From the Guidelines
No, you should not safely discharge a baby with a total serum bilirubin (TSB) of 144 μmol/L and transcutaneous bilirubin (TCB) of 268 μmol/L at 72 hours of life. This discrepancy between TSB and TCB values is concerning and requires immediate attention, as suggested by the most recent guidelines on phototherapy to prevent severe neonatal hyperbilirubinemia 1. The TSB value of 144 μmol/L may be within acceptable limits for a 72-hour-old infant depending on gestational age and risk factors, but the significantly higher TCB reading suggests either a measurement error or rapidly rising bilirubin levels.
Before considering discharge, you should repeat the TSB measurement to confirm the actual bilirubin level and assess the need for phototherapy, following the recommendations for TSB measurement and phototherapy initiation based on gestational age, neurotoxicity risk factors, and age of the infant in hours 1. Additionally, evaluate the infant for risk factors such as prematurity, ABO/Rh incompatibility, G6PD deficiency, or other hemolytic conditions.
The baby should remain hospitalized for:
- Monitoring
- Further diagnostic workup including direct bilirubin, complete blood count, blood type, and Coombs test
- Potential treatment until the discrepancy is resolved and a clear downward trend in bilirubin levels is established. Severe hyperbilirubinemia can lead to kernicterus and permanent neurological damage, so a cautious approach is warranted, as emphasized by the guidelines on management of hyperbilirubinemia in newborn infants 1.
From the Research
Discharge Criteria for Babies with Hyperbilirubinemia
To determine if a baby with a total serum bilirubin (TSB) of 144 and a transcutaneous bilirubin (TCB) of 268 at 72 hours can be safely discharged, we need to consider the following factors:
- The baby's overall health and risk factors for hyperbilirubinemia
- The effectiveness of phototherapy in reducing bilirubin levels
- The risk of kernicterus and other complications associated with high bilirubin levels
Phototherapy and Hyperbilirubinemia Management
According to 2, phototherapy is a effective way to reduce bilirubin levels and prevent kernicterus. The study proposes specific intervention thresholds for phototherapy and exchange transfusion in term and preterm infants. However, the exact thresholds are not specified in the provided text.
Screening for Hyperbilirubinemia
A systematic review and meta-analysis 3 found that universal screening for hyperbilirubinemia using transcutaneous bilirubin (TcB) or total serum bilirubin (TSB) testing at discharge may improve clinical outcomes for term healthy neonates. The review suggests that TcB screening may decrease readmission for jaundice and severe hyperbilirubinemia, but the evidence is of low certainty.
Decision to Discharge
Based on the available evidence, it is unclear if a baby with a TSB of 144 and a TCB of 268 at 72 hours can be safely discharged. The decision to discharge should be made on a case-by-case basis, taking into account the baby's individual risk factors and the effectiveness of phototherapy in reducing bilirubin levels. As stated in 4, any infant with high serum bilirubin or a rapidly rising bilirubin level needs to be treated urgently to avoid neurotoxicity.
Key Considerations
- The baby's bilirubin levels are high, and phototherapy may be necessary to reduce the risk of kernicterus
- The effectiveness of phototherapy in reducing bilirubin levels depends on various factors, including the intensity and duration of treatment
- Close monitoring of the baby's bilirubin levels and overall health is necessary to ensure safe discharge and prevent complications.