title: Identifying newborns at risk of significant hyperbilirubinaemia: a comparison of two recommended approaches.
abstract: OBJECTIVE
  To compare the predictive performance of clinical risk factor assessment and pre-discharge bilirubin measurement as screening tools for identifying infants at risk of developing significant neonatal hyperbilirubinaemia (post-discharge total serum bilirubin (TSB) >95th centile).
  
  
  METHODS
  Retrospective cohort study of term and near term infants born in an urban community teaching hospital in Pennsylvania (1993-97). A clinical risk factor scoring system was developed and its predictive performance compared to a pre-discharge TSB expressed as a risk zone on a bilirubin nomogram. Main outcome measures were prediction model discrimination, range of predicted probabilities, and sensitivity, specificity, positive and negative predictive values, and likelihood ratios for various positivity criteria.
  
  
  RESULTS
  The clinical risk factor scoring system developed included birth weight, gestational age <38 weeks, oxytocin use during delivery, vacuum extraction, breast feeding, and combination breast and bottle feeding. The pre-discharge bilirubin risk zone had better discrimination (c = 0.83; 95% CI 0.80 to 0.86) than the clinical risk factor score (c = 0.71; 95% CI 0.66 to 0.76) and predicted risk of significant hyperbilirubinaemia as high as 59% compared with a maximum of 44% for the clinical risk factor score. Neither the risk score nor the pre-discharge TSB risk zone predicted the outcome with > or =0.98 sensitivity without significantly compromising specificity (0.13 and 0.21, respectively). Multi-level clinical risk factor scores and TSB risk zones produced likelihood ratios of 0.15-3.25 and 0.05-9.43, respectively.
  
  
  CONCLUSIONS
  The pre-discharge bilirubin expressed as a risk zone on an hour specific bilirubin nomogram is more accurate and generates wider risk stratification than a clinical risk factor score.
authors.affiliation: Division of General Pediatrics, Pediatric Generalist Research Group, The Children's Hospital of Philadelphia, PA, USA. keren@email.chop.edu
authors.forename: R
authors.initials: R
authors.lastname: Keren
authors.forename: V K
authors.initials: VK
authors.lastname: Bhutani
authors.forename: X
authors.initials: X
authors.lastname: Luan
authors.forename: S
authors.initials: S
authors.lastname: Nihtianova
authors.forename: A
authors.initials: A
authors.lastname: Cnaan
authors.forename: J S
authors.initials: JS
authors.lastname: Schwartz
mesh_terms: D015331:Cohort Studies; D005260:Female; D006764:Hospitals, Community; D006784:Hospitals, Teaching; D006786:Hospitals, Urban; D006801:Humans; D006932:Hyperbilirubinemia / Q000175:diagnosis* / Q000209:etiology; D007231:Infant, Newborn; D008297:Male; D015997:Neonatal Screening / Q000379:methods*; D010414:Pennsylvania; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods*; D012307:Risk Factors; D012680:Sensitivity and Specificity