Medical Student Research Fellowship for Summer 2011
Mentor: Gregory (“Greg”) L. Jackson, M.D., M.B.A.,
William D. Engle, M.D.
Department: Pediatrics
Room number: Parkland Memorial Hospital Newborn Nursery
Mail Code: 9063
Phone number: (214) 590-8034
E-mail: greg.jackson@utsouthwestern.edu
Project title: Evaluation of Transcutaneous Bilirubinometry (TcB) in the First Hours of Life to Predict Subsequent Jaundice during the First Week of Life
Human subjects IRB approved project number (where applicable): IRB is pending
Animal subjects IRB approved project number (where applicable): N/A
Project Type (patient-based research, animal-based research, or basic research; this characterization is only to permit a general classification for grouping similar types of projects) – Patient-based
Brief Description of Project:
BACKGROUND: In recent years, pediatricians and numerous professional organizations have voiced concern about the apparent increase in neonates with kernicterus, staining of the motor pathways of the brain, leading to motor deficits and other problems. This disorder is associated with and felt to be primarily related to elevated bilirubin levels, but it is influenced by other risk factors. In July 2004, the AAP published clinical practice guidelines regarding management of jaundice in the term and near-term newborn; in general, these guidelines have had the effect of lowering the threshold for monitoring and treatment of jaundiced neonates.
The guidelines have had major implications for newborn nurseries, since they state that every baby should have a formal assessment for jaundice. In addition, the Joint Commission for Accreditation of Healthcare Organizations has stated that assessment of risk for hyperbilirubinemia be performed on every neonate prior to discharge. This assessment may include a transcutaneous bilirubin (TcB), a total serum bilirubin (TSB), or formal documentation of a physical examination for jaundice and assessment of clinical risk factors for hyperbilirubinemia.
The AAP guidelines include a nomogram with hour-specific bilirubin levels for identifying those neonates who may be at risk for hyperbilirubinemia. The AAP approves the use of TcB with the nomogram in the evaluation of neonates for jaundice. Multiple articles have been written that support the use of transcutaneous bilirubinometry in the evaluation of neonates.
The use of a transcutaneous device to estimate serum bilirubin has been developed through the work of several color technology companies, notably Minolta Corporation, since the 1970s. The current generation of devices uses a benign, safe light source that flashes and renders a bilirubin determination upon gently compressing the rounded end of the device onto the skin at the level of the nipples. (http://www.konicaminolta.com/instruments/products/medical/jaundice-meter/jm103/specifications.html)
The current standard procedure – implemented in October 2005— in the Parkland Memorial Hospital Newborn Nursery is to evaluate neonates with the Minolta JM103 transcutaneous bilirubinometer. We have many of these devices located within the nurseries and on all of the mother-baby (post-partum) units. It is performed by any nurse or provider at any time during the hospital stay. Every baby routinely has TcB determinations performed at least once a day.
Neonates who are ≥35 weeks’ gestation and ≥2100 grams in birth weight, and who have no transitional issues in the Delivery Room, are admitted to the Newborn Nursery. After spending a variable period of time with their mother, the babies are brought to Admissions Nursery for several admission routines.
The long sought-after ‘holy grail’ for the prevention of significant hyperbilirubinemia (>20 mg/dL) in the age of neonatal early hospital discharge is a predictive marker for high levels of jaundice occurring after the hospital stay. The physiology, epidemiology, and genetics of bilirubin metabolism do not allow such a simplistic ‘single predictor’; several investigators have advocated for assessment of risk factor combinations for jaundice. A few studies in non-Hispanic populations have attempted to assess the rate of rise – the hourly progression of a transcutaneous measure of jaundice – but these studies have yielded inconsistent results.
CONCISE SUMMARY OF PROJECT: We will perform TcB determinations on a convenience sample of neonates in Admissions Nursery. These values will be combined with other TcB values, as well as other laboratory values related to jaundice done during the normal course of hospitalization. The primary outcome is need for a higher level of care (early follow-up visits, phototherapy, and/or readmission for jaundice) and its relation, if any, to the TcB values performed in Admissions Nursery and at other times during the hospital stay. As a secondary analysis, additional risk factors (e.g., ethnicity, gestational age, type of delivery, maternal anesthesia) will be evaluated to discover any additional refinement of prediction of the occurrence of significant hyperbilirubinemia.
Importance / implications of the research: Although there will be no direct benefit to the subjects, one potential benefit includes improved early discharge planning in relation to follow-up of neonatal jaundice. That is, in the age of early hospital discharge – sometimes at several hours of age – providers need additional tools to predict which infants need a higher level of follow-up care.
Role of the student: The student will be involved in input for data collection and the performance of transcutaneous bilirubin determinations on a convenience sample of infants during the first hours of life. The student will also assist in analysis of data and be included in the process of developing a poster and scientific paper. As part of the project, we also anticipate that the student will participate in clinical rounds and conferences, as an adjunct to learning about clinical aspects of neonatal jaundice.