Benefits and harms of screening infants for hyperbilirubinemia still unclear

Sep 29 2009

According to a new recommendation from the U.S. Preventive Services Task Force, there is insufficient evidence to assess the balance of benefits and harms of screening infants for hyperbilirubinemia to prevent chronic bilirubin encephalopathy. Hyperbilirubinemia is a condition marked by a high level of bilirubin in the blood, which is often apparent as yellow-colored skin and eyes (jaundice). This recommendation and the accompanying summary of evidence will appear in the October issue of Pediatrics.

About 60 percent of all infants have jaundice, and it generally clears up without any medical treatment. Some infants are more likely to have severe jaundice and higher bilirubin levels than others. In some infants, hyperbilirubinemia may lead to chronic bilirubin encephalopathy, a rare but devastating neurological condition. The brain damage associated with chronic bilirubin encephalopathy, or kernicterus, may result in cerebral palsy, auditory processing problems, gaze and vision abnormalities, and cognitive problems. The number of children who develop chronic bilirubin encephalopathy is unknown and difficult to determine.

"There is inadequate evidence that screening all full-term and near-term infants for elevated bilirubin leads to improved health outcomes," said Task Force Chair Ned Calonge, M.D., who is also chief medical officer for the Colorado Department of Public Health and Environment. "More research is necessary to understand how often chronic bilirubin encephalopathy occurs, its risk factors, and whether screening is associated with a reduction in chronic bilirubin encephalopathy."

There is evidence that screening using risk factor assessment or bilirubin level measurement can identify infants at risk of developing hyperbilirubinemia, but there is no known screening test that will reliably identify all infants at risk of developing chronic bilirubin encephalopathy. Not all infants with chronic bilirubin encephalopathy have a history of hyperbilirubinemia, and not all infants who have extremely high levels of bilirubin develop chronic bilirubin encephalopathy.

In assessing the potential benefits and harms of screening infants for hyperbilirubinemia, the Task Force looked for evidence that screening reduced the number of new cases of chronic bilirubin encephalopathy. No studies have directly addressed whether screening, either risk-factor assessment or bilirubin testing, reduced the number of new cases of chronic bilirubin encephalopathy. The current evidence on screening has evaluated the effectiveness of screening to identify infants for treatment intended to reduce high levels of bilirubin.

The Task Force found that the evidence is currently insufficient regarding whether treating infants with high levels of bilirubin results in fewer children developing chronic bilirubin encephalopathy. There is a critical gap in the evidence regarding the relationship between screening infants without symptoms of hyperbilirubinemia and the desired outcome of reducing cases of chronic bilirubin encephalopathy. When the Task Force finds insufficient evidence to make a recommendation, it does not mean a clinician shouldn't provide a service but that the evidence is lacking, and if a service is offered, patients should understand the uncertainty about the balance of benefits and harms. The Task Force recognizes that clinical or policy decisions involve more consideration than their recommendations alone, and clinicians and policy makers should understand the evidence but individualize decision-making to the specific patient or situation.

Efforts have been made by clinicians to eliminate this rare disorder by applying measures to screen for and aggressively manage high bilirubin levels. Universal screening for jaundice is widespread in the United States, and clinicians and parents should continue to work together to decide whether to screen in the face of insufficient evidence. Clinicians must remain aware that screening and resulting treatment of hyperbilirubinemia have potential harms such as weight loss, gastrointestinal problems, and disruption of the mother-infant bonding.

The Task Force is the leading independent panel of experts in prevention and primary care. The Task Force, which is supported by the Agency for Healthcare Research and Quality, conducts rigorous, impartial assessments of the scientific evidence for the effectiveness of a broad range of clinical preventive services, including screening, counseling and preventive medications. Its recommendations are considered the gold standard for clinical preventive services.

http://www.ahrq.gov