Effect of Neonatal Jaundice and Phototherapy on the Frequency of First-Year Outpatient Visits

Effect of Neonatal Jaundice and Phototherapy on the Frequencyof First-Year Outpatient Visits

Danielle Usatin, BAa, Petra Liljestrand, PhDb,c, Michael W. Kuzniewicz, MD, MPHc,d, GabrielJ. Escobar, MDc,e, and Thomas B. Newman, MD, MPHb,c,d

aAlbert Einstein College of Medicine, Bronx, New YorkbDepartment of Epidemiology and Biostatistics, School of Medicine, University of California, SanFrancisco, San Francisco, CaliforniacDivision of Research, Kaiser Permanente Medical Care Program, Oakland, CaliforniadDepartment of Pediatrics, School of Medicine, University of California, San Francisco, SanFrancisco, CaliforniaeDepartment of Pediatrics, Kaiser Permanente Medical Center, Walnut Creek, California

AbstractObjective—The objective of this study was to determine whether either hyperbilirubinemia orinpatient phototherapy is associated with increased subsequent outpatient visit rates, a possibleeffect of the “vulnerable child syndrome.”

Methods—We compared 3 groups of otherwise well term and late-preterm infants who wereborn between 1995 and 2004 in Northern California Kaiser hospitals: group 1 never had adocumented total serum bilirubin (TSB) level ≥12 mg/dL (n = 128 417); group 2 had a TSB level≥17 and <23 mg/dL as outpatients between 48 hours and 7 days of age and did not receiveinpatient phototherapy (n = 6777); and group 3 met criteria for group 2 but did receive inpatientphototherapy (n = 1765). We compared outpatient visit rates from 15 to 364 days of age adjustingfor other predictors of visit rates by using Poisson and linear regression.

Results—The mean total number of visits between 15 and 364 days was 9.83. Compared withgroup 1, adjusted total first-year visit rates were slightly increased in group 2 (adjusted incidencerate ratio: 1.04 [95% confidence interval: 1.02–1.05]) and group 3 (incidence rate ratio: 1.07 [95%confidence interval: 1.05–1.10]). The increases in visit rates were greatest for visits from 15 to 59days of age, for specialty visits, and for unspecified diagnoses. These rates correspond to adjustedincreases in total first-year visits (compared with group 1) of 0.36 visits in group 2 and 0.73 visitsin group 3.

Conclusions—Neonatal jaundice and inpatient phototherapy are associated with only smallincreases in first-year outpatient visit rates, consistent with mild or infrequent contribution to thevulnerable child syndrome in this population.

Copyright © 2010 by the American Academy of PediatricsAddress correspondence to Thomas B. Newman, MD, MPH, Department of Epidemiology and Biostatistics, UCSF Box 0560, SanFrancisco, CA 94143. newman@epi.ucsf.edu.This work was presented at the annual meeting of the Pediatric Academic Societies; May 5, 2008; Honolulu, HI.Financial Disclosure: The authors have indicated they have no financial relationships relevant to this article to disclose.

NIH Public AccessAuthor ManuscriptPediatrics. Author manuscript; available in PMC 2011 October 21.

Published in final edited form as:Pediatrics. 2010 April ; 125(4): 729–734. doi:10.1542/peds.2009-0172.

-PA Author Manuscript

Keywordschild health services/utilization; disease susceptibility/psychology; jaundice; neonatal/therapy;mother-child relations; phototherapy/adverse effects

Approximately 60% of newborns develop jaundice in the first few days after birth.1Although in most cases jaundice is harmless, the need to monitor bilirubin levels withrepeated visits and blood draws and occasionally to readmit infants to the hospital forphototherapy may cause parental anxiety and adversely affect the parent–infantrelationship.2,3 Mothers, including those with previous experience with neonatal jaundice,may feel at fault for having caused the jaundice, worry when total serum bilirubin (TSB)levels increase, and have difficulty bonding with their infants.4

Green and Solnit5 first coined the term “vulnerable child syndrome” in 1964 to refer to apattern of parental overprotection and excessive medical concerns that followed children'srecovery from life-threatening illness. Subsequent work has found that children may beperceived as vulnerable after less serious illnesses or events, even as minor as a febrileillness that led to a negative lumbar puncture,6 sickle cell trait,6,7 or a false-positive result onnewborn screening.8–10 Indeed, Shonkoff,11 commenting on Green and Solnit's classicarticle 34 years later, wrote, “The most important contribution of this report is the extent towhich it underscores the critical importance of what physicians say (and don't say) toparents. . . . Anything that a pediatrician conveys to a mother or father, whether it is thoughtthrough clearly or not, can have enormous impact on them and their children. Moreover, theeffect may not only be immediate, but it often can be long-lasting.”

Previous studies have raised concern that neonatal jaundice may be a cause of the vulnerablechild syndrome. Kemper et al2,3 found that mothers of infants with jaundice (TSB ≥12 mg/dL) were less likely than mothers of control infants to leave their infants with another personand more likely to bring them for well-child, sick, and emergency department (ED) visits.Such disproportionate use of health care resources by children who are perceived asvulnerable has been reported by others as well6,12–15 and is 1 of the hallmarks of thevulnerable child syndrome.16

The studies of Kemper et al2,3 included only 85 infants who had jaundice and were born in1987 and 1988. Our access to an integrated health care delivery system has allowed us toanalyze data for a larger and more recent cohort of infants who were born in a setting inwhich considerable variation in the use of phototherapy has been documented.17 Althoughthis study based on electronically available data cannot assess parental perceptions ofvulnerability directly, our very large sample size allows us to quantify precisely andobjectively 1 important manifestation of perceived vulnerability: increased use of outpatientservices for sick- and well-child care. Thus, the main goal of this study was to determine, byusing a more recent cohort, whether either neonatal hyperbilirubinemia or its treatment withinpatient phototherapy is associated with an increase in subsequent outpatient visit rates.

MethodsThe study was approved by the Kaiser Permanente Medical Care Program (KPMCP) and theUniversity of California, San Francisco, institutional review boards for the protection ofhuman subjects. This was a retrospective cohort study of children who were born in theNorthern California KPMCP hospitals between 1995 and 2004. We obtained data fromKPMCP demographic, laboratory, outpatient visit, and hospitalization databases asdescribed elsewhere.18–20

Usatin et al. Page 2

Pediatrics. Author manuscript; available in PMC 2011 October 21.

PatientsEligible patients were infants with gestational age ≥36 weeks and birth weight ≥2000 g. Toidentify a group of infants with otherwise uncomplicated nursery stays, we excludednewborns who received phototherapy during their birth hospitalization, those with a birthhospitalization length of stay >48 hours, or a conjugated or direct bilirubin level ≥2 mg/dLin the first 30 days after birth. Patients were eligible when they either never had a TSB level≥12 mg/dL or when they had a TSB level ≥17and <23 mg/dL at 2 to 7 days (48–168 hours)after birth. This range was selected to identify a range at which phototherapy might bediscretionary; we therefore excluded infants who previously had a TSB level ≥23 mg/dL,because the vast majority would be expected to receive phototherapy. To avoid includinginfants who might be perceived as vulnerable for other reasons or who might have had anunusually complicated treatment course for neonatal jaundice, we excluded those who wererehospitalized for any reason with a length of stay ≥96 hours within the first 14 days afterbirth. To restrict attention to infants who were likely to have been covered by the health planfor their first year, we included only patients with at least 4 outpatient visits in first year andat least 1 visit in the second year after birth.

Predictor VariablesThe main predictor variable—study group—was determined from TSB levels and whetherthere was a rehospitalization with a procedure code for phototherapy. Phototherapyprocedure codes in this data set are ∼90.5% sensitive and 100% specific compared withchart review.20 Other predictor (potentially confounding) variables included in multivariableanalyses were the mother's age and the infant's year, month, and facility of birth; gestationalage; gender; and race. For comparisons between groups that did and did not receivephototherapy, we also included the TSB level that qualified the infant for the study(dichotomized at 17.0–19.9 and 20.0–22.9 mg/dL).

Outcome VariablesOur principal outcome variables were the total numbers of various types of outpatient visitsat the following ages (in days): 15 to 59, 60 to 119, 120 to 179, 180 to 364, and total (15 to364). We did not consider visits at <15 days because visits for follow-up of jaundice wouldbe expected during that period. We grouped the visits into ED, specialty, well-child, andillness on the basis of the department and the first 5 International Classification of Diseases,Ninth Revision (ICD-9) codes for the visit diagnoses by using the following classificationhierarchy: (1) any visit to the ED was coded as ED regardless of ICD-9 code; (2) all visits todepartments coded neither as ED nor as pediatrics were categorized as specialty visits; and(3) all pediatrics visits were classified as well-child or illness on the basis of ICD-9 codes.Well-child included those with ICD-9 codes V20.1 (routine child health examination),V20.2 (care of healthy child), V40.9 (mental behavioral problem), V65.3 (dietarysurveillance and counseling), V65.43 (counseling for injury prevention), V65.49 (otherspecified counseling), V67.9 (follow-up examination), V68.9 (administrative encounter), orV70.9 (general medical examination). The illness category included all pediatrics visits thatwere not coded as well-child visits as defined.

Data AnalysisWe compared demographic and clinical characteristics of infants in the 3 study groups byusing t tests, rank sum, or χ2 test as appropriate. To quantify the effects of jaundice andphototherapy on outpatient visit rates, we used Poisson regression. We examined rates forthe 5 types of outpatient visits in the 4 age groups, controlling for the potential confounderslisted already and accounting for clustering of visits by infant. Poisson regression yields anadjusted incidence rate ratio (IRR), which is the ratio of the estimated underlying probability

of a visit during a short period in 1 group compared with another, adjusting for confoundingvariables. For comparisons of visit types associated with the 8 most common outpatientdiagnoses, we calculated the adjusted effects of study groups and corresponding P values byusing multiple linear regression models that included the same confounding variables listedalready.

We did not adjust for multiple comparisons,21 but P values and confidence intervals shouldbe interpreted with awareness that we compared 5 visit types and 4 time periods and 8different diagnoses in 3 groups of patients. All statistical analyses were performed by usingStata 9.2 (Stata Corp, College Station, TX).

ResultsFigure 1 shows how the 3 study groups were extracted from the KPMCP birth cohort. Table1 compares the demographic characteristics of the 128 417 infants who never had a TSBlevel ≥12 mg/dL (group 1), the 6777 infants who had TSB levels of 17.0 to 22.9 mg/dL andwere not rehospitalized for phototherapy (group 2), and the 1765 infants who werereshospitalized (group 3). Groups 2 and 3 had slightly lower birth weight and gestationalage, a higher proportion of Asian infants, and older mothers than group 1, with thedifferences greater in group 3 than in group 2, consistent with their significantly highermaximum TSB levels. The average total number of outpatient visits from 15 to 364 dayswas 9.83 ± 4.90 (mean ± SD; Table 2); however, the number of outpatient visits variedwidely within each visit type and age bracket. For example, for the ED visit type, the meanwas typically close to 0 (eg, the mean for the 15- to 59-day age range was 0.03 visits) butwith an SD much larger than the mean (±0.19), indicating that the distribution of numbers ofED visits were skewed to the right.

We found a small increase in total outpatient visit rates in group 2 compared with group 1(overall adjusted IRR for days 15–364: 1.04 [95% CI: 1.02–1.05]). There was a slightlysmaller additional increase with rehospitalization for phototherapy (adjusted IRR for group 3versus group 2: 1.03 [95% CI: 1.01–1.06]). This corresponds to adjusted increases in totalfirst-year visits, when compared with group 1, of 0.36 visits in group 2 and 0.73 visits ingroup 3. Both increases in rates were greatest between 15 and 59 days after birth; theadditional effect of phototherapy in infants with jaundice (ie, comparison of group 3 andgroup 2) was not statistically significant in any of the other individual periods.

The visit type that was associated with the largest increase in visit rates was specialty visits(Table 3), with the effect apparently attributable to jaundice itself (group 2 versus group 1IRR: 1.17 [95% CI: 1.08 –1.97]), with little or no additional increase with phototherapy(group 3 versus group 2 IRR: 1.02 [95% CI: 0.87–1.19]; Table 3). The increase in specialtyvisits in group 2 versus group 1 was statistically significant and of similar magnitude in eachof the 4 periods (IRR range: 1.14–1.20). (Full cross-tabulations of adjusted IRRs by visittype and age group are available from the authors.) In models that examined the effect ofphototherapy in the infants with jaundice (ie, comparing group 3 with group 2), there was nosignificant difference in any of the outcomes when the TSB level that qualified the infant forthe study was 20.0 to 22.9 vs 17.0 to 19.9 mg/dL.

The average number of outpatient visits for most of the 8 most common sick-visit diagnosiscodes did not vary by phototherapy use (Table 4). Only 1 diagnosis code, that for“unspecified morbidity,” had a difference of at least 0.1 visits in the first year between group1 and groups 2 and 3; this is the code given when the physician writes text rather thanchecks a box on the encounter form. There was a statistically significant increase in visitsfor “viral illness” in the phototherapy group compared with the group without jaundice, but

the magnitude of the difference was small (adjusted difference: 0.048 visits [95% CI: 0.016–0.079]).

DiscussionWe observed only a small increase in first-year outpatient visit rates in infants withhyperbilirubinemia, with the increase only slightly larger in those who receivedphototherapy than in those who did not. The increase in visit rates was greatest from 15 to59 days of age, and specialty and illness visit rates were increased more than well-child orED visit rates. A strength of this study is the large sample size, permitting narrow CIsaround estimates of these small effects.

The study also has potential limitations. First, other factors that are associated with eitherjaundice or phototherapy might also be associated with subsequent outpatient use. The mostimportant predictor of jaundice that we could not include in our models is breastfeeding.Breastfeeding provides protection against infectious diseases and therefore might beexpected to attenuate any positive association between jaundice and subsequent visit rates.Thus, if infants with jaundice were more likely to be breastfed and if jaundice led todiscontinuation of breastfeeding (as it often did in the study by Kemper et al2), then thebeneficial effect of breastfeeding on visit rates would be diminished or even reversed ininfants with jaundice. The comparison between infants who had jaundice and did and did notget phototherapy could be similarly affected if phototherapy (more than just jaundice) led todiscontinuation of breast-feeding. In addition, that comparison could be confounded byparental anxiety. For example, if newborns of anxious parents were more likely to receivephototherapy at a given bilirubin level and gestational age, then there could be a subsequentincrease in outpatient visits as a result of this parental anxiety, rather than of a causal effectof phototherapy itself; however, given the small magnitude of the differences that weobserved, it seems unlikely that significant confounding by either breast-feeding or parentalanxiety occurred.

Second, we studied infants who remained in the KPMCP for at least 1 year after birth. It ispossible that some of the patients who left the system experienced different perceptions ofvulnerability than those who remained in the health plan. Third, the particular visit type thatwas associated with the highest IRR, specialty visits, was the type of visit that we a prioribelieved was least likely to be affected by the vulnerable child syndrome. In the study byKemper et al,2 infants with jaundice had an excess of well-child visits, sick visits, and EDvisits; specialty visits were not mentioned. Because specialty visits often involve a referralfrom the primary care provider, they seem less likely to be affected by parental anxiety.Because we excluded infants with high conjugated bilirubin levels and the increase inspecialty visits was not greater in the lowest age groups, it seems unlikely that a significantnumber of these specialty visits were directly related to jaundice. It seems more likely thatthey may have been related to physician anxiety or practice style (ie, physicians with a lowerthreshold for admission for phototherapy may have a lower threshold for subspecialtyreferral as well).

Finally, although the use of electronic data allowed a large sample size, it did not allow us toaddress directly the vulnerable child syndrome but rather just 1 manifestation of it: increasedoutpatient use. The small increase in outpatient visits that we observed does not rule out thepresence of parental fear and vulnerable child syndrome sequelae in the parent-childrelationship at home. For example, other aspects of the vulnerable child syndrome found byKemper et al, such as reluctance to leave the child with a baby-sitter, were not examined inthis study and might be greater in magnitude.

Although statistically significant, the differences that we observed in this study were muchsmaller than those reported by Kemper et al.2 At 1 month of age, infants with jaundice inthat study had risk ratios of 4.1 for >2 well-child visits, 3.1 for >1 sick visit, and 8 for anyED visit. Risk ratios for excessive well-child and sick visits and any ED visits had declinedto 1.2, 1.3, and 2.4, respectively, by 6 months in that study, with only the last stillstatistically significant,3 but were still much higher than the rate ratios observed in thisstudy. One reason for this may be that as a result of previous studies highlighting concernabout the vulnerable child syndrome (cited in the American Academy of Pediatrics 1994guideline1), clinicians who cared for the newborns in this study were sensitive to thatpossibility and were able to explain the importance of follow-up and/or phototherapy forjaundice while at the same time providing reassurance about the lack of any late sequelae.22

Despite the limitations of our study, our data will help to guide physicians in the future whenmaking decisions about phototherapy. Although clinicians should remain sensitive to thepossibility of the vulnerable child syndrome to avoid overly alarming parents of infants withjaundice, the small effect size and narrow CIs in this study suggest that concern about thedevelopment of vulnerable child syndrome should not discourage close follow-up or use ofphototherapy for infants with jaundiced when it is indicated.

AcknowledgmentsThis work was supported by grant 1 RO1 HD047557-01A1 from the Eunice Kennedy Shriver National Institute ofChild Health and Human Development. Dr Kuzniewicz was supported by a grant from the Glaser PediatricResearch Network.

References1. Practice parameter: management of hyperbilirubinemia in the healthy term newborn. American

Academy of Pediatrics. Provisional Committee for Quality Improvement and Subcommittee onHyperbilirubinemia [published correction appears in Pediatrics. 1995;95(3):458–461]. Pediatrics.1994; 94(4 pt 1):558–665. [PubMed: 7755691]

2. Kemper K, Forsyth B, McCarthy P. Jaundice, terminating breast-feeding, and the vulnerable child.Pediatrics. 1989; 84(5):773–778. [PubMed: 2797972]

3. Kemper KJ, Forsyth BW, McCarthy PL. Persistent perceptions of vulnerability following neonataljaundice. Am J Dis Child. 1990; 144(2):238–241. [PubMed: 2301331]

4. Hannon PR, Willis SK, Scrimshaw SC. Persistence of maternal concerns surrounding neonataljaundice: an exploratory study. Arch Pediatr Adolesc Med. 2001; 155(12):1357–1363. [PubMed:11732956]

5. Green M, Solnit A. Reactions to the threatened loss of a child: a vulnerable child syndrome—pediatric management of the dying child, part III. Pediatrics. 1964; 34:58–66. [PubMed: 14181986]

6. Levy JC. Vulnerable children: parents' perspectives and the use of medical care. Pediatrics. 1980;65(5):956–963. [PubMed: 7367141]

7. Hampton ML. Sickle cell “nondisease”: a potentially serious public health problem. Am J Dis Child.1974; 128(1):58–61.

8. Tymstra T. False positive results in screening tests: experiences of parents of children screened forcongenital hypothyroidism. Fam Pract. 1986; 3(2):92–96. [PubMed: 3721101]

9. Fyrö K, Bodegard G. Four-year follow-up of psychological reactions to false positive screening testsfor congenital hypothyroidism. Acta Paediatr Scand. 1987; 76(1):107–114. [PubMed: 3564986]

10. Gurian EA, Kinnamon DD, Henry JJ, Waisbren SE. Expanded newborn screening for biochemicaldisorders: the effect of a false-positive result. Pediatrics. 2006; 117(6):1915–1921. [PubMed:16740831]

11. Shonkoff CJ. Reactions to the threatened loss of a child: a vulnerable child syndrome, by MorrisGreen, MD, and Albert A. Solnit, MD, Pediatrics, 1964;34:58–66. Pediatrics. 1998; 102(1 pt 2):239–241. [PubMed: 9651442]

12. Forsyth BW, Horwitz SM, Leventhal JM, Burger J, Leaf PJ. The child vulnerability scale: aninstrument to measure parental perceptions of child vulnerability. J Pediatr Psychol. 1996; 21(1):89–101. [PubMed: 8820075]

13. Forsyth BW, Canny PF. Perceptions of vulnerability 3 1/2 years after problems of feeding andcrying behavior in early infancy. Pediatrics. 1991; 88(4):757–763. [PubMed: 1896279]

14. Spurrier NJ, Sawyer MG, Staugas R, Martin AJ, Kennedy D, Streiner DL. Association betweenparental perception of children's vulnerability to illness and management of children's asthma.Pediatr Pulmonol. 2000; 29(2):88–93. [PubMed: 10639198]

15. Thomasgard M, Metz WP. Differences in health care utilization between parents who perceivetheir child as vulnerable versus overprotective parents. Clin Pediatr (Phila). 1996; 35(6):303–308.[PubMed: 8782954]

16. Kokotos F. The vulnerable child syndrome. Pediatr Rev. 2009; 30(5):193–194. [PubMed:19411339]

17. Atkinson, L.; Escobar, G.; Takayama, J.; Newman, T. Phototherapy use in jaundiced newborns in alarge managed care organization: do physicians adhere to the guideline?. Pediatrics. 2003.Available at: www.pediatrics.org/cgi/content/full/111/5/e555

18. Newman TB, Escobar GJ, Gonzales V, Armstrong MA, Gardner M, Folck B. Frequency ofneonatal bilirubin testing and hyperbilirubinemia in a large health maintenance organization[published correction appears in Pediatrics. 2001;1(2):126]. Pediatrics. 1999; 104(5 pt 2):1198–1203. [PubMed: 10545573]

19. Newman TB, Liljestrand P, Escobar GJ. Combining clinical risk factors with serum bilirubin levelsto predict hyperbilirubinemia in newborns. Arch Pediatr Adolesc Med. 2005; 159(2):113–119.[PubMed: 15699303]

20. Newman TB, Kuzniewicz MW, Liljestrand P, Wi S, McCulloch C, Escobar GJ. Numbers neededto treat with phototherapy according to American Academy of Pediatrics guidelines. Pediatrics.2009; 123(5):1352–1359. [PubMed: 19403502]

21. Newman, TB.; Kohn, MA. Evidence-based Diagnosis. New York, NY: Cambridge UniversityPress; 2009. p. 220-238.

22. Newman TB, Liljestrand P, Jeremy RJ, et al. Outcomes among newborns with total serum bilirubinlevels of 25 mg per deciliter or more. N Engl J Med. 2006; 354(18):1889–1900. [PubMed:16672700]

Abbreviations

TSB total serum bilirubin

ED emergency department

KPMCP Kaiser Permanente Medical Care Program

ICD-9 International Classification of Diseases, Ninth Revision

IRR incidence rate ratio

CI confidence interval

What's Known on This Subject

Previous studies found that neonatal jaundice was associated with increased parentalperceptions of infant vulnerability and significantly increased outpatient visit rates. It wasnot known whether these effects would be seen in a more recent cohort of infants.

What This Study Adds

Compared with infants who never had a bilirubin level >12 mg/dL, infants with bilirubinlevels of 17.0 to 22.9 mg/dL averaged only 0.36 extra first-year visits when they did notreceive phototherapy and 0.73 extra visits when they did.

FIGURE 1.Definition of the study groups.

TABLE 1Demographic Characteristics of Study Subjects

Characteristic Group 1(n = 128 417)

Group 2(n = 6777)

Group 3(n = 1765)

Male, n (%) 62 573 (49) 3878 (57) 985 (56) .290

Race, n (%) .030

White 61 700 (48) 2667 (39) 690 (39)

Asian 20 080 (16) 1963 (29) 569 (32)

Hispanic 29 060 (23) 1517 (22) 353 (20)

Black 9791 (8) 210 (3) 63 (4)

Other 5039 (4) 269 (4) 59 (3)

Missing 2747 (2) 161 (2) 31 (2)

Year of birth, % .180

1995–1999 53 49 47

2000–2004 47 51 53

Gestational age, mean ± SD, wk 39.44 ± 1.17 38.78 ± 1.30 38.52 ± 1.37 <.001

Birth weight, mean ± SD, kg 3.49 ± 0.46 3.40 ± 0.46 3.37 ± 0.48 .003

Mother's age at child's birth, mean ± SD, y 28.76 ± 5.82 29.16 ± 5.75 29.41 ± 5.56 .013

Maximum TSB level, mean ± SD, mg/dL 18.93 ± 1.46 21.32 ± 1.92 <.001

Group 1:no bilirubin level ≥12 mg/dL; group 2: bilirubin 17.0 to 22.9 at 48 to 168 hours and no inpatient phototherapy; group 3: bilirubin 17.0 to

22.9 at 48 to 168 hours, received inpatient phototherapy. P values for categorical variables based on χ2 tests; means compared with analysis ofvariance.

15–5

–119

120–

180–

TABLE 3Adjusted IRR (95% CI) for Comparisons Between Groups

Parameter Group 2 Versus Group 1 Group 3 Versus Group 2 Group 3 Versus Group 1

Age group, d

15–59 1.05 (1.04–1.08) 1.07 (1.03–1.12) 1.14 (1.10–1.18)

60–119 1.02 (1.00–1.04) 1.03 (0.99–1.08) 1.06 (1.02–1.10)

120–179 1.02 (1.00–1.04) 1.02 (0.98–1.07) 1.04 (1.00–1.08)

180–364 1.04 (1.03–1.06) 1.02 (0.99–1.06) 1.07 (1.04–1.10)

Visit type

Well-child 1.01 (1.01–1.02) 1.02 (1.01–1.04) 1.04 (1.03–1.06)

Illness 1.05 (1.03–1.07) 1.04 (0.98–1.09) 1.10 (1.05–1.14)

Specialist 1.17 (1.08–1.27) 1.02 (0.87–1.19) 1.20 (1.05–1.38)

ED 1.00 (0.94–1.06) 1.08 (0.93–1.24) 1.07 (0.95–1.21)

Total of all types of visits, 15–364 d 1.04 (1.02–1.05) 1.03 (1.01–1.06) 1.07 (1.05–1.10)

Adjusted with Poisson regression for mother's age and infant's year, month, and facility of birth; gestational age; gender; race; and total bilirubinlevel (group 3 versus 2 group only). Group 1: no bilirubin level ≥12 mg/dL; group 2: bilirubin 17.0 to 22.9 at 48 to 168 hours and no inpatientphototherapy; group 3: bilirubin 17.0 to 22.9 at 48 to 168 hours, received inpatient phototherapy.

TABLE 4Mean Numbers of Visits Between 15 and 364 Days With the 8 Most Commonly CodedIllness Diagnoses, by Study Group

Diagnosis Group 1 Group 2 Group 3

Upper respiratory infection 1.56 1.58 1.57

Otitis media 1.16 1.07 1.03

Unspecified morbidity 0.69 1.00a 1.10a

Viral illness 0.34 0.35 0.38b

Conjunctivitis 0.31 0.30 0.28

Acute gastroenteritis 0.28 0.29 0.29

Asthma 0.13 0.13 0.13

Pharyngitis 0.08 0.07 0.07

aP < .001 versus group 1.

bP = .003 versus group 1.

Effect of Neonatal Jaundice and Phototherapy on the Frequency of First-Year Outpatient Visits

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