3 Top Papers You May Have Missed in August 2022
Scott T. Vergano, MD
Department of Pediatrics, Children’s Hospital of The King’s Daughters, Norfolk, VA
Vergano ST. 3 top papers you may have missed in August 2022. Consultant360. Published online September 21, 2022.
For this month's column, I focus on a careful reading of the latest revision of the American Academy of Pediatrics (AAP) clinical practice guideline on the management of hyperbilirubinemia. No matter how much you know about neonatal jaundice or how long you have been treating it, I think you will learn something from a careful review of its content. In case you do not have a chance, I have shared some of the most interesting pearls that the committee has included in the statement. In addition, I briefly offer my thoughts on growing pains and on the recent case of polio in New York. Please feel free to share with your colleagues, discuss in your offices, and write to firstname.lastname@example.org with your thoughts and opinions.
Management of Hyperbilirubinemia in Infants Born at 35 Weeks or More of Gestation1
Although the most significant aspect of this publication from the AAP is the mild revision of the thresholds for initiating phototherapy in term and late-preterm infants, the clinical pearls contained within make this new clinical practice guideline worth reading. The committee updated the levels at which initiation of phototherapy is recommended. In addition to raising the levels slightly, they also stratified levels characterized by week of gestation. A quick glance at the phototherapy nomograms will reveal that values are separated by week of gestation, with different values for an infant born at 35 weeks than at 36 weeks and at 38 weeks than at 39 weeks.
Another key feature of the new guideline is the definition of an "escalation-of-care threshold", which for any neonate is a total serum bilirubin level less than 2 mg/dL below the exchange transfusion level. Such infants need to be treated and followed aggressively to avoid potential kernicterus. Recommendations include emergent intensive phototherapy, intravenous therapy fluid hydration, serial bilirubin levels at minimum every 2 hours, and consultation with a neonatologist to consider transfer to a neonatal intensive care unit capable of initiating exchange transfusion.
As mentioned, numerous pearls and nuances are included within the guideline, making it worthy of your perusal. Here are a few:
- If maternal blood type is Rh+ (so the mother does not need Rh immune globulin), determining neonate blood type is an option but is not mandatory if the rest of the guidelines are followed.
- All neonates should have a least 1 transcutaneous or serum bilirubin level measured, regardless of whether they appear to have jaundice.
- Serum bilirubin, rather than transcutaneous bilirubin, is recommended at levels greater than 15 mg/dL or within 3 mg/dL of the phototherapy threshold.
- A fractionated bilirubin level is recommended at 2 weeks of age for formula-fed infants, and at 3 to 4 weeks of age for breastfed infants, who remain jaundiced, to evaluate for direct hyperbilirubinemia.
- It is recommended to repeat an elevated direct bilirubin level within a few days, as 99% of neonates with a single elevated direct bilirubin level (>1.0 mg/dL) will not have biliary atresia.
- Prolonged indirect hyperbilirubinemia in a breastfed infant, or breastmilk jaundice, can last up to 3 months and is almost always benign.
- G6PD deficiency should be suspected in a neonate with atypical hyperbilirubinemia, which includes early, prolonged, or rapidly rising jaundice, as well as late jaundice, recurrent jaundice, or jaundice in a formula-fed neonate. In addition, testing for G6PD deficiency should be performed in any infant who requires escalation of care.
- Testing for G6PD can be falsely within normal range after an acute hemolytic event or after an exchange transfusion and should be repeated 3 months later.
- Risk of rebound hyperbilirubinemia is highest in infants with hemolytic disease or who require phototherapy during the birth hospitalization. These infants require the testing of rebound bilirubin levels. All others require clinical assessment in 1 to 2 days after discontinuation of phototherapy but do not necessarily require repeat bilirubin levels.
Defining Growing Pains2
In an effort better to define growing pains, the authors of this article in Pediatrics perform a scoping review of the literature on the somewhat nebulous topic. They searched 8 electronic databases and 6 disease classification systems and included any peer-reviewed English articles or diagnostic codes that included growing or growth pains. They examined each of the 145 studies, as well as the ICD-10 and SNOWMED codes, for its definition of the condition.
No single characteristic was cited in more than 50% of the definitions. The most consistent features included lower limb pain (referenced in 50% of the definitions), evening or nighttime pain (48%), episodic or recurrent pain (42%), normal physical exam findings (35%), and bilateral pain (31%). They conclude that their scoping review does not provide any consistent features of growing pains, and that clinicians and researchers should be cautious in drawing conclusions based upon what they consider the condition to be.
I believe that most clinicians in general practice have seen what we consider to be growing pains and that the condition is real and is common. I have always taught learners that in my definition, 4 criteria are required: (1) the pain must at some point involve both legs (it cannot be localized only to one area or one leg); (2) the pain must occur predominantly at night; (3) the pain cannot interfere with regular daytime activity; and (4) the physical exam must be normal, and in particular not involve swelling or point tenderness. Any leg pains that do not meet these criteria require further investigation. Although far less scientific than this scoping review, my 4 criteria have served me well in my clinical practice.
Public Health Response to a Case of Paralytic Poliomyelitis in an Unvaccinated Person and Detection of Poliovirus in Wastewater3
This case report published in Morbidity and Mortality Weekly Report provides details about the widely publicized case of paralytic polio in an immunocompetent unvaccinated adult in Rockland County, New York. The man, who was transferred to a rehabilitation hospital and is recovering, did not travel internationally during the transmission period and appears to have acquired the infection from a vaccine-associated strain transmitted from another individual in the community who had been vaccinated with live-attenuated polio vaccine. Investigations revealed significant vaccine-associated poliovirus strains in wastewater from Rockland and neighboring Orange counties, and substantially low polio vaccine coverage (60.3% among children less than 2 years old) in Rockland County.
The last case of wild poliovirus transmission in the United States occurred in 1979. I recall starting in practice at a time when there were 4 to 8 cases of vaccine-associated polio infections in the United States annually, which led to the removal of live-attenuated oral polio vaccine from the routine vaccine schedule in 2000. This case should serve as a warning that if we allow vaccine coverage to drop substantially, we will place our unvaccinated children and adults at risk for serious and potentially fatal diseases that have become rare at present but always remain a threat. We need to commit ourselves to educating our families and communities in order to eradicate these vaccine-preventable illnesses.
- Kemper AR, Newman TB, Slaughter JL, et al. Clinical practice guideline revision: management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics. 2022;150(3):e2022058859. doi:10.1542/peds.2022-058859
- O'Keeffe M, Kamper SJ, Montgomery L, et al. Defining growing pains: a scoping review. Pediatrics. 2022;150(2):e2021052578. doi:10.1542/peds.2021-052578
- Link-Gelles R, Lutterloh E, Schnabel Ruppert P, et al; 2022 U.S. Poliovirus Response Team. Public health response to a case of paralytic poliomyelitis in an unvaccinated person and detection of poliovirus in wastewater - New York, June-August 2022. MMWR Morb Mortal Wkly Rep. 2022;71(33):1065-1068. doi:10.15585/mmwr.mm7133e2