When I was chair of the CPS Fetus and Newborn committee, we produced several position statements, one of which I was quite proud was written by myself and by Dr Sankaran from Saskatoon, it was a guideline for the screening and treatment of hyperbilirubinemia in full term babies. The guideline recommended among other things, universal pre-discharge bilirubin screening.
When you write these things you are never sure what sort of effect it will have, we hoped that it would reduce the numbers of babies receiving phototherapy, and reduce the frequency of kernicterus, while having little effect on hospital costs or the total number of bilirubin tests prescribed. Of course, there will only be an effect if people actually follow the guidelines.
So I was pleased to see that in Ontario at least most hospitals that deliver babies do now screen routinely for high bilirubin at discharge, and most of them started doing so after the guidelines were published.
That is not to say there aren’t problems, the new study shows that the biggest problem is how to organize follow up testing. To clarify, infants at significant risk who have levels at discharge that are high, but not high enough to need immediate phototherapy, have to get follow up testing. In some communities this can be a problem, especially at weekends. In many places the mothers (or fathers) bring the baby back to the hospital, either to the lab or to the newborn nursery in order to be re-tested. This is certainly not optimal, requiring often longer journeys, and disrupting the post-partum period. Community based testing available 7 days a week is needed. Testing at home with optical bilirubinometers during a home visit from a health professional who can also check on breast feeding and progress of weight would be optimal.
Finally did it work? Is there a reduction in kernicterus? well, we don’t yet know, is I think the right answer, the guidelines were published in 2007, this new article from Ontario shows that it took until 2011 for 75% of the hospitals to be screening. In 2007, 2008 kernicterus was still a problem (albeit rare) in Canada; and not as rare as we might think, with a calculated incidence of at least 1 in 44,000 live births. It would be great to repeat the Canadian Paediatric Surveillance Program study on kernicterus to see if the guideline had an effect. I think I will drop them a line and see if that is possible…