Skin bilirubin nomogram for the first 96 h of life in a European normal healthy newborn population, obtained with multiwavelength transcutaneous bilirubinometry

The use of transcutaneous bilirubin nomograms for the prevention of bilirubin neurotoxicity in the neonates

Purpose

Although neonatal jaundice is a ubiquitous and predominantly benign phenomenon, the risk of neurotoxicity exists in a number of infants with unconjugated hyperbilirubinemia. Plotting bilirubin values on nomograms enables clinicians to employ an anticipatory and individualized approach with the goal of avoiding excessive hyperbilirubinemia and preventing acute bilirubin encephalopathy and its progression to kernicterus. We aimed to construct nomograms for White term infants based on transcutaneous bilirubin (TcB) measurements using a JM-105 device.

Methods

TcB measurements were taken in infants at ages ranging from 0 to 96 postnatal hours. We then constructed hour-specific TcB nomograms from forehead and sternum measurements in infants who did not require subsequent phototherapy.

Results

We included 2,981 TcB measurements taken on the forehead and 2,977 measurements taken on the sternum in 301 White term newborn infants. We assessed the predictive abilities of the nomograms at six postnatal time intervals using receiver operating characteristic curves. The areas under the curves indicated reasonable prediction of hyperbilirubinemia requiring phototherapy, except for the forehead measurement taken within the first 12 h of life. Sensitivity tended to rise as postnatal age increased.

Conclusion

The nomograms illustrate dermal bilirubin dynamics in White term neonates during the first 4 days of life. They may be useful tools to predict individualized risk of hyperbilirubinemia requiring treatment, and to plan optimal follow-up of infants at risk of bilirubin neurotoxicity.

Gestational Age-Specific Nomogram of Transcutaneous Bilirubin in First 120 h of Life for Term and Late Preterm Indian Neonates

OBJECTIVE

To create a nomogram based on transcutaneous bilirubin values (TCB) in first week of life for term and late preterm (>34 weeks) neonates.

METHODS AND DESIGN

Prospective longitudinal study.

SETTING

Four tertiary-care teaching hospitals (one each in eastern and southern India, two in northern India) between February 2019 and March 2020.

PARTICIPANTS

A total of 2492 term and late preterm (>34 weeks) neonates.

INTERVENTION

Bilirubin was measured by transcutaneous bilirubinometer (Drager JM-105, Germany) in all neonates in pre-specified times of the day, 12 hourly every day since birth till discharge between 48 and 72 h, and data were recorded in epochs of 6 hourly intervals. Post-discharge, all neonates were called for review in next 48 h.

OUTCOME MEASURES

Primary-TCB in first week of life. Secondary-factors having significant association with significant hyperbilirubinaemia requiring phototherapy.

RESULTS

Total of 2492 neonates (males 1303 and female 1189), with a total of 14 162 TCB recordings were analysed and mean hourly bilirubin (TCB) at hourly intervals till 120 h and then daily bilirubin values on Days 6 and 7 were tabulated. We have constructed hour-specific bilirubin nomogram with percentiles as per gestational age in term and near-term Indian neonates till 120 h of life. Amongst the known risk factors, delayed cord clamping, primipara and breastfeeding jaundice had significant association for hyperbilirubinaemia needing phototherapy.

CONCLUSIONS

We have created gestation-specific nomogram of TCB levels in 6 hourly intervals for the first 120 postnatal hours, obtained from a large predominantly breast fed healthy, term and near-term Indian neonates.

Real-Time Monitoring of Blood Parameters in the Intensive Care Unit: State-of-the-Art and Perspectives

The number of patients in intensive care units has increased over the past years. Critically ill patients are treated with a real time support of the instruments that offer monitoring of relevant blood parameters. These parameters include blood gases, lactate, and glucose, as well as pH and temperature. Considering the COVID-19 pandemic, continuous management of dynamic deteriorating parameters in patients is more relevant than ever before. This narrative review aims to summarize the currently available literature regarding real-time monitoring of blood parameters in intensive care. Both, invasive and non-invasive methods are described in detail and discussed in terms of general advantages and disadvantages particularly in context of their use in different medical fields but especially in critical care. The objective is to explicate both, well-known and frequently used as well as relatively unknown devices. Furtehrmore, potential future direction in research and development of realtime sensor systems are discussed. Therefore, the discussion section provides a brief description of current developments in biosensing with special emphasis on their technical implementation. In connection with these developments, the authors focus on different electrochemical approaches to invasive and non-invasive measurements in vivo.

Evaluation of a new transcutaneous bilirubinometer in newborn infants

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.

Natural history of early neonatal bilirubinemia: a global perspective

BACKGROUND AND OBJECTIVE

Due to selection bias and other issues, the only available serum bilirubin-based nomogram does not reflect the natural history of early neonatal bilirubinemia. Our objective was to obtain a global picture of the natural history of early post-natal bilirubin trajectories.

STUDY DESIGN

We pooled readings from 19 published transcutaneous bilirubin nomogram reports including many newborns at multiple sites. We constructed a universal transcutaneous bilirubin nomogram which included the 25th, 50th, 75th, and 95th percentiles from 12 to 120 h.

RESULTS

The global transcutaneous bilirubin nomogram included >119,000 readings from 44,392 apparently normal, predominantly breastfed newborns ≥35 weeks gestation. The pooled transcutaneous bilirubin trajectories increased during the first 3 post-natal days, and peaked or plateaued between the 3rd and 4th days.

CONCLUSIONS

We provide the first globally derived transcutaneous bilirubin nomogram that reflects the natural history of early neonatal bilirubinemia in neonates ≥35 weeks gestation.

Clinical predictive score of predischarge screening for severe hyperbilirubinemia in late preterm and term infants

BACKGROUND

Early identification and appropriate follow-up of infants at risk of severe hyperbilirubinemia are part of preventing complications. This study aims to develop the clinical predictive score to predict subsequent severe hyperbilirubinemia in healthy Thai infants.

METHODS

A case-control study was conducted using medical records of 147 hyperbilirubinemia cases and 147 age-matched controls among healthy late preterm and term Thai newborn infants during January 2015 and December 2016. The routinely measured TcB values at 48-54 hours of age and all predischarge clinical characteristics were collected. Multivariable logistic regression was used to find a clinical prediction model to predict subsequent severe hyperbilirubinemia within 7 days after birth which defined as a postdischarge bilirubin level exceeding the hour-specific recommended threshold for phototherapy by the American Academy of Pediatrics (AAP).

RESULTS

The best clinical predictors for subsequent severe hyperbilirubinemia were TcB values at 48-54 hours and gestational age of infants. Predischarge TcB at 48-54 hours of life was classified into 3 levels: < 10 mg/dL, 10-12 mg/dL and > 12 mg/dL. Gestational age was categorized into 5 groups. The risk score derived from these 2 significant factors predicted subsequent severe hyperbilirubinemia with an AuROC curve of 81.0% (95% CI: 76.2-85.9%) in 3 risk group, high, moderate and low. The positive likelihood ratio for subsequent severe hyperbilirubinemia of the high-risk group (score > 5) was 4.53 (95% CI: 2.91-7.04) with specificity of 87.1%. The negative predictive value of low-risk group (score < 3) was 81%.

CONCLUSIONS

A simple predischarge prediction score using gestational age and TcB values at 48-54 hours of life was developed. This score classified late preterm and term newborn infants into 3 distinct risk levels and may be useful to identify high-risk infants for outpatient follow-up of subsequent severe hyperbilirubinemia.

Knowledge of Neonatal Hyperbilirubinemia Among Primary Health Care Physicians: A Single-Center Experience

Background and objectives:

To evaluate the knowledge of the primary health care physicians (PHCP) in Kalubia governorate, Egypt, about the causes, diagnosis, complications, and treatment of neonatal hyperbilirubinemia (NHB).

Methods:

Cross-sectional survey distributed by interview to 500 physicians working in the primary health care (PHC) sector in Kalubia.

Results:

Out of 500 distributed surveys, 419 (84%) PHCP completed the questionnaire. They represent 174 (90%) out of 193 PHC units and centers. About 18% were males and 82% females with mean age of 28.5 ± 5.2 years, and mean duration of work was 3.3 ± 4.4 years. All of the respondents have patients with NHB in their daily practice. The knowledge of the PHCP was good in some aspects about NHB; however, it was poor and may be even hazardous in other aspects.

Conclusions:

Many areas of defects are detected in PHCP knowledge about NHB. Pre-service and continuous training of the PHCP about the diagnosis and management of NHB are essential.

Transcutaneous bilirubin nomogram for the first 144 hours in Thai neonates

Objectives: To develop an hour-specific transcutaneous bilirubin (TcB) nomogram for Thai neonates and to compare the ability of this nomogram with that of Bhutani's total serum bilirubin (TSB) nomogram for prediction of significant hyperbilirubinemia requiring phototherapy.Methods: Healthy Thai neonates, gestational age ≥35-week-gestation and birth weight ≥2000 grams were enrolled. Neonates who could not attend the postdischarge follow-up at our center were excluded. TcB measurements were routinely performed at 6 am and 6 pm using JM103 transcutaneous bilirubinometer until the neonates were discharged or received phototherapy. TcB levels were also measured at least once during 24-72 hours after discharge and thereafter depending on the pediatricians' decision. The nomogram was developed from the TcB data during age 12-144 hours of neonates who did not require phototherapy. The TcB values that obtained predischarge or before receiving phototherapy of all neonates were used to determine the predictive ability of this nomogram and Bhutani's TSB nomogram.Results: A total of 1071 neonates were included. Two hundred forty-one neonates (22.5%) required phototherapy. The nomogram was constructed using 4834 hour-specific TcB values. It provided a good prediction with the area under curve (AUC) of 0.89. The 75th percentile tract revealed sensitivity and negative predictive value (NPV) of 87.1 and 95.4% while that of the 40th percentile tract were 97.9 and 98.5% respectively. When Bhutani's nomogram was used, the AUC was 0.84. The sensitivity and NPV of the 75th percentile tract were 56.4 and 88.2%, and for the 40th percentile tract were 97.1 and 98.0% respectively.Conclusion: The newly developed TcB nomogram revealed slightly better predictive ability than Bhutani's TSB nomogram for term and late preterm Thai neonates who were the population with high prevalence of significant hyperbilirubinemia. The 40th percentile curve of both nomograms should be considered as an appropriate cut-off level for prediction.

The smartphone camera as a potential method for transcutaneous bilirubin measurement

BACKGROUND

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

Israel transcutaneous bilirubin nomogram predicts significant hyperbilirubinemia

OBJECTIVE

We constructed a transcutaneous bilirubin (TcB) nomogram to represent major sectors of the Israeli population. We studied the risk of hyperbilirubinemia, defined as meeting the requirements for phototherapy, per percentile risk category.

STUDY DESIGN

Newborns ⩾36 weeks gestation were tested daily for TcB, using Drager JM-103 devices, during birth hospitalization. A nomogram was constructed and divided into four risk groups and validated by calculating the need for phototherapy for each group.

RESULTS

A total of 3303 measurements were performed on 1059 consecutive newborns including Ashkenazi, Sephardic and mixed Ashkenazi/Sephardic Jews, Arab and Ethiopian Jewish. Phototherapy risk increased progressively and more than 100-fold, from 0/225 in the <40th percentile group through 27/120 (22.5%) for those >95th percentile (relative risk (95% confidence interval) 102 (6 to 1669) for those >95th percentile compared with those <40th percentile). The optimal risk for discriminating the need for phototherapy was >75th percentile (sensitivity 93.33, specificity 59.47).

CONCLUSION

The risk of significant hyperbilirubinemia increased progressively with increasing percentile. Newborns >75th percentile groups are at high risk for phototherapy and should be closely monitored.

Transcutaneous Bilirubin Nomogram for Healthy Term and Late Preterm Neonates in First 96 Hours of Life

BACKGROUND

To develop nomogram of Transcutaneous Bilirubin among healthy term and late-preterm neonates during first 96 hours of age.

DESIGN

Longitudinal observational study.

SETTING

Neonatal unit of a tertiary care Hospital of Central Gujarat, India.

Participants

1075 healthy term and late preterm neonates (≥35weeks).

INTERVENTION

Six-hourly transcutaneous bilirubin was obtained from birth to 96 hour of life using Drager JM 103 Transcutaneous Bilirubinometer.

METHODS

Main outcome measures: Nomogram of Transcutaneous Bilirubin with percentile values was obtained, rate of rise of bilirubin was calculated and predictive ability of normative data was analyzed for subsequent need of phototherapy.

RESULTS

The age-specific percentile curves and nomogram were developed from the transcutaneous bilirubin readings of 1,010 neonates. Rate of rise in first 12 hour was 0.2 mg/dL and was 0.17 mg/dL in 12 to 24 hour of life which decreased on second day of life. Neonates who required phototherapy had consistently higher readings of transcutaneous bilirubin and also higher rate of rise in first 48 hrs.

CONCLUSION

Neonates whose transcutaneous bilirubin is above the 50th percentile should be monitored for the development of significant hyperbilirubinemia.

Transcutaneous bilirubin nomograms in African neonates

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 75^th and 95th percentiles to detect significant hyperbilirubinemia was evaluated between 24–96 hours of age. The 95^th percentile curve was compared with those from other populations.

Results

The velocity of TcB rise at 75^th and 95^th percentiles was generally higher with JM-103 than Bilichek. Both percentiles also peaked at higher TcB levels with JM-103. The 95^th 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.

Transcutaneous Bilirubin Levels during the First Month of Life in Term and Late-preterm Newborns

OBJECTIVE

We aimed to develop a transcutaneous bilirubin (TcB) nomogram for assessment of the risk of significant hyperbilirubinemia and prolonged jaundice during the first month of life in term and late-preterm Turkish newborns.

METHODS

On the basis of the daily (3rd, 7th, 15th and 30th days) TcB measurements, 3rd, 10th, 25th, 50th, 75th, 90th and 97th percentiles, and 5 percentile tracks were obtained. TcB measurements were made by a transcutaneous bilirubinometer (JaundiceDetector JH20-1C).

RESULTS

We screened 729 healthy term and late-preterm Turkish infants 3-30 days old and developed a nomogram of TcB levels. TcB level was ≥5 mg/dl in 41.98% and 25.9% of infants at age 15.0  ±  2.1 days and 30.9  ±  2.6 days, respectively. The TcB measurement-based nomogram values of the 97th percentiles (cutoff values) at age 15.0  ±  2.1 and 30.9  ±  2.6 days were 11.4 (10.82-12.13) mg/dl and 10.0 (9.40-10.70) mg/dl, respectively.

CONCLUSION

This nomogram can be used to determine the risk status of Turkish newborns regarding significant hyperbilirubinemia and prolonged jaundice on the basis of TcB measurement in the first month of life.

Relationship between transcutaneous bilirubin and circulating unbound bilirubin in jaundiced neonates

BACKGROUND

Transcutaneous bilirubin (TcB) consists of the skin-deposited bilirubin. Free bilirubin represents the protein-unbound bilirubin (UB) that is able to pass into the tissues. We aimed to describe the relationship UB-TcB and study the passage of UB into the skin.

METHODS

We prospectively enrolled 194 neonates and we measured TcB, UB, serum bilirubin and albumin. Multiple sites TcB measurement was performed, bilirubin-albumin equilibrium constant and plasma bilirubin avidity (PBA) were calculated.

RESULT

TcB has a similar correlation with UB and TSB. There is a quadratic relationship between UB and TcB (R²=0.48; p<0.001), remaining significant (β for UB²=-0.8; p<0.001. β for UB=1.1; p<0.001) after adjustment for gestational age, birth weight, postnatal age and albumin (Adj-R²=0.72). UB contributes to the skin bilirubin deposition, as there are significant correlations between albumin and TcB (r=-0.202; p=0.01) and between PBA and ΔTcB (r=0.323; p=0.017).

CONCLUSION

TcB assay does not seem to directly replace UB measurement. However, TcB and UB are linked by a quadratic relationship: UB contributes to the skin bilirubin deposition but it is not the only bilirubin species measured by transcutaneous bilirubinometry.

A Model for Predicting Significant Hyperbilirubinemia in Neonates From China

OBJECTIVES

To develop and validate a predischarge risk stratification model by using transcutaneous bilirubin (TcB) values and clinical factors to predict significant postdischarge hyperbilirubinemia in healthy term and late preterm Chinese neonates.

METHODS

In a prospective cohort study, 8215 healthy term and late preterm neonates in 8 hospitals in China underwent TcB measurement at <168 hours of age. TcB percentiles were calculated and used to develop an hour-specific nomogram, and 9 empirically weighted items were used to derive a prediction model. A risk stratification model was developed by combining the TcB nomogram with clinical risk scores to predict significant hyperbilirubinemia, defined as a postdischarge bilirubin level that exceeded the hour-specific recommended threshold value for phototherapy. Data from another 13,157 neonates were used to validate the model.

RESULTS

A TcB nomogram for every 12 hours of the studied interval was constructed from the development set. Gestational age, male gender, history of previous neonate who received phototherapy, bruising, feeding mode, weight loss, and early discharge were predictors of postdischarge significant hyperbilirubinemia. The combination of the TcB nomogram and clinical risk score provided the best prediction of significant hyperbilirubinemia with an area under the curve of 0.95 (95% confidence interval: 0.94-0.95) in the development data set and 0.94 (95% confidence interval: 0.93-0.94) in the validation data set. A risk stratification model with 6 distinct risk levels was developed and validated.

CONCLUSIONS

A risk classification model, combining discharge transcutaneous bilirubin values and clinical risk factors, separated term and late preterm Chinese neonates into 6 risk classes for the timely follow-up of postdischarge hyperbilirubinemia detection.

An hour-specific transcutaneous bilirubin nomogram for Mongolian neonates

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.

Transcutaneous bilirubinometry

Although the modern era of transcutaneous bilirubin monitoring (TcB) began only about 35 years ago, this screening tool is now widely used in newborn nurseries and outpatient clinics, offices, and emergency departments to obtain a rapid and non-invasive estimate of the degree of hyperbilirubinemia. TcB devices have become more sophisticated, and major breakthroughs include the following: (a) ability to report a bilirubin value rather than an index value, (b) enhanced correction for chromophores other than bilirubin, and (c) technologic improvements including interface with electronic medical records. Good agreement with laboratory bilirubin measurement has been demonstrated, and the ability of TcB screening to predict and decrease the incidence of subsequent hyperbilirubinemia has been well-documented. To date, it has not been shown that this screening results in improved long-term outcomes.

Individualized follow up programme and early discharge in term neonates

BACKGROUND

Early discharge of mother/neonate dyad has become a common practice, and its effects are measured by readmission rates. We evaluated the safety of early discharge followed by an individualized Follow-up programme and the efficacy in promoting breastfeeding initiation and duration.

METHODS

During a nine-month period early discharge followed by an early targeted Follow-up was carried out in term neonates in the absence of weight loss <10% or hyperbilirubinaemia at risk of treatment. Follow-up visits were performed at different timepoints with a specific flow-chart according to both bilirubin levels and weight loss at discharge.

RESULTS

During the study period early discharge was performed in 419 neonates and Follow-up was carried out in 408 neonates (97.4%). No neonates required readmission for hyperbilirubinaemia and dehydration during the first 28 days of life. Breastfeeding rate was 90.6%, 75.2%, 41.5% at 30, 90 and 180 days of life, respectively. A six-month phone interview was performed for 383 neonates (93.8%) and satisfaction of parents about early discharge was high in 345 cases (90.1%).

CONCLUSIONS

Early discharge in association with an individualized Follow-up programme resulted safe for the neonate and effective for breastfeeding initation and duration.

Validation of transcutaneous bilirubin nomogram for identifying neonatal hyperbilirubinemia in healthy Chinese term and late-preterm infants: a multicenter study

OBJECTIVE

to prospectively validate a previously constructed transcutaneous bilirubin (TcB) nomogram for identifying severe hyperbilirubinemia in healthy Chinese term and late-preterm infants.

METHODS

this was a multicenter study that included 9,174 healthy term and late-preterm infants in eight hospitals of China. TcB measurements were performed using a JM-103 bilirubinometer. TcB values were plotted on a previously developed TcB nomogram, to identify the predictive ability for subsequent significant hyperbilirubinemia.

RESULTS

in the present study, 972 neonates (10.6%) developed significant hyperbilirubinemia. The 40(th) percentile of the nomogram could identify all neonates who were at risk of significant hyperbilirubinemia, but with a low positive predictive value (PPV) (18.9%). Of the 453 neonates above the 95(th) percentile, 275 subsequently developed significant hyperbilirubinemia, with a high PPV (60.7%), but with low sensitivity (28.3%). The 75(th) percentile was highly specific (81.9%) and moderately sensitive (79.8%). The area under the curve (AUC) for the TcB nomogram was 0.875.

CONCLUSIONS

this study validated the previously developed TcB nomogram, which could be used to predict subsequent significant hyperbilirubinemia in healthy Chinese term and late-preterm infants. However, combining TcB nomogram and clinical risk factors could improve the predictive accuracy for severe hyperbilirubinemia, which was not assessed in the study. Further studies are necessary to confirm this combination.

Italian guidelines for management and treatment of hyperbilirubinaemia of newborn infants ≥ 35 weeks' gestational age

Hyperbilirubinaemia is one of the most frequent problems in otherwise healthy newborn infants. Early discharge of the healthy newborn infants, particularly those in whom breastfeeding is not fully established, may be associated with delayed diagnosis of significant hyperbilirubinaemia that has the potential for causing severe neurological impairments. We present the shared Italian guidelines for management and treatment of jaundice established by the Task Force on hyperbilirubinaemia of the Italian Society of Neonatology.

The overall aim of the present guidelines is to provide an useful tool for neonatologists and family paediatricians for managing hyperbilirubinaemia.

Plotting transcutaneous bilirubin measurements on specific transcutaneous nomogram results in better prediction of significant hyperbilirubinemia in healthy term and near-term newborns: a pilot study

BACKGROUND

The American Academy of Pediatrics has recommended a systematic assessment before discharge for the risk of severe hyperbilirubinemia. Plotting total serum bilirubin (TSB) or transcutaneous bilirubin (TcB) on a TSB hour-specific nomogram is proposed as a tool for laboratory evaluation.

OBJECTIVES

The aim of this study was to compare the predictive characteristics, particularly the incidence of false negative rate (FNR), of the practice of plotting TcB values on the TSB hour-specific risk nomogram versus on transcutaneous nomogram.

METHODS

Paired TSB and TcB measurements were conducted on 141 newborns. Risk of developing significant hyperbilirubinemia was defined as infants with bilirubin level ≥ 75% on TSB or ≥ 95% on TcB nomogram. TSB values, plotted on the TSB nomogram of Bhutani et al. [Pediatrics 1999;103:6-14], were used as reference. TcB values were plotted on the TSB nomogram and on the transcutaneous nomograms of Maisels and Kring [Pediatrics 2006;117:1169-1173] and Fouzas et al. [Pediatrics 2010;125:e52-e57].

RESULTS

Plotting TcB measurements on a TSB nomogram resulted in a trend towards a higher FNR when compared to Maisels' and Fouzas' nomograms (18.0/1,000 compared to 10.2/1,000 and 8.6/1,000 respectively). Although not statistically significant, plotting TcB on transcutaneous nomogram resulted in better predictive values with the Fouzas' nomogram, having the best sensitivity (90.0%) and specificity (87.79%) as well as the highest positive (35.97%) and negative (99.14%) predictive value.

CONCLUSION

Plotting TcB on a TSB nomogram may result in increased rate of FNR and decreased predictive characteristics. The practice of plotting TcB on a TSB nomogram needs further evaluation.

Hour-specific nomogram for transcutaneous bilirubin in Japanese neonates

BACKGROUND

The measurement of transcutaneous bilirubin (TcB) is very important to screen for hyperbilirubinemia in newborns. Until now, however, there has been no hour-specific, percentile-based TcB nomogram during the early neonatal period in Japanese neonates. The aim of this study was to develop a TcB nomogram within 72 h of birth in Japanese neonates.

METHODS

A total of 3152 TcB measurements for 181 healthy Japanese neonates (gestational age ≥36 weeks, birthweight ≥2300 g) were obtained within 72 h of birth. All measurements were performed with a Konica Minolta jaundice meter, the JM-103. A nomogram curve was plotted to show the trend of TcB level over time.

RESULTS

The nomogram curves rose almost linearly for all percentiles until 72 h after birth.

CONCLUSION

An hour-specific, percentile-based TcB nomogram during the first 72 h after birth in Japanese neonates was successfully developed. Because Japanese neonates have higher and later peak bilirubin, an original hour-specific 97.5th percentile-based TcB nomogram may be needed to identify early-onset jaundice and manage neonatal hyperbilirubinemia.

Validation of a transcutaneous bilirubin meter in Mongolian neonates: comparison with total serum bilirubin

BACKGROUND

Neonatal hyperbilirubinemia, especially kernicterus, can be prevented by screening for neonatal jaundice. The transcutaneous bilirubin (TcB) meter is a non-invasive medical device for screening neonates. The study aimed to investigate the validity of a TcB meter in a resource-limited setting such as Mongolia.

METHODS

Term and late preterm neonates from the National Center for Maternal and Child Health of Ulaanbaatar in Mongolia who met the inclusion criteria (gestational age ≥35 weeks, birth weight ≥2000 g, postnatal age ≤ 1 month) were enrolled in the study. We used a TcB meter, JM-103 to screen for neonatal jaundice. TcB measurements at the infant's forehead and midsternum were performed within 3 h of obtaining samples for total serum bilirubin (TSB) measurement. We analyzed the correlation between TcB measurements and TSB measurements to validate the meter.

RESULTS

A total of 47 term and six late preterm neonates were included in the study. TcB measured by the meter at both the forehead and the midsternum showed a strong correlation with TSB measured in the laboratory. The correlation equations were TSB = 1.409+0.8655 × TcB (R2=0.78871) at the forehead, and TSB = 0.7555+0.8974 × TcB (R2=0.78488) at the midsternum. Bland-Altman plots and the Bradley-Blackwood test showed no significant differences between the two methods at all measured ranges of bilirubin. The mean areas under the curves of TcB at the forehead and midsternum at three TSB levels (>10 mg/dL, >13 mg/dL, >15 mg/dL) of TcB were greater than 0.9, and all had high sensitivity and specificity.

CONCLUSIONS

This study established the validity of the JM-103 meter as a screening tool for neonatal jaundice in term and late preterm infants in Mongolia. Future studies are needed, including the establishment of a TcB hour-specific nomogram, for more effective clinical practice to prevent severe hyperbilirubinemia.

How to use: transcutaneous bilirubinometry

The National Institute for Health and Clinical Excellence neonatal jaundice guidelines recommend checking the bilirubin level in all infants with visible jaundice. The gold standard for this measurement is total serum bilirubin (TSB). Transcutaneous bilirubinometry (TcB) is an alternative to TSB that has been validated for clinical use through extensive study. TcB provides many advantages over TSB including instantaneous measurements without requiring a painful lab draw. For infants >35&emsp14;weeks gestation, TcB can reliably identify infants at risk for severe hyperbilirubinaemia and can decrease the number of TSB measurements obtained. However, paediatric providers should be aware of limitations in clinical use of TcB including decreasing accuracy at higher bilirubin levels, lack of independently validated nomograms for interpretation and limited research regarding its use during phototherapy.

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

Background

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

Methods

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

Results

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

Conclusions

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

Trends of transcutaneous bilirubin in neonates who develop significant hyperbilirubinemia

OBJECTIVES

To provide data on the natural course of transcutaneous bilirubin (TcB) levels in neonates before the development of significant hyperbilirubinemia, and to assess the effect of different demographic and perinatal factors on the rate of TcB increase.

METHODS

We analyzed 2454 TcB measurements from 419 neonates before the development of significant hyperbilirubinemia. Mean TcB values and TcB percentiles for designated times were calculated, and the effect of different risk factors on the rate of TcB increase was assessed. TcB percentile curves were plotted for comparison on a population-based TcB nomogram.

RESULTS

Blood incompatibilities and glucose-6-phosphate dehy-drogenase deficiency were associated with higher rates of TcB in-crease during the first 36 to 48 postnatal hours, whereas smaller gestational age, increased weight loss, and exclusive breastfeeding had a similar but later effect. Compared with general population norms, a different pattern of TcB increase was noted in neonates who developed significant hyperbilirubinemia, but with a sub-stantial overlap of TcB values during the first 24 to 48 postnatal hours.

CONCLUSIONS

We provide data on the natural course of TcB levels before the development of significant hyperbilirubinemia in a white population of term and near-term neonates. Smaller gestational age, blood incompatibilities, glucose-6-phosphate dehydrogenase deficiency, increased weight loss, and exclusive breastfeeding significantly affected the rate of TcB increase in a time-dependent manner. These findings may assist in assessing the risk for significant hyperbilirubinemia and planning appropriate follow-up strategies for neonates with borderline bilirubin levels.

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

Background

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

Methods

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

Results

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

Conclusion

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

Validation of transcutaneous bilirubin nomogram in identifying neonates not at risk of hyperbilirubinaemia: a prospective, observational, multicenter study

BACKGROUND

Transcutaneous bilirubin (TcB) measurement is widely used as screening for neonatal hyperbilirubinaemia.

AIMS

To prospectively validate TcB measurement using hour-specific nomogram in identifying newborn infants not at risk for severe hyperbilirubinaemia.

STUDY DESIGN

prospective, observational, multicenter.

SUBJECTS

2167 term and late preterm infants born in 5 neonatal units in the Lazio region of Italy.

METHODS

All neonates had simultaneous TcB and total serum bilirubin (TSB) measurements, when jaundice appeared and/or before hospital discharge. TcB and TSB values were plotted on a percentile-based hour-specific transcutaneous nomogram previously developed, to identify the safe percentile able to predict subsequent significant hyperbilirubinaemia defined as serum bilirubin >17 mg/dL or need for phototherapy.

RESULTS

Fifty-five babies (2.5%) developed significant hyperbilirubinaemia. The 50th percentile of our nomogram was able to identify all babies who were at risk of significant hyperbilirubinaemia, but with a high false positive rate. Using the 75th percentile, two false negatives reduced sensitivity in the first 48 hours but we were able to detect all babies at risk after the 48th hour of age.

CONCLUSIONS

This study demonstrates that the 75th percentile of our TcB nomogram is able to exclude any subsequent severe hyperbilirubinaemia from 48 h of life ahead.

Transcutaneous bilirubin in exclusively breastfed healthy term newborns up to 12 days of life

OBJECTIVE

To determine the curve of transcutaneous bilirubin in breastfed term neonates up to 12 days of life.

METHODS

In a prospective cohort study, we performed a 12-day evaluation of 223 healthy, exclusively breastfed, appropriate-for-gestational-age neonates who roomed-in for at least 48 hours. Each newborn had forehead transcutaneous bilirubin and body weight measured at the end of 1, 2, 3, 4, 5, 6, 8, 10, and 12 days. Regression analysis was used with bilirubin as a third-degree polynomial function of time. The 25th, 50th, 75th, 90th, and 95th percentile curves were constructed by using the residual mean square for each day.

RESULTS

Patients were 46% white, 34% mixed race, and 20% black, the mean birth weight was 3260 g (range: 2560-4090 g), the mean gestational age was 39.4 weeks (range: 37.0-41.9 weeks), 51% were male, 74% were born by vaginal delivery, and 66% had been breastfed since delivery. The mean highest weight loss was 4.7% (range: 1%-12%) at the second or third day, and in most infants the weight returned to the birth weight at the fifth day. With 2007 total bilirubin measurements, bilirubin concentrations reached the 50th percentile level (5.6 mg/dL) at the third and fourth days and returned to the 24-hour level (4.8 mg/dL) at the sixth day. The 95th percentile bilirubin level was 8.2 mg/dL at 24 hours of life, reached 12.2 mg/dL on the fourth day, and declined to 8.5 mg/dL on the 12th day.

CONCLUSIONS

The transcutaneous bilirubin curve represents the natural history of bilirubinemia in exclusively breastfed healthy term newborns in the first 12 days of life.

Transcutaneous bilirubin nomogram for predicting neonatal hyperbilirubinemia in healthy term and late-preterm Chinese infants

Identifying infants that will develop significant hyperbilirubinemia with the risk of kernicterus, and planning appropriate follow-up strategies, is particularly challenging. In this study, 36,921 transcutaneous bilirubin (TcB) measurements were obtained from 6,035 healthy neonates (gestational age ≥ 35 weeks and birth weight ≥ 2,000 g) between January 1 and December 31, 2009. All measurements were performed with the JM-103 bilirubinometer at designated times between 0 and 168 postnatal hours. TcB percentiles were calculated and used to develop an hour-specific nomogram. The rate of increase in TcB was higher during the first 72 h of age, after which levels declined to a plateau by 72-108 h of age. We constructed a TcB nomogram by using the 40th, 75th, and 95th percentile values of TcB for every 12 h of the studied interval. The 75th percentile curve of the nomogram may be an ideal cutoff point for intensive follow-up of the neonate for hyperbilirubinemia as it carries very high sensitivity (78.7%) and negative predictive value (98.5%). The specificity (45.7%) and positive predictive value (15.5%) decreased to reach their lowest levels at the 40th percentile. Of the neonates in the high-risk zone, 167 (48.8%) infants had persistent subsequent hyperbilirubinemia post-discharge, compared with 292 (27.0%) infants in the high-intermediate-risk zone at discharge. One-hundred and seventeen (5.5%) infants in the low-intermediate-risk zone moved into the high-risk zone during follow-up. No newborn infants in the low-risk zone became high-risk during follow-up. We provide an hour-specific TcB nomogram to predict neonatal hyperbilirubinemia in healthy term and late-preterm Chinese infants.

Transcutaneous bilirubin levels in late preterm neonates

OBJECTIVE

To examine transcutaneous bilirubin (TcB) levels in late preterm neonates.

STUDY DESIGN

Between July 2006 and December 2009, we performed 4387 TcB measurements with a BiliCheck bilirubinometer in 793 healthy late preterm neonates at designated times up to 120 postnatal hours. TcB percentiles are presented on an hour-specific nomogram. Mean increment TcB rates and the rates of increase for different percentiles are calculated as well.

RESULTS

We present a percentile-based nomogram that reflects the natural history of TcB in late preterm neonates up to the fifth day of life. TcB levels demonstrated a different pattern of increase in neonates who developed significant hyperbilirubinemia compared with those who did not. However, the rates of TcB increase were quite similar up to age 48 hours, with a substantial overlap of TcB values between the two groups.

CONCLUSIONS

We developed of a TcB nomogram designated for hour-specific evaluation of hyperbilirubinemia in neonates born between 35(0/7) and 37(6/7) weeks' gestation.

Assessing jaundice in infants of 35-week gestation and greater

PURPOSE OF REVIEW

In 2004, the American Academy of Pediatrics officially recommended universal predischarge risk assessment for severe neonatal hyperbilirubinemia with the goal of minimizing subsequent risk of chronic bilirubin encephalopathy (formerly known as kernicterus). In this article, we review recent research regarding jaundice predischarge risk assessment, current expert recommendations for universal predischarge bilirubin screening, and concerns expressed in the literature regarding these recommendations.

RECENT FINDINGS

A group of experts have recently recommended universal predischarge bilirubin screening to identify newborns at risk for developing severe neonatal hyperbilirubinemia. In contrast, the United States Preventive Services Task Force states that there is insufficient evidence to make this recommendation. Transcutaneous bilirubinometry has emerged as a noninvasive, quick method to screen for neonatal hyperbilirubinemia, although refinement and validation of transcutaneous bilirubin nomograms are needed. Newer studies suggest that the combined use of a predischarge bilirubin and gestational age risk assessment offers a simple, objective, and accurate way to identify infants at risk for subsequent, severe hyperbilirubinemia.

SUMMARY

All newborns should be systematically assessed for risk of developing severe hyperbilirubinemia prior to hospital discharge. Although limited data exist to recommend its use universally, predischarge bilirubin screening should be considered given recent expert opinion. The role of transcutaneous bilirubinometry remains promising, although further research evaluating and validating its use in varied and diverse populations is imperative. Combined models of risk assessment may offer the best approach to identifying infants at risk for subsequent, severe hyperbilirubinemia.

Transcutaneous bilirubin levels in healthy term and late preterm Indian neonates

OBJECTIVE

To provide normative data for transcutaneous bilirubin (TcB) measurements in healthy term and late-preterm Indian neonates during first 72 h of age using a multiwavelength reflectance transcutaneous bilimeter.

METHODS

TcB measurements were performed in healthy neonates (gestation 35 wk), in a well-baby ward, using a multiwavelength transcutaneous bilimeter (BiliCheck, SpectRx Inc, Norcross, GA). Age-specific percentiles values for each 6-h epoch starting at 0 h of age were calculated and an age-specific TcB nomogram was developed using different percentile values. Diagnostic ability of each percentile curve for prediction of hyperbilirubinemia, defined as requirement of phototherapy, was calculated.

RESULTS

We performed 925 TcB measurements on 625 healthy newborn infants (gestation: 35 to 41 wk; age: 0 to 72 h; mean birth weight: 2808+/-437 g). TcB increased in a linear manner with maximum rate of rise observed during first 24 h of age (50th percentile: 0.22 mg/dL/h). 50th percentile curve of age-specific TcB nomogram had high negative predictive value (99.8%) and acceptable positive predictive value (16.4%) for prediction of hyperbilirubinemia.

CONCLUSION

We provided age-specific nomogram of TcB for first 72 h of age in healthy term and late-preterm Indian neonates. Percentile curves and rate of rise in TcB may help in identification of neonates at low-risk of development of hyperbilirubinemia facilitating their safer discharge from the hospital. Diagnostic utility of this nomogram for predicting hyperbilirubinemia needs to be tested in a separate validation cohort.

Transcutaneous bilirubin levels for the first 120 postnatal hours in healthy neonates

OBJECTIVE

The objective of this study was to provide data on transcutaneous bilirubin (TcB) levels for the first 120 postnatal hours and to develop an hour-specific TcB nomogram for healthy term and near-term neonates.

METHODS

From September 2005 to August 2008, we obtained 14864 TcB measurements from 2818 healthy neonates (gestational age >or= 35 weeks and birth weight >or= 2000 g). All measurements were performed with the BiliCheck bilirubinometer, at designated times from 12 to 120 postnatal hours. TcB percentiles for each designated time were calculated and used for the development of an hour-specific nomogram. TcB percentiles for neonates who required phototherapy are also presented.

RESULTS

The developed TcB nomogram reflects the natural history of TcB levels in healthy neonates up to the fifth postnatal day. A different pattern of TcB increasing rate was noted in neonates who did and did not require phototherapy but with substantial overlap of TcB values between the 2 groups.

CONCLUSIONS

We provide data on TcB levels for the first 120 postnatal hours from a large population of white, healthy, term and near-term neonates. We also present a percentile-based TcB nomogram designated for noninvasive and hour-specific evaluation of neonatal hyperbilirubinemia.

Bhutani-based nomograms for the prediction of significant hyperbilirubinaemia using transcutaneous measurements of bilirubin

AIM

Prospectively establish the relationship between transcutaneous bilirubin (TcB) and total serum bilirubin (TSB), and develop nomograms similar to Bhutani's nomograms, based on our TcB data.

METHODS

Our study sample was from a total population of 1069 infants, near term and term healthy newborns, admitted during 2.5 month period of the study. TSB was performed on all infants who were felt to be clinically jaundiced. Before obtaining the TSB, a TcB was performed (Jaundice Meter Minolta/Draeger JM-103). Measurements were performed on two sites: forehead and mid-sternum, and the mean of both measurements was calculated.

RESULTS

A total of 1091 paired measurements were obtained from 628 infants. Linear regression showed a significant relation between TSB and TcB (R(2) of 0.846). In multiple regression analysis, all independent variables studied, i.e. gestational age (or birthweight), age at sampling and ethnicity had a negligible influence on the relationship. We subsequently developed our local-nomograms of hour-specific mean TcB with 40, 75 and 95 percentile lines.

CONCLUSIONS

In our local settings and population, we found a reliable correlation between laboratory measurements of TSB and TcB. We were able to develop our local-Bhutani-based TcB nomograms for screening babies during hospital stay and pre-discharge for assessing the risk of hyperbilirubinaemia.

Does measuring the changes in TcB value offer better prediction of Hyperbilirubinemia in healthy neonates?

OBJECTIVE

We evaluated the diagnostic value of changes in transcutaneous bilirubin (TcB) levels for prediction of subsequent hyperbilirubinemia in healthy term and late-preterm neonates.

METHODS

Neonates at 35 weeks of gestation were enrolled in a prospective study. Two TcB determinations were performed for all enrolled neonates (N = 358). The first assessment (TcB(1)) was performed at 24 +/- 6 hours of age, followed by a second (TcB(2)) >or=12 hours later. Changes in TcB levels were calculated. TcB values were plotted on an hour-specific serum bilirubin nomogram, and risk zones were recorded. Of the 358 neonates enrolled, 325 neonates (91%) were monitored for hyperbilirubinemia until 5 days of age.

RESULTS

The mean ages of TcB(1) and TcB(2) estimations were 23 +/- 4 hours and 42 +/- 4 hours, respectively. A total of 14.9% of neonates (48 of 325 neonates) developed hyperbilirubinemia by 5 days of age. The sensitivity, specificity, and positive and negative likelihood ratios for prediction of subsequent hyperbilirubinemia for TcB(1) (zone >2, >75th percentile) were 80.4%, 58.0%, 1.9, and 0.34; those for TcB(2) (zone >2, >75th percentile) were 82.6%, 79.0%, 4.0, and 0.22; and those for the change in TcB levels (>0.18 mg/dL per hour, >75th percentile) were 82.5%, 82.9%, 4.8, and 0.21, respectively. Gestational age, TcB risk zone, and change in TcB levels were found to be independent predictors of subsequent hyperbilirubinemia.

CONCLUSIONS

Single TcB measurements at 30 to 48 hours predict hyperbilirubinemia with a reasonably high degree of accuracy. Changes in TcB levels do not offer any added clinical benefit.

Implementing and validating transcutaneous bilirubinometry for neonates

Noninvasive, transcutaneous bilirubin (TcB) measurement is an attractive option for neonates, but opinions about its usefulness vary among studies. We collected paired measurements of TcB and serum bilirubin (SB) in 343 term neonates using the BiliCheck meter (SpectRx, Norcross, GA) and 3 different SB methods. Correlations between SB and TcB were similar for all laboratory methods and TcB measurement sites. However, TcB bias varied depending on the comparison SB method and TcB measurement site. TcB bias also varied with race when measurements were done on the forehead but not when they were done on the sternum. Several factors must be considered before implementing TcB measurement: (1) Each laboratory instrument has its own unique relationship to TcB. (2) The chosen measurement site affects the relationship. (3) Race can affect TcB bias when the measurement is taken on the forehead. Properly used, TcB measurement, especially when taken from the sternum, can be a useful screening method for neonatal jaundice.

Neonatal hyperbilirubinemia and early discharge from the maternity ward

Early discharge from the maternity hospital is almost becoming the rule: it is not clear if this practice actually increases the rate of newborn rehospitalization, but it surely poses some problems for jaundice management, since hyperbilirubinemia is the most frequent reason for hospital readmission. Available guidelines for jaundice management and early discharge are reviewed. Evidence-based update is given about four new points: use of gestational age as predictor jointly with the nomogram evaluation, two-point bilirubin assay, and rate of rise evaluation; choice of the "right" curve and unforeseen jaundice risk factors. In conclusion, available predictive tools allow reliable jaundice prediction and safe early discharge if adequate follow-up is planned according to the prediction. Advice about things to avoid is provided together with a practical flowchart based on guidelines and recent evidence-based data.

Hyperbilirubinemia and Transcutaneous Bilirubinometry

Background: Neonatal jaundice or hyperbilirubinemia is a common occurrence in newborns. Although most cases of neonatal jaundice have a benign course, severe hyperbilirubinemia can lead to kernicterus, which is preventable if the hyperbilirubinemia is identified early and treated appropriately.

Content: This review discusses neonatal jaundice and the use of transcutaneous bilirubin (TcB) measurements for identification of neonates at risk of severe hyperbilirubinemia. Such a practice requires appropriate serial testing and result interpretation according to risk level from a nomogram that provides bilirubin concentrations specific for the age of the neonate in hours. In this context, we have evaluated the potential impact on clinical outcome and limitations of TcB methods in current use.

Summary: TcB measurement is a viable option in screening neonates to determine if they are at risk for clinically significant hyperbilirubinemia. Total serum bilirubin should be measured by a clinical laboratory if a newborn is shown to be at higher risk for clinically significant hyperbilirubinemia. In addition, external quality assessment to identify biases and operator training issues should be part of any TcB monitoring program.