Transcutaneous bilirubin measurements and serum total bilirubin levels in indigenous African infants

Transcutaneous bilirubinometry for detecting jaundice in term or late preterm neonates

BACKGROUND

The American Academy of Pediatrics and the Canadian Paediatric Society both advise that all newborns should undergo bilirubin screening before leaving the hospital, and this has become the standard practice in both countries. However, the US Preventive Task Force has found no strong evidence to suggest that this practice of universal screening for bilirubin reduces the occurrence of significant outcomes such as bilirubin-induced neurologic dysfunction or kernicterus.

OBJECTIVES

To evaluate the effectiveness of transcutaneous screening compared to visual inspection for hyperbilirubinemia to prevent the readmission of newborns (infants greater than 35 weeks' gestation) for phototherapy.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, ClinicalTrials.gov, ICTRP, and ISRCTN in June 2023. We also searched conference proceedings, and the reference lists of included studies.

SELECTION CRITERIA

We included randomized controlled trials (RCTs), quasi-randomized, cluster-randomized, or prospective cohort studies with control arm that evaluated the use of transcutaneous bilirubin (TcB) screening for hyperbilirubinemia in newborns before hospital discharge.

DATA COLLECTION AND ANALYSIS

We used standard methodologic procedures expected by Cochrane. We evaluated treatment effects using a fixed-effect model with risk ratio (RR) and 95% confidence intervals (CI) for categorical data and mean, standard deviation (SD), and mean difference (MD) for continuous data. We used the GRADE approach to evaluate the certainty of evidence.

MAIN RESULTS

We identified one RCT (1858 participants) that met our inclusion criteria. The study included 1858 African newborns at 35 weeks' gestation or greater who were receiving routine care at a well-baby nursery, and were randomly recruited prior to discharge to undergo TcB screening. The study had good methodologic quality. TcB screening versus visual assessment of hyperbilirubinemia in newborns: - may reduce readmission to the hospital for hyperbilirubinemia (RR 0.25, 95% CI 0.14 to 0.46; P < 0.0001; moderate-certainty evidence); - probably has little or no effect on the rate of exchange transfusion (RR 0.20, 95% CI 0.01 to 14.16; low-certainty evidence); - may increase the number of newborns who require phototherapy prior to discharge (RR 2.67, 95% CI 1.56 to 4.55; moderate-certainty evidence). - probably has little or no effect on the rate of acute bilirubin encephalopathy (RR 0.33, 95% CI 0.01 to 8.18; low-certainty evidence). The study did not evaluate or report cost of care.

AUTHORS' CONCLUSIONS

Moderate-certainty evidence suggests that TcB screening may reduce readmission for hyperbilirubinemia compared to visual inspection. Low-certainty evidence also suggests that TcB screening probably has little or no effect on the rate of exchange transfusion compared to visual inspection. However, moderate-certainty evidence suggests that TcB screening may increase the number of newborns that require phototherapy before discharge compared to visual inspection. Low-certainty evidence suggests that TcB screening probably has little or no effect on the rate of acute bilirubin encephalopathy compared to visual inspection. Given that we have only identified one RCT, further studies are necessary to determine whether TcB screening can help to reduce readmission and complications related to neonatal hyperbilirubinemia. In settings with limited newborn follow-up after hospital discharge, identifying newborns at risk of severe hyperbilirubinemia before hospital discharge will be important to plan targeted follow-up of these infants.

Skin color influences transcutaneous bilirubin measurements: a systematic in vitro evaluation

OBJECTIVE

Concerns have been raised about the effect of skin color on the accuracy of transcutaneous bilirubin (TcB) measurements, a widely used method for hyperbilirubinemia diagnosis in newborns. Literature is inconclusive, with both reported under- and overestimations of the TcB with increasing skin pigmentation. Therefore, the influence of skin color on TcB measurements was systematically evaluated in a controlled, in vitro setting.

METHODS

A bilirubin meter (JM-105) was evaluated on layered phantoms that mimic neonatal skin with varying dermal bilirubin concentrations (0-250 µmol/L) and varying epidermal melanosome volume fractions (0-40%; light-dark skin color).

RESULTS

TcB measurements were influenced by skin pigmentation. Larger mimicked melanosome volume fractions and higher bilirubin levels led to larger underestimations of the measured TcB, compared to an unpigmented epidermis. In the in vitro setting of this study, these underestimations amounted to 26-132 µmol/L at a TcB level of 250 µmol/L.

CONCLUSION

This in vitro study provides insight into the effect of skin color on TcB measurements: the TcB is underestimated as skin pigmentation increases and this effect becomes more pronounced at higher bilirubin levels. Our results highlight the need for improved TcB meter design and cautious interpretation of TcB readings on newborns with dark skin.

IMPACT

Key message: Skin color influences transcutaneous bilirubin measurements: the darker the skin, the larger the underestimation. What this study adds to existing literature: Existing literature is inconclusive regarding the influence of skin color on transcutaneous bilirubin measurements. This study systematically evaluates and clarifies the influence of skin color on transcutaneous bilirubin measurements in a controlled, in vitro setting.

IMPACT

This study aids to better interpret the measured TcB level in patients with varying skin colors, and is particularly important when using TcB meters on patients with dark skin colors.

Transcutaneous Bilirubin Accuracy Before, During, and After Phototherapy: A Meta-Analysis

CONTEXT

Transcutaneous bilirubinometry (TcB) is used as a valid screening to identify neonates requiring measurement of total serum bilirubin (TSB) before phototherapy. Its use during and after phototherapy is not advised yet because of unknown reliability.

OBJECTIVES

To determine the agreement of TcB and TSB measurements before, during, and after phototherapy.

DATA SOURCES

PubMed Medline, Cochrane Library, and references of eligible studies were searched.

STUDY SELECTION

Prospective and retrospective cohort and cross-sectional studies reporting Bland-Altman statistics of paired TcB and TSB measurements in term and preterm newborns.

DATA EXTRACTION

Meta-analysis was performed using the Mantel-Haenszel weighted approach. The agreement between TcB and TSB in μmol/L was described by pooled mean differences (MDs) and limits of agreement (LoA).

RESULTS

Fifty-four studies were included. The pooled MD before phototherapy is 2.5 μmol/L (LoA -38.3 to 43.3). The pooled MD during phototherapy is -0.3 μmol/L (LoA -34.8 to 34.2) on covered skin and -28.6 μmol/L (LoA -105.7 to 48.5) on uncovered skin. The pooled MD after phototherapy is -34.3 μmol/L (LoA -86.7 to 18.1) on covered skin and -21.1 μmol/L (LoA -88.6 to 46.4) on uncovered skin. Subgroup analysis revealed the best agreement at the forehead. We did not find any difference in agreement between term and preterm neonates.

LIMITATIONS

Language restriction.

CONCLUSIONS

TcB measurements before and during phototherapy on covered skin show good agreement compared with TSB in term and preterm newborns. More studies are needed to evaluate the accuracy after phototherapy.

Transcutaneous bilirubinometry versus total serum bilirubin measurement for newborns

BACKGROUND

Jaundice is a very common condition in newborns, affecting up to 60% of term newborns and 80% of preterm newborns in the first week of life. Jaundice is caused by increased bilirubin in the blood from the breakdown of red blood cells. The gold standard for measuring bilirubin levels is obtaining a blood sample and processing it in a laboratory. However, noninvasive transcutaneous bilirubin (TcB) measurement devices are widely available and used in many settings to estimate total serum bilirubin (TSB) levels.

OBJECTIVES

To determine the diagnostic accuracy of transcutaneous bilirubin measurement for detecting hyperbilirubinaemia in newborns.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL and trial registries up to 18 August 2022. We also checked the reference lists of all included studies and relevant systematic reviews for other potentially eligible studies.

SELECTION CRITERIA

We included cross-sectional and prospective cohort studies that evaluated the accuracy of any TcB device compared to TSB measurement in term or preterm newborn infants (0 to 28 days postnatal age). All included studies provided sufficient data and information to create a 2 × 2 table for the calculation of measures of diagnostic accuracy, including sensitivities and specificities. We excluded studies that only reported correlation coefficients.

DATA COLLECTION AND ANALYSIS

Two review authors independently applied the eligibility criteria to all citations from the search and extracted data from the included studies using a standard data extraction form. We summarised the available results narratively and, where possible, we combined study data in a meta-analysis.

MAIN RESULTS

We included 23 studies, involving 5058 participants. All studies had low risk of bias as measured by the QUADAS 2 tool. The studies were conducted in different countries and settings, included newborns of different gestational and postnatal ages, compared various TcB devices (including the JM 101, JM 102, JM 103, BiliChek, Bilitest and JH20-1C) and used different cutoff values for a positive result. In most studies, the TcB measurement was taken from the forehead, sternum, or both. The sensitivity of various TcB cutoff values to detect significant hyperbilirubinaemia ranged from 74% to 100%, and specificity ranged from 18% to 89%.

AUTHORS' CONCLUSIONS

The high sensitivity of TcB to detect hyperbilirubinaemia suggests that TcB devices are reliable screening tests for ruling out hyperbilirubinaemia in newborn infants. Positive test results would require confirmation through serum bilirubin measurement.

Hyperbilirubinemia in Preterm Infants Admitted to Neonatal Intensive Care Units in Ethiopia

Background. Hyperbilirubinemia is prevalent and protracted in preterm infants. This study assessed the pattern of hyperbilirubinemia in preterm infants in Ethiopia. Methods. This study was part of multi-centered prospective, cross-sectional, observational study that determined causes of death among preterm infants. Jaundice was first identified based on clinical visual assessment. Venous blood was then sent for total and direct serum bilirubin level measurements. For this study, a total serum bilirubin level ≥5 mg/dL was taken as the cutoff point to diagnose hyperbilirubinemia. Based on the bilirubin level and clinical findings, the final diagnoses of hyperbilirubinemia and associated complications were made by the physician. Result. A total of 4919 preterm infants were enrolled into the overall study, and 3852 were admitted to one of the study’s newborn intensive care units. Of these, 1779 (46.2%) infants were diagnosed with hyperbilirubinemia. Ten of these (0.6%) developed acute bilirubin encephalopathy. The prevalence of hyperbilirubinemia was 66.7% among the infants who were less than 28 weeks of gestation who survived. Rh incompatibility (P = .002), ABO incompatibility (P = .0001), and sepsis (P = .0001) were significantly associated with hyperbilirubinemia. Perinatal asphyxia (P-value = 0.0001) was negatively associated with hyperbilirubinemia. Conclusion. The prevalence of hyperbilirubinemia in preterm babies admitted to neonatal care units in Ethiopia was high. The major risk factors associated with hyperbilirubinemia in preterm babies in this study were found to be ABO incompatibility, sepsis, and Rh isoimmunization.

Predictability of transcutaneous bilirubinometry in late preterm and term infants at risk for pathological hyperbilirubinemia

BACKGROUND

The aim was to assess the predictability of transcutaneous bilirubinometry in late preterm and term neonates at risk for pathological hyperbilirubinemia, and to identify the neonatal population in which transcutaneous bilirubin most accurately predicts serum bilirubin level (SB, mg/dl).

METHODS

The correlations between transcutaneous bilirubin (TCB, mg/dl) and SB in different neonatal population subsets; and between ΔTSB (TCB-SB) and relevant neonatal variables and clinical groups were analyzed.

RESULTS

TCB correlated with SB (r = 0.82, p < 0.05) in the cohort (n = 350) and in population subsets (r = 0.81-0.9, p < 0.001). Black infants with gestational age (GA) >35 weeks and chronological age (CA) >3 days recorded strongest correlation (r = 0.9, p < 0.001) followed by Blacks, and non-Black infants with CA >3 days and GA >35 weeks. ΔTSB was positive in Blacks, and in infants with CA <3 days, or with no phototherapy. ΔTSB was negative in non-Blacks, in infants with positive direct Coombs test (DC+) or those receiving phototherapy. Black race [beta (SE) = 1.3(0.33), p < 0.001] had positive, while CA [beta (SE) =-1.74 (0.36), p < 0.001], DC + status [beta (SE) =-0.72 (0.25), p = 0.004] and receipt of phototherapy [beta (SE) =-0.84 (0.21), p < 0.001] each had negative correlation with ΔTSB. ΔTSB for Blacks was >Whites, Hispanics and Asians.

CONCLUSION

SB is best predicted by TCB in Black infants with CA over 3 days and GA over 35 weeks. Variability in SB estimation by TCB is race, CA and immune mediated hemolysis specific.

Six sigma approach for neonatal jaundice patients in an Indian rural hospital - a case study

PURPOSE

The purpose of this paper is to implement Six Sigma approach to decrease the length of stay (LOS) of neonatal jaundice patients in an Indian government rural hospital situated in northern hill region.

DESIGN/METHODOLOGY/APPROACH

Six Sigma's Define-Measure-Analyse-Improve-Control procedure is applied in order to decrease the LOS of neonatal jaundice patients. The mean and standard deviation have been computed as 34.53 and 20.01 h, respectively. The cause and effect diagram is used in the "Analyse" phase of the Six Sigma. The regression analysis and GEMBA observation techniques are used to validate the causes identified through cause and effect diagram.

FINDINGS

The waiting time for registration, waiting time for tests, waiting time for phototherapy and time for discharge implementation are the main factors that are responsible for longer LOS. Based on the identified root causes, some recommendations are suggested to the hospital administration and staff members in order to reduce the LOS.

RESEARCH LIMITATIONS/IMPLICATIONS

The present research is limited to provide recommendations to the hospital administration to reduce LOS and it entirely depends upon the implementation of the administration. However, target of administration is to reduce the LOS up to 24 h.

PRACTICAL IMPLICATIONS

Six Sigma model will reduce bottlenecks in LOS and enhance service quality of hospital. The developed regression model will help the doctors and staff members to assess and control the LOS by controlling and minimising the independent variables.

SOCIAL IMPLICATIONS

The project will directly provide benefits to society, as LOS will decrease and patients' satisfaction will automatically increase.

ORIGINALITY/VALUE

Six Sigma is a developed methodology, but its application in paediatric department is very limited. This is the first ever study of applying Six Sigma for neonatal jaundice patients in India.

Smartphone screening for neonatal jaundice via ambient-subtracted sclera chromaticity

Jaundice is a major cause of mortality and morbidity in the newborn. Globally, early identification and home monitoring are significant challenges in reducing the incidence of jaundice-related neurological damage. Smartphone cameras are promising as colour-based screening tools as they are low-cost, objective and ubiquitous. We propose a novel smartphone method to screen for neonatal jaundice by imaging the sclera. It does not rely on colour calibration cards or accessories, which may facilitate its adoption at scale and in less economically developed regions. Our approach is to explicitly address three confounding factors in relating colour to jaundice: (1) skin pigmentation, (2) ambient light, and (3) camera spectral response. (1) The variation in skin pigmentation is avoided by imaging the sclera. (2) With the smartphone screen acting as an illuminating flash, a flash/ no-flash image pair is captured using the front-facing camera. The contribution of ambient light is subtracted. (3) In principle, this permits a device- and ambient-independent measure of sclera chromaticity following a one-time calibration. We introduce the concept of Scleral-Conjunctival Bilirubin (SCB), in analogy with Transcutaneous Bilirubin (TcB). The scleral chromaticity is mapped to an SCB value. A pilot study was conducted in the UCL Hospital Neonatal Care Unit (n = 37). Neonates were imaged using a specially developed app concurrently with having a blood test for total serum bilirubin (TSB). The better of two models for SCB based on ambient-subtracted sclera chromaticity achieved r = 0.75 (p<0.01) correlation with TSB. Ambient subtraction improved chromaticity estimates in proof-of-principle laboratory tests and screening performance within our study sample. Using an SCB decision threshold of 190μmol/L, the sensitivity was 100% (specificity 61%) in identifying newborns with TSB>250μmol/L (area under receiver operating characteristic curve, AUROC, 0.86), and 92% (specificity 67%) in identifying newborns with TSB>205μmol/L (AUROC 0.85). These results are comparable to modern transcutaneous bilirubinometers.

Determinants of neonatal jaundice among neonates admitted to five referral hospitals in Amhara region, Northern Ethiopia: an unmatched case-control study

BACKGROUND

Neonatal jaundice is associated with a significant risk of neonatal morbidity and mortality. It is a major cause of hospital neonatal intensive care unit admission and readmissions during the neonatal period. Hence, the study aimed to identify the determinant factors of neonatal jaundice among neonates admitted at five referral hospitals in Amhara region, Northern Ethiopia.

METHOD

A hospital-based unmatched case-control study design was employed, on 447 neonates (149 cases and 298 controls) at referral hospitals in Amhara region, Northern Ethiopia, from 1 March to 30 July 2019. Consecutive sampling method was used to select both the cases and controls. The collected data were entered into Epi data V.4.2 and then exported into SPSS window V.24 for analysis. Bivariable and multivariable analysis were carried out by using binary logistic regression. A p value of <0.05 was considered as significant difference between cases and controls for the exposure variable of interest.

RESULTS

The median (±IQR) age of neonate at the time of admission and gestational age were 3±2 days and 38 (±3) weeks, respectively. Prolonged duration of labour (adjusted OR (AOR)=2.45, 95% CI 1.34 to 4.47), being male sex (AOR=3.54, 95% CI 1.99 to 6.29), low birth weight (AOR=5.06, 95% CI 2.61 to 9.82), birth asphyxia (AOR=2.88, 95% CI 1.38 to 5.99), sepsis (AOR=2.49, 95% CI 1.22 to 5.11) and hypothermia (AOR=2.88, 95% CI 2.63 to 14.02) were the determinant factors for neonatal jaundice.

CONCLUSIONS

Prolonged duration of labour, hypothermia, sepsis, birth asphyxia, low birth weight and sex of neonate were independent determinants of neonatal jaundice. Early recognition and management of identified modifiable determinants are the recommended interventions.

Knowledge Level and Determinants of Neonatal Jaundice: A Cross-Sectional Study in the Effutu Municipality of Ghana

Background

Neonatal jaundice (NNJ) is a major cause of hospital admission during the neonatal period and is associated with significant mortality. This case-control study with cross-sectional design sought to identify the possible factors associated with neonatal jaundice and assess maternal knowledge level of this condition.

Methods

One hundred and fifty (150) neonates comprising 100 with clinically evident jaundice and 50 without jaundice were conveniently recruited from the Trauma and Specialist Hospital in the Effutu Municipality. Blood samples were collected for the determination of serum bilirubin, glucose-6-phosphate dehydrogenase (G6PD), status and blood group (ABO and Rhesus). Well-structured questionnaire was used to collect maternal and neonate sociodemographic and clinical history.

Results

Majority (54%) of neonates developed jaundice within 1–3 days after birth with 10% having it at birth. Duration of labour and neonatal birth weight were associated with neonatal jaundice (P < 0.05). G6PD abnormality was found in 11 (12%) of the neonates with jaundice and ABO incompatibility was present in 18%. Neonates delivered by mothers with formal occupation and those who had prolonged duration of labour were significantly more likely to have neonatal jaundice (OR = 4.174, P = 0.003; OR = 2.389, P = 0.025, resp.). Neonates with low birth weight were also more likely to develop neonatal jaundice (OR = 2.347, P = 0.044). Only 17.3% of mothers had heard of neonatal jaundice. School was the major source of information on neonatal jaundice (34.6%). Majority of participants (mothers) did not know that NNJ can cause damage to other organs in the body (90%).

Conclusion

Low neonatal birth weight and prolonged duration of labour are associated with neonatal jaundice. Mothers had inadequate knowledge of neonatal jaundice and its causes.

Use of a Smartphone App to Assess Neonatal Jaundice

BACKGROUND

The assessment of jaundice in outpatient neonates is problematic. Visual assessment is inaccurate, and more exact methodologies are cumbersome and/or expensive. Our goal in this study was to assess the accuracy of a technology based on the analysis of digital images of newborns obtained using a smartphone application called BiliCam.

METHODS

Paired BiliCam images and total serum bilirubin (TSB) levels were obtained in a diverse sample of newborns (<7 days old) at 7 sites across the United States. By using specialized software, data on color values in the images ("features") were extracted. Machine learning and regression analysis techniques were used to identify features for inclusion in models to predict an estimated bilirubin level for each newborn. The correlation between estimated bilirubin levels and TSB levels was calculated. In addition, the sensitivity and specificity of the estimated bilirubin levels in identifying newborns with high TSB levels were calculated by using 2 recommended decision rules for jaundice screening.

RESULTS

Estimated bilirubin levels were calculated and compared with TSB levels in a diverse sample of 530 newborns (20.8% African American, 26.3% Hispanic, and 21.2% Asian American). The overall correlation was 0.91, and correlations among white, African American, Hispanic, and Asian American newborns were 0.92, 0.90, 0.91, and 0.88, respectively. The sensitivities of BiliCam in identifying newborns with high TSB levels were 84.6% and 100%, respectively, by using 2 decision rules; specificities were 75.1% and 76.4%, respectively.

CONCLUSIONS

BiliCam provided accurate estimates of TSB values, demonstrating that an inexpensive technology that uses commodity smartphones could be used to effectively screen newborns for jaundice.

Use of Transcutaneous Bilirubin to Determine the Need for Phototherapy in Resource-Limited Settings

BACKGROUND

Routine and timely determination of total serum bilirubin (TSB) remains a challenge in many resource-limited countries with substantial burden of severe neonatal hyperbilirubinemia. Limited evidence exists on the potential usefulness of transcutaneous bilirubin (TcB) to identify infants who may require phototherapy based on possible treatment criteria in such settings.

OBJECTIVE

To compare the number of infants requiring phototherapy across different TSB criteria and determine the predictive performance of TcB under each criterion.

METHODS

Infants with paired TcB and TSB measurements in a maternity hospital in Lagos, Nigeria, were assessed for phototherapy based on TSB criteria by the American Academy of Pediatrics (AAP), National Institute for Health and Clinical Excellence (NICE) UK, and World Health Organization (WHO), and an absolute threshold of ≥12 mg/dL. The predictive performance of TcB across treatment criteria was evaluated with receiver operating curve analysis.

RESULTS

A total of 1,011 infants with a mean TcB of 10.54 ± 3.19 (range: 2.7-19.9) mg/dL and TSB of 9.63 ± 2.61 (range: 0.3-19.5) mg/dL were assessed. Some 60 (5.9%) infants required phototherapy by 1 or more TSB criteria, with TSB ≥12 mg/dL identifying 55 (91.7%) and AAP 27 (45%) of these infants. All infants identified by the NICE and WHO criteria were equally detected by the AAP criterion. TcB showed negative predictive values of 99.0-99.9%, and positive predictive values of 7.7-15.5% across all criteria.

CONCLUSIONS

The number of infants requiring phototherapy varies significantly across treatment criteria. TcB may be useful in identifying infants who do not require phototherapy, but may also identify a high proportion of false positives that is burdensome in resource-limited settings.

Clinical utility of transcutaneous bilirubinometer (TcB) in very low birth weight (VLBW) infants

OBJECTIVE

This is a comprehensive study designed to evaluate the clinical usefulness of transcutaneous bilirubinometry (TcB) in very low birth weight (VLBW) newborns of African American (AA) descent.

METHODS

TcB was conducted at the anterior superior iliac spine (ASIS), temporal region and sternum within 2 h of total serum bilirubin (TSB) measurements in newborns born at ≤32 weeks' gestation prospectively. Average (AVG) TcB levels were also calculated. The relationships between TSB and TcB levels were analyzed using non-parametric Spearman bivariate correlations, a Bland-Altman plot procedure and a decision tree (DT) analysis.

RESULTS

One hundred newborns and 555 TSB data points were available. Eighty-nine percent of the newborns were AA. A significant correlation (P<0.0001) was observed between TSB and TcB values obtained at the ASIS (r=0.73), sternum (0.73), temporal region (0.61) and AVG (0.77). The Bland-Altman plot revealed a good agreement between AVG TcB values and TSB values. A DT analysis indicated that AVG TcB was also found to be the most significant predictor of TSB values in both the no phototherapy (PT) and biliblanket subgroups.

CONCLUSION

TcB can be used reliably in VLBW AA newborns in the absence of overhead PT. The use of TcB in monitoring jaundice in VLBW newborns would help decrease the number of blood draws and cost of care.

Differences Between Transcutaneous and Serum Bilirubin Measurements in Black African Neonates

BACKGROUND AND OBJECTIVE

Transcutaneous bilirubin (TcB) correlates positively with total serum bilirubin (TSB) across different racial populations. However, little is known about the pattern of divergence between TcB and TSB at individual patient-level and the relationship with TcB measuring techniques among African neonates. This study, therefore, investigates TcB-TSB discrepancies and the contribution of 2 models of transcutaneous bilirubinometers to the observed divergence in a black African population.

METHODS

Medical records were retrieved for late preterm and term infants with 1 to 3 pairs of TcB and TSB measurements between December 2011 to June 2015 in Nigeria. Divergence between TcB and TSB values for each infant was determined and the associated factors explored with generalized estimating equations for logistic regression. Contributions of BiliChek and JM-103 transcutaneous bilirubinometers to the divergence were further explored through linear regression and Bland-Altman analysis.

RESULTS

Overall, 2107 TcB/TSB measurements from 1553 infants were analyzed. TSB was overestimated by ≥2 mg/dL in 64.5%, ≥3 mg/dL in 42.7%, and ≥4 mg/dL in 25.7% of all measurements. In contrast, TSB was underestimated by ≥2 mg/dL in 1.1%, ≥3 mg/dL in 0.5%, and ≥4 mg/dL in 0.3% of all recordings. Postnatal age, feeding mode, and type of TcB instrument were predictive of TSB overestimation. The JM-103 was associated with greater imprecision than BiliChek at all TSB levels.

CONCLUSIONS

BiliChek and JM-103 bilirubinometers significantly overestimate TSB in black African neonates and may result in unnecessary or excessive treatments. Additional development of appropriate bilirubin determination devices for this racial group, especially in resource-limited settings, is warranted.

Utility of Decision Rules for Transcutaneous Bilirubin Measurements

BACKGROUND

Transcutaneous bilirubin (TcB) meters are widely used for screening newborns for jaundice, with a total serum bilirubin (TSB) measurement indicated when the TcB value is classified as "positive" by using a decision rule. The goal of our study was to assess the clinical utility of 3 recommended TcB screening decision rules.

METHODS

Paired TcB/TSB measurements were collected at 34 newborn nursery sites. At 27 sites (sample 1), newborns were routinely screened with a TcB measurement. For sample 2, sites that typically screen with TSB levels also obtained a TcB measurement for the study. Three decision rules to define a positive TcB measurement were evaluated: ≥75th percentile on the Bhutani nomogram, 70% of the phototherapy level, and within 3 mg/dL of the phototherapy threshold. The primary outcome was a TSB level at/above the phototherapy threshold. The rate of false-negative TcB screens and percentage of blood draws avoided were calculated for each decision rule.

RESULTS

For sample 1, data were analyzed on 911 paired TcB-TSB measurements from a total of 8316 TcB measurements. False-negative rates were <10% with all decision rules; none identified all 31 newborns with a TSB level at/above the phototherapy threshold. The percentage of blood draws avoided ranged from 79.4% to 90.7%. In sample 2, each rule correctly identified all 8 newborns with TSB levels at/above the phototherapy threshold.

CONCLUSIONS

Although all of the decision rules can be used effectively to screen newborns for jaundice, each will "miss" some infants with a TSB level at/above the phototherapy threshold.

Management of late-preterm and term infants with hyperbilirubinaemia in resource-constrained settings

Hyperbilirubinaemia is a ubiquitous transitional morbidity in the vast majority of newborns and a leading cause of hospitalisation in the first week of life worldwide. While timely and effective phototherapy and exchange transfusion are well proven treatments for severe neonatal hyperbilirubinaemia, inappropriate or ineffective treatment of hyperbilirubinaemia, at secondary and tertiary hospitals, still prevails in many poorly-resourced countries accounting for a disproportionately high burden of bilirubin-induced mortality and long-term morbidity. As part of the efforts to curtail the widely reported risks of frequent but avoidable bilirubin-induced neurologic dysfunction (acute bilirubin encephalopathy (ABE) and kernicterus) in low and middle-income countries (LMICs) with significant resource constraints, this article presents a practical framework for the management of late-preterm and term infants (≥35 weeks of gestation) with clinically significant hyperbilirubinaemia in these countries particularly where local practice guidelines are lacking. Standard and validated protocols were followed in adapting available evidence-based national guidelines on the management of hyperbilirubinaemia through a collaboration among clinicians and experts on newborn jaundice from different world regions. Tasks and resources required for the comprehensive management of infants with or at risk of severe hyperbilirubinaemia at all levels of healthcare delivery are proposed, covering primary prevention, early detection, diagnosis, monitoring, treatment, and follow-up. Additionally, actionable treatment or referral levels for phototherapy and exchange transfusion are proposed within the context of several confounding factors such as widespread exclusive breastfeeding, infections, blood group incompatibilities and G6PD deficiency, which place infants at high risk of severe hyperbilirubinaemia and bilirubin-induced neurologic dysfunction in LMICs, as well as the limited facilities for clinical investigations and inconsistent functionality of available phototherapy devices. The need to adjust these levels as appropriate depending on the available facilities in each clinical setting and the risk profile of the infant is emphasised with a view to avoiding over-treatment or under-treatment. These recommendations should serve as a valuable reference material for health workers, guide the development of contextually-relevant national guidelines in each LMIC, as well as facilitate effective advocacy and mobilisation of requisite resources for the optimal care of infants with hyperbilirubinaemia at all levels.

Discrepancies between transcutaneous and serum bilirubin measurements

OBJECTIVE

To characterize discrepancies between transcutaneous bilirubin (TcB) measurements and total serum bilirubin (TSB) levels among newborns receiving care at multiple nursery sites across the United States.

METHODS

Medical records were reviewed to obtain data on all TcB measurements collected during two 2-week periods on neonates admitted to participating newborn nurseries. Data on TSB levels obtained within 2 hours of a TcB measurement were also abstracted. TcB--TSB differences and correlations between the values were determined. Data on demographic information for individual newborns and TcB screening practices for each nursery were also collected. Multivariate regression analysis was used to identify characteristics independently associated with the TcB--TSB difference.

RESULTS

Data on 8319 TcB measurements were collected at 27 nursery sites; 925 TSB levels were matched to a TcB value. The mean TcB--TSB difference was 0.84 ± 1.78 mg/dL, and the correlation between paired measurements was 0.78. In the multivariate analysis, TcB--TSB differences were 0.67 mg/dL higher in African-American newborns than in neonates of other races (P < .001). The TcB--TSB difference also varied significantly based on brand of TcB meter used and hour of age of the infant. For 2.2% of paired measurements, the TcB measurement underestimated the TSB level by ≥ 3 mg/dL.

CONCLUSIONS

During routine clinical care, TcB measurement provided a reasonable estimate of TSB levels in healthy newborns. Discrepancies between TcB and TSB levels were increased in African-American newborns and varied based on brand of meter used.

A Comparison between Transcutaneous and Total Serum Bilirubin in Healthy-term Greek Neonates with Clinical Jaundice

The accuracy of transcutaneous bilirubin meters has been assessed in newborns from various ethnic backgrounds. However, there are limited data on Greek newborns. Our study examined the accuracy of transcutaneous bilirubin measurements in clinically jaundiced healthy-term Greek newborns, using total serum bilirubin as the reference standard, in order to re-evaluate our local guidelines about neonatal jaundice. Clinically jaundiced newborns requiring total serum bilirubin level estimation were recruited prospectively. 368 pairs of total serum bilirubin/transcutaneous bilirubin measurements were taken in 222 newborns, using a direct spectrophotometric device and the BiliCheck device, respectively. The level of agreement between the obtained transcutaneous bilirubin and total serum bilirubin values was assessed. Our data were analysed using the Stata/SE 12.0 (StataCorp LP, USA) statistical programme. The mean (± SD) TSB was 225.4 ± 25.4 μmol/l and the mean (± SD) TcB was 237.9 ± 21.0 μmol/l. The correlation between the values was poor (Pearson’s correlation coefficient 0.439; Lin’s concordance coefficient 0.377 [95% CI 0.301 to 0.453]; P<0.001). The Bland-Altman analysis demonstrated that transcutaneous bilirubin measurements tended to overestimate the total serum bilirubin value (mean difference 12.5 ± 24.9 μmol/l), with wide 95% limits of agreement (–36.2 μmol/l to 61.3 μmol/l). Transcutaneous bilirubin values did not correlate well with total serum bilirubin values, being often imprecise in predicting the actual total serum bilirubin levels. This permits us to continue estimating total serum bilirubin in clinically jaundiced newborns according to our local guidelines, in order to safely decide the appropriate care plan.

Transcutaneous bilirubinometry

Although the modern era of transcutaneous bilirubin monitoring (TcB) began only about 35 years ago, this screening tool is now widely used in newborn nurseries and outpatient clinics, offices, and emergency departments to obtain a rapid and non-invasive estimate of the degree of hyperbilirubinemia. TcB devices have become more sophisticated, and major breakthroughs include the following: (a) ability to report a bilirubin value rather than an index value, (b) enhanced correction for chromophores other than bilirubin, and (c) technologic improvements including interface with electronic medical records. Good agreement with laboratory bilirubin measurement has been demonstrated, and the ability of TcB screening to predict and decrease the incidence of subsequent hyperbilirubinemia has been well-documented. To date, it has not been shown that this screening results in improved long-term outcomes.

Addressing the burden of neonatal hyperbilirubinaemia in countries with significant glucose-6-phosphate dehydrogenase deficiency

Glucose-6-phosphate dehydrogenase (G6PD) deficiency is an established worldwide risk factor for severe hyperbilirubinaemia. This literature review examined the pattern and management of severe hyperbilirubinaemia in low- and middle-income countries (LMICs) where G6PD deficiency was 10% or more and found that it was frequently associated with neonatal mortality and, or, neurodevelopmental disorders.

CONCLUSION

Low- and middle-income countries need to pay urgent attention to G6PD deficiency to curtail the preventable burden of jaundice-related morbidity, mortality and disability.

Correlation of transcutaneous bilirubinometry (TcB) and total serum bilirubin (TsB) levels after phototherapy

AIM

To investigate the correlation between transcutaneous bilirubinometry (TcB) and total serum bilirubin (TsB) in jaundiced infants before and after, but not during phototherapy.

METHODS

This study prospectively investigated the correlation between TcB and TsB in term and near term infants before and after phototherapy.

RESULTS

Overall 673 pairs of measurements (TcB and TsB) were performed on 371 infants of ≥35 weeks gestation and with birth weight above 2000 g. Of these 337 sets were from 200 infants who had not been treated with phototherapy (Group 1) and 336 measurements from 171 infants taken between 1 h and 5 d after phototherapy (Group 2). The correlation coefficient between TcB and TsB in the whole cohort was r = 0.72. The correlation was low during the first 8 h after phototherapy (r = 0.56), but thereafter the correlation returned to the range of 0.65-0.8. Using the Sobel test, no significant difference was found between the correlation coefficients at the different time periods, with the possible exception of the difference between 1 and 8 h and 9 and 16 h which was of borderline significance with a p value of 0.06.

CONCLUSION

This study demonstrates good correlation between TcB and TsB by 8 h after phototherapy. This adds validity to community-based screening programs employing TcB measurements plotted on TsB nomograms. Such programs may contribute to prevention of tragic cases of bilirubin-induced neurologic damage.

Transcutaneous bilirubinometry is not influenced by term or skin color in neonates

BACKGROUND

The utility of transcutaneous bilirubin measurements (TcB) in screening for hyperbilirubinemia in preterm infants (<34 weeks) and in non-white infants remains a matter of debate.

AIM

To evaluate accuracy of TcB in preterm and term infants of different ethnic backgrounds, using a second generation bilirubinometer.

STUDY DESIGN

The Draeger JM-103® device was used to measure TcB. Eighty five measurements of TcB and total serum bilirubin (TSB) were retrospectively compared. Neonates were stratified into groups according to gestational age: <34 weeks (group 1, n=44) and >34 weeks (group 2, n=41), and according to ethnic origin: Caucasians (group A, n=49) and non-Caucasians (group B, n=36). Statistical analysis, using Pearson's correlation coefficient (r) and Bland-Altman analysis were performed to evaluate correlation and agreement between TSB and TcB values. Multiple linear regression was used to control for confounders for TSB values.

RESULTS

Correlation between TSB and TcB was high. Pearson's correlation coefficients were over 0.9 in all groups (0.910, 0.908, 0.916 and 0.934, p<0.0001 in groups 1, 2, A, and B respectively). Bland-Altman plots showed acceptable and close limits of agreements (56.8/-57.7, 54.2/-67.2, 57.7/-55.8, and 51.3/-69.9μmol/L in groups 1, 2, A and B respectively) with a trend for TcB to overestimate TSB in groups 2 and B. Birth term and skin color were not identified as confounding factors for predicting TSB in multiple linear regression.

CONCLUSIONS

TcB measurements using the Draeger JM-103® device correlate significantly with TSB, regardless of term and skin color. Transcutaneous bilirubinometry seems to be a safe and cost-effective screening method for severe hyperbilirubinemia in newborns of different terms and ethnic origins.

Can transcutaneous bilirubinometry safely guide phototherapy treatment of neonatal jaundice in Malawi?

OBJECTIVES

To assess the correlation between total serum bilirubin (TSB) and transcutaneous bilirubin (TcB) values in Malawian newborn infants, and to investigate whether TcB can be used safely to guide phototherapy treatment in the absence of TSB results.

METHODS

128 newborn jaundiced infants were studied in the neonatal nursery at Queen Elizabeth Central Hospital, Blantyre. Paired TSB and TcB measurements (from forehead and sternum) were compared using the linear regression and Bland-Altman methods. Clinical decisions based on TcB results were compared with those based on 'gold standard' TSB results.

RESULTS

For infants not under phototherapy, the lowest TcB reading (from forehead or sternum) gave the strongest correlation with TSB: r = 0·83 for term infants and r = 0·71 for premature infants. For infants undergoing phototherapy, the highest TcB reading gave the strongest correlation with TSB: r = 0·66 for term infants and r = 0·71 for premature infants. TcB values overestimated the degree of jaundice. For infants not under phototherapy, the mean (SD) bias and imprecision of TcB was 25 (72) μmol/L for term infants and 37 (73) μmol/L for premature infants. For infants under phototherapy, the mean bias and imprecision was 30 (79) μmol/L for term infants and 44 (77) μmol/L for premature infants. For infants not under phototherapy, using the lowest TcB reading to guide treatment decisions (n = 167) had good sensitivity (91%) and specificity (90%). For infants undergoing phototherapy, using the highest TcB reading to guide treatment decisions (n = 129) had good sensitivity (94%), but lower specificity (36%).

CONCLUSIONS

TcB can be used to safely guide phototherapy treatment in a resource-poor setting.

Impact of a transcutaneous bilirubinometry program on resource utilization and severe hyperbilirubinemia

OBJECTIVES

Our goal was to assess the impact of programmatic and coordinated use of transcutaneous bilirubinometry (TcB) on the incidence of severe neonatal hyperbilirubinemia and measures of laboratory, hospital, and nursing resource utilization.

METHODS

We compared the neonatal hyperbilirubinemia-related outcomes of 14 796 prospectively enrolled healthy infants ≥35 weeks gestation offered routine TcB measurements in both hospital and community settings by using locally validated nomograms relative to a historical cohort of 14 112 infants assessed by visual inspection alone.

RESULTS

There was a 54.9% reduction (odds ratio [OR]: 2.219 [95% confidence interval (CI): 1.543-3.193]; P < .0001) in the incidence of severe total serum bilirubin values (≥342 µmol/L; ≥20 mg/dL) after implementation of routine TcB measurements. TcB implementation was associated with reductions in the overall incidence of total serum bilirubin draws (134.4 vs 103.6 draws per 1000 live births, OR: 1.332 [95% CI: 1.226-1.446]; P < .0001) and overall phototherapy rate (5.27% vs 4.30%, OR: 1.241 [95% CI: 1.122-1.374]; P < .0001), a reduced age at readmission for phototherapy (104.3 ± 52.1 vs 88.9 ± 70.5 hours, P < .005), and duration of phototherapy readmission (24.8 ± 13.6 vs 23.2 ± 9.8 hours, P < .05). There were earlier (P < .01) and more frequent contacts with public health nurses (1.33 vs 1.66, P < .01) after introduction of the TcB program.

CONCLUSIONS

Integration of routine hospital and community TcB screening within a comprehensive public health nurse newborn follow-up program is associated with significant improvements in resource utilization and patient safety.

Transcutaneous bilirubin levels in an outpatient and office population

OBJECTIVE

The use of transcutaneous bilirubin (TcB) measurements has been studied extensively in the newborn population, but there have been few studies in outpatient populations and none from the offices of practicing pediatricians.

STUDY DESIGN

We performed TcB measurements on a mixed-race population of 120 jaundiced infants, ≥ 35 weeks of gestation, in two hospital-based outpatient clinics, a regional public health nurse follow-up program and two pediatric office practices. Three individual TcB readings were obtained from the mid-sternum, and the average and maximum values were recorded.

RESULT

There was good correlation between the TcB and total serum bilirubin (TSB) measurements (r=0.78, P=0.0). 59% of TSB's were ≥15 mg dl(-1) and, although the number of false-negative readings increased when the TSB values exceeded 15 mg dl(-1), it was nevertheless possible to use TcB measurements to accurately predict the risk of TSB levels ≥ 15 mg dl(-1).

CONCLUSION

In outpatient settings, a TcB measurement with the JM-103 provides a reliable screening method for the identification of hyperbilirubinemia even when the TSB level exceeds 15 mg dl(-1). Using the maximum of three independent measurements reduces the number of false negatives, but increases the number of false positives. The use of TcB measurements in an outpatient practice should be a valuable tool for the practitioner.

Transcutaneous bilirubin measurement at the time of hospital discharge in a multiethnic newborn population

BACKGROUND

Severe neonatal hyperbilirubinemia continues to occur in healthy newborns. Recent guidelines have supported using transcutaneous devices in estimating bilirubin levels. Previous studies using these devices are limited.

METHODS

Newborns requiring serum bilirubin level measurements before hospital discharge were recruited prospectively. The agreement between a transcutaneous bilirubin (TCB) and total serum bilirubin (TSB) level was assessed. Sensitivity analysis was conducted.

RESULTS

A total of 430 infants were enrolled. Correlation between the values was high (Pearson's correlation coefficient 0.83; Lin's concordance coefficient 0.81 [95% CI 0.77 to 0.84]; P<0.001). The mean (± SD) TSB level was 194±60 μmol/L. The TCB measurement tended to overestimate the value (mean difference 12.7), with wide 95% limits of agreement (-52 μmol/L to 77 μmol/L). Sensitivity and specificity analysis of TCB values allowed estimation of clinically important TSB levels.

CONCLUSIONS

The TCB correlated, but was imprecise in predicting TSB. TCB values can be used at the time of discharge to safely plan care for jaundiced infants if the limits of agreement are considered and clinical judgment is maintained.

Estudo comparativo entre a medida plasmática e transcutânea de bilirrubina em recém-nascidos

OBJETIVO: Comparar as medidas transcutânea e plasmática da bilirrubina antes e durante a fototerapia, em área de pele exposta e coberta, analisando-se a associação com variáveis do recém-nascido (RN). MÉTODOS: Estudo de corte transversal, que avaliou 44 RN entre abril e outubro de 2008. Realizaram-se dosagens transcutâneas (região frontal e esternal) e plasmáticas da bilirrubina antes e 24 horas após o início da fototerapia. Tanto na região frontal como na esternal, ocluiu-se pequena região de pele e obteve-se a medida transcutânea da área coberta e de área adjacente exposta. Calculou-se a associação entre as medidas e variáveis do RN (peso, sexo, raça/cor, idade gestacional e pós-natal) e presença de fatores de risco para hiperbilirrubinemia significativa. RESULTADOS: Houve forte correlação entre a bilirrubina plasmática e a transcutânea, no momento da indicação e após 24 horas de fototerapia, nas regiões frontal e esternal, com intervalos de confiança estreitos tanto a 95 como a 99%. Observou-se que, com relação à medida transcutânea na área coberta, 24 horas após o início da fototerapia, a medida esternal apresentou correlação mais forte com a plasmática (r=0,86; p<0,001). As variáveis do RN analisadas não interferiram nas medidas de bilirrubina. CONCLUSÕES: As dosagens transcutânea e plasmática apresentam correlação forte antes da fototerapia nas regiões frontal e esternal. Após 24 horas de fototerapia, a medida transcutânea esternal em área coberta apresentou melhor correlação.

Impact of skin tone on the performance of a transcutaneous jaundice meter

AIM

To evaluate the performance of the Konica Minolta/Air-Shields JM-103 jaundice meter on the basis of infant skin tone during the early neonatal period.

METHODS

Infants were prospectively categorized into light, medium and dark skin tone groups relative to two reference colours. Transcutaneous bilirubin readings were taken at predetermined intervals through the early neonatal period on a convenience sample of 938 healthy infants > or =37 weeks gestation. Serum bilirubin measurements were drawn routinely with metabolic studies and repeated in the presence of an elevated transcutaneous reading or clinically significant jaundice.

RESULTS

Multivariate linear regression analysis showed a significant impact on serum and transcutaneous bilirubin agreement by skin tone. Highest precision and lowest bias were observed for medium skin toned infants. Greater disagreement between serum and transcutaneous measurements was noted at serum bilirubin concentrations >200 micromol/L. Insufficient numbers of dark skin toned infants were enrolled to evaluate fully the performance of the jaundice meter for this group.

CONCLUSION

The JM-103 jaundice meter displayed good correlation with serum bilirubin concentrations in light and medium skin tone infants, although it showed a tendency to under-read in the lighter skin tone group and to over-read in the darker skin tone group. The device shows excellent performance characteristics for use as a screening device.

Comparison of a new transcutaneous bilirubinometer (Bilimed) with serum bilirubin measurements in preterm and full-term infants

Background

The gold standard to assess hyperbilirubinemia in neonates remains the serum bilirubin measurement. Unfortunately, this is invasive, painful, and costly. Bilimed^®, a new transcutaneous bilirubinometer, suggests more accuracy compared to the existing non-invasive bilirubinometers because of its new technology. It furthermore takes into account different skin colours. No contact with the skin is needed during measurement, no additional material costs occur. Our aim was to assess the agreement between the Bilimed^® and serum bilirubin in preterm and term infants of different skin colours.

Methods

The transcutaneous bilirubin measurements were performed on the infant's sternum and serum bilirubin was determined simultaneously. The agreement between both methods was assessed by Pearson's correlation and by Bland-Altman analysis.

Results

A total of 117 measurement cycles were performed in 99 term infants (group1), further 47 measurements in 38 preterm infants born between 34 - 36 6/7 gestational weeks (group 2), and finally 21 measurements in 13 preterm infants born between 28 - 33 6/7 gestational weeks (group 3). The mean deviation and variability (+/- 2SD) of the transcutaneous from serum bilirubin were: -14 (+/- 144) μmol/l; -0.82 (+/- 8.4) mg/dl in group 1, +16 (+/- 91) μmol/l;+0.93(+/- 5.3) mg/dl in group 2 and -8 (+/- 76) μmol/l; -0.47 (+/- 4.4) mg/dl in group 3. These limits of agreement are too wide to be acceptable in a clinical setting. Moreover, there was to be a trend towards less good agreement with increasing bilirubin values.

Conclusion

Despite its new technology the Bilimed^® has no advantages, and more specifically no better agreement not only in term and near-term Caucasian infants, but also in non-Caucasian and more premature infants.

Implementing and validating transcutaneous bilirubinometry for neonates

Noninvasive, transcutaneous bilirubin (TcB) measurement is an attractive option for neonates, but opinions about its usefulness vary among studies. We collected paired measurements of TcB and serum bilirubin (SB) in 343 term neonates using the BiliCheck meter (SpectRx, Norcross, GA) and 3 different SB methods. Correlations between SB and TcB were similar for all laboratory methods and TcB measurement sites. However, TcB bias varied depending on the comparison SB method and TcB measurement site. TcB bias also varied with race when measurements were done on the forehead but not when they were done on the sternum. Several factors must be considered before implementing TcB measurement: (1) Each laboratory instrument has its own unique relationship to TcB. (2) The chosen measurement site affects the relationship. (3) Race can affect TcB bias when the measurement is taken on the forehead. Properly used, TcB measurement, especially when taken from the sternum, can be a useful screening method for neonatal jaundice.

Hyperbilirubinemia and Transcutaneous Bilirubinometry

Background: Neonatal jaundice or hyperbilirubinemia is a common occurrence in newborns. Although most cases of neonatal jaundice have a benign course, severe hyperbilirubinemia can lead to kernicterus, which is preventable if the hyperbilirubinemia is identified early and treated appropriately.

Content: This review discusses neonatal jaundice and the use of transcutaneous bilirubin (TcB) measurements for identification of neonates at risk of severe hyperbilirubinemia. Such a practice requires appropriate serial testing and result interpretation according to risk level from a nomogram that provides bilirubin concentrations specific for the age of the neonate in hours. In this context, we have evaluated the potential impact on clinical outcome and limitations of TcB methods in current use.

Summary: TcB measurement is a viable option in screening neonates to determine if they are at risk for clinically significant hyperbilirubinemia. Total serum bilirubin should be measured by a clinical laboratory if a newborn is shown to be at higher risk for clinically significant hyperbilirubinemia. In addition, external quality assessment to identify biases and operator training issues should be part of any TcB monitoring program.

Point of care testing: transcutaneous bilirubinometry in neonates

Physicians taking care of infants in the first days of life are often faced with neonatal jaundice, especially in an era where post-partum discharge occurs earlier and assessment of newborn bilirubinemia status is required prior to discharge. The Canadian Pediatric Society and the American Academy of Pediatrics have developed and published guidelines for the diagnosis and management of hyperbilirubinemia in newborns. Point of care testing refers to any test performed outside of laboratory by clinical personnel and close to the site of patient care. Based on a summary of multiple reports during the last twenty years, we realize that devices which provide a non-invasive transcutaneous bilirubin (TcB) measurement have proven to be very useful as screening tools and provide a valid estimate of the total serum bilirubin level (TSB). Published data suggest that these devices provide measurements within 30-50 micromol/L of the TSB levels and can replace laboratory measurement particularly when TSB levels are less than 260 micromol/L. At the present time, in the literature, evidence is insufficient to abandon neonatal serum bilirubin testing and replace it with TcB. Any measurement, TSB or TcB, has potential for error. However, we have evidence that TcB, can help avoiding potential errors associated with even visual assessment of jaundice and may be useful as screening device to detect significant jaundice and decrease a large number of unnecessary skin punctures. The current manuscript is based on a careful comprehensive literature review concerning neonatal hyperbilirubinemia. We consider that this manuscript will help clinicians and laboratory professionals in the management of neonatal jaundice.

Transcutaneous bilirubin in predicting hyperbilirubinemia in term neonates

OBJECTIVE

To assess the utility of 24 and 48 hours transcutaneous bilirubin (TcB) index for predicting subsequent significant hyperbilirubinemia in healthy term neonates.

METHODS

TcB indices were obtained for healthy, breastfed, term AGA newborns at 24 +/- 2, 48 +/- 2 and subsequently at intervals of 24 hours. Neonates with illness, on treatment and positive Direct Coomb's test were excluded. Serum bilirubin levels were obtained whenever indicated. Neonates having serum bilirubin > or = 17 mg/dL were considered as significant hyperbilirubinemia. The 24 and 48 hour TcB indices, as risk predictors for such hyperbilirubinemia were determined.

RESULTS

Study included 461 healthy term neonates. The mean birth weight was 2949 (+/- 390) gm and mean gestation of 38.6 (+/- 1.1) weeks. Eight one (17.6%) had significant hyperbilirubinemia. Of 461, 135 (29.3%) had TcB index.

CONCLUSION

The 24 and 48 hour TcB indices are predictive for subsequent significant hyperbilirubinemia and can guide clinician in early discharge of healthy term newborns.

Early recognition of neonatal hyperbilirubinemia and its emergent management

Hyperbilirubinemia and kernicterus are re-emerging as prominent clinical concerns and have been hypothesized to be secondary to increased breast-feeding rates, early hospital discharges and overall lack of concern for the potential impact of severe hyperbilirubinemia on healthy term newborns. Although the clinical symptoms can be non-specific and vague, they could be early, insidious and heralding signs of acute bilirubin encephalopathy (ABE) or acute stage kernicterus. Because it is highly prevalent, evaluation of a jaundiced neonate requires detailed questions about specific signs, review of birth and postnatal histories, evaluation of predischarge data, and possibly an emergency clinical evaluation of the neurological status of the infant. Medical urgency to evaluate, investigate and monitor such a newborn ensues from the possibility of rapid progression that might lead to permanent sequelae of bilirubin-induced neurologic dysfunction (BIND). Early recognition of the urgency and rapid transition to treatment seem to be the major barriers leading to delay in therapy. However, because there is a well-established and relatively safe treatment for neonatal jaundice, there should be zero tolerance for kernicterus, and BIND prevention has become a national priority in the USA. This paper reviews the clinical signs and epidemiology of ABE and BIND and presents a system-based strategy for preventing their occurrence, focusing particularly on the transition from recognition of clinical jaundice to actual treatment. A novel emergency-room-based protocol is presented as an example of how to expedite and facilitate rapid progression to treatment.

Transcutaneous bilirubinometry: a noninvasive tool for studying newborn jaundiced rats before and after exposure to light

The homozygous Gunn rat is the most frequently used animal model for the study of neonatal jaundice. We evaluated the applicability of noninvasive transcutaneous bilirubin (TcB) measurements as an index of serum total bilirubin (STB) levels in neonatal rats by comparison to invasive STB measurements. TcB measurements were made during the first 96 h of life with the Model 101 Minolta/Air-Shields Jaundice Meter (JM) and SpectRx BiliCheck System (BC). Measurements with both devices displayed parallel TcB profiles, rapidly rising within 24 h, increasing during the next 6 h, then leveling off after 30 h. Linear regressions for the JM (n = 60) were as follows: STB (mg/dL) = 0.79 (JM) - 0.01 (units, r = 0.95, head); STB (mg/dL) = 0.82 (JM) + 1.51 (units, r = 0.95, upper back); and STB (mg/dL) = 0.74 (JM) + 1.60 (units, r = 0.91, lower back). Mean bias +/- imprecision were as follows: -0.02 +/- 3.99 mg/dL, -0.01 +/- 3.90, and 0.01 +/- 4.28 at the head, upper back, and lower back, respectively. For the BC, only lower back measurements were taken, and the regression was as follows: STB (mg/dL) = 0.77 (BC) + 1.65 mg/dL, (r = 0.93, n = 29) with a mean bias +/- imprecision of -1.08 +/- 3.08 mg/dL. When pups were exposed to light, correlations remained strong but intercepts increased. These results demonstrate that noninvasive TcB measurements correlate highly with STB in the Gunn rat during the first 96 h of life and after exposure to light. We conclude that JM measurements at the head and BC at the lower back reflect STB most reliably and consistently. Thus, in addition to being a useful tool for evaluating jaundice in human neonates, TcB methodology can be used successfully for the noninvasive monitoring of jaundice in neonatal Gunn rats pre- and postlight exposure.

Immunizations, neonatal jaundice, and animal-induced injuries

PURPOSE OF REVIEW

To concisely review data published over the past year on three topics pertinent to the practicing pediatrician: immunizations, neonatal jaundice, and animal-induced injuries.

RECENT FINDINGS

Updates on immunizations, including varicella and pneumococcus in the post-vaccine era, use of a polyvalent conjugated meningococcal vaccine, and influenza vaccination during a vaccine shortage are discussed. Mortality and morbidity from varicella, and risk of invasive disease from pneumococcal infections have declined. The Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention released guidelines for the use of a tetravalent meningococcal conjugate vaccine in adolescents 11 years and older. Infants at younger gestational age are at higher risk for developing hyperbilirubinemia. The American Academy of Pediatrics has released new guidelines emphasizing breastfeeding, systematic pre-discharge assessment for risk factors, early follow-up and intervention. Use of home nursing services in the postnatal period is cost-effective. Although the incidence of rabies is low, many receive postexposure prophylaxis. Spider bites cause fewer systemic effects in children than adults. Pet reptile carriage of salmonella necessitates handwashing after handling of animals.

SUMMARY

Recommendations for adolescent meningococcal vaccination, and the impact of varicella and pneumococcal immunization on our communities reflect an evolution in our management of infectious diseases. The latest practice guidelines on hyperbilirubinemia emphasize close follow-up of all newborns after postpartum discharge and even more careful evaluation of those infants near term. Education on rabies prophylaxis, spider bites, and salmonella from pet reptiles should focus on judicious use of resources and the proper handling of pets.