P2.I162: Variability in the Screening and Management of Hyperbilirubinemia Across US Birthing Hospitals: A BORN Study

Background: Neonatal hyperbilirubinemia is common and carries potential for significant morbidity. In the United States (US), universal bilirubin screening has been the standard of care for several decades, resulting in reduced incidence of severe hyperbilirubinemia. In 2022, the American Academy of Pediatrics (AAP) published updated guidelines to improve early detection and management of clinically significant hyperbilirubinemia. This study aimed to evaluate variation in neonatal hyperbilirubinemia screening and management across newborn nurseries in the US after the AAP update was initiated.

Methods: A 58-item survey regarding neonatal hyperbilirubinemia screening and management practices was disseminated by the Academic Pediatric Association’s (APA) Better Outcomes through Research for Newborns (BORN) network. The lead clinician at each birthing hospital within the BORN network was contacted via email for recruitment. Descriptive statistics were used to report the findings.

Results: One hundred twenty-three birthing hospitals were contacted between April 2023 and July 2023; 67 birthing hospitals consented to participate (54.5% response rate). 83.6% of respondents were from academic hospitals with the majority (82.1%) delivering >2000 neonates annually. Most hospitals utilize transcutaneous bilirubin (TcB) (83.5%) at 24 hours of age (55.2%) for hyperbilirubinemia screening. 43.2% of hospitals obtain daily bilirubin levels for term neonates, and 59.7% screen late pre-term infants daily. Forty-two hospitals obtain a direct antiglobulin test (DAT) on all neonates (62.7%). 95.5% of respondents have a standard approach for ABO incompatibility screening. 68.7% screen neonates of antibody positive mothers. 94.0% screen for ABO incompatibility using blood type and DAT. 85% screen DAT positive neonates earlier, the majority before 12 hours (50.7%). 44.8% of centers determine bilirubin measurement frequency for ABO incompatible neonates utilizing AAP guidelines. Following phototherapy initiation, 58.2% obtain the next bilirubin based on AAP guidelines. There were differences in laboratory evaluations completed before phototherapy for neonates with and without ABO incompatibility: CBC/hemoglobin/hematocrit (52.2% vs 21.2%), direct bilirubin (40.3% vs 45.5%), reticulocyte count (37% vs 13.6%), no labs (29.9% vs 42.4%). Sixty respondents start phototherapy below threshold, typically related to difficulty accessing follow-up, a bilirubin level approaching threshold, and rapidly rising bilirubin. Responses were similar for deciding to discontinue phototherapy for neonates with and without ABO incompatibility. Most consider cessation when the bilirubin is greater than 2mg/dL below threshold at phototherapy initiation. 75.8% of centers do not obtain TcB after discontinuing phototherapy.

Conclusion: Despite the 2022 guideline revision from the AAP, results from this study demonstrate wide variation in the evaluation and management of neonatal hyperbilirubinemia in US birthing hospitals. Variation in practice may result from guideline misinterpretation, delayed implementation, unfamiliarity with the revisions, or allowance for individualization. Additional research is needed to better understand the clinical implications and cost of this variation in practice.