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The Utility of Inpatient Rebound Bilirubin
The Utility of Inpatient Rebound Bilirubin
23.2 hours; P = .001). Patients with bilirubin levels lowered to 14 mg/dL were FINANCIAL DISCLOSURE: The authors have
less likely to receive repeat phototherapy than those with levels >14 mg/dL (2 of indicated they have no financial relationships
129 vs 12 of 97; P = .001). relevant to this article to disclose.
The 2004 American Academy of Pediatrics (AAP) guideline on the evaluation and
management of hyperbilirubinemia in the newborn infant states that discharge
from the hospital need not be delayed to observe the infant for rebound bilirubin
levels.1 Despite this recommendation, many pediatricians obtain early (48 hours)
rebound bilirubin levels after discontinuation of phototherapy. There is currently
a lack of robust data addressing the value of early (<12 hours) inpatient rebound
bilirubin levels; much of the previous research used to create the AAP guideline
focused on rebound bilirubin levels that were drawn, on average, 12 hours from
the cessation of phototherapy.26
after their birth hospitalization. The fol- and the 2009 update on the evaluation the 2-sample t test. We analyzed cat-
lowing outcomes were assessed: sub- and management of hyperbilirubine- egorical data by using either the 2
sequent hospital readmission rates, mia in the newborn infant.1,8 Infants test or Fischers exact test as dictated
length of stay, discharge time, and were stratified into low-, medium-, or by sample size. The Yale University
re-initiation of phototherapy during a high-risk groups based on presence Human Investigation Committee pro-
current admission. We hypothesized of risk factors for hyperbilirubinemia/ vided approval for the review of all
that inpatient rebound bilirubin levels kernicterus. Decisions to implement medical records.
would not affect readmission rate. phototherapy were based on single
serum bilirubin levels obtained at the RESULTS
METHODS There were 252 infants identified in the
time of admission and the correspond-
We identified subjects readmitted to search, and 226 were included in the
ing light level based on hours of life on
YaleNew Haven Childrens Hospital, final analysis (Fig 1). Overall, 130 (58%)
the nomogram.8 All patients requiring
a tertiary care center with 3800 new- phototherapy received triple light ther- of the 226 patients had a rebound bili-
borns delivered annually. The medi- rubin level checked a mean of 6.1 2.4
apy, and no changes in the dosage of
cal records database was reviewed hours from phototherapy cessation,
phototherapy occurred during the study
for infants <10 days of age with period. and 96 (42%) of 182 patients had no
International Classification of Diseases, rebound level checked. There were no
Ninth Revision, codes for a principal The primary outcome was readmis- significant differences in the baseline
diagnosis of jaundice and a principal sion for repeat phototherapy within characteristics between the 2 groups
or secondary procedure of photo- 72 hours of discharge. Secondary out- (Table 1). Table 2 displays the biliru-
therapy between January 2007 and comes include length of inpatient stay, bin levels at phototherapy initiation
April 2014. Patients were eligible for duration of phototherapy, and hospital and cessation, as well as the duration
inclusion if they had a gestational age discharge time. A separate analysis of phototherapy. Initial bilirubin levels
35 weeks and were readmitted from compared characteristics of patients were higher in the rebound group com-
the newborn nursery for phototherapy who required repeat phototherapy pared with the no-rebound group, and
treatment of indirect hyperbilirubine- (either with readmission or on the they were also higher at time of light
mia. Exclusion criteria consisted of: same admission) with those patients cessation. The rebound group had a
history of phototherapy in the first who did not. Continuous variables in significantly shorter duration of photo-
24 hours of life, admission to the ICU, the 2 groups were compared by using therapy (15.1 vs 17.7 hours; P = .008).
exchange transfusion, direct hyper-
bilirubinemia, and evidence of sepsis
at time of admission. If a child had >1
hospitalization with a primary diagno-
sis of jaundice, only the first encounter
was included in the analysis.
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HOSPITAL Pediatrics AN OFFICIAL JOURNAL OF THE AMERICAN ACADEMY OF PEDIATRICS
TABLE 3 Readmissions and Length of Stay typically influence this decision, and
Variable Rebound Group No-Rebound Group P we found no significant differences
(n = 130) (n = 96) in these characteristics between the
Total no. of readmissions, (%) 5 (3.8) 4 (4.2) .98a 2 groups. There was a statistically sig-
Mean length of stay for current admission, h 27.7 23.2 .001
Mean discharge time for current admission 15:19 12:54 <.001 nificant difference between bilirubin
Total no. of patients discharged before 10 (7.7) 36 (37.5) <.001 levels at the time of phototherapy ini-
11:00 AM, (%) tiation and cessation, implying that the
a
Fishers exact test. rebound groups jaundice was more
severe than the no-rebound group.
repeat phototherapy during the same Patients in the rebound group had However, the significantly shorter
admission. Of these 5 infants, 1 had longer lengths of stay and later dis- period of time under phototherapy for
a cephalohematoma, and 2 had ABO charge times, exposing them to potential the rebound group argued against this
incompatibility with negative results iatrogenic complications. These patients idea, as one would potentially expect
on the Coombs test. Importantly, all of also received significantly less time patients with more severe conditions
these patients had phototherapy halted under phototherapy than children who to require more phototherapy. In addi-
at a level >14 mg/dL, with bilirubin levels did not have a rebound level. Thus, the tion, the mean bilirubin levels at initia-
of 14.7, 15.9, 16.7, 16.8, and 17.6 mg/dL rebound group spent more time in the tion of phototherapy did not approach
at phototherapy cessation. In cases in hospital but received less total therapy. exchange transfusion levels in either
which phototherapy was initially con- Keeping these patients under the lights group.
tinued to reach the AAP recommenda- for additional time to lower bilirubin lev-
tion of 14 mg/dL, all rebound bilirubin Another significant limitation was the
els to 14 mg/dL was more likely to pre-
levels remained below the light level for studys relatively small sample size, par-
vent readmission than monitoring them
recommended phototherapy. ticularly considering that the primary
with a rebound bilirubin level.
outcome of hospital readmission was
In the entire cohort, children with bili- Furthermore, there was an increase such a rare occurrence. These circum-
rubin levels 14 mg/dL were much less in cost associated with the rebound stances made it difficult to obtain the
likely to receive repeat phototherapy groups prolonged length of stay and power necessary to definitively detect
than those who had phototherapy extra laboratory testing. Our institu- subtle differences in readmission rates
discontinued at a level >14 mg/dL. In tions financial department provided between the 2 groups, and our post hoc
the 14 children who required repeat estimates for hourly hospital charges power analysis showed our study to be
phototherapy, 12 had phototherapy of approximately $25.00 and $50.00 powered at 80% to detect a 12% differ-
discontinued at a level >14 mg/dL. for serum bilirubin testing. Using ence in readmission rates. Before 2007,
There were only 2 patients who these estimates, the rebound bilirubin our institutions policy was to obtain
received repeat phototherapy despite group averaged approximately $150.00 rebound bilirubin levels on all patients
adherence to the AAP guideline of extra per patient. This cost is further receiving phototherapy, which limited
lowering the bilirubin to 14 mg/dL. compounded when considering the our ability to increase patient recruit-
Interestingly, one of these patients improvements in patient flow associ- ment before this time period. After
(originally from the no-rebound group) ated with the earlier discharge times 2007, the hospitalist group adopted the
had a rebound bilirubin level checked observed in the no-rebound group. policy of not obtaining rebound bilirubin
on a subsequent hospitalization, and levels, whereas the majority of commu-
this rebound level still failed to prevent The present studys main limitation nity pediatricians continued to obtain
a third hospitalization. He was eventu- was its retrospective design, which rebound bilirubin levels. This clinical
ally diagnosed with elliptocytosis. This provides no concrete way to control environment made the comparison of
finding suggests that children who for why individual attending physi- the 2 groups possible but again did not
require recurrent phototherapy despite cians chose to check a rebound level provide a large enough sample size to
a level at cessation of 14 mg/dL in some infants but not in others. We afford substantial power to detect sub-
may warrant additional evaluation for tried to address this limitation by eval- tle differences in an outcome with such
hemolysis. uating baseline characteristics that a rare occurrence.
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HOSPITAL Pediatrics AN OFFICIAL JOURNAL OF THE AMERICAN ACADEMY OF PEDIATRICS