Neonatal Hyperbilirubinemia is the most common abnormal physical finding and public health concern during the early neonatal period as many of the otherwise healthy term and near term newborn develops significant hyperbilirubinemia and kernicterus. About 60-70 % of term and 80 % of preterm have clinical jaundice. The incidence of significant hyperbilirubinemia is 15% among preterm and 3% normal term newborns. It is also the most common cause of readmission to the hospital during the early neonatal period [1,2]. Our hospital is a baby-friendly hospital with approximately 3000 deliveries per year. Healthy full-term newborns born following an uncomplicated delivery are discharged within 48 hours of life.

Hour-specific monitoring as used by developing countries is not applicable in most busy government settings. Under these circumstances, it is also not reliable to discharge full-term newborns examining only by visual assessment of hyperbilirubinemia by Kramer's rule applying cephalo-caudal progression of bilirubin and may also have observer variability. If newborns at risk of hyperbilirubinemia can be identified using reliable predictors, they can be timely treated and can be provided better follow-up care, band observing closely before discharge will further reduce morbidity and readmission rate in such newborns.[3].

Albumin helps in bilirubin clearance via increasing hepatic transportation. Low serum bilirubin may decrease the hepatic clearance and thus will increase significant hyperbilirubinemia. The lower Normal limit for serum albumin in term babies is 2.8gm/dl. The mean serum albumin level at term is 3.1gm/dl. Hence the normal range of Serum albumin at term is 3.1±3g./dl.[4]. The present study was conducted to find out the correlation between cord blood albumin and serum bilirubin at 48 hrs of life and to study whether low serum cord albumin level at birth can be used as a predictor for the development of hyperbilirubinemia above the high intermediate risk zone (>75th percentile) in healthy newborns.[2,5,6].

Setting: This was a prospective study, conducted at Mahatma Gandhi Memorial Medical College and Maharaja Yashwant Rao Holkar Hospital Indore. The study includes 200 term healthy neonates delivered at the hospital from July 2018 to May 2019.

Sensitivity, specificity, likelihood ratio for a positive

Out of the 200 infants enrolled in our study, 111(55.5%) were males and 89(44.5%). 16% newborn had cord albumin <2.8 ,50% recorded values between 2.8 to 3.4 and 68(34%) recorded cord albumin >3.4 g/dl. Newborns with higher birth weight had a significantly lesser incidence of low cord albumin (<2.8)*. gestational age and gender of the study population did not have a significant association with low cord albumin. (table 1, figure 1)

out of 200 newborns, 48(24%) serum bilirubin levels were at the low-risk zone, 112(56%) at the low intermediate risk zone, while 40 (20%) were at the high intermediate risk zone at 48 hrs of age. 59.4% of newborns with cord albumin level <2.8 g/dl recorded serum bilirubin at or above high intermediate risk zone, while 11 were at low intermediate risk zone and 2 new-born were at low-risk zone at 48 hrs of age. This correlation was statistically significant. [χ2= 122.28; Likelihood Ratio=115.13; P=<0.05*] ( table 2 figure2) We found that a cut‐off level of cord blood albumin of

According to recent AAP guidelines, healthy term newborns should be discharged within 48 hours of birth [2]. Hence it is necessary to identify the newborns at risk of developing hyperbilirubinemia following an early discharge from the hospital to avoid readmissions and complications as bilirubin encephalopathy and long term complications [3]. Albumin has a role in the transport and clearance of bilirubin. Albumin acts as a carrier protein for the transport of bilirubin, which eventually helps in the transfer of bilirubin to the liver where conjugation occurs.

Bilirubin binds to albumin in an equimolar ratio. Around 8.5 mg of bilirubin will bind covalently to 1 g of albumin, this process is interrupted due to decreased albumin levels in newborns. It is documented in the literature that newborns have an immature liver function as compared to adults leading to decreased production and synthesis of all the major proteins including albumin which has a major role in the conjugation of bilirubin.

And the neonatal liver is also immature with less ability to excrete and handle excessive production of bilirubin than can be caused by various aetiologies in newborns. Low production of albumin in newborns will lower its transport and binding capacity and may increase bilirubin in these newborns.[4]. In the present study we aimed to assess the correlation between cord blood albumin and serum bilirubin for early identification of hyperbilirubinemia and use of cord blood Albumin level as a tool for screening for the risk of subsequent Neonatal hyperbilirubinemia.

present study. Similar observations were also made by Asit Kumar et al. [5]. Dr Pushpanjali et al[14]. Dhanjal SS et al[15] and Pathak NN et al [16]. The limitations of our study were that we restricted the duration of follow-up for only the first 48 hours, due to our early discharge policy for healthy term newborns, and maximum serum bilirubin concentration is seen at 72 to 96 hrs. The strength of the study is that this is the first study that evaluated the hyperbilirubinemia using Bhutani nomogram as a cutoff limit to predict hyperbilirubinemia of high intermediate risk zone, making our results more reliable and accurate for healthy term newborns as early as 48 hrs, who are discharged early and often with poor followup for development of subsequent hyperbilirubinemia.

Figure 3-ROC curve analysis to correlate cord blood albumin as a tool to identify serum bilirubin level above high intermediate risk zone according to Bhutani’s nomogram with the area under curve is 0.872 which is statistically significant.

In summary, we have demonstrated the predictive usefulness and clinical value of cord blood albumin level of <2.8 g/dl. This can be used as a risk indicator and an easy tool to predict the significant hyperbilirubinemia as early as at birth and at risk newborns can be provided better pre-discharge advice and early treatment to prevent complications associated with significant hyperbilirubinemia. This can further reduce morbidity, cost of treatment and readmission in such at-risk newborns In a developing country like India with high neonatal mortality and morbidity, cord blood albumin can be used by clinicians and health workers for early identification and early referral of at-risk neonates