Transcutaneous bilirubinometry decreases the need for serum bilirubin measurements and saves money

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.

Non-invasive estimation of hemoglobin, bilirubin and oxygen saturation of neonates simultaneously using whole optical spectrum analysis at point of care

The study was aimed to evaluate the performance of a newly developed spectroscopy-based non-invasive and noncontact device (SAMIRA) for the simultaneous measurement of hemoglobin, bilirubin and oxygen saturation as an alternative to the invasive biochemical method of blood sampling. The accuracy of the device was assessed in 4318 neonates having incidences of either anemia, jaundice, or hypoxia. Transcutaneous bilirubin, hemoglobin and blood saturation values were obtained by the newly developed instrument which was corroborated with the biochemical blood tests by expert clinicians. The instrument is trained using Artificial Neural Network Analysis to increase the acceptability of the data. The artificial intelligence incorporated within the instrument determines the disease condition of the neonate. The Pearson's correlation coefficient, r was found to be 0.987 for hemoglobin estimation and 0.988 for bilirubin and blood gas saturation respectively. The bias and the limits of agreement for the measurement of all the three parameters were within the clinically acceptance limit.

Reliability of transcutaneous bilirubin determination based on skin color determined by a neonatal skin color scale of our own

Measurement of transcutaneous bilirubin (TcB) is widely used to estimate serum bilirubin (SB). However, its reliability depending on skin tone is still controversial. Ethnic classification does not correlate well with skin tone. We aimed to determine the reliability of transcutaneous bilirubin in a multiethnic population based on skin color according to our neonatal skin color scale. We conducted a prospective, observational study comparing SB and TcB among different skin colors. With the blood sample routinely obtained at 48-72 h for the screening of inborn errors of metabolism, we determined SB and TcB with a jaundice meter. We obtained data from 1359 newborns (color 1 337, color 2 750, color 3 249, color 4 23) and analyzed 1549 dyads SB/TcB. Correlation between TcB and serum bilirubin was very good (R² = 0.908-0.956), globally and by color group, with slight differences between darker and lighter skin colors. Bland-Altman plots showed different mean bias depending on skin color. Conclusions: Our study not only supports the reliability of TcB to assess SB regardless of skin color, but also supports the fact that TcB tends to overestimate SB in a higher degree in dark-skinned neonates. This may help reduce the number of blood samples for newborns. What is Known: • Jaundice meters are extensively used to diagnose neonatal hyperbilirubinemia, although controversies exist on their reliability depending on skin color. • Only a few studies have analyzed their accuracy in multiethnic populations, but none has used a validated neonatal skin color scale. What is New: • We verified correlation between serum and transcutaneous bilirubin in a multiethnic population depending on skin color after classifying our neonates into color groups with our own validated neonatal skin color scale.

Decision Accuracy and Safety of Transcutaneous Bilirubin Screening at Intermountain Healthcare

OBJECTIVE

To quantify the risk that transcutaneous bilirubin (TcB) screening would fail to recommend phototherapy for a neonate who would have qualified for it if total serum bilirubin (TSB) screening were used.

STUDY DESIGN

We conducted a quality improvement project where simultaneous TcB and TSB were obtained on neonates ≥35 weeks of gestation during birth hospitalizations in our hospital system. Using our Utah bilirubin management algorithm, we quantified the risk that TcB screening would fail to identify the need for a confirmatory TSB when TSB screening alone would have revealed that phototherapy was indicated.

RESULTS

In 3 hospitals, we obtained 727 paired TcB/TSB measurements. Two instances utilized a blood gas radiometer for TSB, and 725 utilized the clinical laboratory-based TSB method. One of the 727 instances had a TcB indicating NO PHOTOTHERAPY, when the simultaneous TSB indicated PHOTOTHERAPY NEEDED. The TSB from that instance was 1 of the 2 from the blood gas radiometer. We estimate the risk of such an error occurring is 1.4 per 1000 TcB measurements (95% CI 0.03-7.6 per 1000). When only the laboratory TSB is used, we estimate the risk of such an error occurring to be 0 per 1000 TcB measurements (95% CI 0.0-5.1 per 1000).

CONCLUSIONS

Using TcB for screening at the birth hospital can identify those qualifying for phototherapy, using the Utah guidelines, with 1 of 727 neonates with a blood gas bilirubin and none of 725 with a laboratory-based analysis misidentified as not needing phototherapy when by TSB they did.

Large scale validation of a new non-invasive and non-contact bilirubinometer in neonates with risk factors

The study was aimed to evaluate the performance of a newly developed non-invasive and non-contact bilirubin measurement device (AJO-Neo) as an alternative to the conventional invasive biochemical method of total serum bilirubin (TSB) estimation in preterm and term neonates suffering from hyperbilirubinemia associated with risk factors, and/or undergoing phototherapy. The safety and efficacy of the device were assessed in 1968 neonates with gestational ages ranging from 28 to 41 weeks and suffering from incidences of hyperbilirubinemia. Linear regression analysis showed a good correlation between AJO-Neo and the conventional method of TSB (Pearson’s coefficient, r = 0.79). The small bias (0.27 mg/dL) and limits of agreements (− 3.44 to 3.99 mg/dL) were within the range of clinical acceptance. The device was also precise in the measurement of bilirubin levels in all subgroups of the study. The receiver operator curve (ROC), that takes account of both sensitivity and specificity of a device showed high efficacy of the device (area under the curve, AUC = 0.83) in the detection of bilirubin. While monitoring the bilirubin level during phototherapy, the device indicated promising results showing good agreement with TSB. Specificities and sensitivities of the device indicated a much higher accuracy in neonates with associated risk factors for hyperbilirubinemia. Hence, the newly developed device (AJO-Neo) is reliable in measuring bilirubin level in preterm, and term neonates irrespective of gestational or postnatal age, sex, risk factors, feeding behavior or skin color.

Reducing Outpatient Infant Blood Draws with Transcutaneous Measurement of Bilirubin

Introduction:

Newborn jaundice is a common outpatient problem. Transcutaneous bilirubin (TcB) measurements correlate well with total serum bilirubin (SB) measurements below 15 mg/dl and are efficient and noninvasive. Some concern exists that TcB measurement may subsequently lead to an increase in the number of SB measurements performed in the outpatient setting. We aimed to implement the use of a TcB device in an outpatient clinic. By doing so, we sought to increase the number of newborns screened solely by TcB as opposed to SB, by 30%, within 12 months.

Methods:

We conducted plan-do-study-act cycles with targeted interventions to promote the use of TcB in an outpatient clinic for eligible newborns older than 35 weeks gestational age, aged 1–20 days, and without a history of transfusion, phototherapy, extensive bruising, or risk of hemolysis. We used statistical process control methods to measure proportions of newborns evaluated with TcB (run chart) and patients-between SB measurements (G-chart) over time in the outpatient clinic.

Results:

We collected preintervention data for 18-months and intervention data for 12 months. For newborns attending the outpatient clinic, the proportion of TcB measurements increased after implementation of the use of TcB measurement. There was an increase in patients-between SB measurements. At project inception, SB was drawn for every 8 eligible patients. By the end of the project, there were 98 eligible newborns between instances of SB testing.

Conclusion:

Implementation of a quality-improvement initiative to measure TcB in the outpatient clinic was feasible and reduced the number of SB tests.

The accuracy of transcutaneous bilirubinometry in preterm infants

OBJECTIVE

To evaluate the correlation between total serum and transcutaneous bilirubin and to determine the reliability of transcutaneous bilirubinometry for screening and monitoring of neonatal jaundice among preterms.

STUDY DESIGN

Ninety nine infants with gestational ages ≤34 weeks were prospectively enrolled. Babies were classified into three groups as; 24-28, 29-31, and 32-34 weeks. Total serum bilirubin and simultaneous transcutaneous bilirubin were measured before the onset of phototheraphy, during and at 24 h after discontinuing phototherapy.

RESULTS

Total serum bilirubin significantly correlated with transcutaneous bilirubin in the whole cohort (r = 0.867, p < 0.001) and in each group before, during and after phototheraphy. Hypotension was the only variable which effects the difference between two methods at postnatal first day of life (p = 0.039).

CONCLUSION

Transcutaneous bilirubin levels were highly correlated with total serum bilirubin levels even in 24-28 GW babies. Transcutaneous bilirubin may be useful for screening and monitoring of jaundice in very preterm newborns.

Chromatic techniques for in vivo monitoring jaundice in neonate tissues

OBJECTIVE

A chromatic method is described for providing a preliminary indication of unacceptable bilirubin levels in a newly born baby in order to avoid the development of serious mental deficiencies. The aim was to investigate the reliability of a new chromatic approach using a novel template unit for a preliminary, non-invasive monitoring of the skin tissue of newly born babies with jaundice and its capability for use with different mobile phone cameras.

APPROACH

A description of the monitoring system is given along with an explanation of the monitoring technique used. Preliminary tests have been performed on 48 different neonates each being addressed by one of six different mobile phone cameras, which were randomly available to the operating clinicians.

MAIN RESULTS

The test results have a correlation (R ²) of 0.81, a sensitivity (Sn) of 0.97, a specificity (Sp) of 0.82, a positive predictive value (PPV) of 0.95 and a negative predictive value (NPV) of 0.9.

SIGNIFICANCE

The significance of the results obtained is that they show the approach to have a high level of fail-safe reliability in indicating the bilirubin levels when compared with blood test results. The results also show that the approach can be used with a few different mobile phone cameras and that because of its non-invasive nature and its cost effectiveness, has the potential for remote use from a medical hospital to provide an immediate preliminary diagnosis.

A Prospective Comparison of Transcutaneous and Serum Bilirubin Within Brief Time Intervals

The American Academy of Pediatrics recommends screening newborns ≥35 weeks' gestation with total serum bilirubin (TSB) or transcutaneous bilirubin (TcB) to detect hyperbilirubinemia. Retrospective studies show TcB measurements strongly correlate with TSB; however, few prospective trials document this relationship. Furthermore, Dräger's newest TcB instrument, JM-105, remains unstudied in the United States. We measure TcB on foreheads and sternums of newborns using JM-105 and Bilichek devices within 30 minutes of TSB measurement. We find best overall TcB/TSB correlation with JM-105 on the sternum (mean TcB-TSB difference: -0.21 ± 1.15 mg/dL). Correlations between paired measurements for TcB on the sternum using JM-105 were 0.93 for all TSB levels (n = 178), 0.82 for TSB > 10 (n = 19), 0.69 for TSB > 12 (n = 11), and 0.52 for TSB > 15 (n = 6). TcB accuracy via JM-105 on the sternum significantly differed among races ( P < .001). For 5% of paired measurements, TcB with JM-105 on the sternum underestimated TSB by ≥2 mg/dL, and for <1% by ≥3 mg/dL.

Transcutaneous bilirubin measurement during phototherapy in term neonates

BACKGROUND

We tested whether direct transcutaneous bilirubin (TcB) measurement from an area unexposed to phototherapy is reliable for estimation of total serum bilirubin (TSB) in neonates during phototherapy and whether it contributes to reduction in TSB blood sampling in phototherapy decision making.

METHODS

This was a retrospective observational study of term neonates who received phototherapy in the mother's room. TSB and TcB from the neonate's sternum were measured before and during phototherapy and compared using linear regression analysis and Bland-Altman plot, respectively. Various cut-offs of TcB for estimating TSB during phototherapy at >72 h after birth were analyzed.

RESULTS

There were moderate correlations between TSB and TcB before (r = 0.56) and during (r = 0.47) phototherapy in 125 neonates. The mean difference (TSB-TcB) before and during phototherapy was 1.2 ± 1.7 mg/dL and 1.0 ± 1.7 mg/dL, respectively. The 95% limits of agreement for the difference before and during phototherapy ranged from -2.1 to 4.5 and from -2.3 to 4.3 mg/dL, respectively. For TSB ≤18 mg/dL during phototherapy, a TcB cut-off of 14 mg/dL had a specificity of 1.0; with this method, 43% of the TSB measurements could have been avoided.

CONCLUSIONS

Direct measurement of TcB during phototherapy using a bed-type device is a reliable method to estimate TSB in term neonates and would contribute to a reduction in blood sampling. It cannot, however, be used as a substitute for TSB measurement.

Transcutaneous Bilirubinometry in Jaundiced Neonates: A Randomized Controlled Trial

BACKGROUND

For evaluation of jaundiced neonates, serum bilirubin (SB) or transcutaneous bilirubinometry (TcB) is used. Few data are available on the quantitative reduction of blood sampling by using TcB.

METHODS

We conducted a randomized controlled trial in hospitalized jaundiced neonates ≥32 weeks' gestational age. In the intervention group, TcB was used and in the control group the decision to obtain a blood sample for SB was based on visual and clinical assessment. Outcome measure was the number of blood samples before phototherapy. When TcB was <50 µmol/L below the threshold for phototherapy, SB was obtained. The decision to start treatment was always based on an SB value.

RESULTS

A total of 430 were randomized and included in the intention-to-treat analysis: 213 in the TcB group and 217 in the control group. In the TcB group, 104 (48.4%) had at least 1 blood sample taken for SB, versus 172 (79.3%) in the control group (difference 30.5%, 95% confidence interval 21.5-38.7, P < .001). The number of blood draws was significantly reduced by 38.5% (0.9 ± 1.1 vs 1.3 ± 1.0, difference -0.5, 95% confidence interval -0.7 to -0.3, P < .001). Peak of bilirubin value, indications for phototherapy, or exchange transfusion and hospitalization length were not different between groups.

CONCLUSIONS

The use of TcB in jaundiced neonates is feasible and safe, resulting in a reduction of more than one-third in blood draws.

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.

Effect of Phototherapy on the Reliability of Transcutaneous Bilirubin Devices in Term and Near-Term Infants: A Systematic Review and Meta-Analysis

BACKGROUND

Transcutaneous bilirubin (TcB) devices are commonly used for screening of hyperbilirubinemia in term and near-term infants not exposed to phototherapy. However, the accuracy of TcB devices in infants exposed to phototherapy is unclear.

OBJECTIVES

To conduct a systematic review of studies comparing TcB devices with total serum bilirubin (TSB) in infants receiving phototherapy or in the postphototherapy phase.

METHODS

MEDLINE, EMBASE, Cochrane Library, CINAHL and Scopus databases (from inception to May 8, 2014) were searched. Additional citations were identified from the bibliography of selected articles and from the abstracts of conference proceedings. The studies were included if they compared TcB results with TSB in term and near-term infants during phototherapy or after discontinuation of phototherapy. Two reviewers independently assessed studies for inclusion, and discrepancies were resolved with consensus. Risk of bias was assessed using the QUADAS-2 tool.

RESULTS

Fourteen studies were identified. The pooled estimates of correlation coefficients (r) during phototherapy were: covered sites 0.71 (95% CI 0.64-0.77, 11 studies), uncovered sites 0.65 (95% CI 0.55-0.74), 8 studies), forehead 0.70 (95% CI 0.64-0.75, 12 studies) and sternum 0.64 (95% CI 0.43-0.77, 5 studies). Two studies also provided results as Bland-Altman difference plots (mean TcB-TSB differences -29.2 and 30 µmol/l, respectively). The correlation coefficient improved marginally in the postphototherapy phase (r = 0.72, 95% CI 0.64-0.78, 4 studies).

CONCLUSION

We found a moderate correlation between TcB and TSB during phototherapy with a marginal improvement in the postphototherapy phase. Further research is needed before the use of TcB devices can be recommended for these settings.

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.

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.

Reliability of transcutaneous bilirubin devices in preterm infants: a systematic review

BACKGROUND AND OBJECTIVE

Transcutaneous bilirubin (TcB) devices are widely used for the estimation of serum bilirubin levels in term and near-term infants. Our objective was to review the diagnostic accuracy of TcB devices in preterm infants.

METHODS

Medline, Embase, Cochrane library, Cumulative Index to Nursing and Allied Health Literature, and Scopus were searched (from database inception date until December 2012). Additional citations were identified by using the bibliographies of selected articles and from conference proceedings. The studies were included if they compared TcB with total serum bilirubin in preterm infants before phototherapy and presented data as correlation coefficients or as Bland-Altman difference plots. Data were extracted by 1 reviewer and checked for accuracy by the second reviewer. An assessment tool (quality assessment of diagnostic accuracy studies) was used for risk of bias assessments.

RESULTS

Twenty-two studies met the inclusion criteria; 21 studies reported results as correlation coefficients, with pooled estimates of r = 0.83 for each site of measurement. Pooled estimates in infants <32 weeks' gestation were similar to the overall preterm population (r = 0.89 [95% confidence interval: 0.82-0.93]). For the 2 commonly used TcB devices (ie, JM103 and BiliCheck), the results were comparable at the forehead site, although the JM103 device exhibited better correlation at the sternum. Analysis of the Bland-Altman plots (13 studies) revealed negligible bias in measurement at the forehead or sternum site by using either the JM-103 or BiliCheck device; however, the JM-103 device exhibited better precision than the BiliCheck (SD for TcB - total serum bilirubin differences: 24.3 and 31.98 µmol/L, respectively).

CONCLUSIONS

The TcB devices reliably estimated bilirubin levels in preterm infants and could be used in clinical practice to reduce blood sampling.

BiliCheck vs JM-103 in identifying neonates not at risk of hyperbilirubinaemia

Background

Transcutaneous bilirubinometry is widely used to predict hyperbilirubinemia by using several devices. The aim of this study was to compare the predictive ability of BiliCheck vs JM-103 in identifying neonates not at risk of significant hyperbilirubinemia, putting the data obtained with the two instruments on our transcutaneous bilirubin nomogram built with the BiliCheck.

Methods

Transcutaneous bilirubin (TcB) measurement was performed when jaundice appeared in newborn babies and/or just before discharge from the hospital. It was performed at the forehead with the two instruments within 5 minutes by two experienced neonatologists, each one blind to the value obtained by the other. Blood samples were drawn to obtain total serum bilirubin (TSB) levels soon after TcB measurements.

Results

A total of 627 paired-sample measurements were obtained from 298 newborn babies. Out of the total population studied, 16 newborn babies (5.4%) showed significant hyperbilirubinemia defined as TSB value >17 mg/dL, or as need for phototherapy treatment according to the AAP guidelines. TcB measurements showed false negative results in the first 60 hours of life using both devices. After the 60^th hour of life, TcB measurements using both devices successfully predicted newborn babies not at risk of significant hyperbilirubinemia, being the JM-103 more reliable than BC because of fewer false positive results.

Conclusions

Our study shows that both BC and JM-103 can exclude subsequent significant hyperbilirubinemia when the measurements are performed after the 60^th hour of life. Nevertheless, the transcutaneous pre-discharge screening should be considered only as the first step, and it has to be followed by a follow-up through the first days after discharge.

Neonatal bilirubin triage with transcutaneous meters: when is a blood draw necessary?

OBJECTIVE

To find the optimal transcutaneous bilirubin (TcB) screening level in term neonates that minimizes the discomfort of phlebotomy, while protecting the child from harm and controlling costs.

METHODS

All available TcB and total serum bilirubin (TSB) measurements taken between 27 and 51 hours of life from a cohort of term newborns were analyzed in a retrospective chart review. TcB cutoffs between 6 and 12 mg/dL were evaluated for their negative predictive values (NPVs) for high risk (HR) and for the combination of high-intermediate risk and HR on the Bhutani TSB risk nomogram.

RESULTS

One thousand seventy-one full-term newborns were entered into the study. Of 601 newborns with TcB < 7 mg/dL, none were HR by TSB. Of newborns with a TcB of < 8 mg/dL, 1 in 759 was HR. The NPVs for screening levels of 7 and 8 mg/dL were of 100% and 99.9%, respectively, for HR and 99% and 97.60%, respectively, for high-intermediate/HR. A cutoff at 12 mg/dL had NPVs of 99.3% for HR, with 7 neonates, and 92.7% for high-intermediate/HR, with 76 infants of 1041.

CONCLUSIONS

In our center, term infants with a TcB of < 8 mg/dL may be safely discharged without a follow-up TSB, with the understanding that -1/1000 infants may be at HR for developing severe hyperbilirubinemia. Practices with universal follow-up may safely choose cutoffs up to 12 mg/dL. An institution's degree of comfort and confidence in follow-up of the newborn cohort will guide the choice of an appropriate TcB cutoff requiring a TSB.

Measuring transcutaneous bilirubin: a comparative analysis of three devices on a multiracial population

Background

Hyperbilirubinemia can lead to potentially irreversible bilirubin-induced neurotoxicity. Transcutaneous bilirubin (TcB) determination has become a valuable aid in non invasive screening of neonatal jaundice.

The aim of this study is to compare the performance of three most widespread transcutaneous bilirubinometers on a multiracial population of term and late pre-term neonates.

Methods

Bilirubin concentration was determined using traditional photometric determination and transcutaneously with Bilicheck, BiliMed and JM-103, in random order.

Total serum bilirubin (TSB) was determined over a wide concentration range (15,8–0,7 mg/dl) with a mean of 9,5 mg/dl. Related TcB values using Bilicheck (TcB-BC), BiliMed (TcB-BM), and JM-103 (TcB-JM) are reported in Table 1.

Results

A multiracial population of 289 neonates was enrolled with a gestational age ranging from 35 to 41 weeks; birth weight ranging from 1800to 4350 grams; hours of life ranging from 4 to 424. In the total study population correlation analysis using Pearson coefficients showed good results for Bilicheck (r = 0.86) and JM-103 (r = 0.85) but poor for BiliMed (r = 0,70). Similar results were found for the non-Caucasian neonates subgroup. Bilicheck and JM-103 had a greater area under the curve than BiliMed when TSB =14 mg/dl was chosen as a threshold value both for the total study population and the non-Caucasian subgroup.

Conclusions

Bilicheck and JM-103, but not BiliMed, are equally reliable screening tools for hyperbilirubinemia in our multiracial neonatal population.

Limitations and opportunities of transcutaneous bilirubin measurements

OBJECTIVE

Although transcutaneous bilirubinometers have existed for over 30 years, the clinical utility of the technique is limited to a screening method for hyperbilirubinemia, rather than a replacement for invasive blood sampling. In this study, we investigate the reason for this limited clinical value and address possibilities for improvement.

METHODS

To obtain better insight into the physiology of bilirubin measurements, we evaluated a transcutaneous bilirubinometer that determines not only the cutaneous bilirubin concentration (TcB) but also the blood volume fraction (BVF) in the investigated skin volume. For 49 neonates (gestational age 30 ± 3.1 weeks, postnatal age 6 [4-10] days) at our NICU, we performed 124 TcB and 55 BVF measurements.

RESULTS

The TcB correlated well with the total serum bilirubin concentration (TSB) (r = 0.88) with an uncertainty of 55 µmol/L. The BVF in the measured skin volume ranged between 0.1% and 0.75%.

CONCLUSIONS

The performance of our bilirubinometer is comparable to existing transcutaneous devices. The limited clinical value of current bilirubinometers can be explained by the low BVF in the skin volume that is probed by these devices. Because the TcB depends for over 99% on the contribution of extravascular bilirubin, it is a physiologically different parameter from the TSB. Hence, the standard method of evaluation that compares the TcB to the TSB is insufficient to fully investigate the clinical value of transcutaneous bilirubinometers, ie, their predictive value for kernicterus. We suggest that the clinical value may be improved considerably by changing either the method of evaluation or the technological design of transcutaneous bilirubinometers.

Development and validation of serum bilirubin nomogram to predict the absence of risk for severe hyperbilirubinaemia before discharge: a prospective, multicenter study

Background

Early discharge of healthy late preterm and full term newborn infants has become common practice because of the current social and economic necessities. Severe jaundice, and even kernicterus, has developed in some term infants discharged early. This study was designed to elaborate a percentile-based hour specific total serum bilirubin (TSB) nomogram and to assess its ability to predict the absence of risk for subsequent non physiologic severe hyperbilirubinaemia before discharge.

Methods

A percentile-based hour-specific nomogram for TSB values was performed using TSB data of 1708 healthy full term neonates. The nomogram's predictive ability was then prospectively assessed in five different first level neonatal units, using a single TSB value determined before discharge.

Results

The 75 ^th percentile of hour specific TSB nomogram allows to predict newborn babies without significant hyperbilirubinemia only after the first 72 hours of life. In the first 48 hours of life the observation of false negative results did not permit a safe discharge from the hospital.

Conclusion

The hour-specific TSB nomogram is able to predict all neonates without risk of non physiologic hyperbilirubinemia only after 48 to 72 hours of life. The combination of TSB determination and risk factors for hyperbilirubinemia could facilitate a safe discharge from the hospital and a targeted intervention and follow-up.

Covered skin transcutaneous bilirubin estimation is comparable with serum bilirubin during and after phototherapy

OBJECTIVE

To determine whether transcutaneous bilirubin (TcB) from covered skin (TcB-C) during and after discontinuing phototherapy (PHT) is reliable in treating neonatal jaundice.

STUDY DESIGN

In this prospective observational study, before starting PHT, part of the forehead was covered. TcB-C and TcB from exposed skin (TcB-E) to PHT were measured before starting PHT, on a 12-hourly basis while receiving PHT and 6 h after stopping PHT. We used ANOVA (analysis of variance) and Bonferroni's t-tests.

RESULT

A total of 39 infants were enrolled (mean gestation 39 weeks, 51% males and 80% Hispanic). The mean TSB over all time periods was 10.9±2.4, TcB-C 10.9±2.4 and TcB-E 7.2±3.4. Before PHT, there were no significant differences in bilirubin by all three techniques. TcB-C was not significantly different from TSB at any time point. However, TcB-E was significantly lower during PHT and after stopping PHT.

CONCLUSION

TcB-C is a reliable method in the management of neonatal jaundice.

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.

'Halving the heel pricks': evaluation of a neonatal jaundice protocol incorporating the use of a transcutaneous bilirubinometer

AIM

This study aimed to assess the impact of implementing a new jaundice protocol incorporating the use of the Konica Minolta/Air Shields JM 103 Jaundice Meter (JM103) (Konica Minolta Sensing Inc., Osaka, Japan) in the setting of an Australian post-natal ward.

METHODS

A before-and-after study was completed following the introduction of a protocol integrating the use of the JM103 monitor on to the post-natal ward. Eligible infants were ≥ 36 weeks gestation, > 24 h and < 8 days of age. The number of Total Serum Bilirubin tests (TSBRs) were compared for the 12 months prior (T1) with a 6-month period and 6 months after protocol introduction (T2). Transcutaneous bilirubin (TcBR) results were also collected in T2. Rates of phototherapy and peak TSBRs at commencement were also compared as measures of safety.

RESULTS

Four hundred and twenty-six of the 2197 live births in T1 required one or more TSBRs compared with 119 of the 1169 live births in T2. This represents an odds ratio of 0.47 (95% confidence interval 0.38-0.58) for infants in T2 having ≥ 1 TSBR compared with T1. There was no difference between the groups for rates of phototherapy (3.8% vs. 3.0%; P= 0.2) nor any difference between the groups for peak SBR during phototherapy (301.9 µmol/L (standard deviation, SD 58) for T1 vs. 303.2 µmol/L (SD 54) for T2; P= 0.45). The estimated cost saving per year is $6966.00.

CONCLUSION

TcBR measurement in conjunction with our protocol significantly reduces painful procedures and costs without increasing the risk of delaying treatment with phototherapy.

Screening and early postnatal management strategies to prevent hazardous hyperbilirubinemia in newborns of 35 or more weeks of gestation

Although kernicterus is a rare condition, it is still being reported in North America and Western Europe in addition to less developed parts of the world. The majority of affected infants are term and late-preterm newborns who have been discharged from the nursery as 'healthy newborns' yet have subsequently developed extreme hyperbilirubinemia and the classic neurodevelopmental findings associated with kernicterus. Published guidelines provide the basic tools for preventing hazardous hyperbilirubinemia and the two most important of these are a systematic assessment, prior to discharge, of each infant, for the risk of severe hyperbilirubinemia, and appropriate follow-up based on the time of discharge and the risk assessment. The most recent recommendations call for a predischarge measurement of the serum or transcutaneous bilirubin in all infants. When combined with the gestational age and other risk factors for hyperbilirubinemia, this provides the best estimate of the risk, or lack of risk, for subsequent hyperbilirubinemia, and determines the timing of follow-up and the need for further evaluation and treatment. The application of these principles to the management of the jaundiced newborn might not eliminate every case of kernicterus, but should contribute to a reduction in its occurrence.

Transcutaneous bilirubinometry reduces the need for blood sampling in neonates with visible jaundice

OBJECTIVES

We determined usefulness of transcutaneous bilirubinometry to decrease the need for blood sampling to assay serum total bilirubin (STB) in the management of jaundiced healthy Indian neonates.

METHODS

Newborns, > or =35 weeks' gestation, with clinical evidence of jaundice were enrolled in an institutional approved randomized clinical trial. The severity of hyperbilirubinaemia was determined by two non-invasive methods: i) protocol-based visual assessment of bilirubin (VaB) and ii) transcutaneous bilirubin (TcB) determination (BiliCheck). By a random allocation, either method was used to decide the need for blood sampling, which was defined to be present if assessed STB by allocated method exceeded 80% of hour-specific threshold values for phototherapy (2004 AAP Guidelines).

RESULTS

A total of 617 neonates were randomized to either TcB (n = 314) or VaB (n = 303) groups with comparable gestation, birth weight and postnatal age. Need for blood sampling to assay STB was 34% lower (95% CI: 10% to 51%) in the TcB group compared with VaB group (17.5% vs 26.4% assessments; risk difference: -8.9%, 95% CI: -2.4% to -15.4%; p = 0.008).

CONCLUSION

Routine use of transcutaneous bilirubinometry compared with systematic visual assessment of bilirubin significantly reduced the need for blood sampling to assay STB in jaundiced term and late-preterm neonates. (ClinicalTrials.gov number, NCT00653874).

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.

Evaluation of transcutaneous bilirubinometry in preterm neonates

OBJECTIVE

To determine the accuracy and precision of transcutaneous bilirubin (TcB) measurements in preterm neonates.

STUDY DESIGN

Neonates were stratified into three groups on the basis of gestational age: 24 to 28 weeks (Group 1, n=30), 29 to 31 weeks (Group 2, n=29) and 32 to 34 weeks (Group 3, n=31). TcB was measured using the Draeger Air Shields JM-103, and when possible, measurements were made by two observers. TcB and total serum bilirubin (TSB) measurements were compared, and interobserver precision for TcB measurements was assessed.

RESULT

Correlations between TcB and TSB ranged from 0.79 to 0.92. Most of the differences between TcB and TSB were +/-2 mg per 100 ml, and there was no trend for the difference to increase with increasing bilirubin values. Sensitivity, specificity and negative predictive values ranged from 0.67 to 1.0, 0.29 to 0.81 and 0.60 to 1.0, respectively. Intraclass correlations were 0.87 to 0.92.

CONCLUSION

TcB correlates significantly with TSB in preterm neonates, and interobserver precision is significant. Routine measurement of TcB in preterm neonates may provide enhanced clinical monitoring for hyperbilirubinemia.

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.

Assessment of transcutaneous bilirubinometry in hospitalized adults

BACKGROUND

Transcutaneous techniques to measure serum bilirubin have been validated in neonates but not in adult patients. We evaluated transcutaneous bilirubinometry (TcB) in adults at risk for or diagnosed with hepatic dysfunction to determine if this technology has clinical use in quantifying the presence and magnitude of hyperbilirubinemia.

DESIGN

Unblinded, consecutive hospitalized adult patients (n = 80) from the general surgery, trauma surgery, and liver resection/transplantation services of a tertiary care, university-affiliated medical center, who were having serum bilirubin measurements performed, underwent transcutaneous bilirubin measurement from the forehead, sternum, forearm, and deltoid. Transcutaneous bilirubin measurements were repeated each time serum bilirubin measurements were performed.

RESULTS

Transcutaneous bilirubin measurements from the forehead correlated with serum bilirubin better (r, 0.963) than measurements from the forearm (r, 0.792), deltoid (r, 0.922), or sternum (r, 0.928). Forehead TcB detected hepatic dysfunction (serum bilirubin > or = 2 mg/dL) by receiver operator curves (area under the curve = 0.971) and sternum (area under the curve = 0.970) and better than deltoid and forearm measurements (area under the curve = 0.935 and 0.893, respectively). A Bland-Altman plot demonstrated that forehead measurements became less accurate as the magnitude of hyperbilirubinemia increased.

CONCLUSIONS

Forehead TcB correlated best with serum bilirubin levels but became less accurate at higher values. Refinements in the technology will be required before this technique, although promising, can be considered for routine clinical application in adults being evaluated for hyperbilirubinemia.

[Transcutaneous bilirubin measurement in preterm infants]

Transcutaneous bilirubinometry is an effective screening tool for neonatal jaundice in full-term babies. But its accuracy is not shown yet in preterm infants.

METHODOLOGY

We carried out a prospective study in a neonatal intensive care unit. The study included 47 preterm infants. From birth, a transcutaneous bilirubin measurement (BTc) using the BiliCheck was made on the forehead of each newborn every 8 h. Blood sampling for determination of total serum bilirubin (BS) was combined with BTc: 1) if value of BTc was higher than limits values for phototherapy; 2) on the second day of life and 3) 4 hours after cessation of phototherapy.

RESULTS

Mean gestational age was 30 week and mean birth weight was 1419 g. We studied 151 pairs of BTc and BS. Mean values obtained by BTc and BS were respectively 160.6+/-50 mumol/L and 190.6+/-61.4 mumol/L. A significant correlation between BTc and BS was found. But the limits of agreement were very wide. The negative predictive value (NPV) of BTc was above 90% in each group of gestational age.

DISCUSSION

The need for phototherapy cannot be determined by BTc in preterm infants. But the BTc is reliable when its value is under the limits for phototherapy.

CONCLUSION

With a very high incidence of neonatal jaundice (87%) in our cohort, a value of BTc under the limits for phototherapy has a good NPV in preterm infants.

Evaluation of a new transcutaneous bilirubinometer in Chinese newborns

OBJECTIVE

To evaluate the use of a new transcutaneous bilirubinometer (JM-103 Minolta Airshields) for detection of hyperbilirubinaemia in term or near-term healthy Chinese newborns.

METHODS

Transcutaneous bilirubin (TcB) was used to screen for severe hyperbilirubinaemia in newborn infants. Blood was taken for total serum bilirubin (TSB) measurement if the initial TcB level was higher than the 40th centile in Bhutani's nomogram. Paired TcB and TSB results were then reviewed over 6 months. The correlation as well as the mean difference between the two methods were calculated. The clinical application of TcB with Bhutani's nomogram in the prediction of severe hyperbilirubinaemia in low-risk, medium-risk and high-risk thresholds for phototherapy was also analysed.

RESULTS

997 paired TcB and TSB measurements were evaluated in term or near-term newborns. TcB was significantly correlated with TSB, with a correlation coefficient of 0.83 (p<0.001). Their mean difference was 21.7 micromol/l (SD 21.2, p<0.001), with the 95% limits of agreement between -19.9 and 63.3 micromol/l. In both low-risk and medium-risk thresholds for phototherapy, using the 75th centile of Bhutani's nomogram as threshold, TcB could identify all cases and had a sensitivity and negative predictive value of 100% each, a specificity of 56% and positive predictive value of 23%. For high-risk cases, using the 75th centile as cut-off, the sensitivity and negative predictive value were reduced to 86.7% and 97.0%, respectively.

CONCLUSION

An accurate point-of-care bilirubin analyser facilitates bilirubin screening and avoids unnecessary blood tests. Although using the transcutaneous bilirubinometer JM-103 might result in a significant difference between TcB and TSB measured in Chinese newborns, combining the use of TcB and the 75th centile in Bhutani's nomogram as the cut-off level can identify all cases of significant hyperbilirubinaemia.

Biochemistry testing associated with pregnancy and the newborn period -- a lot has changed since you were a baby!

Everyone has been a newborn, and everyone's mother has been pregnant. Despite the commonality of these events, medical care and the clinical chemistry laboratory's role in it have changed remarkably over the last 50 years. This review is a historical overview of clinical chemistry testing that is related to pregnancy and the newborn period.

Bilirubin measurement for neonates: comparison of 9 frequently used methods

OBJECTIVE

High blood concentrations of bilirubin are toxic to the brain and may cause kernicterus. Therefore, determination of bilirubin levels is performed for many newborns, and several different methods are available. We compared 9 frequently used methods for bilirubin determination among newborns under routine conditions, to define their sequence of use.

METHODS

In a prospective study, bilirubin concentrations were determined with 9 different methods, ie, 3 skin test devices, 3 nonchemical photometric devices (including 2 blood gas analyzers), and 3 laboratory analyzers.

RESULTS

A total of 124 samples were obtained. All 3 laboratory methods showed very strong correlations with each other, and their means were used as comparison values. To these comparison values, the skin test devices had correlation coefficients between 0.961 and 0.966, and the nonchemical photometric devices between 0.980 and 0.994. Bland-Altman plots demonstrated good agreement with the comparison values for all nonchemical photometric devices. All skin test devices and 1 nonchemical photometric device underestimated bilirubin levels, particularly at high concentrations.

CONCLUSIONS

In the routine care of newborns, the first method for bilirubin testing should be a skin test. If the skin test result exceeds 200 micromol/L and other analytes are to be determined with a nonchemical photometric device, then bilirubin can be included in this analysis and the result trusted up to 250 micromol/L. If the skin test result exceeds 200 micromol/L and only bilirubin concentrations are needed, then a standard laboratory method is the first choice, to avoid repeated blood sampling. Bilirubin concentrations from nonchemical photometric devices that exceed 250 micromol/L should be confirmed with standard laboratory methods.

Cutaneous colorimetric evaluation of serum concentrations of bilirubin in healthy term neonates: a new methodological approach

BACKGROUND

In recent years, many non-invasive instruments have been used to examine the correlation between transcutaneous bilirubin (TcB) measurements and serum concentrations of bilirubin (SB) in newborns with a view to reducing the need for blood samples. However, their exact role has not been univocal. The aim of the present study was to determine whether non-invasive measurement of skin colour combined with appropriate clinico-statistical methodology can be used to better quantify SB in the first days of life.

METHODS

The study group consisted of 49 healthy term breast-fed newborns. Skin colour was measured with a Minolta CR-300 colorimeter and measurements were made in the first 12 h of life, at 48 h and in 13 babies at 96 h. To determine changes in SB from variations in skin colour between birth and 48 h (and also 96 h in 13 cases), a multivariate linear regression model was designed. To test the generalisation power of the regression model, we examined its predictive power for SB a third time (96 h; 13/49 cases) with respect to the previous two times.

RESULTS

The model made it possible to recognise increases in SB accurately with a mean absolute error 0.99 mg/dL with a good generalisation power.

CONCLUSIONS

The methodological model proposed here made it possible to accurately recognise increases in SB with respect to an initial value. Provided the methodological protocol is observed, TcB can therefore be used in the screening and follow-up of neonatal jaundice.

Detection of hyperbilirubinaemia in jaundiced full-term neonates by eye or by bilirubinometer?

The aim of this study was to compare predictions of hyperbilirubinaemia by eye, performed by trained physicians and nurses, with predictions obtained using two commercial bilirubinometers. Jaundice was assessed in 92 white and 48 non-white healthy full-term neonates using three non-invasive methods and by total serum bilirubin as the reference method. Clinical assessment of cephalocaudal progression of jaundice was carried out independently by a physician and by nurses. Simultaneously, the Minolta Airshields JM-102 was applied on the sternum, the BiliCheck on both the forehead and the sternum, and finally, serum bilirubin concentrations were determined. The Minolta JM-102 showed the best performance with r2 = 0.90, an intraclass correlation coefficient (ICC) of 0.93, and a 95% confidence interval (CI) of +/- 4 units (approx. 56 micromol/l). The BiliCheck performed slightly better on the forehead than over the sternum with r2=0.90, an ICC of 0.88, and a CI of +/- 62 microtmol/l. Assessment of jaundice by eye was least accurate with r2 = 0.74, an ICC of 0.67, and a CI of +/- 1.5 zones (corresponding to 75 Lmol/l). Skin pigmentation and ambient light both adversely affected noninvasive bilirubin estimation.

CONCLUSION

All three non-invasive methods are well suited for estimation of serum bilirubin but show large confidence intervals. In healthy term newborns, hyperbilirubinaemia (>250 Lmol/l) can be safely ruled out by eye if jaundice does not reach the abdomen or the extremities (Kramer zones 1 and 2), with < 22 units ( < 230 micromol/l) for the Minolta JM-102, or with a cut-off of 190 microlmol/l for the Bili-Check. If these respective thresholds are exceeded, serum bilirubin concentrations should be measured.

An evidence-based review of important issues concerning neonatal hyperbilirubinemia

This article is adapted from a published evidence report concerning neonatal hyperbilirubinemia with an added section on the risk of blood exchange transfusion (BET). Based on a summary of multiple case reports that spanned more than 30 years, we conclude that kernicterus, although infrequent, has at least 10% mortality and at least 70% long-term morbidity. It is evident that the preponderance of kernicterus cases occurred in infants with a bilirubin level higher than 20 mg/dL. Given the diversity of conclusions on the relationship between peak bilirubin levels and behavioral and neurodevelopmental outcomes, it is apparent that the use of a single total serum bilirubin level to predict long-term outcomes is inadequate and will lead to conflicting results. Evidence for efficacy of treatments for neonatal hyperbilirubinemia was limited. Overall, the 4 qualifying studies showed that phototherapy had an absolute risk-reduction rate of 10% to 17% for prevention of serum bilirubin levels higher than 20 mg/dL in healthy infants with jaundice. There is no evidence to suggest that phototherapy for neonatal hyperbilirubinemia has any long-term adverse neurodevelopmental effects. Transcutaneous measurements of bilirubin have a linear correlation to total serum bilirubin and may be useful as screening devices to detect clinically significant jaundice and decrease the need for serum bilirubin determinations. Based on our review of the risks associated with BETs from 15 studies consisting mainly of infants born before 1970, we conclude that the mortality within 6 hours of BET ranged from 3 per 1000 to 4 per 1000 exchanged infants who were term and without serious hemolytic diseases. Regardless of the definitions and rates of BET-associated morbidity and the various pre-exchange clinical states of the exchanged infants, in many cases the morbidity was minor (eg, postexchange anemia). Based on the results from the most recent study to report BET morbidity, the overall risk of permanent sequelae in 25 sick infants who survived BET was from 5% to 10%.

Transcutaneous bilirubinometry in very low birthweight infants

AIM

To evaluate whether transcutaneous bilirubinometry (TcB) would be a reliable and efficient screening technique for hyperbilirubinaemia in very low birthweight (VLBW, < or =1500 g) infants in an intensive care unit setting.

METHODS

TcB measurements (Minolta Airshield Jaundice Meter JM-102, Osaka, Japan) were obtained immediately before or within 10 min following routine blood sampling for plasma bilirubin concentration measurements in 124 VLBW infants not receiving phototherapy. The relationship between the two techniques was analysed by linear regression analysis. A plasma bilirubin > or =150 micromol/l was defined as hyperbilirubinaemia. The sensitivity and specificity of possible TcB cut-off readings to detect hyperbilirubinaemia was evaluated.

RESULTS

There was a significant correlation between the measurements of both techniques (p < 0.0001, r = 0.68). In the present study, a TcB cut-off reading of 14 would have reduced the need for plasma bilirubin measurements by 26% without missing true hyperbilirubinaemia.

CONCLUSION

The data suggest that TcB will improve VLBW infant care in an intensive care unit setting by reducing the need for invasive bilirubin concentration measurements.

Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation

Jaundice occurs in most newborn infants. Most jaundice is benign, but because of the potential toxicity of bilirubin, newborn infants must be monitored to identify those who might develop severe hyperbilirubinemia and, in rare cases, acute bilirubin encephalopathy or kernicterus. The focus of this guideline is to reduce the incidence of severe hyperbilirubinemia and bilirubin encephalopathy while minimizing the risks of unintended harm such as maternal anxiety, decreased breastfeeding, and unnecessary costs or treatment. Although kernicterus should almost always be preventable, cases continue to occur. These guidelines provide a framework for the prevention and management of hyperbilirubinemia in newborn infants of 35 or more weeks of gestation. In every infant, we recommend that clinicians 1) promote and support successful breastfeeding; 2) perform a systematic assessment before discharge for the risk of severe hyperbilirubinemia; 3) provide early and focused follow-up based on the risk assessment; and 4) when indicated, treat newborns with phototherapy or exchange transfusion to prevent the development of severe hyperbilirubinemia and, possibly, bilirubin encephalopathy (kernicterus).

Evaluation of a new transcutaneous bilirubinometer

OBJECTIVE

The objective of this study was to evaluate the Minolta/Hill-Rom Air-Shields Transcutaneous Jaundice Meter model JM-103.

METHODS

We studied a convenience sample of 849 newborns > or =35 weeks of gestation in 3 hospitals. These infants had total serum bilirubin (TSB) levels measured on clinical indication, and transcutaneous bilirubin (TcB) levels were obtained within 1 hour of the TSB levels. The population was 59.2% white, 29.8% black, 4.5% East Asian, 3.8% Middle Eastern, 1.6% Indian/Pakistani, and 1.1% Hispanic.

RESULTS

There was a close correlation between TSB and TcB values in all of the population groups: white (n = 503, r =.949); black (n = 253, r =.822); and East Asian, Indian/Pakistani, and Hispanic (n = 93, r =.926). In the black population, the correlation was less close than in the other groups, and differences between the TcB and TSB measurements tended to increase with rising TSB values. JM-103 values differed from TSB values by 3 mg/dL or more in 2% of white, 3.2% of other, and 17.4% of black infants. In these black infants, the JM-103 value was always greater than the TSB value.

CONCLUSIONS

We conclude that TcB measurements using the JM-103 jaundice meter correlate very closely with TSB levels over the range of TSB encountered in this study. Because only 3.3% of our infants had TSB values >15 mg/dL (257 micro mol/L), more data are needed in this range of TSB concentration. The correlation in black infants is not as close as in other groups, but because the tendency in blacks is for the JM-103 to overestimate serum bilirubin levels, dangerous clinical errors are unlikely to occur. The measurement technique is rapid and simple, and it is easy to perform repeated measurements over time, thus reducing the likelihood of error. TcB measurements with the JM-103 jaundice meter should obviate the need for most serum bilirubin levels in newborn infants > or =35 weeks of gestation, although serum bilirubin measurements are still required when treatment with phototherapy or exchange transfusion is being considered.

The accuracy of transcutaneous bilirubin measurements in neonates: a correlation study

A prospective observational study was conducted on 212 neonates born between 24 and 42 weeks of gestation who required blood sampling to determine total serum bilirubin (TSB) in the first week of life, prior to phototherapy. The transcutaneous bilirubin (TcB) measurements were performed on the infant's forehead using BiliCheck within +/-30 min of a blood sample being drawn. There was significant (r = 0.78) correlation between bilirubin levels obtained transcutaneously and those measured in the infant's blood. The correlation was not affected by birth weight and was dependent on the bilirubin levels. The negative nonsignificant correlation appears when TSB levels are greater than 11 mg/dl. Thus, TcB measurements can accurately predict TSB values lower than 11 mg/dl in a multiracial preterm and term neonatal population.