Predicting the Need for Phototherapy After Discharge

Pediatrics. 2021 May;147(5):e2020019778. doi: 10.1542/peds.2020-019778.


Background and objectives: Bilirubin screening before discharge is performed to identify neonates at risk for future hyperbilirubinemia. The American Academy of Pediatrics recommends using a graph of bilirubin levels by age (the Bhutani Nomogram) to guide follow-up and a different graph to determine phototherapy recommendations. Our objective was to evaluate predictive models that incorporate the difference between the last total serum bilirubin (TSB) before discharge and the American Academy of Pediatrics phototherapy threshold (Δ-TSB) to predict a postdischarge TSB above the phototherapy threshold by using a single graph.

Methods: We studied 148 162 infants born at ≥35 weeks' gestation at 11 Kaiser Permanente Northern California facilities from 2012 to 2017 whose TSB did not exceed phototherapy levels and who did not receive phototherapy during the birth hospitalization. We compared 3 logistic models (Δ-TSB; Δ-TSB-Plus, which included additional variables; and the Bhutani Nomogram) by using the area under the receiver operating characteristic curve (AUC) in a 20% validation subset.

Results: A total of 2623 infants (1.8%) exceeded the phototherapy threshold postdischarge. The predicted probability of exceeding the phototherapy threshold after discharge ranged from 56% for a predischarge Δ-TSB 0 to 1 mg/dL below the threshold to 0.008% for Δ-TSB >7 mg/dL below the threshold. Discrimination was better for the Δ-TSB model (AUC 0.93) and the Δ-TSB-Plus model (AUC 0.95) than for the Bhutani Nomogram (AUC 0.88).

Conclusions: The use of Δ-TSB models had excellent ability to predict postdischarge TSB above phototherapy thresholds and may be simpler to use than the Bhutani Nomogram.

Keywords: AAP; AUC; American Academy of Pediatrics; DAT; KPNC; Kaiser Permanente; Northern California; ROR; TSB; area under the receiver operating characteristic curve; direct antiglobulin test; rate of rise; total serum bilirubin.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aftercare*
  • Bilirubin / blood*
  • Cohort Studies
  • Female
  • Forecasting
  • Humans
  • Infant, Newborn
  • Male
  • Models, Theoretical
  • Patient Discharge
  • Phototherapy*
  • Retrospective Studies


  • Bilirubin