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Jiménez-Díaz G, Aune A, Elizarrarás-Rivas J, Gierman LM, Keitsch M, Marcuzzi A, Infanti JJ. Neonatal jaundice detection in low-resource Mexican settings: possibilities and barriers for innovation with mobile health. BMC Health Serv Res 2024; 24:671. [PMID: 38807158 PMCID: PMC11134921 DOI: 10.1186/s12913-024-11141-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 05/22/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND Neonatal jaundice is a common condition that can lead to brain damage and disabilities when severe cases go undetected. Low- and middle-income countries often lack accurate methods for detecting neonatal jaundice and rely on visual assessment, resulting in a higher incidence of adverse consequences. Picterus Jaundice Pro (Picterus JP), an easy-to-use and affordable smartphone-based screening device for the condition, has demonstrated higher accuracy than visual assessment in Norwegian, Philippine and Mexican newborns. This study aimed to identify the barriers and facilitators to implementing Picterus JP in public health services in low-income settings in Mexico by exploring the current process of neonatal jaundice detection and stakeholders' perspectives in that context. METHODS Qualitative data collection techniques, including one focus group, 15 semi-structured interviews and four observations, were employed in urban and rural health facilities in Oaxaca, Mexico. The participants included medical doctors, nurses and health administrators. The data were analysed by thematic analysis guided by the Consolidated Framework for Implementation Research. RESULTS The analysis yielded four main themes: (I) the current state of neonatal care and NNJ detection, (II) the needs and desires for enhancing NNJ detection, (III) the barriers and facilitators to implementing Picterus JP in the health system and (IV) HCWs' expectations of Picterus JP. The findings identify deficiencies in the current neonatal jaundice detection process and the participants' desire for a more accurate method. Picterus JP was perceived as easy to use, useful and compatible with the work routine, but barriers to adoption were identified, including internet deficiencies and costs. CONCLUSIONS The introduction of Picterus JP as a supporting tool to screen for neonatal jaundice is promising but contextual barriers in the setting must be addressed for successful implementation. There is also an opportunity to optimise visual assessment to improve detection of neonatal jaundice.
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Affiliation(s)
- Gabriela Jiménez-Díaz
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway.
- Picterus AS, Trondheim, Norway.
| | - Anders Aune
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
- Picterus AS, Trondheim, Norway
- Department of Pediatrics, St Olav's University Hospital, Trondheim, Norway
| | - Jesús Elizarrarás-Rivas
- Health Research Coordination, Mexican Institute of Social Security, IMSS, Oaxaca, Mexico
- Faculty of Medicine and Surgery, Universidad Autónoma Benito Juárez de Oaxaca, Oaxaca City, México
| | | | - Martina Keitsch
- Department of Design, Faculty of Architecture and Design, Norwegian University of Science and Technology, Trondheim, Norway
| | - Anna Marcuzzi
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
- Department of Physical Medicine and Rehabilitation, St. Olav's University Hospital, Trondheim, Norway
| | - Jennifer J Infanti
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, NTNU-Norwegian University of Science and Technology, Trondheim, Norway
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2
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Abiha U, Banerjee DS, Mandal S. Demystifying non-invasive approaches for screening jaundice in low resource settings: a review. Front Pediatr 2023; 11:1292678. [PMID: 38054187 PMCID: PMC10694303 DOI: 10.3389/fped.2023.1292678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 10/18/2023] [Indexed: 12/07/2023] Open
Abstract
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.
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Affiliation(s)
- Umme Abiha
- Department of Smart Healthcare, Indian Institute of Technology, Jodhpur, India
- All India Institute of Medical Science, Jodhpur, India
| | - Dip Sankar Banerjee
- Computer Science and Engineering, Indian Institute of Technology, Jodhpur, India
| | - Saptarshi Mandal
- Transfusion Medicine and Blood Bank, All India Institute of Medical Science, Jodhpur, India
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3
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Hegde D, Rath C, Amarasekara S, Saraswati C, Patole S, Rao S. Performance of smartphone application to accurately quantify hyperbilirubinemia in neonates: a systematic review with meta-analysis. Eur J Pediatr 2023; 182:3957-3971. [PMID: 37368007 DOI: 10.1007/s00431-023-05073-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 06/15/2023] [Accepted: 06/19/2023] [Indexed: 06/28/2023]
Abstract
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.
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Affiliation(s)
- Deeparaj Hegde
- King Edward Memorial Hospital, Subiaco, WA, 6008, Australia
- Perth Children's Hospital, Nedlands, WA, 6008, Australia
| | - Chandra Rath
- King Edward Memorial Hospital, Subiaco, WA, 6008, Australia.
- Perth Children's Hospital, Nedlands, WA, 6008, Australia.
- School of Medicine, University of Western Australia, Crawley, WA, Australia.
| | - Sathika Amarasekara
- King Edward Memorial Hospital, Subiaco, WA, 6008, Australia
- Perth Children's Hospital, Nedlands, WA, 6008, Australia
| | | | - Sanjay Patole
- King Edward Memorial Hospital, Subiaco, WA, 6008, Australia
- School of Medicine, University of Western Australia, Crawley, WA, Australia
| | - Shripada Rao
- Perth Children's Hospital, Nedlands, WA, 6008, Australia
- School of Medicine, University of Western Australia, Crawley, WA, Australia
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4
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Banerjee A, Bhattacharyya N, Ghosh R, Singh S, Adhikari A, Mondal S, Roy L, Bajaj A, Ghosh N, Bhushan A, Goswami M, Ahmed ASA, Moussa Z, Mondal P, Mukhopadhyay S, Bhattacharyya D, Chattopadhyay A, Ahmed SA, Mallick AK, Pal SK. Non-invasive estimation of hemoglobin, bilirubin and oxygen saturation of neonates simultaneously using whole optical spectrum analysis at point of care. Sci Rep 2023; 13:2370. [PMID: 36759533 PMCID: PMC9911772 DOI: 10.1038/s41598-023-29041-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 01/30/2023] [Indexed: 02/11/2023] Open
Abstract
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.
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Affiliation(s)
- Amrita Banerjee
- Department of Physics, Jadavpur University, 188, Raja S.C. Mallick Rd, Kolkata, 700032, India.,Technical Research Centre, S. N. Bose National Centre for Basic Sciences, Block JD, Sector III, Salt Lake, Kolkata, West Bengal, 700106, India.,Department of Paediatric Medicine, Nil RatanSircar Medical College & Hospital, 138, AJC Bose Road, Sealdah, Raja Bazar, Kolkata, 700014, India
| | - Neha Bhattacharyya
- Department of Radio Physics and Electronics, University of Calcutta, 92, Acharya Prafulla Chandra Rd, Machuabazar, Kolkata, 700009, India.,Department of Chemical and Biological Sciences, S. N. Bose National Centre for Basic Sciences, Block JD, Sector 3, Salt Lake, Kolkata, 700106, India
| | - Ria Ghosh
- Department of Chemical and Biological Sciences, S. N. Bose National Centre for Basic Sciences, Block JD, Sector 3, Salt Lake, Kolkata, 700106, India
| | - Soumendra Singh
- Department of Chemical and Biological Sciences, S. N. Bose National Centre for Basic Sciences, Block JD, Sector 3, Salt Lake, Kolkata, 700106, India.,Neo Care Inc, 27, Parker St, Dartmouth, NS, B2Y 2W1, Canada.,Electrical and Computer Engineering Department, Dalhousie University, 6299 South St, Halifax, NS B3H 4R2, Halifax, Canada
| | - Aniruddha Adhikari
- Department of Chemical and Biological Sciences, S. N. Bose National Centre for Basic Sciences, Block JD, Sector 3, Salt Lake, Kolkata, 700106, India.,Chemical and Biomolecular Engineering, University of California, Los Angeles, CA, 90095, USA
| | - Susmita Mondal
- Department of Chemical and Biological Sciences, S. N. Bose National Centre for Basic Sciences, Block JD, Sector 3, Salt Lake, Kolkata, 700106, India
| | - Lopamudra Roy
- Technical Research Centre, S. N. Bose National Centre for Basic Sciences, Block JD, Sector III, Salt Lake, Kolkata, West Bengal, 700106, India.,Department of Applied Optics and Photonics, JD-2, Sector-III, Salt Lake, Kolkata, West Bengal, 700 106, India
| | - Annie Bajaj
- Department of Paediatric Medicine, Nil RatanSircar Medical College & Hospital, 138, AJC Bose Road, Sealdah, Raja Bazar, Kolkata, 700014, India
| | - Nilanjana Ghosh
- Department of Paediatric Medicine, Nil RatanSircar Medical College & Hospital, 138, AJC Bose Road, Sealdah, Raja Bazar, Kolkata, 700014, India
| | - Aman Bhushan
- Department of Biotechnology, Thapar Institute of Engineering and Technology, Bhadson Road, Patiala, Punjab, 147004, India
| | - Mahasweta Goswami
- Technical Research Centre, S. N. Bose National Centre for Basic Sciences, Block JD, Sector III, Salt Lake, Kolkata, West Bengal, 700106, India
| | - Ahmed S A Ahmed
- Faculty of Medicine, Assiut University, Assiut, 71516, Egypt
| | - Ziad Moussa
- Department of Chemistry, College of Science, United Arab Emirates University, Al Ain, P.O. Box 15551, Abu Dhabi, United Arab Emirates
| | - Pulak Mondal
- Department of Radio Physics and Electronics, University of Calcutta, 92, Acharya Prafulla Chandra Rd, Machuabazar, Kolkata, 700009, India
| | - Subhadipta Mukhopadhyay
- Department of Physics, Jadavpur University, 188, Raja S.C. Mallick Rd, Kolkata, 700032, India
| | - Debasis Bhattacharyya
- Department of Gynecology & Obstetrics, Nil Ratan Sircar Medical College & Hospital, 138, AJC Bose Road, Sealdah, Raja Bazar, Kolkata, 700014, India
| | - Arpita Chattopadhyay
- Department of Basic Science and Humanities, Techno International, Kolkata, 700156, India.,Department of Physics, Sister Nivedita University, Kolkata, India
| | - Saleh A Ahmed
- Department of Chemistry, Faculty of Applied Science, Umm Al-Qura University, Makkah, 21955, Saudi Arabia.
| | - Asim Kumar Mallick
- Department of Paediatric Medicine, Nil RatanSircar Medical College & Hospital, 138, AJC Bose Road, Sealdah, Raja Bazar, Kolkata, 700014, India.
| | - Samir Kumar Pal
- Department of Chemical and Biological Sciences, S. N. Bose National Centre for Basic Sciences, Block JD, Sector 3, Salt Lake, Kolkata, 700106, India.
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5
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Sankar MN, Ramanathan R, Joe P, Katheria AC, Villosis MFB, Cortes M, Bhatt DR, Truong H, Paje V, Tan RC, Arora V, Nguyen M, Biniwale M. Transcutaneous bilirubin levels in extremely preterm infants less than 30 weeks gestation. J Perinatol 2023; 43:220-225. [PMID: 35931798 DOI: 10.1038/s41372-022-01477-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 07/20/2022] [Accepted: 07/25/2022] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The primary objective of this study was to determine the relationship between transcutaneous bilirubin (TcB) levels and total serum bilirubin (TSB) levels in extremely preterm infants. STUDY DESIGN We conducted a prospective multicenter study of extremely preterm infants less than 30 weeks gestation in California. Difference between paired TcB and TSB values were compared based on gestational age, birth weight, maternal race/ethnicity, chronological age as well as during and after phototherapy. RESULTS TSB values ranged from 0 to 12.6 mg/dl and the TcB values ranged from 0 to 14.2 mg/dl. TSB was predicted with a high degree of accuracy at TSB = 2.37 + 0.54 (TcB) with r = 0.786. There was good correlation across gestational age, birth weight, race/ethnic, chronological age subgroups as well as during and after phototherapy. CONCLUSION Our study supports the use of TcB as a screening tool for monitoring jaundice in extremely preterm infants.
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Affiliation(s)
- Meera N Sankar
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University, Stanford, CA, USA.
| | - Rangasamy Ramanathan
- Division of Neonatology, LAC + USC Medical Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Priscilla Joe
- Neonatology, UCSF Benioff Children's Oakland, Oakland, CA, USA
| | - Anup C Katheria
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, USA
| | | | - Maria Cortes
- Department of Pediatrics/Neonatology, Santa Clara Valley Medical Center, San Jose, CA, USA
| | - Dilip R Bhatt
- Neonatology, Kaiser Permanente Fontana Medical Center, Fontana, CA, USA
| | - Huy Truong
- Neonatology, Kaiser Permanente Fontana Medical Center, Fontana, CA, USA
| | - Virna Paje
- Neonatology, Kaiser Permanente Fontana Medical Center, Fontana, CA, USA
| | - Rosemarie C Tan
- Neonatology, Miller Children's Hospital, Long Beach, CA, USA
| | - Vasudha Arora
- Neonatology, Kaiser Foundation Hospital, Downey, CA, USA
| | - Marielle Nguyen
- Neonatology, Kaiser Permanente Southern California Orange County, Anaheim, CA, USA
| | - Manoj Biniwale
- Division of Neonatology, LAC + USC Medical Center, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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6
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Kemper AR, Newman TB, Slaughter JL, Maisels MJ, Watchko JF, Downs SM, Grout RW, Bundy DG, Stark AR, Bogen DL, Holmes AV, Feldman-Winter LB, Bhutani VK, Brown SR, Maradiaga Panayotti GM, Okechukwu K, Rappo PD, Russell TL. Clinical Practice Guideline Revision: Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. Pediatrics 2022; 150:188726. [PMID: 35927462 DOI: 10.1542/peds.2022-058859] [Citation(s) in RCA: 120] [Impact Index Per Article: 60.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/29/2022] [Indexed: 11/24/2022] Open
Affiliation(s)
- Alex R Kemper
- Division of Primary Care Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Thomas B Newman
- Departments of Epidemiology & Biostatistics and Pediatrics, School of Medicine, University of California, San Francisco, San Francisco, California
| | | | - M Jeffrey Maisels
- Department of Pediatrics, Oakland University William Beaumont School of Medicine, Rochester, Michigan
| | - Jon F Watchko
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Stephen M Downs
- Department of Pediatrics, Wake Forest University, Winston-Salem, North Carolina
| | - Randall W Grout
- Children's Health Services Research, Indiana University School of Medicine, Indianapolis, Indiana
| | - David G Bundy
- Medical University of South Carolina, Charleston, South Carolina
| | | | - Debra L Bogen
- Allegheny County Health Department, Pittsburgh, Pennsylvania
| | - Alison Volpe Holmes
- Geisel School of Medicine at Dartmouth, Children's Hospital at Dartmouth-Hitchcock, Lebanon, New Hampshire
| | - Lori B Feldman-Winter
- Department of Pediatrics, Division of Adolescent Medicine, Cooper Medical School of Rowan University, Camden, New Jersey
| | - Vinod K Bhutani
- Department of Pediatrics, Neonatal and Developmental Medicine Stanford University School of Medicine, Stanford, California
| | | | - Gabriela M Maradiaga Panayotti
- Division of Primary Care, Duke Children's Hospital and Health Center, Duke University Medical Center, Durham, North Carolina
| | - Kymika Okechukwu
- Department of Quality, American Academy of Pediatrics, Itasca, Illinois
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7
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Akuamoah-Boateng G, Stetson RC, Karon BS, Brumbaugh JE. Refining interpretation of transcutaneous bilirubin measurement in newborns born late preterm. Pediatr Neonatol 2022; 63:484-488. [PMID: 35659749 DOI: 10.1016/j.pedneo.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 03/16/2022] [Accepted: 05/10/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Transcutaneous bilirubin (TCB) monitoring is widely used for jaundice screening in the newborn period. Limited data exists on adjusting TCB for bias in late preterm infants. The objective of this study was to determine the median bias between transcutaneous bilirubin and total serum bilirubin levels in newborns born at 35-36 weeks' gestation. METHODS This was a retrospective cohort study of late preterm infants born at 35-0/7 to 36-6/7 weeks' gestation who were admitted to a level III neonatal intensive care unit from May 2018 to February 2020. Transcutaneous and total serum bilirubin levels were assessed within 2 h of each other during the first 60 h of life. Bland-Altman plots were used to evaluate transcutaneous bilirubin bias. Bilirubin risk stratification based on age (in hours) was done using an adaptation of the Bhutani nomogram for transcutaneous, adjusted transcutaneous, and total serum bilirubin measurements. RESULTS The median bias between transcutaneous and total serum bilirubin bias was 2.4 mg/dL (IQR 1.7-3.4, 95% CI 2.2-2.7). The kappa statistic demonstrated slight agreement between the unadjusted transcutaneous bilirubin and total serum bilirubin (k = 0.033, p = 0.194. The kappa statistic demonstrated fair agreement between an adjusted transcutaneous bilirubin (subtract 1 mg/dL) and total serum bilirubin (k = 0.298, p < 0.0001) and moderate agreement between another adjusted transcutaneous bilirubin (subtract 2 mg/dL) and total serum bilirubin (k = 0.430, p < 0.0001). CONCLUSION In a single center study of late preterm infants, transcutaneous bilirubin systematically overestimated the total serum bilirubin level. Subtracting 1 mg/dL from the transcutaneous bilirubin identified infants with total serum bilirubin levels in the high or high intermediate risk range. Adjusting the transcutaneous bilirubin prior to risk stratification may reduce unnecessary blood draws for total serum bilirubin. Studies of racially and ethnically diverse newborns using various transcutaneous bilirubin meters are needed prior to broad application of the adjusted transcutaneous bilirubin approach.
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Affiliation(s)
- Gloria Akuamoah-Boateng
- Department of Pediatric and Adolescent Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Raymond C Stetson
- Division of Neonatal Medicine, Department of Pediatric and Adolescent Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Brad S Karon
- Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Jane E Brumbaugh
- Division of Neonatal Medicine, Department of Pediatric and Adolescent Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.
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8
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Evaluation of a new transcutaneous bilirubinometer in newborn infants. Sci Rep 2022; 12:5835. [PMID: 35393482 PMCID: PMC8989875 DOI: 10.1038/s41598-022-09788-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 03/18/2022] [Indexed: 11/09/2022] Open
Abstract
To avoid brain damage in newborn infants, effective tools for prevention of excessive neonatal hyperbilirubinemia are needed. The objective of this study was to evaluate a new transcutaneous bilirubinometer (JAISY). For this purpose, 930 bilirubin measurements were performed in 141 newborn infants born near-term or at term (gestational age 35–41 weeks; postnatal age 1–6 days; 71 boys; including 29 infants with darker skin) and compared to those of a previously validated instrument (JM105). In each infant, the mean of three repeated measurements in the forehead was calculated for each instrument, followed by a similar measurement on the chest. The bilirubin values varied between 0 and 320 µmol/l (0–18.8 mg/dl). There was a high degree of agreement with significant correlations between bilirubin values measured with the two devices on the forehead (Pearson’s r = 0.94, p < 0.001) and the chest (r = 0.94, p < 0.001). The correlations remained after stratifying the data by gestational age, postnatal age and skin color. The coefficient of variation for repeated bilirubin measurements was 8.8% for JAISY and 8.0% for JM105 (p = 0.79). In conclusion, JAISY provides accurate and reproducible information on low to moderately high bilirubin levels in newborn infants born near-term or at term.
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9
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Thomas M, Greaves RF, Tingay DG, Loh TP, Ignjatovic V, Newall F, Oeum M, Tran MTC, Rajapaksa AE. Current and emerging technologies for the timely screening and diagnosis of neonatal jaundice. Crit Rev Clin Lab Sci 2022; 59:332-352. [PMID: 35188857 DOI: 10.1080/10408363.2022.2038074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
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.
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Affiliation(s)
- Mercy Thomas
- New Vaccines, Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia.,Newborn Research Centre, Royal Women's Hospital, Melbourne, Australia.,Department of Nursing, Royal Children's Hospital, Melbourne, Australia
| | - Ronda F Greaves
- Department of Paediatrics, University of Melbourne, Melbourne, Australia.,School of Health and Biomedical Sciences, RMIT University, Melbourne, Australia.,Victorian Clinical Genetics Services, Melbourne, Australia.,International Federation of Clinical Chemistry and Laboratory Medicine-Emerging Technologies Division (C-ETPLM), Milan, Italy
| | - David G Tingay
- Department of Paediatrics, University of Melbourne, Melbourne, Australia.,Newborn Research Centre, Royal Women's Hospital, Melbourne, Australia.,Neonatal Research, Murdoch Children's Research Institute, Melbourne, Australia.,Department of Neonatology, Royal Children's Hospital, Melbourne, Australia
| | - Tze Ping Loh
- International Federation of Clinical Chemistry and Laboratory Medicine-Emerging Technologies Division (C-ETPLM), Milan, Italy.,Department of Laboratory Medicine, National University Hospital, Singapore, Singapore
| | - Vera Ignjatovic
- Department of Paediatrics, University of Melbourne, Melbourne, Australia.,Hematology, Murdoch Children's Research Institute, Melbourne, Australia
| | - Fiona Newall
- Department of Paediatrics, University of Melbourne, Melbourne, Australia.,Department of Nursing, Royal Children's Hospital, Melbourne, Australia
| | - Michelle Oeum
- New Vaccines, Murdoch Children's Research Institute, Melbourne, Australia
| | - Mai Thi Chi Tran
- International Federation of Clinical Chemistry and Laboratory Medicine-Emerging Technologies Division (C-ETPLM), Milan, Italy.,National Children's Hospital, Hanoi, Vietnam.,Hanoi Medical University, Hanoi, Vietnam
| | - Anushi E Rajapaksa
- New Vaccines, Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia.,Newborn Research Centre, Royal Women's Hospital, Melbourne, Australia.,Think Project Global, Melbourne, Australia
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10
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Khan DS, Mirza A, Bhatti A, Shabbir A, Tariq B, Rizvi A. Effectiveness of Transcutaneous Bilirubin Measurement in High-Risk Neonates and to Evaluate Validity of Transcutaneous Bilirubin With Total Serum Bilirubin Levels in Both Low and High-Risk Neonates at a Tertiary Care Center in a Developing Country. Cureus 2021; 13:e13685. [PMID: 33833911 PMCID: PMC8019100 DOI: 10.7759/cureus.13685] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Objectives To evaluate the usefulness of transcutaneous bilirubin (TcBR) nomogram in high-risk neonates and to identify the validity of TcBR and total serum bilirubin (TsBR) in both low and high-risk neonates to guide management in under-resourced settings. Methodology A cross-sectional study was conducted at the well-baby nursery of a tertiary care center in Karachi, Pakistan. All neonates admitted in the well-baby nursery with jaundice were stratified into high and low-risk groups. Eighty-seven neonates were included in the low-risk group and 121 neonates in the high-risk group. The usefulness of the TcBR nomogram in high-risk neonates and the validity of TcBR and TsBR in both low and high-risk neonates were determined through sensitivity and specificity analysis. Results The correlation coefficients (r) were found to be comparable in the high-risk group (r = 0.82, p < 0.001) and the low-risk group (r = 0.87, p < 0.001). The specificity of cutaneous bilirubin measurement based on bilirubin levels in the high-risk group was higher (93.0%) than that of the low-risk group (90.1%). However, the sensitivity was found to be lower (60.0%) in the high-risk group compared to the low-risk group (68.8%). The mean value of TsBR was equal in both groups. The mean TcBR in the high-risk group was 10 ± 2.3 compared to 11 ± 2.1 in the low-risk group. Phototherapy was given in 67.0% of the high-risk cases and 41.4% of the low-risk cases. Bland Altman analysis was also performed to depict the relationship between TcBR and TsBR measurements. Conclusion The TcBR nomogram was effective in high-risk neonates and also had validity in both high and low-risk neonates. A phototherapy-driven protocol based on TcBR would be a cost-effective and useful tool in the identification and management of neonatal jaundice in both high and low-risk groups in developing countries like Pakistan.
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Affiliation(s)
| | - Adnan Mirza
- Paediatric - Neonatal Medicine, Limerick University Maternity Hospital, Limerick, IRL.,Neonatal Intensive Care, Aga Khan University Hospital, Karachi, PAK
| | - Areesh Bhatti
- Pediatric Medicine, Aga Khan University Hospital, Karachi, PAK
| | - Ali Shabbir
- Neonatology, Aga Khan University Hospital, Karachi, PAK
| | - Batha Tariq
- Pediatric Medicine, Aga Khan University Hospital, Karachi, PAK
| | - Arjumand Rizvi
- Research and Development, Aga Khan University Hospital, Karachi, PAK
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11
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Paul HA, Adams BJ, Venner AA. Improving quality of transcutaneous bilirubin measurements: Value of in-house developed quality control. Pract Lab Med 2021; 24:e00206. [PMID: 33598521 PMCID: PMC7868991 DOI: 10.1016/j.plabm.2021.e00206] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 01/24/2021] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES Quality assurance (QA) plays an integral role in Point of Care Testing (POCT) programs. Quality control (QC) is an important QA program component to ensure high quality results and enhanced patient care. The measurement of transcutaneous bilirubin (TcB) in the POCT setting is an essential part of newborn care in Alberta, Canada. However, there is currently no available commercial QC material for TcB meters. An in-house developed QC material has been in use within a single TcB POCT program within Alberta. The objective of this study was to determine the performance of this QC material by other POCT staff and clinical end-users to assess whether its use could be expanded. DESIGN AND METHODS Two levels of QC material were measured by POCT staff and clinical end-users across 12 different sites using the Dräger Jaundice Meter JM-103® and JM-105® meters. RESULTS The performance of the QC material was acceptable when tested by POCT staff, was stable and reliable over time, and had an acceptable CV (≤8%). However, the data does not support use of the QC material by clinical end-users. CONCLUSIONS The use of the QC material could be expanded into other TcB settings for use by POCT staff. Additional training and experience with the QC material by end-users is needed to facilitate QC use in the clinical setting.
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Affiliation(s)
- Heather Anne Paul
- Alberta Precision Laboratories, 3535, Research Rd NW, Calgary, AB, T2L 2K8, Canada
- Department of Pathology and Laboratory Medicine, Cumming School of Medicine, University of Calgary, 3330, Hospital Drive NW, Calgary, AB, T2N 4N1, Canada
| | - Brenda Joanne Adams
- Alberta Precision Laboratories, 3535, Research Rd NW, Calgary, AB, T2L 2K8, Canada
| | - Allison Anne Venner
- Alberta Precision Laboratories, 3535, Research Rd NW, Calgary, AB, T2L 2K8, Canada
- Department of Pathology and Laboratory Medicine, Cumming School of Medicine, University of Calgary, 3330, Hospital Drive NW, Calgary, AB, T2N 4N1, Canada
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12
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Inamori G, Kamoto U, Nakamura F, Isoda Y, Uozumi A, Matsuda R, Shimamura M, Okubo Y, Ito S, Ota H. Neonatal wearable device for colorimetry-based real-time detection of jaundice with simultaneous sensing of vitals. SCIENCE ADVANCES 2021; 7:eabe3793. [PMID: 33658197 PMCID: PMC7929506 DOI: 10.1126/sciadv.abe3793] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 01/21/2021] [Indexed: 05/19/2023]
Abstract
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.
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Affiliation(s)
- Go Inamori
- Department of Mechanical Engineering, Yokohama National University, 79-5 Tokiwadai, Hodogaya-ku, Yokohama, Kanagawa 240-8501, Japan
| | - Umihiro Kamoto
- Department of Mechanical Engineering, Yokohama National University, 79-5 Tokiwadai, Hodogaya-ku, Yokohama, Kanagawa 240-8501, Japan
| | - Fumika Nakamura
- Department of Mechanical Engineering, Yokohama National University, 79-5 Tokiwadai, Hodogaya-ku, Yokohama, Kanagawa 240-8501, Japan
| | - Yutaka Isoda
- Graduate School of System Integration, Yokohama National University, 79-5 Tokiwadai, Hodogaya-ku, Yokohama, Kanagawa 240-8501, Japan
| | - Azusa Uozumi
- Department of Pediatrics, Graduate School of Medicine, Yokohama City University, 3-9 Fukura, Kanazawa-ku, Yokohama, Kanagawa 236-0004, Japan
| | - Ryosuke Matsuda
- Department of Mechanical Engineering, Yokohama National University, 79-5 Tokiwadai, Hodogaya-ku, Yokohama, Kanagawa 240-8501, Japan
| | - Masaki Shimamura
- Department of Mechanical Engineering, Yokohama National University, 79-5 Tokiwadai, Hodogaya-ku, Yokohama, Kanagawa 240-8501, Japan
| | - Yusuke Okubo
- Division of Cellular and Molecular Toxicology, Biological Safety and Research Center, National Institute of Health Sciences, Tonomachi 3-25-26, Kawasaki, Kanagawa 210-9501, Japan
| | - Shuichi Ito
- Department of Pediatrics, Graduate School of Medicine, Yokohama City University, 3-9 Fukura, Kanazawa-ku, Yokohama, Kanagawa 236-0004, Japan
| | - Hiroki Ota
- Department of Mechanical Engineering, Yokohama National University, 79-5 Tokiwadai, Hodogaya-ku, Yokohama, Kanagawa 240-8501, Japan.
- Graduate School of System Integration, Yokohama National University, 79-5 Tokiwadai, Hodogaya-ku, Yokohama, Kanagawa 240-8501, Japan
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13
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Reliability of transcutaneous bilirubin determination based on skin color determined by a neonatal skin color scale of our own. Eur J Pediatr 2021; 180:607-616. [PMID: 33409587 DOI: 10.1007/s00431-020-03885-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 11/13/2020] [Accepted: 11/20/2020] [Indexed: 10/22/2022]
Abstract
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.
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14
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Accuracy of enhanced transcutaneous bilirubinometry according to various measurement sites. Turk Arch Pediatr 2021; 56:15-21. [PMID: 34013224 DOI: 10.14744/turkpediatriars.2020.54514] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 07/21/2020] [Indexed: 11/20/2022]
Abstract
Objective The goal of the study was to provide missing data on the accuracy of enhanced transcutaneous bilirubinometry in a monoracial population of term neonates, considering three different measurement sites. Material and Methods Transcutaneous bilirubin was measured using the JM-105 device on the forehead, chest, and abdomen. Blood sampling for total serum bilirubin concentration has been performed within 10 minutes of transcutaneous measurements. Paired transcutaneous bilirubin and total serum bilirubin measurements were statistically analyzed. Results The study group consisted of 102 healthy term Slovak infants. The correlation between total serum bilirubin and transcutaneous bilirubin was significant (coefficient of determination R2: 0.9045 forehead, 0.8808 sternum, 0.8467 abdomen). Transcutaneous measurements underestimated serum bilirubin levels significantly when total serum bilirubin values were higher than 15 mg/dL, irrespective of the site of transcutaneous measurements. The lowest mean difference between total serum bilirubin and transcutaneous bilirubin was identified on the sternum (median: -1.1 mg/dL). The area under the curve was >0.97 and >0.93 for detecting total serum bilirubin levels >10 mg/dL and >13 mg/dL, respectively, for all measurement sites. Transcutaneous measurements on the forehead and sternum provided very high sensitivity, with the best performance at the forehead. Conclusion Transcutaneous bilirubinometry using an enhanced device is an accurate, sensitive, and convenient screening method in term Caucasian neonates. Transcutaneous bilirubin measurements on the forehead, sternum, and abdomen are reliable, with the best performance on the forehead. It is necessary to confirm higher transcutaneous bilirubin values with a total serum bilirubin measurement.
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15
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Lai NM, Gerard JP, Ngim CF, Kamar AA, Chen KH. The Association between Serum Bilirubin and Kernicterus Spectrum Disorder: A Systematic Review and Meta-Analysis. Neonatology 2021; 118:654-664. [PMID: 34731859 DOI: 10.1159/000519497] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 09/07/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Total serum bilirubin (TSB) is used in managing neonates with jaundice, but clear evidence on its association with major outcomes is lacking. OBJECTIVES We evaluated the association between TSB and kernicterus spectrum disorder (KSD). METHODS We searched PubMed, EMBASE, and CENTRAL till July 2021. Two authors independently selected relevant cohort studies, extracted data (CHARMS checklist), assessed risk of bias (RoB) (QUIPS tool), and rated certainty-of-evidence (Grades of Recommendation, Assessment, Development, and Evaluation). We pooled adjusted odds ratio (aOR) (random-effect) via generic inverse variance methods. RESULTS From 2,826 records retrieved, we included 37 studies (n = 648,979). Fifteen studies had low, 16 moderate, and 6 high RoB, with majority having concerns on confounder adjustment and statistical analysis. Twenty-two studies contributed meta-analysis data, and 15 were summarized narratively. TSB appears associated with KSD in infants with certain risk factors (aOR 1.10, 95% CI: 1.07-1.13; 5 studies [n = 4,484]). However, TSB (aOR 1.10, 95% CI: 0.98-1.23; 1 study [n = 34,533]) or hyperbilirubinemia (aOR 1.00, 95% CI: 0.51-1.95; 2 studies [n = 56,578]) have no clear association with kernicterus or neurological diagnosis in overall neonatal population (moderate-certainty-evidence). One study shows that infants with hyperbilirubinemia appear likelier to develop attention-deficit disorder (aOR 1.90, 95% CI: 1.10-3.28) and autistic spectrum disorder (aOR 1.60, 95% CI: 1.03-2.49, n = 56,019) (low-certainty-evidence). Certain clinical factors appear associated with KSD, although very few studies contributed to the analyses. CONCLUSIONS Despite the importance of this question, there is insufficient high-quality evidence on the independent prognostic value of TSB for adverse neurodevelopmental outcomes in most neonatal populations. Future studies should incorporate all known risk factors alongside TSB in a multivariable analysis to improve certainty-of-evidence.
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Affiliation(s)
- Nai Ming Lai
- School of Medicine, Faculty of Health and Medical Sciences, Taylor's University, Subang Jaya, Malaysia.,School of Pharmacy, Monash University, Subang Jaya, Malaysia
| | - Joanna Priya Gerard
- Department of Paediatrics, The University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Chin Fang Ngim
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University, Subang Jaya, Malaysia
| | - Azanna Ahmad Kamar
- Department of Paediatrics, The University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Kee-Hsin Chen
- Post-Baccalaureate Program in Nursing, College of Nursing and Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan.,Center for Nursing and Healthcare Research in Clinical Practice Application, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,Evidence-based Knowledge Translation Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
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16
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Validation of a neonatal skin color scale. Eur J Pediatr 2020; 179:1403-1411. [PMID: 32157460 DOI: 10.1007/s00431-020-03623-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 02/20/2020] [Accepted: 02/25/2020] [Indexed: 10/24/2022]
Abstract
Ethnic classification does not correlate well with skin tone. As there are no neonatal skin color scales, we aimed to create and validate one of our own. After creating the scale and briefly training our staff, we conducted a prospective, observational study to assess reproducibility and correlation of each scale color with the melanin and erythema indexes and transcutaneous bilirubin. The reliability of our color scale was measured using Kappa agreement (and its 95% confidence interval) and the concordance index by comparing inter-observer classification of neonatal skin color. We also calculated inter-rater agreement with the intraclass correlation coefficient (ICC). The Kendall tau-b correlation coefficient was used to test the correlation between our color scale and the Mexameter® MX 18. We obtained data from 258 newborns. Inter-observer agreement on color assignment was 83.2%. Median melanin index was significantly different among the 4 color groups, whereas erythema index and transcutaneous bilirubin were not.Conclusions: Our proposed neonatal skin color scale correlates well with the melanin index at 24 h of life, increasing from colors 1 to 4, and the only chromophore different among our four color groups is melanin. Scale color assignment is reproducible. Therefore, it can be used to classify neonatal skin color. Further research is warranted to assess the clinical relevance of these findings. What is known: • Classifying neonates by skin color is difficult because to date there are no skin color scales available based on real skin tone regardless of ethnicity or country of origin. • Skin color differs among individuals from a given ethnic group and depends, among others, on melanin and hemoglobin. What is new: • We created a neonatal skin color scale based on real skin color. • We conducted a study to validate it, and confirmed a good inter-observer agreement in color assignment as well as a good correlation between each color in the scale and the median melanin level.
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17
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Large scale validation of a new non-invasive and non-contact bilirubinometer in neonates with risk factors. Sci Rep 2020; 10:11149. [PMID: 32636410 PMCID: PMC7341797 DOI: 10.1038/s41598-020-67981-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 06/11/2020] [Indexed: 11/08/2022] Open
Abstract
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.
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18
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Rana N, Ranneberg LJ, Målqvist M, KC A, Andersson O. Delayed cord clamping was not associated with an increased risk of hyperbilirubinaemia on the day of birth or jaundice in the first 4 weeks. Acta Paediatr 2020; 109:71-77. [PMID: 31240753 DOI: 10.1111/apa.14913] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 03/28/2019] [Accepted: 06/24/2019] [Indexed: 12/29/2022]
Abstract
AIM Our aim was to investigate the effects of timing of cord clamping on the risk of hyperbilirubinaemia. METHODS We recruited 540 normal vaginal deliveries at the Paropakar Maternity and Women's Hospital in Kathmandu, Nepal, from October 2 to November 21, 2014. They were randomised into two groups: 257/270 were cord clamped within 60 seconds and 209/270 after 180 seconds. Transcutaneous bilirubin was measured at discharge and 24 hours. At 4 weeks, 506 mothers were successfully contacted by phone, and the health status of the baby and their history of jaundice and treatment was recorded. RESULTS Based on transcutaneous bilirubin at discharge, 22/261 (8.4%) in the early group and 25/263 (9.5%) in the delayed group (P = 0.76) were at high risk of subsequent hyperbilirubinemia. At the 4-week follow-up, jaundice was reported in 13/253 (5.1%) in the early and 17/253 (6.7%) in the delayed group (P = 0.57) and 3/253 (1.2 %) of the early and 1/253 (0.4%) of the delayed group (P = 0.62) received treatment. All analyses were based on intention-to-treat. CONCLUSION Delayed cord clamping was not associated with an increased risk of hyperbilirubinaemia during the first day of life or risk of jaundice within 4 weeks compared with the early group.
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Affiliation(s)
- Nisha Rana
- International Maternal and Child Health, Department of Women’s and Children’s Health Uppsala University Uppsala Sweden
| | | | - Mats Målqvist
- International Maternal and Child Health, Department of Women’s and Children’s Health Uppsala University Uppsala Sweden
| | - Ashish KC
- International Maternal and Child Health, Department of Women’s and Children’s Health Uppsala University Uppsala Sweden
- Health Section UNICEF, UN House Lalitpur Nepal
| | - Ola Andersson
- Department of Clinical Sciences Lund, Pediatrics/Neonatology, Skåne University Hospital Lund University Lund Sweden
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19
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Yang ST, Liu FC, Chen HL. Comparison of transcutaneous and serum bilirubin before, under, and after phototherapy in term and late-preterm infants. Kaohsiung J Med Sci 2019; 35:715-724. [PMID: 31436020 DOI: 10.1002/kjm2.12121] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 07/17/2019] [Indexed: 11/08/2022] Open
Abstract
This study aimed to determine the correlation of transcutaneous bilirubin (TcB) with total serum bilirubin (TSB) in infants receiving phototherapy and the accuracy of TcB for deciding the time to discontinue phototherapy. Paired TcB and TSB levels were assessed in 52 term and 56 late-preterm infants receiving phototherapy. TcB was measured in the unexposed skin of the middle forehead using a noninvasive bilirubin analyzer, BiliChek. TSB was measured every morning, and TcB was measured 2 hours after TSB measurements. Bland-Altman plots, linear regression, multivariate pair wise correlation, and receiver operating characteristic curve (ROC) analyses were performed. Bland-Altman plots before, under, and 24 hours after phototherapy in term and late-preterm infants revealed that TcB and TSB have higher consistency. TcB and TSB showed positive linear correlation before, under, and after phototherapy in both infant groups. In the multivariate pair wise correlations, differences between TcB and TSB were negatively correlated with phototherapy duration in term (correlation coefficient = -0.233, P value = .001) and late-preterm (correlation coefficient = -0.198, P value = .002) infants. Cutoff levels of TcB for discontinuing phototherapy based on the ROC analysis were 13.8 (sensitivity of 90%, specificity of 84%, area under the curve [AUC] 0.94) and 11.8 mg/dL (sensitivity of 84%, specificity of 88%, AUC 0.92) in term and late-preterm infants, respectively. TcB and TSB before, under, and after phototherapy in both term and late-preterm infants showed good correlation and higher consistency with jaundice. To reduce repetitive blood sampling for TSB, TcB measurement may be a reliable method for term and late-preterm infants undergoing phototherapy.
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Affiliation(s)
- Shu-Ting Yang
- Division of Neonatology, Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Fen-Chen Liu
- Department of Nursing, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hsiu-Lin Chen
- Division of Neonatology, Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Respiratory Therapy, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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20
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Castro A, Zozaya C, Cuesta MT, González M, Villar G, Alcaraz A. Usefulness of transcutaneous bilirubin assessment measured in non-photo-exposed skin to guide the length of phototherapy: an observational study. J Perinat Med 2019; 47:568-573. [PMID: 30998502 DOI: 10.1515/jpm-2018-0429] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Accepted: 03/26/2019] [Indexed: 11/15/2022]
Abstract
Background Transcutaneous bilirubinometers are a non-invasive tool to estimate serum bilirubin. However, once on phototherapy (PHT) and after PHT, its usefulness is precluded. The objective of this study was to prove the hypothesis that transcutaneous bilirubin (TcB) assessment in a covered skin area during PHT could be used to guide the duration of PHT in term and moderate-late preterm infants with non-isoimmune hyperbilirubinemia. Methods A small area of parasternal skin was covered before starting on PHT. Total serum and TcB (both in exposed and non-exposed areas) were determined before starting treatment, every 12 h once on PHT and 12 h after its discontinuation. Pearson's correlation coefficient and paired mean differences between TcB and total serum bilirubin (TSB) were calculated. Bland-Altman plots were obtained. The percentage of correct treatment decisions made based on non-exposed TcB values was calculated. Results During PHT, there was a relatively good correlation between TSB and non-exposed TcB (0.74) estimates, in contrast to exposed TcB estimates (0.52). However, even when comparing non-exposed TcB with TSB, there was a wide range of agreement limits (-3.8 to 4.6 mg/dL). Decisions based on non-exposed TcB values would have been incorrect in 26.6% of the cases. Conclusion Although there is a relatively strong correlation between total serum and TcB in non-PHT-exposed regions, the difference is not narrow enough to be utilized in guiding clinical decisions on the duration of PHT.
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Affiliation(s)
- Abdón Castro
- Neonatal Unit, Paediatric Service, Hospital Universitario de Getafe, Carretera Madrid - Toledo, Km 12,500, 28905 Getafe, Madrid, Spain
| | - Carlos Zozaya
- Neonatal Unit, Paediatric Service, Hospital Universitario de Getafe, Carretera Madrid - Toledo, Km 12,500, 28905 Getafe, Madrid, Spain
| | - Mª Teresa Cuesta
- Neonatal Unit, Paediatric Service, Hospital Universitario de Getafe, Carretera Madrid - Toledo, Km 12,500, 28905 Getafe, Madrid, Spain
| | - Marina González
- Neonatal Unit, Paediatric Service, Hospital Universitario de Getafe, Carretera Madrid - Toledo, Km 12,500, 28905 Getafe, Madrid, Spain
| | - Gema Villar
- Neonatal Unit, Paediatric Service, Hospital Universitario de Getafe, Carretera Madrid - Toledo, Km 12,500, 28905 Getafe, Madrid, Spain
| | - Andrés Alcaraz
- Neonatal Unit, Paediatric Service, Hospital Universitario de Getafe, Carretera Madrid - Toledo, Km 12,500, 28905 Getafe, Madrid, Spain
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21
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van der Geest BAM, de Graaf JP, Bertens LCM, Poley MJ, Ista E, Kornelisse RF, Reiss IKM, Steegers EAP, Been JV. Screening and treatment to reduce severe hyperbilirubinaemia in infants in primary care (STARSHIP): a factorial stepped-wedge cluster randomised controlled trial protocol. BMJ Open 2019; 9:e028270. [PMID: 31005942 PMCID: PMC6500291 DOI: 10.1136/bmjopen-2018-028270] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
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.
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Affiliation(s)
- Berthe A M van der Geest
- Division of Neonatology, Department of Paediatrics, Erasmus MC - Sophia Children's Hospital, University Medical Centre Rotterdam, Rotterdam, Netherlands
- Department of Obstetrics and Gynaecology, Erasmus MC - Sophia Children's Hospital, University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Johanna P de Graaf
- Department of Obstetrics and Gynaecology, Erasmus MC - Sophia Children's Hospital, University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Loes C M Bertens
- Department of Obstetrics and Gynaecology, Erasmus MC - Sophia Children's Hospital, University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Marten J Poley
- Medical Technology Assessment (iMTA), Erasmus University Rotterdam, Rotterdam, Netherlands
- Paediatric Intensive Care Unit, Department of Paediatrics, Erasmus MC - Sophia Childen's Hospital, University Medical Centre Rotterdam, Rotterdam, Netherlands
- Paediatric Surgery, Erasmus MC - Sophia Children's Hospital, University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Erwin Ista
- Paediatric Intensive Care Unit, Department of Paediatrics, Erasmus MC - Sophia Childen's Hospital, University Medical Centre Rotterdam, Rotterdam, Netherlands
- Nursing Science, Department of Internal Medicine, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - René F Kornelisse
- Division of Neonatology, Department of Paediatrics, Erasmus MC - Sophia Children's Hospital, University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Irwin K M Reiss
- Division of Neonatology, Department of Paediatrics, Erasmus MC - Sophia Children's Hospital, University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Eric A P Steegers
- Department of Obstetrics and Gynaecology, Erasmus MC - Sophia Children's Hospital, University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Jasper V Been
- Division of Neonatology, Department of Paediatrics, Erasmus MC - Sophia Children's Hospital, University Medical Centre Rotterdam, Rotterdam, Netherlands
- Department of Obstetrics and Gynaecology, Erasmus MC - Sophia Children's Hospital, University Medical Centre Rotterdam, Rotterdam, Netherlands
- Department of Public Health, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands
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Cayabyab R, Ramanathan R. High unbound bilirubin for age: a neurotoxin with major effects on the developing brain. Pediatr Res 2019; 85:183-190. [PMID: 30518884 DOI: 10.1038/s41390-018-0224-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 10/15/2018] [Accepted: 10/17/2018] [Indexed: 01/30/2023]
Abstract
Neonatal hyperbilirubinemia is one of the most frequent diagnoses made in neonates. A high level of unconjugated bilirubin that is unbound to albumin is neurotoxic when the level exceeds age-specific thresholds or at lower levels in neonates with neurotoxic risk factors. Lower range of unbound bilirubin results in apoptosis, while moderate-to-high levels result in neuronal necrosis. Basal ganglia and various brain stem nuclei are more susceptible to bilirubin toxicity. Proposed mechanisms of bilirubin-induced neurotoxicity include excessive release of glutamate, mitochondrial energy failure, release of proinflammatory cytokines, and increased intracellular calcium concentration. These mechanisms are similar to the events that occur following hypoxic-ischemic insult in neonates. Severe hyperbilirubinemia in term neonates has been shown to be associated with increased risk for autism spectrum disorders. The neuropathological finding of bilirubin-induced neurotoxicity also includes cerebellar injury with a decreased number of Purkinje cells, and disruption of multisensory feedback loop between cerebellum and cortical neurons which may explain the clinical characteristics of autism spectrum disorders. Severe hyperbilirubinemia occurs more frequently in infants from low- and middle-income countries (LMIC). Simple devices to measure bilirubin, and timely treatment are essential to reduce neurotoxicity, and improve outcomes for thousands of neonates around the world.
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Affiliation(s)
- Rowena Cayabyab
- Keck School of Medicine of University of Southern California, Division of Neonatology, Department of Pediatrics, LAC+USC Medical Center, Los Angeles, CA, USA
| | - Rangasamy Ramanathan
- Keck School of Medicine of University of Southern California, Division of Neonatology, Department of Pediatrics, LAC+USC Medical Center, Los Angeles, CA, USA.
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Transcutaneous bilirubinometer use and practices surrounding jaundice in 150 California newborn intensive care units. J Perinatol 2018; 38:1532-1535. [PMID: 30120424 DOI: 10.1038/s41372-018-0154-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 04/10/2018] [Accepted: 05/17/2018] [Indexed: 11/09/2022]
Abstract
OBJECTIVES Transcutaneous bilirubin measurements (TcBs) provide a noninvasive method for screening infants for hyperbilirubinemia and have been used extensively in term and late preterm newborns in well baby nurseries, offices, and outpatient clinics. Several studies have also demonstrated the utility of TcBs as a screening tool for infants > 28 weeks' gestation and their ability to reduce the need for blood sampling. The objectives of this study are to identify how often TcBs are used among California Newborn Intensive Care Units (NICUs) in preterm, late preterm and term infants, and other aspects of jaundice management. METHODS We conducted a survey on TcB use and practices relating to jaundice management in 150 California NICUs between April and October 2016. RESULTS TcB screening is routinely used in 28% (42/150) of NICUs. Only 7% (11/150) of NICUs use TcB in preterm infants < 28 weeks. Practice varied similarly across NICU levels of care. Among the subset of NICUs that responded to questions related to phototherapy and screening practices, prophylactic phototherapy was used in 38% (23/59) and 90% (55/61) screened for glucose-6-phosphate dehydrogenase deficiency based on race, ethnicity, and/or family history. CONCLUSION(S) Despite studies validating the accuracy of TcB in preterm infants > 28 weeks, only 28% of California NICUs routinely use TcB devices. TcB screening in infants < 28 weeks gestation is not widely used and no recommendation can be made in this regard until there is more experience with its application using a standardized protocol in these infants and on a large scale.
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Ngashangva L, Bachu V, Goswami P. Development of new methods for determination of bilirubin. J Pharm Biomed Anal 2018; 162:272-285. [PMID: 30273817 DOI: 10.1016/j.jpba.2018.09.034] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 09/11/2018] [Accepted: 09/16/2018] [Indexed: 02/06/2023]
Abstract
The ever-increasing demand for a sensitive, rapid and reliable method for determination of serum bilirubin level has been inciting the interest of the researchers to develop new methods for both laboratory set up and point of care applications. These efforts embrace measurement of different forms of bilirubin, such as, unconjugated (free and albumin bound) bilirubin, conjugated (direct) bilirubin, and total (both conjugated and unconjugated) bilirubin in the serum that may provide critical information useful for diagnosis of many diseases and metabolic disorders. Herein, an effort has been made to provide a broad overview on the subject starting from the conventional spectroscopy based analytical methods widely practiced in the laboratory setup along with the sophisticated instrument based sensitive methods suitable for determination of different forms of bilirubin to various portable low cost systems applicable in point of care (POC) settings. In all these discussions emphasis is given on the novel methods and techniques bearing potential to measure the bilirubin level in biological samples reliably with less technical complexity and cost. We expect that this review will serve as a ready reference for the researchers and clinical professionals working on the subject and allied fields.
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Affiliation(s)
- Lightson Ngashangva
- Department of Biosciences and Bioengineering, Indian Institute of Technology Guwahati, Guwahati, Assam, 781039, India
| | - Vinay Bachu
- Department of Biosciences and Bioengineering, Indian Institute of Technology Guwahati, Guwahati, Assam, 781039, India
| | - Pranab Goswami
- Department of Biosciences and Bioengineering, Indian Institute of Technology Guwahati, Guwahati, Assam, 781039, India.
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Neonatal hyperbilirubinaemia: a global perspective. THE LANCET CHILD & ADOLESCENT HEALTH 2018; 2:610-620. [DOI: 10.1016/s2352-4642(18)30139-1] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 04/13/2018] [Accepted: 04/20/2018] [Indexed: 02/07/2023]
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Chokemungmeepisarn P, Tantiprabha W, Kosarat S, Manopunya S. Accuracy of the Bilicare™ transcutaneous bilirubinometer as the predischarge screening tool for significant hyperbilirubinemia in healthy term and late preterm neonates. J Matern Fetal Neonatal Med 2018; 33:57-61. [PMID: 29860925 DOI: 10.1080/14767058.2018.1484098] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Background: The Bilicare™ is a new device that measures transcutaneous bilirubin (TcB) level at the ear pinna. There are only few studies which have evaluated its accuracy in clinical practice.Objective: This study aims to determine the accuracy of Bilicare™ as a predischarge screening tool in late preterm and term neonates and to define the optimal cutoff point for determining the need to measure total serum bilirubin (TSB).Methods: The 35 weeks' gestation or more and healthy neonates who underwent predischarge TSB measurement were enrolled. Bilicare™ TcB was measured within 30 minutes of blood sampling. Paired TcB and TSB data were analyzed.Results: We collected 214 paired samples. Mean age (SD) at TcB measurement was 57.17 (7.47) hours. Mean TSB (SD) was 9.79 (2.83) mg/dL. TcB showed a significant correlation with TSB (r = 0.84, r2 = 0.7). The mean difference (SD) between TcB and TSB was 0.7 (0.21) mg/dL (95%CI 0.49-0.91). TcB tended to overestimate TSB level at the TSB values of <12 mg/dL but underestimate at the higher TSB level. The accuracy of using TcB values to detect neonates who required phototherapy was 92.5%. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 78.3, 94.2, 62.1, and 97.3%, respectively. If TcB +3 mg/dL was applied as a cutoff point, the sensitivity, specificity, PPV, and NPV were 100, 53.9, 20.7, and 100%, respectively.Conclusions: Bilicare™ TcB and TSB measurements were well correlated. The TcB level +3 mg/dL could detect all neonates who had significant hyperbilirubinemia requiring phototherapy during their birth hospitalization.
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Affiliation(s)
| | - Watcharee Tantiprabha
- Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Shanika Kosarat
- Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Satit Manopunya
- Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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27
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Affiliation(s)
- Debra H Pan
- Division of Pediatric Gastroenterology and Nutrition, The Children's Hospital at Montefiore, Bronx, NY
| | - Yolanda Rivas
- Division of Pediatric Gastroenterology and Nutrition, The Children's Hospital at Montefiore, Bronx, NY
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Jones DF, McRea AR, Knowles JD, Lin FC, Burnette E, Reller LA, Lohr JA. A Prospective Comparison of Transcutaneous and Serum Bilirubin Within Brief Time Intervals. Clin Pediatr (Phila) 2017; 56:1013-1017. [PMID: 28366015 DOI: 10.1177/0009922817701170] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Denise F Jones
- 1 North Carolina Children's Hospital, Chapel Hill, NC, USA
| | | | | | - Feng-Chang Lin
- 1 North Carolina Children's Hospital, Chapel Hill, NC, USA
| | - Erin Burnette
- 1 North Carolina Children's Hospital, Chapel Hill, NC, USA
| | - Lara A Reller
- 1 North Carolina Children's Hospital, Chapel Hill, NC, USA
| | - Jacob A Lohr
- 1 North Carolina Children's Hospital, Chapel Hill, NC, USA.,2 University of North Carolina at Chapel Hill, NC, USA
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De Luca D, Dell'Orto V. Patched Skin Bilirubin Assay to Monitor Neonates Born Extremely Preterm Undergoing Phototherapy. J Pediatr 2017; 188:122-127. [PMID: 28662949 DOI: 10.1016/j.jpeds.2017.05.080] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Revised: 05/08/2017] [Accepted: 05/31/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To verify the reliability and safety of transcutaneous bilirubin (TcB) measurements in patched skin areas in neonates born extremely preterm under phototherapy. STUDY DESIGN Sixty neonates (<30 weeks' gestation) receiving phototherapy were enrolled and TcB was measured via a second-generation transcutaneous bilirubinometer in patched skin areas (of at least 2.5 cm diameter). Total serum bilirubin (TSB), lactate, pH, hemoglobin, and skin temperature were measured within 10 minutes of the TcB assay. Clinicians were blinded to TcB values, and clinical decisions about phototherapy were made with the TSB measurement only. RESULTS TcB and TSB significantly were correlated (r = 0.84; P <.001), even after adjustment for hemoglobin, pH, lactate, gestational and postnatal age (standardized β = 0.8; P <.001; adjusted R2 = 0.75), or treatment duration (standardized β = 0.8; P <.001; adjusted R2 = 0.7). When the Bland-Altman analysis was used, TcB overestimated TSB at high values (mean difference TSB - TcB: -2.8 [2.4] mg/dL). If clinicians used the TcB only, no neonate would have had phototherapy stopped prematurely, and 21 (35%) would have continued phototherapy when it could have been stopped. CONCLUSIONS The correlation between TSB and TcB (measured in patched skin areas) was comparable with that obtained in more mature neonates, and it was not influenced by clinical variables or factors affecting skin bilirubin passage. TcB overestimated TSB, and this may expose infants born preterm to unnecessary phototherapy, although it could spare approximately 65% of TSB assays.
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Affiliation(s)
- Daniele De Luca
- Division of Pediatrics and Neonatal Critical Care, "A. Béclère" Medical Center, South Paris University Hospitals, AP-HP and South Paris-Saclay University, Paris, France.
| | - Valentina Dell'Orto
- Division of Pediatrics and Neonatal Critical Care, "A. Béclère" Medical Center, South Paris University Hospitals, AP-HP and South Paris-Saclay University, Paris, France
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Olusanya BO, Mabogunje CA, Imosemi DO, Emokpae AA. Transcutaneous bilirubin nomograms in African neonates. PLoS One 2017; 12:e0172058. [PMID: 28192492 PMCID: PMC5305223 DOI: 10.1371/journal.pone.0172058] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 01/30/2017] [Indexed: 12/19/2022] Open
Abstract
Background The use of transcutaneous bilirubin (TcB) as a screening tool, based on relevant population-specific nomogram, or proxy for total serum bilirubin (TSB) levels in assessing the risk of subsequent hyperbilirubinemia is supported by several clinical guidelines on the management of neonatal hyperbilirubinemia. However, while TcB has been found to significantly over-estimate TSB in neonates of African-American ancestry, with variations across TcB devices, no nomogram has been specifically reported for this racial group. This study therefore set out to develop TcB nomograms for healthy late pre-term and term black African neonates derived from two widely used bilirubinometers. Methods A retrospective analysis of 12,377 TcB measurements obtained from 6,373 neonates in the first postnatal week, over a period of 48 months using Bilichek and JM-103 bilirubinometers. TcB percentiles were computed from hour-specific TcB values and nomograms developed for each of the screening devices. Predictive ability of the 75th and 95th percentiles to detect significant hyperbilirubinemia was evaluated between 24–96 hours of age. The 95th percentile curve was compared with those from other populations. Results The velocity of TcB rise at 75th and 95th percentiles was generally higher with JM-103 than Bilichek. Both percentiles also peaked at higher TcB levels with JM-103. The 95th percentile for both instruments showed a downward trend as from approximately 114 hours. Both instruments had high negative predictive values across the selected time-epochs and lower discriminatory ability than reported in non-black populations. Conclusions The predictive utility of TcB as a potential screening tool varies across devices in black African neonates with or without risk of significant hyperbilirubinemia, and lower than levels reported in non-black populations. Equipment-specific nomograms should be considered for TcB monitoring in this racial population where TSB is not routinely available.
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Olusanya BO, Emokpae AA. Use of Transcutaneous Bilirubin to Determine the Need for Phototherapy in Resource-Limited Settings. Neonatology 2017; 111:324-330. [PMID: 28073104 DOI: 10.1159/000452788] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 10/22/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Routine and timely determination of total serum bilirubin (TSB) remains a challenge in many resource-limited countries with substantial burden of severe neonatal hyperbilirubinemia. Limited evidence exists on the potential usefulness of transcutaneous bilirubin (TcB) to identify infants who may require phototherapy based on possible treatment criteria in such settings. OBJECTIVE To compare the number of infants requiring phototherapy across different TSB criteria and determine the predictive performance of TcB under each criterion. METHODS Infants with paired TcB and TSB measurements in a maternity hospital in Lagos, Nigeria, were assessed for phototherapy based on TSB criteria by the American Academy of Pediatrics (AAP), National Institute for Health and Clinical Excellence (NICE) UK, and World Health Organization (WHO), and an absolute threshold of ≥12 mg/dL. The predictive performance of TcB across treatment criteria was evaluated with receiver operating curve analysis. RESULTS A total of 1,011 infants with a mean TcB of 10.54 ± 3.19 (range: 2.7-19.9) mg/dL and TSB of 9.63 ± 2.61 (range: 0.3-19.5) mg/dL were assessed. Some 60 (5.9%) infants required phototherapy by 1 or more TSB criteria, with TSB ≥12 mg/dL identifying 55 (91.7%) and AAP 27 (45%) of these infants. All infants identified by the NICE and WHO criteria were equally detected by the AAP criterion. TcB showed negative predictive values of 99.0-99.9%, and positive predictive values of 7.7-15.5% across all criteria. CONCLUSIONS The number of infants requiring phototherapy varies significantly across treatment criteria. TcB may be useful in identifying infants who do not require phototherapy, but may also identify a high proportion of false positives that is burdensome in resource-limited settings.
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van den Esker-Jonker B, den Boer L, Pepping RMC, Bekhof J. Transcutaneous Bilirubinometry in Jaundiced Neonates: A Randomized Controlled Trial. Pediatrics 2016; 138:peds.2016-2414. [PMID: 27940715 DOI: 10.1542/peds.2016-2414] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/01/2016] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
| | - Lieve den Boer
- Department of Pediatrics, Amalia Children's Clinic, Isala, Zwolle, Netherlands
| | - Rianne M C Pepping
- Department of Pediatrics, Amalia Children's Clinic, Isala, Zwolle, Netherlands
| | - Jolita Bekhof
- Department of Pediatrics, Amalia Children's Clinic, Isala, Zwolle, Netherlands
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Accuracy of transcutaneous bilirubin measurement in newborns after phototherapy. J Perinatol 2016; 36:858-61. [PMID: 27279078 DOI: 10.1038/jp.2016.91] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 04/29/2016] [Accepted: 05/04/2016] [Indexed: 11/08/2022]
Abstract
OBJECTIVE We tested the accuracy of transcutaneous bilirubin (TcB) measure in newborns undergoing phototherapy. STUDY DESIGN In a prospective study of 150 term Caucasian neonates, 255 measurements of total serum bilirubin (TSB) and TcB concentration were obtained 2 h after discontinuing phototherapy. TcB measurements obtained on the forehead, sternum, abdomen and covered lower abdomen were statistically compared with the corresponding TSB. RESULT TcB consistently underestimated TSB levels significantly. The smallest but significant difference between TSB and TcB was found on the lower abdomen. The correlation between TSB and TcB was found to be moderately close (r=0.4 to 0.5). TcB measurements were inaccurate, regardless of phototherapy technique (Bilibed, conventional phototherapy). CONCLUSION Phototherapy significantly interferes with the accuracy of transcutaneous bilirubinometry. TcB measurements performed 2 h after stopping phototherapy were not reliable, even if they were carried out on the unexposed body area. TSB assessment remains necessary, if treatment of hyperbilirubinemia is being considered.
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Olusanya BO, Imosemi DO, Emokpae AA. Differences Between Transcutaneous and Serum Bilirubin Measurements in Black African Neonates. Pediatrics 2016; 138:peds.2016-0907. [PMID: 27577578 DOI: 10.1542/peds.2016-0907] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/30/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Transcutaneous bilirubin (TcB) correlates positively with total serum bilirubin (TSB) across different racial populations. However, little is known about the pattern of divergence between TcB and TSB at individual patient-level and the relationship with TcB measuring techniques among African neonates. This study, therefore, investigates TcB-TSB discrepancies and the contribution of 2 models of transcutaneous bilirubinometers to the observed divergence in a black African population. METHODS Medical records were retrieved for late preterm and term infants with 1 to 3 pairs of TcB and TSB measurements between December 2011 to June 2015 in Nigeria. Divergence between TcB and TSB values for each infant was determined and the associated factors explored with generalized estimating equations for logistic regression. Contributions of BiliChek and JM-103 transcutaneous bilirubinometers to the divergence were further explored through linear regression and Bland-Altman analysis. RESULTS Overall, 2107 TcB/TSB measurements from 1553 infants were analyzed. TSB was overestimated by ≥2 mg/dL in 64.5%, ≥3 mg/dL in 42.7%, and ≥4 mg/dL in 25.7% of all measurements. In contrast, TSB was underestimated by ≥2 mg/dL in 1.1%, ≥3 mg/dL in 0.5%, and ≥4 mg/dL in 0.3% of all recordings. Postnatal age, feeding mode, and type of TcB instrument were predictive of TSB overestimation. The JM-103 was associated with greater imprecision than BiliChek at all TSB levels. CONCLUSIONS BiliChek and JM-103 bilirubinometers significantly overestimate TSB in black African neonates and may result in unnecessary or excessive treatments. Additional development of appropriate bilirubin determination devices for this racial group, especially in resource-limited settings, is warranted.
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A decision-making tool for exchange transfusions in infants with severe hyperbilirubinemia in resource-limited settings. J Perinatol 2016; 36:338-41. [PMID: 26938921 DOI: 10.1038/jp.2016.25] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 01/18/2016] [Accepted: 01/26/2016] [Indexed: 11/08/2022]
Abstract
Late presentation and ineffective phototherapy account for excessive rates of avoidable exchange transfusions (ETs) in many low- and middle-income countries. Several system-based constraints sometimes limit the ability to provide timely ETs for all infants at risk of kernicterus, thus necessitating a treatment triage to optimize available resources. This article proposes a practical priority-setting model for term and near-term infants requiring ET after the first 48 h of life. The proposed model combines plasma/serum bilirubin estimation, clinical signs of acute bilirubin encephalopathy and neurotoxicity risk factors for predicting the risk of kernicterus based on available evidence in the literature.
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Kurokawa D, Nakamura H, Yokota T, Iwatani S, Morisawa T, Katayama Y, Sakai H, Ioroi T, Iijima K, Morioka I. Screening for Hyperbilirubinemia in Japanese Very Low Birthweight Infants Using Transcutaneous Bilirubinometry. J Pediatr 2016; 168:77-81.e1. [PMID: 26410797 DOI: 10.1016/j.jpeds.2015.08.038] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 07/21/2015] [Accepted: 08/13/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To assess the accuracy of transcutaneous bilirubin (TcB) measurements at 5 different body sites in Japanese very low birthweight (VLBW) infants and to determine a cut-off value of TcB to detect total serum/plasma bilirubin (TB) levels ≥10 mg/dL (171 μM). STUDY DESIGN In a prospective multicenter study, 85 Japanese VLBW infants were enrolled from 5 neonatal intensive care units during the study period. A total of 383 blood samples from infants not receiving phototherapy or ≥24 hours postphototherapy were analyzed. TcB was measured at the forehead, sternum, upper back, lower abdomen, and waist within 1 hour of blood collection. Linear regression analysis and Bland-Altman plots were used to compare TcB values at each site with TB levels. The TcB cut-off value for detecting TB ≥10 mg/dL was determined by receiver operating characteristics curve analysis. RESULTS TcB significantly correlated with TB, but the coefficient of determination varied among the sites (forehead: 0.5294, sternum: 0.6488, upper back: 0.6321, lower abdomen: 0.5430, waist: 0.7396). At a TcB value ≥8, the sensitivity was 100% at the sternum and upper back, 85% at the waist, 84% at the forehead, and 64% at the lower abdomen to detect TB ≥10 mg/dL. CONCLUSIONS In Japanese VLBW infants, the accuracy of TcB measurements varies according to body site. TcB ≥8 on the sternum or upper back is more reliable than that on the forehead, lower abdomen, or waist to detect TB levels ≥10 mg/dL.
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Affiliation(s)
- Daisuke Kurokawa
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hajime Nakamura
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Tomoyuki Yokota
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan; Department of Pediatrics, Kakogawa West Municipal Hospital, Kakogawa, Japan
| | - Sota Iwatani
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takeshi Morisawa
- Department of Pediatrics, Kakogawa West Municipal Hospital, Kakogawa, Japan
| | | | - Hitomi Sakai
- Department of Neonatology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Tomoaki Ioroi
- Department of Pediatrics, Japanese Red Cross Society Himeji Hospital, Himeji, Japan
| | - Kazumoto Iijima
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Ichiro Morioka
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan.
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Akahira-Azuma M, Yonemoto N, Mori R, Hosokawa S, Matsushita T, Sukhbat K, Nansal G, Bavuusuren B, Shonkhuuz E. An hour-specific transcutaneous bilirubin nomogram for Mongolian neonates. Eur J Pediatr 2015; 174:1299-304. [PMID: 25869495 PMCID: PMC4575357 DOI: 10.1007/s00431-015-2536-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 03/29/2015] [Accepted: 04/01/2015] [Indexed: 11/26/2022]
Abstract
UNLABELLED Transcutaneous bilirubin (TcB) nomograms have been developed for different populations. However, the TcB level, rate of rise and peak varies among countries and ethnicities. The aim of this study was to establish an hour-specific TcB nomogram for healthy term and late preterm Mongolian neonates during the first 144 h after birth. A total of 5084 TcB measurements from 1297 healthy neonates (gestational age ≥35 weeks, birth weight ≥2000 g) were obtained from October 2012 to October 2013. All measurements were performed using the Jaundice Meter, the JM-103 at 6 to 144 postnatal hours. Mongolian infants had the following characteristics: 27.1 % were delivered by cesarean section, 17.8 % had a birth weight >4000 g, and >90 % were being breastfed. TcB percentiles for each designated time point were calculated for the development of an hour-specific nomogram. TcB levels increased most rapidly in the first 24 h and less rapidly from 24 to 78 h, reaching a plateau after 78 h for the 50th percentile. TcB levels of Mongolian neonates for each time point were higher than those of previous studies. CONCLUSION The higher values of the TcB nomogram for Mongolian neonates may be due to their Asian ethnicity and exclusive breastfeeding. WHAT IS KNOWN • TcB nomograms for neonatal jaundice screening have been established for many countries and ethnicities. The pattern of the TcB nomogram varies by country and ethnicity. What is New: • A TcB nomogram for neonates of Mongolian ethnicity at 6-144 postnatal hours was created and it had higher values than those in previous studies.
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Affiliation(s)
- Moe Akahira-Azuma
- Department of Pediatrics, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan.
| | - Naohiro Yonemoto
- Department of Neuropsychopharmacology, National Institute of Mental Health, National Center of Neurology and Psychiatry, 4-1-1 Ogawahigashimachi, Kodaira, 187-8553, Tokyo, Japan.
| | - Rintaro Mori
- Department of Health Policy, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, 157-8535, Tokyo, Japan.
| | - Shinichi Hosokawa
- Department of Pediatrics, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan.
| | - Takeji Matsushita
- Department of Pediatrics, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan.
| | - Khulan Sukhbat
- National Center for Maternal and Child Health of Mongolia, Huvisgalchid Street, Bayangol District, Ulaanbaatar, 16060, Mongolia.
| | - Gerelmaa Nansal
- National Center for Maternal and Child Health of Mongolia, Huvisgalchid Street, Bayangol District, Ulaanbaatar, 16060, Mongolia.
| | - Bayasgalantai Bavuusuren
- National Center for Maternal and Child Health of Mongolia, Huvisgalchid Street, Bayangol District, Ulaanbaatar, 16060, Mongolia.
| | - Enkhtur Shonkhuuz
- National Center for Maternal and Child Health of Mongolia, Huvisgalchid Street, Bayangol District, Ulaanbaatar, 16060, Mongolia.
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