.6%) were more common in DS neonates with CB versus those with no CB. No relationship between thrombocytopenia and polycythemia was observed. Unlike previous reports, we did not observe a male predominance in those DS neonates with CB. Thrombocytopenia occurred frequently in DS neonates and was significantly more likely in those with CB than in those with no CB. CBC screening should be performed routinely in DS neonates.

Hospital course and short-term outcomes of term and late preterm neonates following exposure to prolonged rupture of membranes and/or chorioamnionitis.

Our objective was to characterize the hospital course and short-term outcomes of neonates exposed to prolonged rupture of membranes (PROM), chorioamnionitis (CH), or both PROM and CH. Outcomes were positive blood culture and/or clinical signs of infection (+BC/CSI) prompting >4 days of antibiotics. Six neonates had a positive BC, 2 (0.6%) in the CH group and 4 (2.7%) in the PROM + CH group (P = 0.05); none of the neonates exposed to PROM alone had a +BC. These results support our current approach of withholding routine antibiotic therapy in neonates exposed to PROM alone.

Maternal human immunodeficiency virus infection and congenital transmission of cytomegalovirus.

OBJECTIVES: To determine the frequency of congenital cytomegalovirus (CMV) infection in infants born to human immunodeficiency virus (HIV)-infected mothers and assess risk factors that may facilitate intrauterine transmission of CMV, including the role of perinatal HIV infection. METHODS: Retrospective cohort study of infants who were born to HIV-infected mothers at Parkland Memorial Hospital and screened for congenital CMV infection according to a standard nursery protocol between February 1, 1997 and May 31, 2005. RESULTS: During the 8-year study period that included 125,781 live births, there were 367 infants (0.3%) born to 303 HIV-infected mothers. Of 333 HIV-exposed infants who were screened for CMV, 10 (3%) had congenital CMV infection and 6 (60%) of these were identified only because of the CMV screening protocol. Four (1%) infants were infected with HIV, and none of these was CMV-infected. Compared with CMV-uninfected infants, CMV-infected, HIV-exposed newborns had lower mean birth weight (2508 versus 3148 g, P < 0.01), lower gestational age (37 vs. 39 weeks, P < 0.01), and higher median maternal HIV viral load at the start of prenatal care (15,411 vs. 2209 copies/mL, P = 0.02). CMV-infected infants were more likely to be born to mothers who were diagnosed with HIV during the pregnancy or at delivery (P = 0.03). CONCLUSIONS: The prevalence of congenital CMV infection among HIV-exposed newborns was 3%. Screening of these infants for CMV would allow identification of infants who are at risk for delayed onset of hearing loss and other neurodevelopmental impairment.

Anterior fontanel size in term and late preterm Hispanic neonates: description of normative values and an alternative measurement method.

We sought to determine anterior fontanel size (AFS) in Hispanic neonates and to compare two methods of measurement. The traditional method (TRAD) was defined as the sum of the longitudinal and transverse dimensions, divided by 2. Diagonal measurements (DIAG) were obtained between the estimated midpoints of the edges of the frontal and parietal bones, and the sum was divided by 2. Interobserver reliability was assessed in a subset of the study population. One hundred seventy neonates with gestational age 38.9 +/- 1.5 weeks were studied at a median age of 32 hours. Measurements by TRAD and DIAG (mean +/- standard deviation) were 22.5 +/- 7.9 mm and 20.9 +/- 6.7 mm, respectively ( P = 0.12). AFS was greater in males and in neonates whose mothers had longer duration of labor. Interobserver reliability was excellent for both methods. This study provides normative data for AFS using two methods in Hispanic neonates. A modest trend toward less variability with the DIAG method was noted. Male gender and longer duration of labor were associated with larger AFS.

Transcutaneous bilirubin nomograms: a systematic review of population differences and analysis of bilirubin kinetics.

OBJECTIVES: To compare available nomograms in the literature defining trends in bilirubin levels across populations with different risk factor profiles and to study a mathematical bilirubin kinetics model describing the natural course of jaundice and the bilirubin rate of rise needed to cross percentile curves. DATA SOURCES: We searched PubMed for publications between March 1999 and March 2009 that created transcutaneous nomograms. We performed the same search among abstracts presented in the past 2 years at meetings of the Pediatric Academic Societies or the European Society for Paediatric Research. STUDY SELECTION: Inclusion criteria were gestational age of at least 35 weeks among study subjects, the use of an electronic transcutaneous bilirubinometer, and creation of a nomogram based on hour-specific bilirubin values. Four articles met the selection criteria. DATA EXTRACTION: Jaundice risk factors were analyzed, and raw data were analyzed using nonlinear regression to describe trends in bilirubin levels and kinetics. The bilirubin exaggerated rate of rise needed to cross percentile curves was calculated. DATA SYNTHESIS: Significant differences in bilirubin values exist across populations, and there is substantial variability in rates of rise. Hispanic neonates demonstrate higher rates of rise and later plateaus. Bilirubin rates of rise tend to plateau and become null (equilibrium between bilirubin production and elimination) at about 96 hours of life. Rates of rise needed to cross percentile curves decrease over time but are lower (approximately 0.11 mg/dL/h [to convert bilirubin level to micromoles per liter, multiply by 17.104]) in the first 48 hours of life than previously thought. CONCLUSIONS: Transcutaneous bilirubin levels plateau and then decrease after about 96 hours of life in healthy neonates, with some differences across populations. A bilirubin rate of rise higher than in the previous period implies that bilirubin production exceeds elimination and indicates high risk for subsequent hyperbilirubinemia in neonates.

An hour-specific nomogram for transcutaneous bilirubin values in term and late preterm Hispanic neonates.

We sought to determine percentile values for hour-specific transcutaneous bilirubin (TcB) measurements in Hispanic neonates during the first 72 hours of age. Neonates with gestational age >or= 35 weeks and body weight >or= 2100 g were included. All neonates were screened with JM-103 TcB measurements at a minimum of every 24 hours by nursing personnel, and only TcB values obtained in Hispanic neonates with postnatal ages of 10 to 74 hours were analyzed. The 5th, 25th, 50th, 75th, and 95th percentile curves were determined. These data were compared with a previously published TcB nomogram predominantly composed of white, non-Hispanic neonates. A total of 3284 TcB values were measured in 2005 neonates. A nomogram was constructed for this exclusively Hispanic population, identifying the 5th, 25th, 50th, 75th, and 95th percentile curves. The 95th percentile values at 24, 48, and 72 hours were 7.6, 11.0, and 12.4 mg/dL, respectively. The comparison between our results and those of the previously published study indicated that small but consistent differences between the two study populations were apparent, with the Hispanic neonates having significantly higher TcB values at the majority of time points analyzed. These observations were made despite a higher proportion of neonates >or= 40 weeks' gestation ( p < 0.001) and a lower proportion exclusively breast-fed ( p < 0.001) in the Hispanic population versus those in the previous study. Although higher bilirubin levels for certain populations are well documented, such differences in Hispanic neonates have not been confirmed. A TcB nomogram for Hispanic neonates is presented as a tool that will aid the clinician in the management of jaundice for this population. Compared with the previous study, this report indicates that although differences were relatively small, significantly higher TcB values were observed in the Hispanic population.

Serotonin reuptake inhibitor use in pregnancy and the neonatal behavioral syndrome.

OBJECTIVE: To assess the severity of neonatal behavioral syndrome (NBS) in infants of serotonin reuptake inhibitor (SRI)-treated pregnancies, compared with infants of women with psychiatric illness not treated with medication. METHODS: This was a retrospective cohort study of pregnancies followed in a prenatal clinic for women with psychiatric illness. Infants of women who received SRI medication through delivery (SRI-treated) were compared with those who did not receive treatment or discontinued medication before the last month of pregnancy (SRI-untreated). NBS was defined as one or more of the following: jitteriness, irritability, lethargy, hypotonia, hypertonia, hyperreflexia, apnea, respiratory distress, vomiting, poor feeding, or hypoglycemia. RESULTS: Findings of NBS were identified in 28% of 46 SRI-treated pregnancies and 17% of 59 untreated pregnancies. There were no differences in rates of prematurity (4% vs. 7%), fetal growth restriction (6% vs. 2%), transfer to a higher nursery for NBS (11% vs. 10%), respiratory abnormality (7% vs. 5%), or hospitalization duration among infants with NBS findings (2 vs. 6 days). CONCLUSIONS: Findings of NBS were identified in 28% of SRI-exposed neonates. However, these infants were not more likely than unexposed infants to be admitted to a higher nursery, experience respiratory abnormalities, or have prolonged hospitalization.

Pulse oximetry screening at 4 hours of age to detect critical congenital heart defects.

OBJECTIVE: The purpose of this prospective study was to assess the feasibility and reliability of pulse oximetry screening to detect critical congenital heart defects in a newborn nursery. METHODS: The study was performed in a large urban hospital with an exclusively inborn population. Stable neonates who had a gestational age of >or=35 weeks and birth weight of >or=2100 g and in whom a critical congenital heart defect was not suspected were admitted to the newborn nursery. When the 4-hour pulse oximetry reading was <96%, pulse oximetry was repeated at discharge, and when the pulse oximetry reading remained at persistently <96%, echocardiography was performed. RESULTS: Of 15299 admissions to newborn nursery during the 12-month study period, 15233 (99.6%) neonates were screened with 4-hour pulse oximetry. Pulse oximetry readings were >or=96% for 14374 (94.4%) neonates; 77 were subsequently evaluated before discharge for cardiac defects on the basis of clinical examination. Seventy-six were normal, and 1 had tetralogy of Fallot with discontinuous pulmonary arteries. Pulse oximetry readings at 4 hours were <96% in 859 (5.6%); 768 were rescreened at discharge, and 767 neonates had a pulse oximetry reading at >or=96%. One neonate had persistently low pulse oximetry at discharge; echocardiography was normal. Although 3 neonates with a critical congenital heart defect had a 4-hour pulse oximetry reading of <96%, all developed signs and/or symptoms of a cardiac defect and received a diagnosis on the basis of clinical findings, not screening results. CONCLUSIONS: All neonates with a critical congenital heart defect were detected clinically, and no cases of critical congenital heart defect were detected by pulse oximetry screening. These results indicate that pulse oximetry screening does not improve detection of critical congenital heart defects above and beyond clinical observation and assessment. Our findings do not support a recommendation for routine pulse oximetry screening in seemingly healthy neonates.

Newborn hearing screening and detection of congenital cytomegalovirus infection.

OBJECTIVES: The objectives were to determine the frequency of congenital cytomegalovirus infection among newborns who did not pass hearing screening tests or had confirmed hearing loss and to determine how often abnormal hearing screening results were the only manifestation of congenital cytomegalovirus infection. METHODS: Retrospective chart review was performed for newborns who had abnormal hearing screening results and positive urine cytomegalovirus culture results at Parkland Memorial Hospital between September 1, 1999, and August 31, 2004. RESULTS: During the 5-year study period, 572 of 79047 newborns (7 of 1000 live births) did not pass hearing screening tests. Cytomegalovirus infection was identified in 24 (5%) of 483 tested infants and 16 (6%) of the 256 infants with subsequently confirmed hearing impairment. Of those 16 infants, 12 (75%) were identified as having congenital cytomegalovirus infection only because of failure to pass newborn hearing screening tests. CONCLUSIONS: Congenital cytomegalovirus infection was present for 6% of newborns with confirmed hearing impairment, and the majority of those infants were identified on the basis of abnormal newborn hearing screening results.

Serum calcium values in term and late-preterm neonates receiving gentamicin.

Since noting an apparent increase in hypocalcemia in neonates receiving gentamicin every 24 h (q 24 h) for > or = 4 days, we have prospectively monitored serum calcium (Ca) values in these patients receiving prolonged gentamicin therapy. This study is a retrospective analysis of those values measured during gentamicin treatment. The study included neonates with gestational age > or = 35 weeks who received > or = 4 days of gentamicin therapy and in whom at least one serum Ca value was measured > or = 47 h after initiation of therapy. Hypocalcemia was defined as a serum Ca level < 8 mg/dl (2 mmol/l). Data were analyzed by Student t-test, chi-square test, and Pearson product moment correlation. There were 1,624 neonates that met the study criteria. Ca was < 8 mg/dl in 241 (15%). Ca < 8 mg/dl was more likely in boys than in girls (16.4% vs 11.8%, P = 0.01) and in neonates < 37 weeks gestational age (GA) than in those > or = 37 weeks GA (23.9% vs 14.1%, P = 0.01). A second Ca value was obtained in 883 neonates (54%); 23.2% of neonates with initial Ca < 8 mg/dl remained hypocalcemic, and 30% of these were receiving oral Ca supplementation. The second Ca value was < 8 mg/dl in eight neonates in whom initial Ca was > or = 8 mg/dl. Hypocalcemia is not uncommon in neonates receiving gentamicin therapy, and it may occur more frequently in boys and late-preterm infants. These data suggest that the monitoring of serum Ca levels should be considered when gentamicin is given > or = 4 days.

Cold stress and hypoglycemia in the late preterm ("near-term") infant: impact on nursery of admission.

Late preterm infants (34-37 weeks gestation) pose unique challenges to physicians and nurses involved in their care after birth. They may be cared for in different units within hospitals after birth, including Neonatal Intensive Care Units, Newborn Nurseries, or rooming in with the mother. As a result of their gestational age and birth weight, the late preterm infant is often assessed quickly and triaged identical to term infants. Such practice can potentially result in a lack of attention to important components for successful transition after birth. Cold stress and hypoglycemia are the two important problems in late preterm infants which require immediate treatment. Thus, surveillance of these and other physiological variables is needed to insure that they do not affect successful adaptation during the early hours and days after birth.

Evaluation of a transcutaneous jaundice meter following hospital discharge in term and near-term neonates.

OBJECTIVES: To evaluate performance of the Minolta JM-103 Jaundice Meter (JM) as a predictor of total serum bilirubin (TSB) in outpatient neonates during the first week postnatal, and to estimate the number of TSB determinations that might be avoided in clinical use. STUDY DESIGN: In neonates evaluated posthospital discharge, JM and TSB results were compared using linear regression and a Bland-Altman plot, and predictive indices were calculated for various JM cutoff values. Utilizing the 2004 American Academy of Pediatrics (AAP) guidelines, the ability of JM to predict risk zone status was determined. RESULTS: Overall correlation between JM and TSB was 0.77 (p<0.001; n=121). When TSB was >17 mg/dl, a cutoff value for JM of 13 mg/dl had a sensitivity of 1.0, and 50% of TSB determinations would be avoided. CONCLUSIONS: JM may facilitate outpatient management of hyperbilirubinemia by reducing the number of TSB determinations required; however, it does not provide a reliable substitute for laboratory measurement of TSB.

Depression at birth in term infants exposed to maternal chorioamnionitis: does neonatal fever play a role?

OBJECTIVES: (1) To determine the incidence and the time course of elevated temperature following delivery in term infants with clinical chorioamnionitis (CHORIO) and (2) to determine if the extent of temperature elevation at birth is associated with increased likelihood of NICU Admissions, birth depression, or with short-term neurological abnormalities. DESIGN/METHODS: The infants were divided into two groups based on the median admission rectal temperature of 37.8 degrees C for the cohort. Depression at birth was defined as either the need of positive pressure ventilation for >2 minutes, intubation, or Apgar score <6 at 5 minutes. Neurological examination and assessment of encephalopathy (Sarnat staging) was performed at birth and daily thereafter, by one investigator blinded to temperature findings. RESULTS: Infants with higher rectal temperature at 30 minutes of life were more likely to be admitted to NICU: OR (2.8, 95% confidence interval (CI) [1.8 to 4.3]), and were more likely to have birth depression OR (3, 95% CI [1.4 to 6.5]). For infants in NICU, a rectal temperature above 37.8 degrees C was present in 87% in the delivery room, persisted in 47% at 30 minutes, and declined to a normal temperature at 60 minutes of life in the absence of medical interventions. There was no relationship between neurological scores and neonatal temperature. CONCLUSIONS: Term infants exposed to CHORIO who had a higher neonatal temperature at 30 minutes of life, were more likely to be admitted to the NICU and to have birth depression, than infants with lesser degree of temperature elevation after birth. Within the NICU group, the extent of temperature elevation was not associated with worse neurological outcomes.

Are complete blood cell counts useful in the evaluation of asymptomatic neonates exposed to suspected chorioamnionitis?

OBJECTIVE: Chorioamnionitis complicates 1% to 10% of pregnancies and increases the risk of neonatal infection. Women with chorioamnionitis receive intrapartum antibiotics, often resulting in inconclusive neonatal blood cultures. Peripheral neutrophil values are used frequently to assist in the diagnosis of neonatal infection and to determine duration of antibiotics; we sought to determine the utility of this approach. METHODS: A prospective observational study was performed in 856 near-term/term neonates who were exposed to suspected chorioamnionitis. Each received antibiotics for 48 hours unless clinical infection or positive blood cultures occurred. Peripheral neutrophils were measured serially and analyzed using the reference ranges of Manroe et al; an additional analysis of only the initial neutrophil values used the normal ranges of Schelonka et al. Results of neutrophil analyses were not used to determine duration of therapy. Fifty percent of asymptomatic neonates were seen postdischarge to ascertain recurrent infection. Local patient charges were examined. RESULTS: Ninety-six percent of neonates were asymptomatic and had negative cultures, and antibiotics were discontinued at 48 hours. A total of 2427 neutrophil counts were analyzed. Although abnormal neutrophil values were more frequent in infected or symptomatic neonates, 99% of asymptomatic neonates had > or = 1 abnormal value. The specificity and negative predictive values for abnormal neutrophil values ranged between 0.12 and 0.95 and 0.91 and 0.97, respectively; sensitivity was 0.27 to 0.76. Significant differences in interpretation of the initial neutrophil values were noted, depending on the normal values used. Follow-up was performed for 373 asymptomatic neonates until 3 weeks' postnatal age. Eight required rehospitalization; none had evidence of bacterial infection. If neutrophil values had been used to determine duration of antibiotics, then local costs would have increased by 76,000 dollars to 425,000 dollars per year. CONCLUSIONS: Single or serial neutrophil values do not assist in the diagnosis of early-onset infection or determination of duration of antibiotic therapy in asymptomatic, culture-negative neonates who are > or = 35 weeks' gestation and are delivered of women with suspected chorioamnionitis.

Pneumonia in term neonates: laboratory studies and duration of antibiotic therapy.

OBJECTIVES: To compare 2 days of antibiotic therapy (AT) to 4 days of AT in neonates with pneumonia and to assess the usefulness of neutrophil values (NV), C-reactive protein (CRP), and procalcitonin (PCT) in this population. DESIGN: The study population consisted of consecutive, eligible term neonates begun on AT for suspected pneumonia. Of 51 neonates, 26 qualified for randomization (14, 2-day group; 12, 4-day group). NV were obtained with the initial evaluation and 12 and 24 hours later. CRP and PCT were obtained 12 and 48 hours after the initial evaluation. RESULTS: None of the 12 neonates in the 4-day group developed recurrent respiratory symptoms. Three of the 14 neonates randomized to the 2-day group had recurrence of symptoms, resulting in study termination. NV, CRP, and PCT were similar in the 2- and 4-day groups. In the three neonates who developed respiratory symptoms, all absolute total neutrophil values and five out of nine absolute total immature neutrophil values were abnormal. However, all immature:total neutrophil values were normal, and CRP was strikingly elevated in only one neonate; only one of six PCT values was abnormal. In a secondary analysis of all 51 study neonates, CRP and PCT did not provide additional benefit over NV in differentiating neonates with pneumonia. CONCLUSIONS: Four days of AT appears to be adequate for selected term neonates with pneumonia; however, 2 days of AT appears to be inadequate for this population. Relative to NV, CRP and PCT appear to have a limited role.

Association of hypocalcemia with a change in gentamicin administration in neonates.

Aminoglycosides are administered frequently to neonates with suspected sepsis. We report the association of hypocalcemia in term and near-term neonates receiving gentamicin therapy for >/=4 days after a change in dosing from every 12 h to every 24 h. The possible association with a higher gentamicin dose and longer dosing interval is described.