Guidelines from the American Academy of Pediatrics, 2004 (RP) for the treatment of hyperbilirubinemia (GBE) in infants determine bilirubin levels requiring the start of phototherapy and replacement of blood transfusion (CLP). However, the RP based on "dubious" estimates and extrapolate data from previous studies and do not show the number of patients who need to treat phototherapy to prevent the emergence of a child's bilirubin level at which the RP recommended ZPK (required number of patients treated phototherapy; NKPF) .
The purpose of this study was to assess the effectiveness of phototherapy in the hospital neonatal GBE and NKPF.
Methods and progress in the study.
A study was conducted 281,898 infants with birth weight (BP) ≥ 2000 g and gestational age (GA) ≥ 35 weeks, which were born on January 1, 1995 through December 31, 2004 at 12 hospitals in Northern California (USA). Of this population has been allocated 22,547 patients whose level of total serum bilirubin (RSD) corresponded to the threshold for phototherapy equal, according to RP, ± 3 mg / dL.
Take into account the following risk groups GBE: 1) low risk: HB ≥ 38 weeks and the lack of positive results of direct antiglobulin test (PAB), 2) medium risk: GW < 38 weeks or a positive result PABand3) high risk: GW <38 weeks and PAB positive. Using multiple logistic regression was evaluated the effectiveness of phototherapy within eight hours to prevent the increase within 48 hours the level of RSD to the thresholds, an indication for ZPK in accordance with the RP and NKPF. The effectiveness of phototherapy was determined by taking into account other risk factors for the GBE. Results. 22 547 newborns with GBE included in the study were compared with those of the general cohort without GBE (259,351 children). Mean BP and HS infant study were lower, whereas maternal age, length of hospital stay at birth and the proportion of boys were taller than in infants without GBE. Among the study, patients were significantly more infants of Asian race, less - of the black race and the allocation of risk has been shifted to a higher risk. From the study of 6,960 infants (30.9%) received phototherapy in the hospital. Phototherapy started within eight hours after determining the level of OSB in 5251 (75.4%) babies of those who have ever received phototherapy. Approximately, 4% of the cohort received home phototherapy. Only in 354 children (1.6%) exceeded the threshold according to the CLP RP; in 187 (53%) happened within 48 hours from the first definition of RSD. Among these 354 patients 278 (79%) had a maximum level of RSD < 25 mg / dL, and 350(99%) - < 30mg / dL. Only 3 children were held ZPK. In two-dimensional studies of the risk of exceeding the threshold of CLP for 48 hours significantly differ in the-risk groups, age, life and levels of RSDonthebackground of phototherapy conducted in accordance with the RP. It was identified as a major link between phototherapy in the hospital and the result of PAB. Phototherapy was less effective in infants with a positive PAB (P = 0, 01). Adjusted hazard ratio (RRR) for phototherapy in the hospital among infants with a positive result PAB was 0.16, which corresponded to 84% efficiency. After exclusion from the analysis of 8,178 infants who have been missing PAB, the results have not changed.
In children with negative PAB with the level of OSB from 0,0 to 0,9 mg / dL above the threshold for phototherapy average GV was 384 / 7 weeks, the average BP - 3,3 kg and the average age at the time of determining the level of OSB - 63 hours. Using these values, NKPF in multivariate models was 222 boys and 339 girls.
The results of the multivariate model were consistent with the results of a simple stratification, although the sample size becomes small, taking into account several variables. For example, from 3186 infants with a level of OSB from 0,0 to 0,9 mg / dL above a threshold for phototherapy RP 1,374 children were in low-risk group and ≥ 48 hours of life while determining the level of RSD. Only 3 patients had crossed the threshold line RSD and had indications for the CLP for 48 hours, and all three were among 1,132 infants who have not received hospital phototherapy within eight hours. Thus, in this group, phototherapy in 100% effective, but it was NKPF 377 (1132 / 3).
Priced NKPF vary widely in HS, sex and age at the time of determining the level of RSD in the range of 10 (95% CI: 6 - 19) for boys with HB 36 weeks of age < 24 hours of life before 3041 (95% CI:888- 11, 096) for girls with GW ≥ 41 weeks of ageand72 hours of life.
Conclusions.
The study authors concluded that phototherapy is effective in the hospital, and NKPF in accordance with the RP varies considerably in different infant subgroups.
According to the authors, the purpose of phototherapy to infants with GBE justified in dangerous levels of bilirubin to reduce them. It should strive to avoid unnecessary treatment.
The limitation of this study was that the basis for identifying patients who had received phototherapy in the hospital, lay procedure code definition of phototherapy in medical records, and the time of admission to a hospital was considered the timing of phototherapy. In addition, clinicians take into account other factors not included in the model used for the decision to phototherapy. Limitation is the fact that before the researchers had no data on breastfeeding.
The authors believe that additional investigation is necessary to determine costs and possible adverse effects of phototherapy in infants with GBE.
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