Home phototherapy in the United Kingdom

Accuracy of transcutaneous bilirubinometry in term infants after phototherapy: a prospective observational study

OBJECTIVE

To test the accuracy of transcutaneous bilirubinometry (TcB) in neonates 12 h after discontinuing phototherapy.

STUDY DESIGN

In a prospective study of 91 neonates at ≥35 weeks of gestation, paired measurements of total serum bilirubin (TSB) and TcB were obtained 12 h after discontinuation of phototherapy. TcB measurements were obtained on the uncovered skin of the sternum and the covered skin of the lower abdomen. Bland-Altman plots were used to evaluate agreement between TSB and TcB.

RESULTS

TcB was found to systematically underestimate TSB on both covered and uncovered skin. The smallest but statistically significant difference between TSB and TcB was found on the covered lower abdomen (-1.03, p < .0001) compared with the uncovered skin of the sternum (-1.44, p < .0001). The correlation between TSB and TcB was excellent on both covered (r = 0.86, p < .001) and uncovered skin (r = 0.90, p < .001). Bland and Altman plots showed poor agreement between TcB and TSB.

CONCLUSIONS

This study demonstrated excellent correlation between TcB and TSB 12 h after phototherapy but poor TcB-TSB agreement. TcB cannot be reliably used in neonates exposed to phototherapy.

Screening and treatment to reduce severe hyperbilirubinaemia in infants in primary care (STARSHIP): a factorial stepped-wedge cluster randomised controlled trial protocol

INTRODUCTION

Jaundice caused by hyperbilirubinaemia is a physiological phenomenon in the neonatal period. However, severe hyperbilirubinaemia, when left untreated, may cause kernicterus, a severe condition resulting in lifelong neurological disabilities. Although commonly applied, visual inspection is ineffective in identifying severe hyperbilirubinaemia. We aim to investigate whether among babies cared for in primary care: (1) transcutaneous bilirubin (TcB) screening can help reduce severe hyperbilirubinaemia and (2) primary care-based (versus hospital-based) phototherapy can help reduce hospital admissions.

METHODS AND ANALYSIS

A factorial stepped-wedge cluster randomised controlled trial will be conducted in seven Dutch primary care birth centres (PCBC). Neonates born after 35 weeks of gestation and cared for at a participating PCBC for at least 2 days within the first week of life are eligible, provided they have not received phototherapy before. According to the stepped-wedge design, following a phase of 'usual care' (visual assessment and selective total serum bilirubin (TSB) quantification), either daily TcB measurement or, if indicated, phototherapy in the PCBC will be implemented (phase II). In phase III, both interventions will be evaluated in each PCBC. We aim to include 5500 neonates over 3 years.Primary outcomes are assessed at 14 days of life: (1) the proportion of neonates having experienced severe hyperbilirubinaemia (for the TcB screening intervention), defined as a TSB above the mean of the phototherapy and the exchange transfusion threshold and (2) the proportion of neonates having required hospital admission for hyperbilirubinaemia treatment (for the phototherapy intervention in primary care).

ETHICS AND DISSEMINATION

This study has been approved by the Medical Research Ethics Committee of the Erasmus MC Rotterdam, the Netherlands (MEC-2017-473). Written parental informed consent will be obtained. Results from this study will be published in peer-reviewed journals and presented at (inter)national meetings.

TRIAL REGISTRATION NUMBER

NTR7187.

Transcutaneous Bilirubin Measurements Can Be Used to Measure Bilirubin Levels during Phototherapy

Objective

To determine whether transcutaneous bilirubin measurements (TcB) before and during phototherapy taken from covered skin during phototherapy correlate with total serum bilirubin (TSB) levels.

Study Design

In this prospective observational study, healthy term newborns who required TSB measurements were included. TcB measurements were taken from the forehead before starting and during phototherapy using the BiliChek device. Before starting phototherapy, part of the forehead was covered. Blood for TSB measurement was collected within 5 minutes of TcB measurements. Correlations and mean differences between TcB and TSB before and during phototherapy were calculated.

Result

Paired TSB and TcB measurements before and during phototherapy in 151 newborns were performed. The mean gestational age was 38.8 weeks and birth weight was 3.1 kg; 53% were male. Before starting phototherapy, TSB and TcB were 183.8 ± 41.6 and 190.5 ± 43 μmol/l, respectively. During phototherapy, TSB and TcB were 191.8 ± 39.4 and 187.8 ± 45.3 μmol/l, respectively. Linear regression analysis showed a significant correlation between TcB and TSB before starting phototherapy and during phototherapy (r: 0.85; p < 0.001 and r: 80.0; p < 0.001), respectively. Before starting phototherapy, the mean difference between TSB and TcB was 6.2 ± 23.2 μmol/l, with a 95% CI of -39.3 to 51.7 μmol. During phototherapy, the mean difference was -2.8 ± 23.5 μmol/l, with a 95% CI of -48.9 to 43.3 μmol/l.

Conclusion

TcB measurements from covered skin in jaundiced term infants during phototherapy correlate with TSB and can be used to monitor bilirubin levels during phototherapy.

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.