Prediction of significant hyperbilirubinemia using first 24 hour serum bilirubin level in healthy term neonates

Subhash Bamnawat, Sanjay Mandot, Suresh Goyal, Neetu Beniwal


Background:Hyperbilirubinemia is most common cause for readmission after early hospital discharge. Severe jaundice and even kernicterus can occur in full term healthy newborns discharged early with no apparent early findings of hemolysis. The objective of the study was to evaluate whether the first 24 hour total serum bilirubin (TSB) value can predict development of significant hyperbilirubinemia subsequently in healthy term neonates.  

Methods: A prospective study was conducted at tertiary care centre in Rajasthan, India during period of October 2010 to September 2011. Healthy full term newborns (gestational age ≥ 37 weeks) without any significant illness and Rh hemolysis were included. Serum bilirubin was estimated in all included neonates within 18 to 30 (24±6 hour) hour of life using Diazo method (absorbance at 552 nm). The neonates were followed up clinically using Kramer’s rule (after first bilirubin estimation at 24 hours of age) every 12 hour till discharge and recalled at fifth day of life after discharge. TSB estimation was repeated on fifth day of life or early (if clinical assessment of jaundice >10 mg/dl before discharge of baby). Hyperbilirubinemia was defined as TSB level >12mg/dl at 25 to 48 hour of life, >15 mg/dl between 49 to 72 hours, and >17 mg/dl beyond 72 hours of life.

Results:A total of 100 neonates were enrolled in the study. Of these, 12 neonates developed hyperbilirubinemia. The mean first 24 hour TSB value in the neonates who subsequently developed hyperbilirubinemia was 7.03±1.10 mg/dl as compared to a value of 5.22±1.61 mg/dl in those who did not develop hyperbilirubinemia subsequently. The difference was significant (p <0.001). Using Receiver operating characteristic (ROC) curve analysis, a value of 6 mg/dl (first 24 hour TSB) was determined to have the best predictive ability for subsequent hyperbilirubinemia. A TSB level of  < 6 mg/dl at 24±6 hour was present in 65 neonates  and only 2 neonates developed hyperbilirubinemia subsequently, In the remaining 35 neonates with TSB >6 mg/dl, subsequent hyperbilirubinemia developed in 10. (Sensitivity 83.33%, specificity 71.59, positive predictive value 28.57%, negative predictive value 96.92%).

Conclusions:Estimation of first day TSB level can help in prediction of neonates who would and who would not develop subsequent hyperbilirubinemia. Neonates with the first day TSB level of less than 6 mg/dl have minimum risk of subsequent hyperbilirubinemia.  


Hyperbilirubinemia, Neonates, Serum bilirubin

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Behrman RE, Kliegman RM, Stanton BF, Schor NF. Jaundice and hyperbilirubinemia in newborn. In. Nelson textbook of pediatrics. 19th ed. Philadelphia: Saunders, 2012: 605-12.

Narang A, Gathwala G, Kumar P. Neonatal Jaundice: An analysis of 551 cases. Indian Pediatr. 1997;34:429-32.

Singhal PK, Singh M, Paul VK, Deorari AK, Ghorpade MG. Spectrum of neonatal hyperbilirubinemia: an analysis of 454 cases. Indian Pediatr. 1992;29:319-25.

Brown AK, Johnson L. Loss of concern about jaundice and the reemergence of kernicterus in the era of managed care. In: Fanroff AA, Klaus MH, Eds. The Year Book of Neonatal and Perinatal Medicine. Philadelphia; Mosby. 1996:17-28.

Maisels MJ, Newman TB. Kernicterus in otherwise healthy, breast-fed term neonates. Pediatrics. 1995;96:730-3.

American academy of pediatrics. Practice parameter: Management of hyper-bilirubinemia in the healthy team newborn. Pediatrics. 1994;94:558-67.

Kramer LI. Advancement of dermal icterus in the jaundiced newborn. Amer J Dis Child. 1969;118:454-8.

Bhutani VK, Johnson L, Sivieri EM. Predictive ability of a predischarge hour - specific serum bilirubin for subsequent significant hyperbilirubinemia in healthy term and near term newborns. Pediatrics. 1999;103:6-14.

Alpay F, Sarici SU, Tosuncuk HD, Serdar MA, Inanc N, Gokcay E. The value of first day bilirubin measurement in predicting the development of significant hyperbilirubinemia in healthy term newborns. Pediatrics. 2000;106:16.

Awasthi S, Rehman H. Early prediction of neonatal hyperbilirubinemia. Indian J Pediatr. 1998;65:131-9.

Agarwal R, Kaushal M, Agarwal R, Paul VK, Deorari AK. Early neonatal hyperbilirubinemia using first day serum bilirubin level. Indian Pediatrics. 2002;39:724-30.