Outpatient management of jaundice needed to lessen paediatric ED visits

Neonatal jaundice (NNJ) and pyrexia (NNP) are the most common diagnoses in the paediatric emergency department (PED) and during discharge from the hospital, a Singapore study has observed. In addition, the rates of hospital admission and referral from polyclinics and other clinics are higher than those in other series, driven by different healthcare structure, protocols, and workflows in the different studies.

“These findings suggest that more robust infrastructure for community paediatrics, coordinated care programmes, and potential facilities for outpatient management of jaundice in newborns can be considered to minimize PED visits and hospitalizations and the consequent exposure of neonates to these infective environments,” the researchers said.

This retrospective analysis included 1,200 neonates (aged <28 days) presenting to the PEDs over 7 months. The researchers analysed the associations between the clinical and demographic data of admissions to the PED and inpatient admissions.

Of the neonates analysed, 79.4 percent presented at <15 days since birth. Length of stay in the PED was <4 hours for most of the patients (94.0 percent), with non-P1 cases forming the predominant triage categories (97.5 percent). [Singapore Med J 2021;doi: 10.11622/smedj.2021160]

The main PED diagnoses were NNJ (66.8 percent), followed by NNP (14.6 percent), which paralleled the main diagnoses upon hospital discharge (NNJ: 68.4 percent; NNP: 19.6 percent). Nearly half of neonates (48.2 percent) were referred from polyclinics or other clinics, and majority of these patients (57.7 percent) were admitted to the hospital.

“In terms of presenting complaints, NNJ was the most common, a similar finding when compared to other series,” the researchers said. “In terms of the eventual diagnosis, NNJ and NNP were the most common diagnoses at the end of the PED consultation in our study.” [Arch Dis Child 2005;90:125-131; Pediatr Emerg Care 2009;25:244-248; Pediatr Emerg Care 2000;16:145-150]

Of note, most of the healthy babies (87.0 percent) who presented to the ED were taken there due to parental concerns, with no prior consultation with the doctor.

“Given that the PED in a tertiary centre should be utilized judiciously for more serious or urgent pathologies, these high rates of self-referrals for well babies could imply childcare doubts and unfamiliarity among caregivers, especially first-time parents, regarding the physiological characteristics of newborns,” the researchers said. [An Pediatr (Barc) 2006;65:123-128]

“Outpatient management of NNJ can be considered. Caregivers should be provided better education regarding normal physiological characteristics of newborns through standardized educational materials,” they suggested.

Compared to other countries (ie, Spain, Canada, and Portugal) where PED visits are free or heavily insured, those in Singapore are not. In these Western countries, parents of neonates may go straight to the PED, where more specialized paediatric care and diagnostic tools are available, instead of seeing a general practitioner first. This results in an overall lower rate of referral to the PED from primary care.

The current study was limited by missing data on neonatal demographics, mortality, and long-term morbidity. The researchers also did not make corrections for multiple comparisons of some of the statistical observations, which could then limit the validity of the findings.