Transcutaneous bilirubinometry in very low birthweight infants

Transcutaneous bilirubinometry for detecting jaundice in term or late preterm neonates

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

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

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

Transcutaneous bilirubinometry versus total serum bilirubin measurement for newborns

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Noninvasive methods for bilirubin measurements in newborns: A report

New technologies have become available for noninvasive assessments of neonatal hyperbilirubinemia. Our objective is to review the noninvasive methods for measuring bilirubin in the newborn. We searched relevant literature from 1966 to January 1, 2020, which included cross-sectional studies to define the accuracy of any noninvasive methods for measuring or estimating total serum/plasma bilirubin (TB) levels in newborns. We identified and included 83 relevant studies of direct visual assessment, icterometry, mobile phone applications, and transcutaneous bilirubinometry (TcB). Compared with laboratory TB measurements, visual assessment was the least accurate and least reliable (r: 0.37 to 074), while TcB was the most accurate, but not always near-equivalent (r: 0.45 to 0.99). The sensitivity and specificity of TcB cut-off values to detect significant hyperbilirubinemia (TB>95th percentile for age in hours) ranged from 74% to 100% and 18% to 89%, respectively.

Prediction of the need for phototherapy during hospital stay in preterm infants by transcutaneous bilirubinometry

BACKGROUND

Neonatal hyperbilirubinemia is a common condition that frequently requires treatment with phototherapy and less commonly by exchange transfusion, especially in preterm infants. It is important to identify and monitor infants at risk of severe unconjugated hyperbilirubinemia early in the postnatal period to instigate appropriate management plans.

AIMS

To evaluate transcutaneous bilirubinometry (TCB) as a screening tool at 24 and 48 h of age to predict the need for phototherapy during hospital stay in preterm infants.

STUDY DESIGN

A single centre prospective cohort study in a level III perinatal centre.

SUBJECTS

Preterm infants (23⁺⁰ to 36⁺⁶ weeks of gestation) were eligible for enrolment.

OUTCOME MEASURES

Primary outcome was to assess the predictive value of TCB at 24 and 48 h of age for the need of phototherapy during hospital stay.

RESULTS

A total of 338 preterm infants were enrolled. The majority of infants (98.1%) born below 32 weeks of gestation required phototherapy. For infants born at >31 + 6 weeks of gestation, TCB at 24 h of age ≥81 μmol/l had sensitivity 83%, specificity 56%, positive predictive value (PPV) 54.7% and negative predictive value (NPV) 84%. TCB at 48 h of age ≥145 μmol/l had sensitivity 65%, specificity 62%, PPV 24% and NPV 90%.

CONCLUSION

TCB performed poorly at 24 and 48 h of age as a predictor of phototherapy during hospital stay in preterm infants. The negative predictive value of the test at 48 h of age might be helpful for infants born after 31 + 6 weeks of gestation.

Comparison of Diagnostic Accuracy of Different Sites for Transcutaneous Bilirubin Measurement in Early Preterm Infants

OBJECTIVE

To evaluate correlation of transcutaneous bilirubin (TcB) measured at different body sites with serum total bilirubin (TSB) in early preterm infants.

METHODS

This hospital based prospective comparative study was carried out in the Department of Pediatrics, SMS Medical College, Jaipur between April 2015 to March 2016. Early preterm infants with gestational age ≤ 34 weeks in whom clinical jaundice was significant mandating TSB measurement were included in the study. Study subjects who met the inclusion criteria were chosen consecutively. Neonates in whom phototherapy was already initiated and those with poor perfusion (capillary refill time > 3 s) were excluded from the study. All the measurements were carried out within first postnatal week. Transcutaneous bilirubin was measured from three sites: forehead, sternum and interscapular region and within 15 min of TcB measurement, blood samples were taken and serum bilirubin level was calculated.

RESULTS

Correlation coefficients of transcutaneous bilirubin measured from forehead, sternum and interscapular sites were 0.82, 0.84 and 0.86 respectively. TcB measured from all the three sites correlated significantly with serum bilirubin (p < 0.001), but the correlation was best at interscapular site. Sensitivity, specificity and false negative rates were calculated with respect to starting phototherapy. Interscapular site had the highest sensitivity and lowest false negative rate (87.6 and 12.4% respectively) as compared to forehead (79.2 and 20.8% respectively) and sternum (87.1 and 12.9% respectively).

CONCLUSIONS

Transcutaneous bilirubin measurement is an acceptable method for identification of hyperbilirubinemia requiring treatment in early preterm newborns. The authors recommend interscapular region as a reliable site in infants of gestational age ≤34 wk for measuring transcutaneous bilirubin.

Prediction of significant hyperbilirubinemia in term neonates by early non-invasive bilirubin measurement

BACKGROUND

Neonatal jaundice is a common problem. We evaluated the utility and best cut-off values of 24-and 48-hour transcutaneous bilirubin indices (TcBI) in predicting subsequent significant hyperbilirubinemia and evaluated various associated maternal and fetal risk factors.

METHODS

TcBI at 24 and 48 hours and serum bilirubin levels at 72 hours of age were obtained for healthy, term, appropriate for gestational age neonates. Neonates with prematurity, birth weight <2500 g, ABO or Rh incompatibility, onset of clinical jaundice <24 hours, clinical suspicion of septicemia, positive pressure ventilation at birth, admission in neonatal intensive care unit and contraindications for BiliChek were excluded. Twently-four and 48-hour TcB indices were assessed as predictors of subsequent hyperbilirubinemia, defined as serum bilirubin >17 mg/dL after 72 hours of life and various cut-offs, and were evaluated by calculating sensitivity, specificity and predictive values.

RESULTS

Of 500 newborns, 4.6% had significant hyperbilirubinemia, 27% had TcBI (mg/dL) <5 at 24 hours, and 27.4% had TcBI <8 at 48 hours. None of them had subsequent hyperbilirubinemia (100% negative predictive value). The percentage of newborns with subsequent hyperbilirubinemia increased from 3.4% to 13.2% as their 24-hour TcBI increased from 6 to above 9 mg/dL and from 4.2% to 7.4% as their 48-hour TcBI increased from 8 to above 11 mg/dL. The best cut-off value was TcBI (mg/dL) 7 (odd ratio=4.86, 95% confidence interval: 1.66-15.22) at 24 hours and 10 (odd ratio=2.87, 95% confidence interval: 1.04-8.29) at 48 hours. Area under the receiver operating characteristic curve for 24- and 48-hour measurements was 0.750 and 0.715, respectively. Maternal premature rupture of membranes, deep transverse arrest, post-date pregnancy, and fetal distress were significant risk factors for hyperbilirubinemia.

CONCLUSIONS

Twenty-four and 48-hour TcB indices are good predictors of subsequent hyperbilirubinemia. Twenty-four-hour TcBI had better predictive ability than 48-hour TcBI.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Screening for Hyperbilirubinemia in Japanese Very Low Birthweight Infants Using Transcutaneous Bilirubinometry

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.

Accuracy of transcutaneous bilirubin measurement in preterm low-birth-weight neonates

The objective of this study was to evaluate the correlation and agreement between transcutaneous and serum bilirubin among preterm low-birth-weight neonates. Neonates born at <35 weeks of gestation with birth weight <2,000 g were enrolled prospectively. Transcutaneous bilirubin (TcB) was measured at forehead, sternum, and abdomen at 24 ± 6 and 72 ± 12 h after birth and when icterus involved arms or legs (Kramer zone 4-5). Serum total bilirubin (STB) was measured by microbilimeter (STB-M) at all these time-points and by high-performance liquid chromatography (STB-H) at one randomly chosen time-point. A total of 1,619 observations were made in 256 neonates (median gestation, 34 weeks (IQR, 32-35), birth weight 1,522 ± 288 g). Overall there was excellent correlation and agreement between TcB and STB-M with TcB on forehead being most accurate (r = 0.84, mean difference, 0.3 ± 1.9 mg/dL) followed by TcB on abdomen (r = 0.73, mean difference, 1.5 ± 2.6 mg/dL) and sternum (r = 0.72, mean difference, 1.5 ± 2.6 mg/dL). TcB performed well at all three points of measurement with best correlations being observed at icterus level 4/5. Correlation between TcB and STB-H measured by high-performance liquid chromatography was less strong but significant (r = 0.59 to 0.69 at different time points of measurement).

CONCLUSIONS

TcB has good correlation and agreement with STB in preterm low-birth-weight neonates born at ≥28 weeks of gestation.

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

BACKGROUND AND OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

Background

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

Methods

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

Results

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

Conclusion

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

Evaluation of transcutaneous bilirubinometry in preterm neonates

OBJECTIVE

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

STUDY DESIGN

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

RESULT

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

CONCLUSION

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