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JAMA Pediatr. Question How effective is subthreshold neonatal phototherapy during the birth hospitalization in preventing readmissions for phototherapy? Formula feeding was also protective against readmission for phototherapy. Meaning Although an effective treatment, subthreshold phototherapy during the birth hospitalization requires treatment of many newborns unnecessarily for each readmission prevented.

Importance Treatment of jaundiced newborns with subthreshold phototherapy phototherapy given to newborns with bilirubin levels below those recommended in American Academy of Pediatrics [AAP] guidelines is common. However, the use of subthreshold phototherapy may have risks and increase costs, and, to date, it has not been systematically studied in newborns. Objectives To estimate the efficacy of subthreshold phototherapy for newborns with total serum bilirubin TSB levels from 0. Data were analyzed from November 1,to November 28, Exposure Subthreshold phototherapy during the birth hospitalization.

Estimated s needed to treat ranged from Newborns who received formula feedings had lower adjusted odds of readmission for phototherapy compared with exclusively breastfed newborns OR, 0. Conclusions and Relevance Subthreshold phototherapy during the birth hospitalization is effective in preventing readmissions for phototherapy; however, for each readmission prevented, many newborns require phototherapy who would otherwise not need it.

Phototherapy is commonly used to treat neonatal hyperbilirubinemia.

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Because phototherapy is generally considered safe, 12 clinicians and parents may consider subthreshold phototherapy to have a favorable risk-benefit profile for newborns with TSB levels close to the threshold for treatment. To our knowledge, no data presently exist regarding the efficacy of subthreshold phototherapy for newborns to prevent future readmissions for phototherapy. In this study, we sought to estimate the efficacy of using phototherapy to treat newborns with TSB levels from 0.

In addition, we sought to identify positive and negative predictors of readmission for phototherapy to identify predictors of the needed to treat NNT for this therapy. We excluded newborns with 7 or more days of birth hospitalization length of stay. We included newborns who had at least 1 TSB level from 0. As in studies, 34 we determined the AAP phototherapy threshold based on chronological age, gestational age, and direct antiglobulin test DAT result of the newborn.

The study was approved by the institutional review board at Kaiser Permanente Northern California and the Committee on Human Research at the University of California, San Francisco, which also determined that patient consent was not required because deidentified records were used. The primary predictor variable was receipt of inpatient subthreshold phototherapy during the birth hospitalization.

As ly described, 5 we classified newborns to have received subthreshold phototherapy if they had either nursing documentation of phototherapy in the electronic medical record or both a procedure code and a physician order for phototherapy. We obtained data about formula feeding from nursing documentation in the electronic medical record. We included a variable for the of formula feedings per day during the birth hospitalization obtained by dividing the total of formula feedings during the birth hospitalization by the length of stay in days.

We also created a variable for home phototherapy within 72 hours of discharge from the birth hospitalization that was based on the date of delivery of a phototherapy unit. As ly reported, 7 Ortho Clinical Diagnostics issued new calibrators for their bilirubin testing instruments in Maywhich resulted in a ificant decrease in measured TSB levels and the use of phototherapy. To for this recalibration, we included a dichotomous variable indicating whether the newborn was born before or after June 1,in addition to the indicator variables for year of birth in the multivariable models.

This study was deed to evaluate readmissions after subthreshold phototherapy use during the birth hospitalization. We restricted our analysis to newborns with TSB levels just below, but not exceeding, the appropriate phototherapy threshold during the birth hospitalization.

Only TSB measurements were used in this study; transcutaneous bilirubin measurements were not used. We categorized the age of the newborn in hour increments at the time that the qualifying TSB level was obtained. Weight loss was estimated using the birth weight and the most recent weight documented at the time that the qualifying TSB level was obtained. Including cubic spline terms for these continuous variables did not improve the fit of the models or alter the coefficient for phototherapy.

We evaluated the following secondary outcomes occurring after discharge: 1 a TSB level that exceeded the appropriate AAP phototherapy threshold by any amount; 2 a TSB level that exceeded the appropriate AAP phototherapy threshold by 2. We used ORs instead of risk ratios to facilitate comparison between crude and adjusted. Multivariable logistic regression was used to control for potential confounding variables while ing for clustering by hospital facility using generalized estimating equations with robust SEs and an independent working correlation structure.

We used multivariable-adjusted linear regression to estimate the effect of subthreshold phototherapy on length of stay. We calculated multivariable-adjusted marginal rates for each outcome. For these analyses, we set the indicator variable for post-recalibration to 1 because we believed the phototherapy rates observed after recalibration were more likely to apply going forward. We estimated NNT as reciprocals of marginal risk differences 1 divided by the estimated mean risk difference. We also divided the newborns into quintiles of predicted risk of readmission based on variables that were associated with the odds of readmission in this study, excluding phototherapy and estimated the marginal NNT by quintile.

All analyses were performed using Stata, version 13 StataCorp. Those who received subthreshold phototherapy had a mean length of stay that was A total of of newborns 4. Receipt of subthreshold phototherapy during the birth hospitalization was associated with ificantly decreased odds of readmission for phototherapy crude OR, 0. In an adjusted analysis, receipt of subthreshold phototherapy during the birth hospitalization was even more strongly associated with decreased odds of readmission rates for phototherapy OR, 0. The multivariable-adjusted marginal decrease in readmission rates for phototherapy after receipt of subthreshold phototherapy during the birth hospitalization was 7.

Conversely, low birth weight, cesarean delivery, DAT positivity, and home phototherapy were associated with decreased odds of readmission for phototherapy. The association between formula feeding and readmission for phototherapy was dose dependent, with increased use of formula being associated with decreased odds of readmission for phototherapy Tables 2 and 3. After combining predictors, the mean NNT of newborns in the quintile at highest risk of readmission was only 6.

The risk of readmission was more than an order of magnitude greater in the highest risk quintile than the lowest risk quintile Despite this, subthreshold phototherapy use was not much higher in the highest risk quintile than the lowest risk quintile Of these, Subthreshold phototherapy during the birth hospitalization decreased the odds of having a TSB level at or above the phototherapy threshold after discharge adjusted OR, 0.

There were newborns 3. Subthreshold phototherapy again decreased the odds of having a TSB level that exceeded the phototherapy threshold after discharge by 2.

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Only 40 newborns 0. Notably, of the newborns readmitted for phototherapy, In this analysis, At first glance, the direction of some of the crude associations in our study may be surprising. Higher-risk infants may be at decreased risk of readmission for phototherapy because they are more likely to have longer lengths of stay.

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Longer lengths of stay reduce the likelihood of readmission for phototherapy because TSB levels are more likely to peak during the birth hospitalization, resulting in newborns being more likely to receive phototherapy during that time. High-risk newborns may also be more likely to receive additional interventions during the birth hospitalization eg, formula supplementation, subthreshold phototherapy, and other interventions that lead to decreased readmissions.

Positive DAT appeared to be protective against readmission for phototherapy in this study because of the exclusion of newborns with TSB levels that exceeded the phototherapy threshold during the birth hospitalization. By excluding these newborns, the lower-risk group of newborns with DAT-positive remained in the cohort. Phototherapy is generally considered a low-risk intervention. Data are emerging that phototherapy may be associated with a small risk of adverse effects. The NNT values for subthreshold phototherapy in preventing readmission for phototherapy varied greatly based on the covariates.

Even for newborns in the highest quintile of risk, the NNT to prevent readmission was 6. The most appropriate NNT when treating infants with hyperbilirubinemia will vary based on individual risk factors. Although many families may find prolonged hospitalization to be less disruptive than readmission, it is not judicious to treat large s of newborns with an unnecessary intervention in order to prevent 1 readmission. For the high-risk infants for whom subthreshold phototherapy is most reasonable, such as those born at lower gestational ages, those with TSB levels close to the phototherapy threshold, or those with uncertain or difficult follow-up, it is reasonable to include the families in the decision-making process.

Receiving 4 to 6 formula feedings per day had a similar benefit in preventing readmission to that of receiving subthreshold phototherapy during the birth hospitalization. Breastfeeding confers numerous health benefits to both mothers and infants, 23 and the AAP recommends that infants exclusively breastfeed for 6 months and continue breastfeeding for at least 1 year.

In the US health care system, hospital readmissions soon after discharge are often considered a negative indicator of quality. Efforts to avoid these readmissions could lead to overtreatment of hyperbilirubinemia during the birth hospitalization and to more newborns receiving phototherapy overall. This study has several limitations. The cohort was a predominantly insured population in Northern California, which may make the less generalizable to other populations.

The study de was observational, not experimental. In addition, we had no data for formula use after discharge and only limited data for formula use during the birth hospitalization because data for formula type and quantity were not available. While subthreshold phototherapy during the birth hospitalization prevents readmission for phototherapy, it in the unnecessary treatment of many newborns.

Corresponding Author: Andrea C. Published Online: February 26, Author Contributions: Drs Wickremasinghe and Newman had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Critical revision of the manuscript for important intellectual content: All authors. Conflict of Interest Disclosures: None reported.

Disclaimer: The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality. Our website uses cookies to enhance your experience. By continuing to use our site, or clicking "Continue," you are agreeing to our Cookie Policy Continue. Table 1. View Large Download. Table 2. Multivariable Predictors of Hospital Readmission for Phototherapy. Table 3. Table 4. Phototherapy for neonatal jaundice. N Engl J Med.

PubMed Google Scholar Crossref. American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Impact of universal bilirubin screening on severe hyperbilirubinemia and phototherapy use. s needed to treat with phototherapy according to American Academy of Pediatrics guidelines. Retrospective cohort study of phototherapy and childhood cancer in Northern California. The Kodak Ektachem clinical chemistry slide for measurement of bilirubin in newborns. Clin Chem. PubMed Google Scholar.

Association between laboratory calibration of a serum bilirubin assay, neonatal bilirubin levels, and phototherapy use. Dinesh D. Review of positive direct antiglobulin tests found on cord blood sampling. J Paediatr Child Health. The side effects of phototherapy for neonatal jaundice.

Eur J Pediatr. Neonatal phototherapy and infantile cancer. Neonatal hyperbilirubinemia and the risk of febrile seizures and childhood epilepsy. Epilepsy Res. Incidence, etiology, and outcomes of hazardous hyperbilirubinemia in newborns. Risk for cerebral palsy in infants with total serum bilirubin levels at or above the exchange transfusion threshold: a population-based study.

Risk of sensorineural hearing loss and bilirubin exchange transfusion thresholds. Prospective surveillance study of severe hyperbilirubinaemia in the newborn in the UK and Ireland. Acta Paediatr. Follow-up of extreme neonatal hyperbilirubinaemia in 5- to year-old children.

Dev Med Child Neurol. Maisels MJ, Gifford K. Normal serum bilirubin levels in the newborn and the effect of breast-feeding.

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Schneider AP II. Breast milk jaundice in the newborn. Prediction and prevention of extreme neonatal hyperbilirubinemia in a mature health maintenance organization.

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