P2.I161: Serum Albumin Assessment in Neonatal Jaundice: Impact on Phototherapy Decision-Making

Background: The American Academy of Pediatrics clinical practice guideline for the management of hyperbilirubinemia in newborn infant ≥ 35 weeks of gestation outlines serum albumin below 3.0 g/dL as a hyperbilirubinemia neurotoxicity risk factor, which contributes to a reduction in the recommended phototherapy thresholds. However, routinely testing serum albumin for all neonates with jaundice was not recommended because there is insufficient evidence to support the practice. This study aims to assess the impact of serum albumin evaluation on phototherapy decisions in newborns.

Methods: A retrospective chart review was conducted on infants ≥ 35 weeks gestation, evaluated for early neonatal jaundice across three hospitals affiliated with Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand, from January 1st to December 31st, 2023. During this period, serum albumin levels were routinely assessed as part of jaundice evaluation. Infant demographics, serum albumin, total serum bilirubin (TSB), laboratory work-up for jaundice, neurotoxicity risk factors, risk-based phototherapy thresholds, and rates of phototherapy initiation/cessation based on known versus presumed normal albumin levels were evaluated.

Results: During the study period, 935 infants were evaluated for jaundice, and 250 infants (26.7%) had serum albumin below 3.0 g/dL. Phototherapy was initiated in 401 infants (42.9%). Among those infants that received phototherapy, 110 infants (27.4%) received phototherapy when TSB levels exceeded 2 mg/dL below the phototherapy threshold, 170 infants (42.4%) received phototherapy when TSB levels were less than or equal to 2 mg/dL below the phototherapy threshold, and 121 infants (30.2%) had TSB levels equal to or above the phototherapy threshold. Among those infants who received phototherapy at TSB levels meeting the threshold designated by the guideline, 49 infants (40.5%) had serum albumin below 3.0 g/dL as one of the neurotoxicity risk factors. However, the decision for phototherapy would not have changed when other neurotoxicity risk factors were presented in these infants, or when TSB at the time of initiation of phototherapy was higher than the threshold for infants without neurotoxicity risk factors, or when TSB at the time of cessation of phototherapy was lower than the threshold for infants with neurotoxicity risk factors. As a result, the identification of serum albumin below 3.0 g/dL only affected the decision of phototherapy in 16 infants, or 1.7% of all infants evaluated for jaundice. Specifically, it affected the decision of phototherapy initiation in 13 infants, the cessation in 1 infant, and both the initiation and cessation in 2 infants.

Conclusion: Serum albumin levels below 3.0 g/dL are common, impacting one in every four infants assessed for jaundice. However, its impact on phototherapy decisions is minimal. Larger population-based studies are required to validate these results and evaluate the clinical consequences of misclassifying these infants with neurotoxicity risk factors to receive a higher phototherapy threshold without serum albumin testing.