Comparison of end-tidal carbon monoxide measurements with direct antiglobulin tests in the management of neonatal hyperbilirubinemia.

OBJECTIVE: Determine whether management of neonatal hyperbilirubinemia differs if one used end-tidal carbon monoxide (CO) corrected for ambient CO (ETCOc) measurements instead of direct antiglobulin test (DAT) results to assess the severity of hemolysis. STUDY DESIGN: Retrospective chart review of infants with total bilirubin and ETCOc levels measured from July 2016 to August 2018. The reported treatment is the hypothetical management infants might have received had there been strict adherence to American Academy of Pediatrics guidelines, rather than the actual management they received. RESULT: Only 27.2% of 191 DAT(+) infants were hemolyzing based on ETCOc, while 29.1% of DAT (-) infants were hemolyzing based on ETCOc. Management of 18 (9.4%) infants differed depending if ETCOc or DAT were used to determine hemolysis. Eight fewer infants would have received phototherapy if ETCOc was used. CONCLUSIONS: ETCOc is a more accurate determinant of hemolysis in the newborn, and its use can lead to less phototherapy.

Effect of genetic variants of bilirubin metabolism on the degree of hyperbilirubinemia in African-American newborns.

OBJECTIVE: The objective of our study was to measure the effect of genetic variants of these two enzymes, UGT1A1 and SLCO1B1, in the bilirubin metabolic pathway on the degree of hyperbilirubinemia in a cohort of African-American (AA) infants from our well-baby nursery. In addition, a second objective was to document the types and frequencies of genetic variations of these enzymes in our cohort. STUDY DESIGN: A prospective study of 180 AA infants from the Well Baby Nursery of an inner city community hospital, all of whose mothers were type O pos. Sixty infants were ABO-incompatible direct antiglobulin test (DAT) pos, 60 were ABO-incompatible DAT neg and 60 were type O+. Blood for carboxyhemoglobin (COHb) and variants of the enzymes uridine diphosphoglucuronosyltransferase 1A1 and hepatic solute carrier organic anion transporter 1B1 (SLCO1B1) was drawn at the time of the infants' initial bilirubin, and the infants' precise percentile on the Bhutani nomogram was calculated. RESULTS: Variants in the two enzymes studied were quite common. In total, 21.1% were positive for a Gilbert phenotype, whereas an additional 42.4% were heterozygous for the *28 or *37 variant of UGT1A1. In total, 67.2% were homozygous for the *60 variant of the phenobarbital responsive enhancer module. In total, 41.1% were homozygous for the *1b variant of SLCO1B1, whereas an additional 12.7% were positive for the *4 variant of this gene. In total, 20.6% of infants had variations in both genes. Using logistic regression when COHbc was assessed with each of the different variants, only COHbc (P<0.0001 to 0.0004) was significantly associated with the level of hyperbilirubinemia as defined by the Bhutani nomogram. CONCLUSION: Although we have found quite a large number of genetic variants of the UGT1A1 and SLCO1B1 genes in the AA population, it does not appear that they have a significant impact on the incidence of hyperbilirubinemia among this group of infants.

Carboxyhemoglobin levels as a predictor of risk for significant hyperbilirubinemia in African-American DAT(+) infants.

OBJECTIVES: To compare the degree of hemolysis in a group of direct antiglobulin test (DAT) positive (pos) African-American (AA) infants as measured by carboxyhemoglobin corrected (COHbc) for carbon monoxide in ambient air to a similar group of DAT negative (neg) ABO incompatible infants and a group without blood group incompatibility. To determine if COHbc is a better predictor of significant hyperbilirubinemia than DAT status. STUDY DESIGN: A prospective study of 180 AA infants from the Well-Baby Nursery of an inner city community hospital, all of whose mothers were type O pos. Infants (60) were ABO incompatible DAT pos, 60 were ABO incompatible DAT neg and 60 were type O(+). Blood for COHbc was drawn at the time of the infants' initial bilirubin and the infants' precise percentile on the Bhutani nomogram was calculated. RESULT: Mean COHbc of type O(+) infants was 0.76±0.21 and 0.78±0.24% for ABO incompatible DAT neg infants (P=0.63). Mean CoHbc for the ABO incompatible DAT pos infants was 1.03±0.41% (P<0.0001 compared with both type O and DAT neg infants). Optimal cutoff on the receiver operating characteristic curve for COHbc to determine the risk for being in the Bhutani curve high risk zone was COHbc >0.90% (area under the curve(AUC) 0.8113). This was similar to the AUC of the receiver operating characteristic curve using any titer strength of DAT pos as a cutoff (0.7960). CONCLUSION: Although not greatly superior to the titer strength of DAT pos, COHbc is useful in determining if the etiology of severe hyperbilirubinemia is a hemolytic process.

C-reactive protein levels following hepatitis B vaccine in healthy newborns.

OBJECTIVE: Evaluate the effect of Hepatitis B vaccine (HepB) on C-reactive protein (CRP) levels in healthy term infants. STUDY DESIGN: A prospective controlled study in an academic medical center serving an inner city community. Subjects were singleton, term and late pre-term infants delivered vaginally with normal physical examination and without risk factors for or signs of sepsis. CRP levels were measured in cord blood and at the time of newborn genetic screening. The early HepB group received HepB within a few hours after birth. The late HepB group had HepB delayed until after the repeat CRP. RESULT: One hundred and eighty-two infants were enrolled (94 early HepB, 88 late HepB) with similar demographic features in each group. Neither the mean cord CRP (early HepB, 0.24±0.23 vs late HepB, 0.30±0.68 mg l(-1), P=0.37) nor the median of the repeat CRP (early HepB, 2.6 (interquartile range, 1.18 to 7.03) vs late HepB, 1.7 (interquartile range, 0.73 to 5.8) mg l(-1), P=0.14) showed significant differences between the two groups. CONCLUSION: HepB does not affect CRP levels in healthy term infants.

Neonatal outcomes of macrosomic births in diabetic and non-diabetic women.

OBJECTIVE: To compare the neonatal outcomes and birth injuries of macrosomic infants born to diabetic mothers (IDM) and non-diabetic mothers (non-IDM). STUDY DESIGN: This is a retrospective survey of all live born, singleton neonates with a birth weight of > or = 4000 g, delivered at the Albert Einstein Medical Center, Philadelphia during a 3-year period (2003 through 2005). 305 infants of the 7158 delivered during this period met entry criteria. Data were analysed using chi(2) and Fisher's exact test. Logistic regression analysis was also performed. RESULT: Compared to IDMs, non-IDMs were born later (40 vs 38 weeks) and were more likely to be delivered vaginally (70% vs 34%). Half of the non-IDMs (49.6%) had at least one morbidity compared with 73.2% of the IDMs. Non-IDMs had a higher incidence of birth injury than IDMs (8% vs 2.4%). Logistic regression showed an increased risk of poor outcome with weight > or = 4500 g and vaginal delivery. CONCLUSION: All macrosomic infants represent a high-risk group, regardless of maternal diabetes status.

Delivery room management of the apparently vigorous meconium-stained neonate: results of the multicenter, international collaborative trial.

OBJECTIVE: Disagreement exists concerning the appropriate delivery room management of the airway of vigorous meconium-stained infants. Some suggest a universal approach to intubation and suctioning of the airway in all such neonates, whereas others advocate a selective approach. We performed this investigation: 1) to assess whether intubation and suctioning of apparently vigorous, meconium-stained neonates would reduce the incidence of meconium aspiration syndrome (MAS); and 2) to determine the frequency of complications from delivery room intubation and suctioning of such infants. METHODS: Inclusion criteria included: 1) gestational age >/=37 weeks; 2) birth through meconium-stained amniotic fluid of any consistency; and 3) apparent vigor immediately after birth. Subjects were randomized to be intubated and suctioned (INT) or to expectant management (EXP). Primary outcome measures included: 1) the incidence of respiratory distress, including MAS, and 2) the incidence of complications from intubation. RESULTS: A total of 2094 neonates were enrolled from 12 participating centers (1051 INT and 1043 EXP). Meconium-stained amniotic fluid consistency was similar in both groups. Of the 149 (7.1%) infants that subsequently demonstrated respiratory distress, 62 (3.0%) had MAS and 87 (4.2%) had findings attributed to other disorders. There were no significant differences between groups in the occurrence of MAS (INT = 3.2%; EXP = 2.7%) or in the development of other respiratory disorders (INT = 3.8%; EXP = 4.5%). Of 1098 successfully intubated infants, 42 (3.8%) had a total of 51 complications of the procedure. In all cases, the complications were mild and transient in nature. CONCLUSIONS: Compared with expectant management, intubation and suctioning of the apparently vigorous meconium-stained infant does not result in a decreased incidence of MAS or other respiratory disorders. Complications of intubation are infrequent and short-lived.

Incidence of intrauterine cocaine exposure in a suburban setting.

This study endeavored to determine the incidence of intrauterine cocaine exposure in a socioeconomically mixed suburban setting. It also assessed the effectiveness of an anonymous questionnaire in eliciting information on maternal use of illicit drugs during pregnancy. Meconium was collected from 500 consecutively born infants and analyzed for the presence of cocaine and its metabolites. An anonymous two-page questionnaire also was distributed to all postpartum mothers. Of the infants' mothers, (73.2%) were covered by some form of insurance (private), whereas 26.8% either had no insurance or were covered by Medicaid (clinic). Fifty-nine (11.8%) babies tested positive for cocaine. The meconium of 6.3% of the babies whose mothers had private insurance tested positive, while the meconium of 26.9% of the babies whose mothers had Medicaid or no insurance tested positive. 316 (63.2%) of the mothers returned a questionnaire. 73% had private insurance and 27% were covered by Medicaid (clinic). Only five mothers with no insurance or covered by Medicaid admitted using cocaine. It appears that neonatal exposure to cocaine may be an even greater problem than previously imagined, particularly in the private population. In addition, anonymous maternal self-reporting forms probably will not be helpful in identifying infants at risk for illicit exposure to drugs.

Effect of water supplementation of full-term newborns on arrival of milk in the nursing mother.

It has been suggested that water supplementation of breast-fed newborns may delay the arrival of true milk. A total of 136 healthy term neonates were divided into two groups. Seventy-eight nursed exclusively on demand, and 58 received in addition supplemental water ad lib. Mean time for arrival of milk in the unsupplemented group was 54.9 hours and in the supplemented group 56.6 hours. This difference was not significant, indicating that water supplementation to the normal term newborn does not affect or disrupt the establishment of lactation.