Evaluation and Management of Newborn Jaundice by Midwest Family Physicians

Journal of Family Practice, Dec, 1998 by Diane J. Madlon-Kay

BACKGROUND. Recognition and management of newborn jaundice is controversial and even more challenging with the early discharge of newborns. The purpose of this study was to describe the jaundice management patterns of family physicians in Minnesota and Wisconsin and compare them with American Academy of Pediatrics recommendations.

METHODS. Forty-two members of the Practice-Based Research Group of the Wisconsin Research Network and of the Minnesota Academy of Family Physicians Research Network recorded information on study cards about the care they provided to healthy full-term newborns for 6 months.

RESULTS. Data was collected on 335 infants, 30% of whom were jaundiced. Physicians ordered limited laboratory testing on selected jaundiced infants. Infants with jaundice were more frequently breast-fed, and had longer hospital stays. Jaundice was commonly managed by phototherapy (17%), home sunlight (28%), and increased breast-feeding (44%). Twenty-six percent of the physicians used a formal phototherapy guideline. The timing of the first follow-up visit did not differ for infants discharged before or after 48 hours of age.

CONCLUSIONS. Family physicians identified and managed newborn jaundice relatively infrequently in our study. Their practice patterns were consistent with most aspects of the American Academy of Pediatrics jaundice guideline, although few of them used it to guide phototherapy use. The study physicians did not generally follow recommendations for follow-up of infants discharged early. Until a large-scale clinical trial of newborn jaundice management is performed, a variety of practices should continue to be acceptable.

KEY WORDS. Jaundice, neonatal; hyperbilirubinemia; practice patterns; physicians, family. (J Fam Pract 1998; 47:461-464)

Approximately 60% of newborns in the United States become clinically jaundiced.[1] The appropriate evaluation and treatment of neonatal jaundice, particularly in the healthy full-term newborn, has been the subject of long-standing controversy. In recent years, jaundice management has become even more challenging with the early discharge of newborns, typically before their jaundice has peaked. Moreover, there have been disturbing reports of increasing severity of jaundice and a reemergence of kernicterus in association with decreasing hospital stays.[2] Not surprisingly, a 1992 survey of American Academy of Pediatrics (AAP) fellows demonstrated a wide range of practice in the treatment of a hypothetical case of a healthy full-term newborn with hyperbilirubinemia.[3]

In October 1994, the AAP published a practice guideline, "Management of Hyperbilirubinemia in the Healthy Term Newborn."[1] The guideline was also published in the American Academy of Family Physicians' journal 3 months later. Some critics have questioned the evidence cited in defense of this guideline.[4] Because no large-scale clinical trial of treatment of full-term newborns with jaundice has ever been undertaken, the evidence cited to support the guideline was primarily retrospective epidemiologic data.[1] In addition, the guideline has been criticized because no formal pilot studies were done to measure its impact.[4] The AAP plans another survey of its fellows' practice patterns in neonatal hyperbilirubinemia in the future.[3]

No studies have been reported to date on physicians' practice patterns regarding neonatal jaundice since the publication of the AAP guideline, and, although 65% of family physicians perform newborn care in the hospital, no studies of their management of jaundice have ever been reported.[5] The purpose of our study was to describe jaundice management patterns of family physicians in Minnesota and Wisconsin when they were providing care for healthy full-term newborns.

METHODS

Members of the Minnesota Academy of Family Physicians Research Network and members of the Practice Based Research group of the Wisconsin Research Network were invited to participate in the study. Participants first completed a brief demographic survey. They then collected data about the healthy full-term newborns they cared for in the nursery and for whom follow-up information was available for the infants' first 2 weeks of life. Participants documented study data by checkmarks on pocket-sized cards that were mailed and returned on a monthly basis for 6 months in 1997. The following data were collected for all study infants: feeding method, age at discharge, age at and location of first follow-up visit, and whether the infant was ever jaundiced. For jaundiced infants, the following data was collected: method of determining jaundice severity, laboratory tests performed, jaundice management, and mother's blood type. Statistical analysis was performed by chi-square tests and analysis of variance.

RESULTS

Forty-two family physicians participated in the study; 32 practiced in Minnesota, 10 in Wisconsin. Sixty-two percent of the physicians were men; the mean age of the entire group was 39 years. Eighty-six percent were residency trained and board certified. Their practice locations were: 42% rural, 26% large city, 19% suburban, and 12% small city. Most participants practiced in a family practice group (36%), multispecialty clinic (31%), or residency clinic (24%). Eleven (26%) physicians reported using a written guideline when deciding whether to start phototherapy. Only 4 (10%) used the AAP phototherapy guideline.[1]