R. M. Dorman1, C. D. Dekonenko1, J. A. Sobrino1, J. R. Noel-MacDonnell2,3, T. A. Oyetunji1,4 1Children’s Mercy Hospital- University Of Missouri Kansas City,Department Of General And Thoracic Surgery,Kansas City, MO, USA 2Children’s Mercy Hospital- University Of Missouri Kansas City,Department Of Health Services And Outcomes Research,Kansas City, MO, USA 3University of Kansas Medical Center,Department Of Biostatistics,Kansas City, KS, USA 4University of Missouri – Kansas City School of Medicine,Department Of Pediatrics,Kansas City, MO, USA
Introduction: Hypertrophic pyloric stenosis (HPS) has historically been associated with the finding of clinical jaundice at presentation in 2-8% of children. Research has suggested that this usually represents either physiologic neonatal jaundice or the unmasking of Gilbert’s syndrome by the fasting and stress that accompany HPS. The role of routine bilirubin testing in children presenting with HPS however remains unknown. We sought to determine the prevalence of bilirubin testing in a population of children undergoing pyloromyotomy, what the distribution of these values was, and whether these data might prompt additional care.
Methods: The pediatric NSQIP database (2012-2015) was queried for children who had undergone pyloromyotomy and had a postoperative diagnosis of HPS. Demographic variables and bilirubin values were compared and investigated for their effect on length of stay (LOS) and readmission. Descriptive, comparative, and regression analyses were completed in STATA v15 and Minitab 18.
Results: Of 5,294 children who met inclusion criteria, 83% were male, 62% were white, median gestational age at birth was 39 weeks (IQR 38, 40), and median age at operation was 35 days (IQR 27, 47). Twenty-five percent of the subjects had a preoperative bilirubin value recorded. Median total bilirubin was 2.0 mg/dL (IQR 1.0, 4.6). Only 10% of reported values were >9mg/dL with a maximum of 15.0 mg/mL. At 4 weeks, where there is overlap with published data from healthy newborns, our 50th and 95th percentiles were 3.5 mg/dL (95% CI 3.1-3.9) and 11.6 mg/dL (95% CI 10.4-12.9), compared with 2.6 and 10.9 mg/dL in the nomogram from Maisels et al (fig). Bilirubin level, controlled for sex and race, was not significantly associated with LOS or readmission.
Conclusion: We found that one in four children who underwent pyloromyotomy also had a total bilirubin checked. Based on historical incidence of jaundice in children with HPS, the majority of testing was likely in children without clinical jaundice. Preoperative bilirubin values among those tested decreased exponentially with increased age at operation, paralleling the natural history of physiologic hyperbilirubinemia in other newborns. Severe hyperbilirubinemia was rare in this population and the degree of bilirubin elevation did not correspond with additional days of care. A diagnosis of HPS alone in the absence of clinical suspicion does not warrant bilirubin testing, and is probably overused in this population.
