Use of a Smartphone App to Assess Neonatal Jaundice

Machine Learning to Improve Accuracy of Transcutaneous Bilirubinometry

INTRODUCTION

This study aimed to develop models for predicting total serum bilirubin by correcting errors of transcutaneous bilirubin using machine learning based on neonatal biomarkers that could affect spectrophotometric measurements of tissue bilirubin.

METHODS

This retrospective study included infants born at our hospital (≥36 weeks old, ≥2,000 g) between January 2020 and December 2022. Infants without a phototherapy history were included. Robust linear regression, gradient boosting tree, and neural networks were used for machine learning models. A neural network, inspired by the structure of the human brain, was designed comprising three layers: input, intermediate, and output.

RESULTS

Totally, 683 infants were included. The mean (minimum-maximum) gestational age, birth weight, participant age, total serum bilirubin, and transcutaneous bilirubin were 39.0 (36.0-42.0) weeks, 3,004 (2,004-4,484) g, 2.8 (1-6) days of age, 8.50 (2.67-18.12) mg/dL, and 7.8 (1.1-18.1) mg/dL, respectively. The neural network model had a root mean square error of 1.03 mg/dL and a mean absolute error of 0.80 mg/dL in cross-validation data. These values were 0.37 mg/dL and 0.28 mg/dL, smaller compared to transcutaneous bilirubin, respectively. The 95% limit of agreement between the neural network estimation and total serum bilirubin was -2.01 to 2.01 mg/dL. Unnecessary blood draws could be reduced by up to 78%.

CONCLUSION

Using machine learning with transcutaneous bilirubin, total serum bilirubin estimation error was reduced by 25%. This integration could increase accuracy, lessen infant discomfort, and simplify procedures, offering a smart alternative to blood draws by accurately estimating phototherapy thresholds.

Innovative approaches to neonatal jaundice diagnosis and management in low-resourced settings

Persistent challenges in addressing severe neonatal hyperbilirubinaemia in resource-constrained settings have led to ongoing and often unacceptable rates of morbidity, disability and mortality. These challenges stem from limitations such as inadequate, inefficient or financially inaccessible diagnostic and therapeutic options. However, over the past decade, noteworthy innovations have emerged to address some of these hurdles, and these innovations are increasingly poised for broader implementation. This review provides a concise summary of these novel, economically viable diagnostic solutions, encompassing point-of-care assays and smartphone applications, as well as treatment modalities, notably more effective phototherapy and filtered sunlight. These advancements hold promise and have the potential to meaningfully reduce the burden of neonatal hyperbilirubinaemia, signifying a promising shift in the landscape of neonatal healthcare.

A Novel Smartphone App for Self-Monitoring of Neonatal Jaundice Among Postpartum Mothers: Qualitative Research Study

Background

Neonatal jaundice (NNJ) or hyperbilirubinemia is a ubiquitous condition in newborn infants. Currently, the transcutaneous bilirubinometer is used to screen for NNJ in health care facilities, where neonates need to be physically present (ie, a centralized model of care for NNJ screening). Mobile health (mHealth) apps present a low-cost, home-based, and noninvasive system that could facilitate self-monitoring of NNJ and could allow mothers the convenience of screening for NNJ remotely. However, end users' acceptability of such mHealth apps is of fundamental importance before the incorporation of such apps into clinical practice.

Objective

The study aimed to explore the perception of postpartum mothers toward self-monitoring of NNJ using a novel mHealth app.

Methods

Mothers attending video consultations for early postpartum care at 2 Singapore primary care clinics watched an instructional video for a hyperbilirubinemia-screening mHealth app (HSMA). An independent researcher used a semistructured topic guide to conduct in-depth interviews with 25 mothers, assessing their views on HSMAs. All interviews were audio recorded, transcribed verbatim, and checked for accuracy before data analysis. Two researchers independently analyzed the transcripts via thematic analysis. Data were managed using NVivo qualitative data management software.

Results

The identified themes were grouped under perceived usability and utility. Mothers valued the convenience and utility of HSMAs for remote monitoring of NNJ. They appreciated the objectivity the app readings provided compared to visual inspection. However, they perceived that the app's applicability would be restricted to severe jaundice, were concerned about its accuracy and restriction to the English language, and lacked confidence in using it. Nevertheless, they were willing to use it once its accuracy was proven and when they received adequate guidance from health care professionals. They also suggested including an action plan for the measured readings and clinical signs within the app. Mothers proposed pairing teleconsultations with HSMAs to boost their confidence and enhance adoption.

Conclusions

Mothers were receptive to using HSMAs but had concerns. Multiple languages, proof of accuracy, and resources to guide users should be incorporated into the app in the next phase to increase its successful adoption. Complementing such apps with a teleconsultation service presents a plausible and pragmatic NNJ care delivery model in general practice.

The past, current, and future of neonatal intensive care units with artificial intelligence: a systematic review

Machine learning and deep learning are two subsets of artificial intelligence that involve teaching computers to learn and make decisions from any sort of data. Most recent developments in artificial intelligence are coming from deep learning, which has proven revolutionary in almost all fields, from computer vision to health sciences. The effects of deep learning in medicine have changed the conventional ways of clinical application significantly. Although some sub-fields of medicine, such as pediatrics, have been relatively slow in receiving the critical benefits of deep learning, related research in pediatrics has started to accumulate to a significant level, too. Hence, in this paper, we review recently developed machine learning and deep learning-based solutions for neonatology applications. We systematically evaluate the roles of both classical machine learning and deep learning in neonatology applications, define the methodologies, including algorithmic developments, and describe the remaining challenges in the assessment of neonatal diseases by using PRISMA 2020 guidelines. To date, the primary areas of focus in neonatology regarding AI applications have included survival analysis, neuroimaging, analysis of vital parameters and biosignals, and retinopathy of prematurity diagnosis. We have categorically summarized 106 research articles from 1996 to 2022 and discussed their pros and cons, respectively. In this systematic review, we aimed to further enhance the comprehensiveness of the study. We also discuss possible directions for new AI models and the future of neonatology with the rising power of AI, suggesting roadmaps for the integration of AI into neonatal intensive care units.

Demystifying non-invasive approaches for screening jaundice in low resource settings: a review

All national and international pediatric guidelines universally prescribe meticulous bilirubin screening for neonates as a critical measure to mitigate the incidence of acute bilirubin encephalopathy (ABE) and Kernicterus. The prevailing gold standard for jaundice detection in neonates necessitates invasive blood collection, followed by subsequent biochemical testing. While the invasive procedure provides dependable bilirubin measurements and continues to be the sole gold standard diagnostic method for assessing bilirubin concentration. There exists a pressing need to innovate non-invasive screening tools that alleviate the sampling stress endured by newborns, mitigate iatrogenic anemia, and expedite the turnaround time for obtaining results. The exploration of non-invasive modalities for bilirubin measurements is gaining momentum, driven by the overarching goal of minimizing the number of pricks inflicted upon neonates, thereby rendering screening a swift, efficient, comfortable, and dependable process. This comprehensive review article delves extensively into the array of non-invasive approaches and digital solutions that have been proposed, implemented, and utilized for neonatal bilirubin screening, with a particular emphasis on their application in low-resource settings. Within this context, the review sheds light on the existing methodologies and their practical applications, with a specific focus on transcutaneous bilirubin meters. Moreover, it underscores the prevailing open challenges in this domain and outlines potential directions for future research endeavors. Notably, the review underscores the imperative need for robust educational programs targeted at both families and healthcare personnel to expedite the process of seeking timely care for neonatal jaundice. Additionally, it underscores the necessity for the development of enhanced screening and diagnostic tools that can offer greater accuracy in clinical practice.

SpeCamX: mobile app that turns unmodified smartphones into multispectral imagers

We present the development of SpeCamX, a mobile application that enables an unmodified smartphone into a multispectral imager. Multispectral imaging provides detailed spectral information about objects or scenes, but its accessibility has been limited due to its specialized requirements for the device. SpeCamX overcomes this limitation by utilizing the RGB photographs captured by smartphones and converting them into multispectral images spanning a range of 420 to 680 nm without a need for internal modifications or external attachments. The app also includes plugin functions for extracting medical information from the resulting multispectral data cube. In a clinical study, SpeCamX was used to implement an augmented smartphone bilirubinometer, predicting blood bilirubin levels (BBL) with superior performance in accuracy, efficiency and stability compared to default smartphone cameras. This innovative technology democratizes multispectral imaging, making it accessible to a wider audience and opening new possibilities for both medical and non-medical applications.

Performance of smartphone application to accurately quantify hyperbilirubinemia in neonates: a systematic review with meta-analysis

Neonatal jaundice is a common clinical condition that can progress to severe hyperbilirubinemia if identification and intervention are delayed. In this study, we aimed to analyze the current evidence on the accurate performance of smartphone applications to quantify bilirubin levels. PubMed, Embase, Emcare, MEDLINE, the Cochrane Library, and Google Scholar were searched from inception until July 2022. Grey literature was searched on "OpenGrey" and "MedNar" databases. We included prospective and retrospective cohort studies that recruited infants with a gestation of ≥ 35 weeks and reported paired total serum bilirubin (TSB) and smartphone app-based bilirubin (ABB) levels. We conducted the review using the guidelines of the Cochrane Collaboration Diagnostic Test Accuracy Working Group and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-diagnostic test accuracy (PRISMA-DTA) statement. The data were pooled using the random effects model. The outcome of interest was agreement between ABB and TSB measurements, provided as correlation coefficient, mean difference, and standard deviation. Certainty of evidence (COE) was assessed based on GRADE guidelines. Fourteen studies were included in the meta-analysis. The number of infants in individual studies ranged between 35 and 530. The pooled correlation coefficient (r) between ABB and TSB was 0.77 (95% CI 0.69 to 0.83; p < 0.01). Reported sensitivities for predicting a TSB of 250 µmol/L in individual studies ranged between 75 and 100% and specificities ranged from 61 to 100%. Similarly, a sensitivity of 83 to 100% and a specificity of 19.5 to 76% were reported for predicting a TSB of 205 μmol/L. Overall COE was considered moderate.    Conclusion: Smartphone app-based bilirubin estimation showed a reasonable correlation to TSB levels. Well-designed studies are required to determine its utility as a screening tool for various TSB cut-off levels. What is Known: • Neonatal jaundice is a common clinical condition. Timely screening and intervention are necessary to prevent neurological morbidities • Transcutaneous bilirubinometer is a widely used non-invasive screening device but is mostly available in hospital settings and has cost limitations. Researchers have recently explored the utility of smartphone applications to estimate bilirubin levels in neonates. What is New: • This is the first systematic review and meta-analysis conducted to assess the performance of smartphone applications to detect neonatal hyperbilirubinemia. • Bilirubin estimates of newborn infants obtained through smartphone applications had a reasonable correlation with serum bilirubin levels.

175 Years of Bilirubin Testing: Ready for Point-of-Care?

Bilirubin was first detected in blood in 1847 and since then has become one of the most widely used biomarkers for liver disease. Clinical routine bilirubin testing is performed at the hospital laboratory, and the gold standard colorimetric test is prone to interferences. The absence of a bedside test for bilirubin delays critical clinical decisions for patients with liver disease. This clinical care gap has motivated the development of a new generation of bioengineered point-of-care bilirubin assays. In this Perspective, recently developed bilirubin assays are critically discussed, and their translational potential evaluated.

Parental detection of neonatal jaundice using a low-cost colour card: a multicentre prospective study

BACKGROUND

Since most infants are usually discharged before age 48-72 hours, peak bilirubin levels will almost always occur after discharge. Parents may be the first to observe the onset of jaundice after discharge, but visual assessment is unreliable. The jaundice colour card (JCard) is a low-cost icterometer designed for the assessment of neonatal jaundice. The objective of this study was to evaluate parental use of JCard to detect jaundice in neonates.

METHODS

We conducted a multicentre, prospective, observational cohort study in nine sites across China. A total of 1161 newborns ≥35 weeks of gestation were enrolled in the study. Measurements of total serum bilirubin (TSB) levels were based on clinical indications. The JCard measurements by parents and paediatricians were compared with the TSB.

RESULTS

JCard values of parents and paediatricians were correlated with TSB (r=0.754 and 0.788, respectively). The parents' and paediatricians' JCard values 9 had sensitivities of 95.2% vs 97.6% and specificities of 84.5% vs 71.7% for identifying neonates with TSB ≥153.9 µmol/L. The parents' and paediatricians' JCard values 15 had sensitivities of 79.9% vs 89.0% and specificities of 66.7% vs 64.9% for identifying neonates with TSB ≥256.5 µmol/L. Areas under the receiver operating characteristic curves of parents for identifying TSB ≥119.7, ≥153.9, ≥205.2, and ≥256.5 µmol/L were 0.967, 0.960, 0.915, and 0.813, respectively, and those of paediatricians were 0.966, 0.961, 0.926 and 0.840, respectively. The intraclass correlation coefficient was 0.933 between parents and paediatricians.

CONCLUSION

The JCard can be used to classify different levels of bilirubin, but it is less accurate with high bilirubin levels. The JCard diagnostic performance of parents was slightly lower than that of paediatricians.

Non-invasive detection of total bilirubin based on multi-wavelength PPG signal

BACKGROUND AND OBJECTIVE

Abnormal bilirubin metabolism can result in various liver function disorders. Current clinical practice for bilirubin level detection involves invasive blood collection from patients, which is time-consuming, painful, and poses infection risks. Thus, there is a pressing need for non-invasive bilirubin detection methods. This study aims to develop a non-invasive total serum bilirubin(TSB) detection method in humans based on multi-wavelength photoplethysmography (PPG) signals.

METHODS

The experimental instrument includes a light source and a spectrometer. PPG signals are collected from the subjects' fingers, and the samples are selected based on the PPG deviation degree screening method. The absorption spectrum of blood is extracted from the PPG signal using dynamic spectroscopy. Finally, locally developed software calculates the total bilirubin value. The instrument is modeled and validated according to the clinical-biochemical test values.

RESULTS

The results of the prediction set (correlation coefficient is 0.91, RSMEP is 2.32 umol/L, average absolute error percentage is 9.3%) show that our method has a strong correlation with the detection results of clinical-biochemical analysis instruments. The Bland-Altman test showed that the device deviated from the data detected by biochemical methods in the clinic with a mean deviation of about 0.12 umol/L and a 95% confidence interval between -2.95 umol/L and 2.7 umol/L.

CONCLUSIONS

This study's non-invasive bilirubin detection method has high accuracy, which can meet the needs of continuous non-invasive total bilirubin detection in clinical practice.

Feasibility of smartphone colorimetry of the face as an anaemia screening tool for infants and young children in Ghana

BACKGROUND

Anaemia affects approximately a quarter of the global population. When anaemia occurs during childhood, it can increase susceptibility to infectious diseases and impair cognitive development. This research uses smartphone-based colorimetry to develop a non-invasive technique for screening for anaemia in a previously understudied population of infants and young children in Ghana.

METHODS

We propose a colorimetric algorithm for screening for anaemia which uses a novel combination of three regions of interest: the lower eyelid (palpebral conjunctiva), the sclera, and the mucosal membrane adjacent to the lower lip. These regions are chosen to have minimal skin pigmentation occluding the blood chromaticity. As part of the algorithm development, different methods were compared for (1) accounting for varying ambient lighting, and (2) choosing a chromaticity metric for each region of interest. In comparison to some prior work, no specialist hardware (such as a colour reference card) is required for image acquisition.

RESULTS

Sixty-two patients under 4 years of age were recruited as a convenience clinical sample in Korle Bu Teaching Hospital, Ghana. Forty-three of these had quality images for all regions of interest. Using a naïve Bayes classifier, this method was capable of screening for anaemia (<11.0g/dL haemoglobin concentration) vs healthy blood haemoglobin concentration (≥11.0g/dL) with a sensitivity of 92.9% (95% CI 66.1% to 99.8%), a specificity of 89.7% (72.7% to 97.8%) when acting on unseen data, using only an affordable smartphone and no additional hardware.

CONCLUSION

These results add to the body of evidence suggesting that smartphone colorimetry is likely to be a useful tool for making anaemia screening more widely available. However, there remains no consensus on the optimal method for image preprocessing or feature extraction, especially across diverse patient populations.

Validation of a smartphone-based screening tool (Biliscan) for neonatal jaundice in a multi-ethnic neonatal population

AIM

Neonatal jaundice is an important and prevalent condition that can cause kernicterus and mortality. This study validated a smartphone-based screening application (Biliscan) in detecting neonatal jaundice.

METHODS

A cross-sectional prospective study was conducted at the neonatal unit in a tertiary teaching hospital between August 2020 and October 2021. All babies born at the gestation of 35 weeks and above with clinical jaundice or are recommended for screening of jaundice within 21 days of post-natal age were recruited. Using Biliscan, images of the babies' skin over the sternum were taken against a standard colour card. The application uses feature extraction and machine learning regression to estimate the bilirubin level. Independent Biliscan bilirubin estimates (BsB) were made and compared with total serum bilirubin (TSB) and transcutaneous bilirubin (TcB) levels. Bland Altman plots were used to establish the agreement between BsB and TSB, as well as TcB, using the clinically acceptable limits of agreement of ±35 μmol/L, which were defined a priori. Pearson correlation coefficient was assessed to establish the strength of the relationship between BsB versus TSB and TcB. Diagnostic accuracy was assessed through receiver operating characteristic curve analysis.

RESULTS

Sixty-one paired TSB-BsB and 85 paired TcB-BsB measurements were obtained. Bland Altman plot for the entire group showed that 54% (33/61) of the pairs of TSB and BsB readings and 66% (56/85) of the pairs of TcB and BsB readings were within the maximum clinically acceptable difference of 35 μmol/L. Pearson r for BsB versus TSB and TcB was 0.54 (P < 0.001) and 0.66 (P < 0.001) respectively. Compared with TSB, the recommended gold standard measure for jaundice, Biliscan has a sensitivity of 76.92% and specificity of 70.83% for jaundice requiring phototherapy. The positive and negative predictive values in term infants were 93.3% and 36.9%, respectively.

CONCLUSION

Our results suggest that there is moderate correlation and mediocre agreement between BsB and TSB, as well as TcB. Improvement to the application algorithm and further studies that include a larger population, and a wider range of bilirubin values are necessary before the tool may be considered for use in screening of jaundice in newborns.

Management challenges in the treatment of severe hyperbilirubinemia in low- and middle-income countries: Encouraging advancements, remaining gaps, and future opportunities

Neonatal jaundice (NJ) is common in newborn infants. Severe NJ (SNJ) has potentially negative neurological sequelae that are largely preventable in high resource settings if timely diagnosis and treatment are provided. Advancements in NJ care in low- and middle-income countries (LMIC) have been made over recent years, especially with respect to an emphasis on parental education about the disease and technological advancements for improved diagnosis and treatment. Challenges remain, however, due to lack of routine screening for SNJ risk factors, fragmented medical infrastructure, and lack of culturally appropriate and regionally specific treatment guidelines. This article highlights both encouraging advancements in NJ care as well as remaining gaps. Opportunities are identified for future work in eliminating the gaps in NJ care and preventing death and disability related to SNJ around the globe.

Assessing and Validating a Model of Study Completion for a Prospective Cohort of Healthy Newborns

OBJECTIVES

To identify potentially modifiable or actionable factors related to study completion among healthy mother-infant dyads participating in prospective research.

PATIENTS/METHODS

We conducted a secondary analysis of completion data from a prospective study on newborn jaundice in the first week of life at a tertiary-care hospital in Philadelphia, PA, from 2015 to 2019. Participation in the original study involved enrollment before newborn discharge and subsequent follow-up for a jaundice assessment between 2 and 6 days of life. For this study, our primary outcome was completion of all study procedures. Associations between predictor variables and the outcome were assessed using bivariate and multivariable analyses. We fit a predictive model of study completion using logistic regression and validated the model using 5-fold cross-validation.

RESULTS

Of 501 mother-infant dyads enrolled in the original study, 304 completed the study. Median maternal age was 28 years and 81.8% of mothers delivered via vaginal birth. Study completion was associated with colocation of the study visit with the initial well-child visit (adjusted odds ratio [aOR], 2.99, 95% confidence interval [CI], 2.01-4.46) and provision of an alternate phone number by the participant (aOR, 1.99; 95% CI, 1.34-2.96). The cross-validated model performed similarly to our final predictive model and had an average area under the receiver operating characteristic curve of 0.67 (range, 0.59-0.72), with a sensitivity of 68% and specificity of 60%.

CONCLUSIONS

Findings demonstrate the importance of communication and patient-centric approaches for recruitment and retention in newborn research. Future work should incorporate these approaches while continuing to evaluate study retention strategies.

Effects of a Smartphone-Based Out-of-Hospital Screening App for Neonatal Hyperbilirubinemia on Neonatal Readmission Rates and Maternal Anxiety: Randomized Controlled Trial

Background

Neonatal hyperbilirubinemia is one of the leading causes of neonatal readmission—especially severe hyperbilirubinemia and its complications—and it influences disease burden as well as neonatal and maternal health. Smartphones have been shown to have satisfactory accuracy in screening neonatal bilirubin levels, but the impact of this technology on neonatal health care service and maternal health outcomes is still unknown.

Objective

The aim of this study was to evaluate the impact of a smartphone-based out-of-hospital neonatal jaundice screening program on neonatal readmission rates for jaundice and related maternal anxiety.

Methods

This was a 2-arm, unblinded, randomized controlled trial with 30 days of intervention and follow-up periods. From August 2019 to August 2020, healthy mother-infant dyads were recruited on-site from 3 public hospitals in Hainan, China. Intervention group mothers used the smartphone app to routinely monitor neonatal jaundice at home under the web-based guidance of pediatricians. Control group participants received routine care. The primary study outcome was the neonatal readmission rate due to jaundice within 30 days of the first hospital discharge. The secondary outcome was the maternal anxiety score associated with neonatal jaundice. The data were collected through a self-assessed questionnaire. All participants were included in the analysis (intention-to-treat).

Results

In this study, 1424 mother-infant dyads were recruited, comprising 1424 mothers and 1424 newborns. The median age of the mothers was 29 (IQR 26-32) years, and there were 714 (50.1%) male neonates. These mother-infant dyads were randomly assigned to the intervention group and the control group, with 712 dyads in each group; only 1187 of these dyads completed the follow-up. We found that the adjusted 30-day neonatal readmission rate due to jaundice reduced by 10.5% (71/605, 11.7% vs 141/582, 24.2%; 95% CI 5%-15.9%; odds ratio 0.4, 95% CI 0.3-0.5; P<.001) and the relevant maternal anxiety mean score decreased by 3.6 (95% CI –4.4 to –2.8; β=–3.6, 95% CI –4.5 to –2.8; P<.001) in the intervention group compared to those in the routine care group.

Conclusions

Our study shows that the smartphone-based out-of-hospital screening method for neonatal hyperbilirubinemia decreased the neonatal readmission rate within 30 days from the first discharge and improved maternal mental health to some degree, thus demonstrating the usefulness of this screening app for follow-up in pediatric care.

Trial Registration

China Clinical Trial Registration Center, ChiCTR2100049567; http://www.chictr.org.cn/showproj.aspx?proj=64245

On AI Approaches for Promoting Maternal and Neonatal Health in Low Resource Settings: A Review

A significant challenge for hospitals and medical practitioners in low- and middle-income nations is the lack of sufficient health care facilities for timely medical diagnosis of chronic and deadly diseases. Particularly, maternal and neonatal morbidity due to various non-communicable and nutrition related diseases is a serious public health issue that leads to several deaths every year. These diseases affecting either mother or child can be hospital-acquired, contracted during pregnancy or delivery, postpartum and even during child growth and development. Many of these conditions are challenging to detect at their early stages, which puts the patient at risk of developing severe conditions over time. Therefore, there is a need for early screening, detection and diagnosis, which could reduce maternal and neonatal mortality. With the advent of Artificial Intelligence (AI), digital technologies have emerged as practical assistive tools in different healthcare sectors but are still in their nascent stages when applied to maternal and neonatal health. This review article presents an in-depth examination of digital solutions proposed for maternal and neonatal healthcare in low resource settings and discusses the open problems as well as future research directions.

Evaluation of a Point-of-Care Test for Bilirubin in Malawi

OBJECTIVES

BiliSpec is a low-cost spectrophotometric reader and disposable paper-based strip to quantify total serum bilirubin from several blood drops. This study was a prospective evaluation of BiliSpec in 2 neonatal wards in Malawi compared with a reference standard bilirubinometer over a large range of bilirubin and hematocrit levels.

METHODS

The accuracy of BiliSpec and a transcutaneous bilirubinometer were compared with the reference standard of spectrophotometry for 475 blood samples collected from 375 subjects across a range of total serum bilirubin concentrations from 0.0 to 33.7 mg/dL. The development of error grids to assess the clinical effects of measurement differences is reported.

RESULTS

BiliSpec was found to have a mean bias of -0.48 mg/dL and 95% limits of agreement of -5.09 mg/dL to +4.12 mg/dL. Results show 90.7% of BiliSpec measurements would have resulted in the same clinical decision as the reference standard, whereas 55.0% of transcutaneous bilirubin measurements would have resulted in the same clinical decision as the reference standard.

CONCLUSIONS

This evaluation supports use of BiliSpec to provide accurate, low-cost, point-of-care bilirubin measurements in low-resource hospitals. Future work is needed to evaluate BiliSpec among a larger number of users.

Validating a Sclera-Based Smartphone Application for Screening Jaundiced Newborns in Ghana

OBJECTIVES

Reducing the burden of bilirubin-induced neurologic complications in low-resource countries requires reliable and accessible screening tools. We sought to optimize and validate a sclera-based smartphone application, Neonatal Scleral-Conjunctival Bilirubin (neoSCB), for screening neonatal jaundice.

METHODS

Using a cross-sectional design, consecutive eligible infants (aged 0-28 days, in the hospital, not critically ill) were enrolled in Ghana from March 2019 to April 2020. Jaundice screening was performed with neoSCB (Samsung Galaxy S8) to quantify SCB and JM-105 (Dräger) for transcutaneous bilirubin (TcB). Screening values were compared with total serum bilirubin (TSB) measured at the point of care.

RESULTS

Overall, 724 infants participated in the optimization and validation phases of the study. The analysis for validation included 336 infants with no previous treatment of jaundice. Single neoSCB image captures identified infants with TSB >14.62 mg/dL (250 μmol/L) with reasonably high sensitivity, specificity, and receiver operating characteristic area under the curve at 0.94 (95% confidence interval [CI], 0.91 to 0.97), 0.73 (95% CI, 0.68 to 0.78), and 0.90, respectively. These findings were comparable to the sensitivity and specificity of JM-105 (0.96 [95% CI, 0.90 to 0.99] and 0.81 [95% CI, 0.76 to 0.86], respectively). The TcB/TSB had a larger correlation coefficient (r = 0.93; P < .01) than SCB/TSB (r = 0.78; P < .01). Performance of both devices was lower in infants with previous phototherapy (n = 231).

CONCLUSIONS

The diagnostic performance of neoSCB was comparable to JM-105 and is a potential, affordable, contact-free screening tool for neonatal jaundice.

Challenges and recommendations to improve implementation of phototherapy among neonates in Malawian hospitals

Background

Severe neonatal jaundice can result in long term morbidities and mortality when left untreated. Phototherapy is the main-stay intervention for treating moderate jaundice and for prevention of the development of severe jaundice. However, in resource-limited health care settings, phototherapy has been inconsistently used. The objective of this study is to evaluate barriers and facilitators for phototherapy to treat neonatal jaundice at Malawian hospitals.

Methods

We conducted a convergent mixed-method study comprised of a facility assessment and qualitative interviews with healthcare workers and caregivers in southern Malawi. The facility assessment was conducted at three secondary-level hospitals in rural districts. In-depth interviews following a semi-structured topic guide were conducted at a district hospital and a tertiary-level hospital. Interviews were thematically analysed in NVivo 12 software (QSR International, Melbourne, Australia).

Results

The facility assessment found critical gaps in initiating and monitoring phototherapy in all facilities. Based on a total of 31 interviews, participants identified key challenges in diagnosing neonatal jaundice, counselling caregivers, and availability of infrastructure. Participants emphasized the need for transcutaneous bilirubinometers to guide treatment decisions. Caregivers were sometimes fearful of potential harmful effects of phototherapy, which required adequate explanation to mothers and family members in non-medical language. Task shifting and engaging peer support for caregivers with concerns about phototherapy was recommended.

Conclusion

Implementation of a therapeutic intervention is limited if accurate diagnostic tests are unavailable. The scale up of therapeutic interventions, such as phototherapy for neonatal jaundice, requires careful holistic attention to infrastructural needs, supportive services such as laboratory integration as well as trained human resources.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03430-y.

Bilirubin Encephalopathy

PURPOSE OF REVIEW

Hyperbilirubinemia is commonly seen in neonates. Though hyperbilirubinemia is typically asymptomatic, severe elevation of bilirubin levels can lead to acute bilirubin encephalopathy and progress to kernicterus spectrum disorder, a chronic condition characterized by hearing loss, extrapyramidal dysfunction, ophthalmoplegia, and enamel hypoplasia. Epidemiological data show that the implementation of universal pre-discharge bilirubin screening programs has reduced the rates of hyperbilirubinemia-associated complications. However, acute bilirubin encephalopathy and kernicterus spectrum disorder are still particularly common in low- and middle-income countries.

RECENT FINDINGS

The understanding of the genetic and biochemical processes that increase the susceptibility of defined anatomical areas of the central nervous system to the deleterious effects of bilirubin may facilitate the development of effective treatments for acute bilirubin encephalopathy and kernicterus spectrum disorder. Scoring systems are available for the diagnosis and severity grading of these conditions. The treatment of hyperbilirubinemia in newborns relies on the use of phototherapy and exchange transfusion. However, novel therapeutic options including deep brain stimulation, brain-computer interface, and stem cell transplantation may alleviate the heavy disease burden associated with kernicterus spectrum disorder. Despite improved screening and treatment options, the prevalence of acute bilirubin encephalopathy and kernicterus spectrum disorder remains elevated in low- and middle-income countries. The continued presence and associated long-term disability of these conditions warrant further research to improve their prevention and management.

Development of a mobile phone camera-based transcutaneous bilirubinometer for low-resource settings

Newborns in high-income countries are routinely screened for neonatal jaundice using transcutaneous bilirubinometery (TcB). In low-and middle-income countries, TcB is not widely used due to a lack of availability; however, mobile-phone approaches for TcB could help expand screening opportunities. We developed a mobile phone-based approach for TcB and validated the method with a 37 patient multi-ethnic pilot study. We include a custom-designed snap-on adapter that is used to create a spatially resolved diffuse reflectance detection configuration with the illumination provided by the mobile-phone LED flash. Monte-Carlo models of reflectance from neonatal skin were used to guide the design of an adapter for filtered red-green-blue (RGB) mobile-phone camera reflectance measurements. We extracted measures of reflectance from multiple optimized spatial-offset regions-of-interest (ROIs) and a linear model was developed and cross-validated. This resulted in a correlation between total serum bilirubin and mobile-phone TcB estimated bilirubin with a R ²= 0.42 and Bland-Altman limits of agreement of +6.4 mg/dL to -7.0 mg/dL. These results indicate that a mobile phone with a modified adapter can be utilized to measure neonatal bilirubin values, thus creating a novel tool for neonatal jaundice screening in low-resource settings.

Neonatal jaundice in Ghanaian children: Assessing maternal knowledge, attitude, and perceptions

Background

Neonatal jaundice (NNJ) is a major cause of preventable childhood mortality and long-term impairment especially in countries with significant prevalence of the inherited condition, glucose-6-phosphate dehydrogenase (G6PD) defect. In Ghana, routine screening of pregnant women for G6PD defect is standard care. Prevention of poor health outcomes from NNJ is contingent on population health literacy and early diagnosis. As part of a project to evaluate a screening tool for NNJ, we assessed the knowledge, attitude, and perceptions of Ghanaian mothers on NNJ at baseline.

Methods

Using a cross-sectional design, mothers attending antenatal and postnatal clinics at 3 selected health facilities in 2 geographical regions of Ghana were interviewed. Data on mothers’ understanding, perceptions, beliefs, and actions towards NNJ were evaluated. Chi-square test was used to determine the association between selected maternal characteristics and knowledge, attitude, and perception to NNJ.

Results

Of the 504 mothers interviewed, 428(85.4%) had heard about NNJ, 346 (68.7%) said the earliest signs are seen in the eyes, 384(76.2%) knew NNJ may be harmful and 467(92.7%) recommended seeking healthcare for the jaundiced newborn. None of the women knew about G6PD or their G6PD status following antenatal screening. Most did not know the signs/symptoms of severe NNJ. Of the 15 mothers who had had a jaundiced neonate, cost was the most perceived (8 out of 15) barrier to accessing health care. There were significant associations (p-value ≤ 0.05) between maternal age, educational level, and knowledge of NNJ.

Conclusion

Despite the high level of awareness of NNJ, gaps still exit in the knowledge, attitudes and perceptions of mothers concerning NNJ. Improving education of women about the causes, symptoms/signs, and the role of G6PD in severe NNJ is recommended. Addressing barriers to accessing healthcare for the jaundiced infant may enhance timely management of NNJ and reduce the associated complications and mortality.

Current and emerging technologies for the timely screening and diagnosis of neonatal jaundice

Neonatal jaundice is one of the most common clinical conditions affecting newborns. For most newborns, jaundice is harmless, however, a proportion of newborns develops severe neonatal jaundice requiring therapeutic interventions, accentuating the need to have reliable and accurate screening tools for timely recognition across different health settings. The gold standard method in diagnosing jaundice involves a blood test and requires specialized hospital-based laboratory instruments. Despite technological advancements in point-of-care laboratory medicine, there is limited accessibility of the specialized devices and sample stability in geographically remote areas. Lack of suitable testing options leads to delays in timely diagnosis and treatment of clinically significant jaundice in developed and developing countries alike. There has been an ever-increasing need for a low-cost, simple to use screening technology to improve timely diagnosis and management of neonatal jaundice. Consequently, several point-of-care (POC) devices have been developed to address this concern. This paper aims to review the literature, focusing on emerging technologies in the screening and diagnosing of neonatal jaundice. We report on the challenges associated with the existing screening tools, followed by an overview of emerging sensors currently in pre-clinical development and the emerging POC devices in clinical trials to advance the screening of neonatal jaundice. The benefits offered by emerging POC devices include their ease of use, low cost, and the accessibility of rapid response test results. However, further clinical trials are required to overcome the current limitations of the emerging POC's before their implementation in clinical settings. Hence, the need for a simple to use, low-cost POC jaundice detection technology for newborns remains an unsolved challenge globally.

Smartphones’ Skin Colour Reproduction Analysis for Neonatal Jaundice Detection

Abstract In recent years, smartphone-based colour imaging systems are being increasingly used for Neonatal jaundice detection applications. These systems are based on the estimation of bilirubin concentration levels that correlates with newborns’ skin colour images corresponding to total serum bilirubin (TSB) and transcutaneous bilirubinometry (TcB) measurements. However, the colour reproduction capacity of smartphone cameras are known to be influenced by various factors including the technological and acquisition process variabilities. To make an accurate bilirubin estimation, irrespective of the type of smartphone and illumination conditions used to capture the newborns’ skin images, an inclusive and complete model, or data set, which can represent all the possible real world acquisitions scenarios needs to be utilized. Due to various challenges in generating such a model or a data set, some solutions tend towards the application of reduced data set (designed for reference conditions and devices only) and colour correction systems (for the transformation of other smartphone skin images to the reference space). Such approaches will make the bilirubin estimation methods highly dependent on the accuracy of their employed colour correction systems, and the capability of reducing device-to-device colour reproduction variability. However, the state-of-the-art methods with similar methodologies were only evaluated and validated on a single smartphone camera. The vulnerability of the systems in making an incorrect jaundice diagnosis can only be shown with a thorough investigation of the colour reproduction variability for extended number of smartphones and illumination conditions. Accordingly, this work presents and discuss the results of such broad investigation, including the evaluation of seven smartphone cameras, ten light sources, and three different colour correction approaches. The overall results show statistically significant colour differences among devices, even after colour correction applications, and that further analysis on clinically significance of such differences is required for skin colour based jaundice diagnosis.

Neonatal Jaundice Diagnosis Using a Smartphone Camera Based on Eye, Skin, and Fused Features with Transfer Learning

Neonatal jaundice is a common condition worldwide. Failure of timely diagnosis and treatment can lead to death or brain injury. Current diagnostic approaches include a painful and time-consuming invasive blood test and non-invasive tests using costly transcutaneous bilirubinometers. Since periodic monitoring is crucial, multiple efforts have been made to develop non-invasive diagnostic tools using a smartphone camera. However, existing works rely either on skin or eye images using statistical or traditional machine learning methods. In this paper, we adopt a deep transfer learning approach based on eye, skin, and fused images. We also trained well-known traditional machine learning models, including multi-layer perceptron (MLP), support vector machine (SVM), decision tree (DT), and random forest (RF), and compared their performance with that of the transfer learning model. We collected our dataset using a smartphone camera. Moreover, unlike most of the existing contributions, we report accuracy, precision, recall, f-score, and area under the curve (AUC) for all the experiments and analyzed their significance statistically. Our results indicate that the transfer learning model performed the best with skin images, while traditional models achieved the best performance with eyes and fused features. Further, we found that the transfer learning model with skin features performed comparably to the MLP model with eye features.

Hyperbilirubinemia in the Term Infant: Re-evaluating What We Think We Know

This article attempts to highlight contemporary issues relating to term neonatal hyperbilirubinemia and to focus attention on controversial issues and concepts with the potential to effect change in clinical approach. On the one hand, the focus is bilirubin neurotoxicity, which is now known to encompass a wide, diverse spectrum of features. The various aspects of this spectrum are outlined and defined. On the other hand, bilirubin also possesses antioxidant properties. As such, mild hyperbilirubinemia is suggested as actually offering the neonate some protective advantage.

Screening methods for neonatal hyperbilirubinemia: benefits, limitations, requirements, and novel developments

Severe neonatal hyperbilirubinemia (SNH) is a serious condition that occurs worldwide. Timely recognition with bilirubin determination is key in the management of SNH. Visual assessment of jaundice is unreliable. Fortunately, transcutaneous bilirubin measurement for screening newborn infants is routinely available in many hospitals and outpatient settings. Despite a few limitations, the use of transcutaneous devices facilitates early recognition and appropriate management of neonatal jaundice. Unfortunately, however, advanced and often costly screening modalities are not accessible to everyone, while there is an urgent need for inexpensive yet accurate instruments to assess total serum bilirubin (TSB). In the near future, novel icterometers, and in particular optical bilirubin estimates obtained with a smartphone camera and processed with a smartphone application (app), seem promising methods for screening for SNH. If proven reliable, these methods may empower outpatient health workers as well as parents at home to detect jaundice using a simple portable device. Successful implementation of ubiquitous bilirubin screening may contribute substantially to the reduction of the worldwide burden of SNH. The benefits of non-invasive bilirubin screening notwithstanding, any bilirubin determination obtained through non-invasive screening must be confirmed by a diagnostic method before treatment. IMPACT: Key message: Screening methods for neonatal hyperbilirubinemia facilitate early recognition and timely treatment of severe neonatal hyperbilirubinemia (SNH). Any bilirubin screening result obtained must be confirmed by a diagnostic method. What does this article add to the existing literature? Data on optical bilirubin estimation are summarized. Niche research strategies for prevention of SNH are presented. Impact: Transcutaneous screening for neonatal hyperbilirubinemia contributes to the prevention of SNH. A smartphone application with optical bilirubin estimation seems a promising low-cost screening method, especially in low-resource settings or at home.

Maternal Blood Group and Routine Direct Antiglobulin Testing in Neonates: Is There a Role for Selective Neonatal Testing?

Recommendations for the screening of hemolytic disease of the newborn (HDN) advise taking a selective approach in using the direct antiglobulin test (DAT) for mothers with blood group O or RhD-negative. This study assessed the relation of DAT results to maternal and neonatal blood groups and evaluated the risk of HDN. A retrospective analysis of all healthy newborns admitted during 2018 was performed. Of 1463 newborns, 4.4% had a positive DAT. There were 541 (37%) maternal–neonatal pairs with ABO incompatibility, most commonly born to mothers with blood group O. The cohort of neonates born to mothers with blood group O was divided into three groups: the O-A and O-B groups and the O-O group as a control. The DAT was positive in 59 (8.3%) neonates; most were in the O-B group (49.2%), whereas 13.6% were in the control group (p < 0.01). While the neonates in the O-B group were more likely to require phototherapy (p = 0.03), this finding was not related to DAT results. We found that selective testing of mothers with blood group O, mothers with blood group O or RhD-negative, neonates with blood group B, and neonates with blood group B born to mothers with blood group O or RhD-negative was ineffective in detecting phototherapy requirements. Our results indicate no difference regarding the need for phototherapy in neonates born to mothers with different blood types regardless of the DAT results.

Smartphone-based imaging systems for medical applications: a critical review

SIGNIFICANCE

Smartphones come with an enormous array of functionality and are being more widely utilized with specialized attachments in a range of healthcare applications. A review of key developments and uses, with an assessment of strengths/limitations in various clinical workflows, was completed.

AIM

Our review studies how smartphone-based imaging (SBI) systems are designed and tested for specialized applications in medicine and healthcare. An evaluation of current research studies is used to provide guidelines for improving the impact of these research advances.

APPROACH

First, the established and emerging smartphone capabilities that can be leveraged for biomedical imaging are detailed. Then, methods and materials for fabrication of optical, mechanical, and electrical interface components are summarized. Recent systems were categorized into four groups based on their intended application and clinical workflow: ex vivo diagnostic, in vivo diagnostic, monitoring, and treatment guidance. Lastly, strengths and limitations of current SBI systems within these various applications are discussed.

RESULTS

The native smartphone capabilities for biomedical imaging applications include cameras, touchscreens, networking, computation, 3D sensing, audio, and motion, in addition to commercial wearable peripheral devices. Through user-centered design of custom hardware and software interfaces, these capabilities have the potential to enable portable, easy-to-use, point-of-care biomedical imaging systems. However, due to barriers in programming of custom software and on-board image analysis pipelines, many research prototypes fail to achieve a prospective clinical evaluation as intended. Effective clinical use cases appear to be those in which handheld, noninvasive image guidance is needed and accommodated by the clinical workflow. Handheld systems for in vivo, multispectral, and quantitative fluorescence imaging are a promising development for diagnostic and treatment guidance applications.

CONCLUSIONS

A holistic assessment of SBI systems must include interpretation of their value for intended clinical settings and how their implementations enable better workflow. A set of six guidelines are proposed to evaluate appropriateness of smartphone utilization in terms of clinical context, completeness, compactness, connectivity, cost, and claims. Ongoing work should prioritize realistic clinical assessments with quantitative and qualitative comparison to non-smartphone systems to clearly demonstrate the value of smartphone-based systems. Improved hardware design to accommodate the rapidly changing smartphone ecosystem, creation of open-source image acquisition and analysis pipelines, and adoption of robust calibration techniques to address phone-to-phone variability are three high priority areas to move SBI research forward.

Neonatal wearable device for colorimetry-based real-time detection of jaundice with simultaneous sensing of vitals

Neonatal jaundice occurs in >80% of newborns in the first week of life owing to physiological hyperbilirubinemia. Severe hyperbilirubinemia could cause brain damage owing to its neurotoxicity, a state commonly known as kernicterus. Therefore, periodic bilirubin monitoring is essential to identify infants at-risk and to initiate treatment including phototherapy. However, devices for continuous measurements of bilirubin have not been developed yet. Here, we established a wearable transcutaneous bilirubinometer that also has oxygen saturation (SpO2) and heart rate (HR) sensing functionalities. Clinical experiments with neonates demonstrated the possibility of simultaneous detection of bilirubin, SpO2, and HR. Moreover, our device could consistently measure bilirubin during phototherapy. These results demonstrate the potential for development of a combined treatment approach with an automatic link via the wearable bilirubinometer and phototherapy device for optimization of the treatment of neonatal jaundice.

Acute bilirubin encephalopathy: Some lessons learned

Acute bilirubin encephalopathy (ABE) is still an insufficiently addressed cause of mortality and long-term morbidity in low- and middle-income countries (LMICs). This article highlights that delayed or incorrect medical advice, inaccurate bilirubin measurements as well as ineffective phototherapy are some of the relevant causes predisposing jaundiced newborns to develop extreme hyperbilirubinemia [EHB, total serum/plasma bilirubin (TB) ≥ 25 mg/dL (428 µmol/L)] and subsequent ABE. Obstacles preventing state of the art management of such infants are also discussed. Prevention of ABE cannot occur without a system-based approach tailored to suit the needs and available resources of each community. Clear set protocols, rigorous training, monitoring, and accurate documentation together with simple innovative affordable technologies that can be locally produced, are essential to observe the change desired.

Neonatal hyperbilirubinemia management: Clinical assessment of bilirubin production

The predominant cause of elevated total/plasma bilirubin (TB) levels is from an increase in bilirubin production primarily because of ongoing hemolysis. If undiagnosed or untreated, the risk for developing extreme neonatal hyperbilirubinemia and possibly bilirubin-induced neurological dysfunction (BIND) is increased. Since carbon monoxide (CO) and bilirubin are produced in equimolar amounts during the heme catabolic process, measurements of end-tidal CO levels, corrected for ambient CO (ETCOc) can be used as a direct indicator of ongoing hemolysis. A newly developed point-of-care ETCOc device has been shown to be a useful for identifying hemolysis-associated hyperbilirubinemia in newborns. This review summarizes the biology of bilirubin production, the clinical utility of a novel device to identify neonates undergoing hemolysis, and a brief introduction on the use of ETCOc measurements in a cohort of neonates in China.

Bilirubin estimates from smartphone images of newborn infants' skin correlated highly to serum bilirubin levels

AIM

Neonatal jaundice is an important cause of morbidity and mortality, and identifying the condition remains a challenge. This study evaluated a novel method of estimating bilirubin levels from colour-calibrated smartphone images.

METHODS

A cross-sectional prospective study was undertaken at two hospitals in Norway from February 2017 to March 2019, with standardised illumination at one hospital and non-standardised illumination at the other hospital. Healthy term-born infants with a normal birthweight were recruited up to 15 days of age. The main outcome measures were bilirubin estimates from digital images, plus total bilirubin in serum (TSB) and transcutaneous bilirubin (TcB).

RESULTS

Bilirubin estimates were performed for 302 newborn infants, and 76 had severe jaundice. The correlation between the smartphone estimates and TSB was measured by Pearson's r and was .84 for the whole sample. The correlation between the image estimates and TcB was 0.81. There were no significant differences between the hospitals. Sensitivity was 100%, and specificity was 69% for identifying severe jaundice of more than 250 µmol/L.

CONCLUSION

A smartphone-based tool that estimated bilirubin levels from digital images identified severe jaundice with high sensitivity and could provide a screening tool for neonatal jaundice.

Side-Channel Sensing: Exploiting Side-Channels to Extract Information for Medical Diagnostics and Monitoring

Information within systems can be extracted through side-channels; unintended communication channels that leak information. The concept of side-channel sensing is explored, in which sensor data is analysed in non-trivial ways to recover subtle, hidden or unexpected information. Practical examples of side-channel sensing are well known in domains such as cybersecurity (CYB), but are not formally recognised within the domain of medical diagnostics and monitoring (MDM). This article reviews side-channel usage within CYB and MDM, identifying techniques and methodologies applicable to both domains. We establish a systematic structure for the use of side-channel sensing in MDM that is comparable to existing structures in CYB, and promote cross-domain transferability of knowledge, mindsets, and techniques.

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.

Management strategies of neonatal jaundice during the coronavirus disease 2019 outbreak

The outbreak of coronavirus disease 2019 (COVID-19; formally known as 2019-nCoV) has become a most challenging health emergency. Owing to rigorous quarantine and control measures taken in China, routine neonatal health surveillance and follow-up have become challenging. Without follow-up surveillance, some rapid and progressive newborn diseases, such as bilirubin encephalopathy, may be ignored. The characteristics of onset age of kernicterus suggest that monitoring of bilirubin level at home provides a useful way to alert hospital visits and to prevent the development of extremely hyperbilirubinemia. Therefore, we developed an online follow-up program for convenient monitoring of bilirubin level of newborns that is based on our practical experiences. The aim is to make our management strategies of neonatal jaundice tailored to the infection prevention and control during the COVID-19 epidemic.

Review of bilirubin neurotoxicity II: preventing and treating acute bilirubin encephalopathy and kernicterus spectrum disorders

Previously in Part I of this two-part review, we discussed the current and recent advances in the understanding of the molecular biology and neuropathology of bilirubin neurotoxicity (BNTx). Here in Part II, we summarize current treatment options available to treat the severely jaundiced infants to prevent significant brain damage and improve clinical outcomes. In addition, we review potential novel therapies that are in various stages of research and development. We will emphasize treatments for both prevention and treatment of both acute bilirubin encephalopathy (ABE) and kernicterus spectrum disorders (KSDs), highlighting the treatment of the most disabling neurological sequelae of children with mild-to-severe KSDs whose "rare disease" status often means they are overlooked by the clinical research community at large. As with other secondary dystonias, treatment of the dystonic motor symptoms in kernicterus is the greatest clinical challenge.

Novel Innovations and Recent Findings in Lactation Support

Rationale

Staying current with the burgeoning amount of breastfeeding research can be a daunting task. It is incumbent upon the IBCLC and other lactation care providers to be cognizant of new research and innovations in lactation support.

Method

Recent products and findings regarding neonatal jaundice, hypoglycemia, mastitis, and therapeutic taping are presented.

Findings

New research findings, techniques, and products have been gathered to augment the provider's knowledge and skill set regarding a broad range of items relevant to clinical lactation practice. Most are affordable options for practitioners and parents, and represent safe and effective options for screening and treatment.

Reliability and accuracy of smartphones for paediatric infectious disease consultations for children with rash in the paediatric emergency department

Objective

Smartphones and associated messaging applications have become the most common means of communication among health care workers and the general population. The aim of this study was to evaluate the reliability and accuracy of smartphones for the diagnosis of rash in children admitted to emergency departments during the night shift.

Methods

The images of the children who were admitted to the paediatric emergency department with rash were included in this study, and at least two images taken with smartphones by residents or paediatric infectious disease fellows were re-directed to the chief consultant of the Paediatric-Infectious Department via smartphone. Initial diagnosis by the consultant was recorded, and the patient’s physical examination was performed by another clinician on the first working day; diagnostic tests were planned by this clinician. The definitive diagnosis was recorded and compared with the initial diagnosis.

Results

Among the 194 patients, the most common final diagnoses were chickenpox (varicella-zoster infections) in 33 patients (17.0%) and skin infections (including impetigo, ecthyma, erysipelas and cellulitis) in 33 patients (17.0%). The initial diagnosis, which was performed via WhatsApp on a smartphone, was identical to the final diagnosis in 96.3% of the cases. Incompatible initial diagnoses included 4 measles cases, 1 staphylococcal scalded skin syndrome case, 1 cutaneous leishmaniasis case and 1 petechial rash case.

Conclusions

Our study has shown that the use of a smartphone-based instant messaging application for transmitting images of paediatric rash is accurate and useful for diagnosis. However, physical examination and medical history are still the primary methods. Consultation via smartphones in emergency departments for paediatric rashes during nightshifts would help both clinicians and patients.

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.

The smartphone camera as a potential method for transcutaneous bilirubin measurement

BACKGROUND

Hyperbilirubinemia is a common problem in neonates that can progress into kernicterus. Suspected neonatal hyperbilirubinemia is a common reason for contact with the healthcare system. The severity and management of jaundice are determined based on estimated bilirubin levels. However, no easy and accessible tool for self-assessing neonatal jaundice is currently available. Smartphones could potentially be transformed into a medical device that could be used by both patients and practitioners.

OBJECTIVE

To investigate whether a digital image produced by a camera embedded on a smartphone can be a used as a screening tool for neonatal hyperbilirubinemia.

STUDY DESIGN

A total of 64 randomly selected newborns were enrolled. The inclusion criteria were healthy Caucasians, gestational age >35 weeks, age >24 hours and ≤14 days old, and parental informed consent. The exclusion criteria were facial skin lesions and light treatment. Images of the glabella were obtained with an iPhone 6 via i) directly applied pressure, ii) a dermatoscope, or iii) a dermatoscope equipped with a Wratten No. 11 filter. The red, green and blue colour intensities of each image were compared to bilirubin levels.

RESULTS

Only the dermatoscope-acquired intensities of the green and blue channels were significantly correlated (p < 0.001) with bilirubin measurements (Pearson's r: 0.59 and 0.48, respectively). For the green and blue channels, discrimination limits of 212 and 190, respectively, revealed a sensitivity and specificity of 100% and 62.5%, respectively, for green and 90.9% and 60%, respectively, for blue for a plasma bilirubin above 205 μmol/L.

CONCLUSIONS

The results of this study indicate that a smartphone equipped with a consistent light source in the form of a dermatoscope may be a simple screening tool for neonatal hyperbilirubinemia. However, the method requires some improvement before clinical application.