Development of a Guideline for Management of Coombs‐Positive Infants in a Community Hospital for Pediatric Hospitalists

Background:

Coombs‐positive (DAT+) infants are commonly encountered in the newborn nursery. These infants are at risk for developing severe hyperbilirubinemia and bilirubin encephalopathy. Multiple hospitalists may care for each infant daily, with diverse approaches to this common clinical problem. The resulting variability in management increases the opportunity for a missed diagnosis of severe hyperbilirubinemia. Our objective was to develop a systematic approach to DAT+ infants in order to detect and treat hyperbilirubinemia in a timely manner, based on locally derived data and practices.

Methods:

All DAT+ infants born in 2007 at a local community hospital were identifed. Available charts were reviewed, and data were collected on DAT+ infants, including gestational age, materns arc infant blood type, transcutaneous (TcB) and total serum (TsB) bilirubin levels, and photototherapy (PT) provided‐ TcB/TsB data were plotted on a Bhutani risk nomogram and AAP PT treatment graph. If TsB surpassed the AAP treatment threshold, we noted the hourly age when the TsB was obtained.

Results:

Two hundred and twenty‐four DAT+ infants were born in 2007 at our community hospital. Two hundred and twenty charts were available for review, and 214 infants had TcB/TsB data. Infants were predominantly term (≥38 weeks' gestation) and A‐Q incompatible. Thirty‐one infants (14.5%) surpassed the PT treatment threshold during their hospitalizations. Of these, 13 (42%) surpassed the treatment threshold in the first 24 hours of life. Twelve of these 13 surpassed the PT treatment threshold with the first measured TcB/TsB, as early as 6 hours of age. Fifteen infants (48%) surpassed the PT treatment threshold between 25 and 48 hours. Four had TcB/TsB in the first 24 hours below the treatment threshold but surpassed the treatment threshold with a subsequent TcB/TsB between 25 and 48 hours. The remaining 11 infants had no TcB/TsB measured in the first 24 hours of life. Initial TcB/TsB was measured between 25 and 48 hours of life, and for all 11, the initial TcB/TsB surpassed the PT treatment threshold. Four of these infants exceeded the treatment threshold by at ≥ 2 mg/dL. Of the 31 infants who met criteria for intensive PT, 4 received no PT, 19 were treated with biIibed/biliblanket (later escalated to intensive PT in 4), and 8 received appropriate intensive PT. Fourteen were ultimately discharged with TsB still above the treatment curve.

Conclusions:

Of DAT+ infants who surpassed the threshold for intensive PT during hospitalizalion, 42% did so in the first 24 hours and 48% in the second 24 hours. Many of these infants did not have TcB/TsB levels measured in the first 24 hours and were markedly above the treatment threshold when a level was obtained, suggesting that more than 40% of our DAT+ infants surpassed the threshold for intensive PT in the first 24 hours of life. This may occur within 6 hours of birth. Our management approach recommends TcB measurements at 6, 12, and 24 hours of life and then once daily until discharge. Six‐hour TcB ≥ 5 mg/dL or any TcB high‐/intermediate‐risk zone should be confirmed with TsB.

Author Disclosure:

K. Hamlin, none; L. Moscoso, none; C. Hrach, none; C. Delaney, none; K. Ross, none.