Identifying infants who might benefit from routine measurement of bilirubin during first 48–72 hours of life

EDITOR—The observation reported by Spurgeon of an increased likelihood of readmission with jaundice after earlier neonatal discharge is well made.1 Lee et al showed that jaundice and dehydration were more severe in newborn infants requiring readmission to hospital after the mean age at discharge fell from 4.5 to 2.7 days,2 while Maisels and Kring found a significantly increased risk for readmission with jaundice among newborn infants discharged from hospital before 72 hours of age.3

In the United Kingdom all newborn infants and mothers can be visited at home regularly by community midwives during the first seven days after discharge. These health professionals are skilled in infant capillary blood sampling and often measure serum bilirubin concentrations as part of their care of mother and infant. The potential clearly exists for possible screening of infants at risk of hyperbilirubinaemia after discharge, but such screening would have to be carefully targeted to avoid an unacceptable increase in workload.

We retrospectively reviewed the casenotes of all infants of ≥37 weeks' gestation who had been admitted over three years to the neonatal intensive care unit at an inner city district hospital with clinically significant jaundice (serum bilirubin >340 μmol/l). Altogether 21 such patients were admitted (mean age 83.5 hours; mean serum bilirubin concentration 415.3 μmol/l (range 340-768)). Eleven were admitted from postnatal wards and 10 from the community. The diagnosis was glucose 6-phosphate dehydrodgenase deficiency in three cases, ABO incompatibility in 10, physiological (including breast milk) jaundice in six, cephalhaematoma in one, and the Crigler-Najar syndrome in one. One infant was white, nine were Asian, and 10 African or Caribbean; one infant was of mixed Asian and Caribbean parentage.

The mean age at admission of infants from the postnatal wards was 59.8 hours and from the community 109.5 hours (two sample unpaired t test, P=0.0004). Mean serum bilirubin concentration was 396.6 μmol/l (range 340-479) and 435.9 μmol/l (range 354-768) respectively. Of the 11 infants from the postnatal wards, eight had ABO incompatibility, two physiological jaundice, and one cephalhaematoma. Of the 10 from the community, three had glucose 6-phosphate dehydrodgenase deficiency, two ABO incompatibility, four physiological jaundice, and one the Crigler-Najar syndrome.

Although based on small numbers, our survey shows that infants who might benefit from routine measurement of serum bilirubin concentration during the first 48–72 hours of life include those of Asian and African or Caribbean ethnic groups and those from groups with a high prevalence of glucose 6-phosphate deficiency. This may result in the earlier detection of clinically significant neonatal jaundice in most cases.

Hyperbilirubinaemia is a marker for inadequate breast feeding

EDITOR—The study reported by Spurgeon found that the most common reason for neonatal readmission was hyperbilirubinaemia and that readmission rates had increased since hospital stay after delivery had decreased.1 Perhaps this reflects a lack of community health services and support for new mothers. In the United States women are often discharged to little or no help at home. Their husband (if they have one) or their mother might be able to take a week off work to help, but that is all. They might receive one visit from a nurse during the first week. This is not enough. Other cultures offer months of support after delivery. This support can come from female relatives (as in Sierra Leone) or healthcare professionals (Plunkett nurses in New Zealand).

New mothers who lack support are prone to postpartum sadness and problems with breast feeding. Hyperbilirubinaemia is a marker for inadequate breastfeeding. 2 3 There may be nothing wrong with sending women home early from hospital, so long as they have help at home from the community until breast feeding is well established and their confidence is strong.