The Effect of Readmission for Phototherapy on Early Breast Milk Feeding.

OBJECTIVES: To estimate the effect of readmission for inpatient phototherapy on parent-reported exclusive and any breast milk feeding at 2-month well-child visits. METHODS: We performed a retrospective cohort study using electronic health record data. From births at 16 Kaiser Permanente Northern California hospitals (2013-2017), we identified a cohort of infants ≥35 weeks' gestation with outpatient total serum bilirubin levels ranging from 1 mg/dL below to 2.9 mg/dL above the American Academy of Pediatrics phototherapy threshold at <15 days of age. We compared breast milk feeding at 2-month well-child visits among those readmitted and not readmitted to the hospital for phototherapy, adjusting for bilirubin and other confounding variables. RESULTS: Approximately one-quarter (26.5%) of the cohort (n = 7729) were readmitted for phototherapy. Almost half (48.5%) of the infants who were not readmitted for phototherapy received exclusively breast milk at the 2-month visit compared with slightly fewer infants who were readmitted (42.9%). In both groups of infants, most (82.2% not readmitted and 81.2% readmitted) received any breast milk. Readmission for phototherapy was associated with a lower adjusted risk of exclusive breast milk feeding (adjusted risk ratio 0.90; 95% confidence interval [CI], 0.84 to 0.96), corresponding to a marginal absolute reduction in exclusive breast milk feeding of 5.0% (95% CI, -7.9% to -2.1%). It was not associated with a reduction in any breast milk feeding (adjusted risk ratio, 1.00; 95% CI, 0.97 to 1.02). CONCLUSIONS: Infants readmitted for phototherapy were more likely to receive any formula, but no less likely to receive any breast milk at 2-month well-child visits.

The effect of hospital phototherapy on early breastmilk feeding.

BACKGROUND: The effect of phototherapy on breastmilk feeding is unclear. OBJECTIVE: To estimate the effect of inpatient phototherapy on breastmilk feeding at 2-month well-child visits. METHODS: We performed a retrospective cohort study using electronic health record data. From births at 16 Kaiser Permanente Northern California hospitals (2013-2017), we identified a cohort of infants ≥ 35 weeks' gestation with total serum bilirubin levels close to the American Academy of Pediatrics 2004 phototherapy threshold during their birth hospitalisation. We compared self-reported breastmilk feeding at 2-month well-child visits among those who had and had not received birth hospitalisation phototherapy, adjusting for bilirubin levels and other confounding variables. We used multiple imputation (K = 200) to address missing data. RESULTS: Approximately a quarter of infants in the cohort (24.5%) received phototherapy during their birth hospitalisation. At the 2-month visit, exclusive breastmilk feeding was less common (RR 0.91, 95% interval [CI] 0.88, 0.95) among those who received phototherapy (41.3%) than those who did not (45.2%). However, no association remained after adjusting for potential confounders (RR 0.99, 95% CI 0.95, 1.04; average treatment effect on the treated [ATET] -0.2%, 95% CI -2.0%, 1.5%). In contrast, any breastmilk feeding was similar between infants who did (76.8%) and did not get phototherapy (77.9%). After adjusting for confounders, phototherapy had a slightly positive association with any breastmilk feeding at 2 months (RR 1.02, 95% CI 1.00, 1.04). Among infants who received phototherapy, the proportion being fed any breastmilk at the 2-month visit was an estimated 1.6 percentage points higher than it would have been if they had not received phototherapy (ATET 1.6%, 95% CI 0.1%, 3.1%). Multiple imputation results were similar. CONCLUSIONS: Birth hospitalisation phototherapy can be delivered in a way that does not adversely affect breastmilk feeding at 2 months.

Evaluation of Home Phototherapy for Neonatal Hyperbilirubinemia.

OBJECTIVE: To characterize home phototherapy treatment for neonatal hyperbilirubinemia and assess the risk factors associated with the need for hospital admission during or after home phototherapy. STUDY DESIGN: This was a retrospective study of newborn infants born at ≥35 weeks of gestation who underwent comprehensive home phototherapy (that included daily in-home lactation support and blood draws) over an 18-month period. We excluded infants who lacked a recorded birth date or time, started treatment at age >14 days, or had a conjugated serum bilirubin level of ≥2 mg/dL (≥34.2 µmol/L). The primary study outcome was any hospital admission during or within 24 hours after completion of home phototherapy. Logistic regression was used to identify risk factors for hospitalization. RESULTS: Of the cohort of 1385 infants, 1324 met the inclusion criteria. At the time home phototherapy was initiated, 376 infants (28%) were at or above the American Academy of Pediatrics phototherapy threshold. Twenty-five infants required hospitalization (1.9%; 95% CI, 1.3%-2.8%). Hospital admission was associated with a younger age at phototherapy initiation (OR, 0.63 for each day older in age; 95% CI, 0.44-0.91) and a higher total serum bilirubin level relative to the treatment threshold at phototherapy initiation (OR, 1.71 for each 1 mg/dL above the treatment threshold; 95% CI, 1.40-2.08). CONCLUSIONS: Comprehensive home phototherapy successfully treated hyperbilirubinemia in the vast majority of the infants in this cohort.

A Simpler Prediction Rule for Rebound Hyperbilirubinemia.

OBJECTIVES: We previously reported a clinical prediction rule to estimate the probability of rebound hyperbilirubinemia using gestational age (GA), age at phototherapy initiation, and total serum bilirubin (TSB) relative to the treatment threshold at phototherapy termination. We investigated (1) how a simpler 2-variable model would perform and (2) the absolute rebound risk if phototherapy were stopped at 2 mg/dL below the threshold for treatment initiation. METHODS: Subjects for this retrospective cohort study were infants born 2012-2014 at ≥35 weeks' gestation at 1 of 17 Kaiser Permanente hospitals who underwent inpatient phototherapy before age 14 days. TSB reaching the phototherapy threshold within 72 hours of phototherapy termination was considered rebound. We simplified by using the difference between the TSB level at the time of phototherapy termination and the treatment threshold at the time of phototherapy initiation as 1 predictor, and kept GA as the other predictor. RESULTS: Of the 7048 infants treated with phototherapy, 4.6% had rebound hyperbilirubinemia. The area under the receiver operating characteristic curve was 0.876 (95% confidence interval, 0.854 to 0.899) for the 2-variable model versus 0.881 (95% confidence interval, 0.859 to 0.903) for the 3-variable model. The rebound probability after stopping phototherapy at 2 mg/dL below the starting threshold was 2.5% for infants ≥38 weeks' GA and 10.2% for infants <38 weeks' GA. CONCLUSIONS: Rebound hyperbilirubinemia can be predicted by a simpler 2-variable model consisting of GA and the starting threshold-ending TSB difference. Infants <38 weeks' gestation may need longer phototherapy because of their higher rebound risk.

A Clinical Prediction Rule for Rebound Hyperbilirubinemia Following Inpatient Phototherapy.

OBJECTIVES: The American Academy of Pediatrics provides little guidance on when to discontinue phototherapy in newborns treated for hyperbilirubinemia. We sought to develop a prediction rule to estimate the probability of rebound hyperbilirubinemia after inpatient phototherapy. METHODS: Subjects for this retrospective cohort study were infants born in 2012 to 2014 at ≥35 weeks' gestation at 16 Kaiser Permanente Northern California hospitals who received inpatient phototherapy before age 14 days. We defined rebound as the return of total serum bilirubin (TSB) to phototherapy threshold within 72 hours of phototherapy termination. We used stepwise logistic regression to select predictors of rebound hyperbilirubinemia and devised and validated a prediction score by using split sample validation. RESULTS: Of the 7048 infants treated with inpatient phototherapy, 4.6% had rebound hyperbilirubinemia. Our prediction score consisted of 3 variables: gestational age <38 weeks (adjusted odds ratio [aOR] 4.7; 95% confidence interval [CI], 3.0-7.3), younger age at phototherapy initiation (aOR 0.51 per day; 95% CI, 0.38-0.68), and TSB relative to the treatment threshold at phototherapy termination (aOR 1.5 per mg/dL; 95% CI, 1.4-1.7). The model performed well with an area under the receiver operating characteristic curve of 0.89 (95% CI, 0.86-0.91) in the derivation data set and 0.88 (95% CI, 0.86-0.90) in the validation data set. Approximately 70% of infants had scores <20, which correspond to a <4% probability of rebound hyperbilirubinemia. CONCLUSIONS: The risk of rebound hyperbilirubinemia can be quantified according to an infant's gestational age, age at phototherapy initiation, and TSB relative to the treatment threshold at phototherapy termination.

Update on Predicting Severe Hyperbilirubinemia and Bilirubin Neurotoxicity Risks in Neonates.

Extreme hyperbilirubinemia and kernicterus, though rare, continue to occur despite the adoption of universal screening. Unless they are known to have glucose-6-phosphate dehydrogenase deficiency, infants who currently develop kernicterus in high resource countries are often otherwise healthy newborns discharged from the well-baby nursery. In this review, we highlight risk factors that increase the risk of a newborn ≥35 weeks gestational age developing severe hyperbilirubinemia, as well as the risk factors that increase the hyperbilirubinemic infant's risk of kernicterus.