Transcutaneous bilirubinometry reduces the need for blood sampling in neonates with visible jaundice

Modified Kramer's versus Kramer's Method for Clinical Assessment of Jaundice in Term and Near-Term Neonates

OBJECTIVES

To compare the performance of Modified Kramer's and Kramer's methods in terms of agreement with total serum bilirubin (TSB).

METHODS

This cross-sectional study was done in Level-III neonatal unit in New Delhi. Visibly jaundiced neonates born at ≥35 wk of gestation were enrolled and examined by (i) conventional Kramer's, (ii) Modified Kramer's in artificial (MK-A) and (iii) natural daylight (MK-N), and finally sampled for estimation of TSB by point-of-care spectrophotometry. The primary outcomes were agreement of Kramer's and Modified Kramer's with TSB and accuracy in terms of proportion of bilirubin estimates lying within ±2 mg/dL of TSB; secondary outcome was agreement of MK-A and MK-N with TSB.

RESULTS

A total of 144 neonates with median gestation of 37 wk and mean birth weight of 2788 g were enrolled. Bland Altman analysis between Kramer's and TSB yielded mean difference of 1.7 mg/dL, 95% limits of agreement (LOA) -3.1 to 6.6 mg/dL. For Modified Kramer's and TSB, mean difference was -0.02 mg/dL, 95% LOA -4.7 to 4.7 mg/dL under artificial light; 0.02 mg/dL, 95% LOA -4.2 to 4.2 mg/dL under natural daylight. MK-N had highest proportion of bilirubin estimates lying within ±2 mg/dL of TSB (68.7%) as compared to MK-A (59.7%) [OR, 1.77; 95% CI, 1.09 to 2.86] and Kramer's (45.8%) [OR, 1.65; 95% CI, 1.27 to 2.15].

CONCLUSIONS

Though all the three methods had poor agreement with TSB, Modified Kramer's method when performed in natural light had reasonable accuracy, however limited clinical utility, in evaluation of clinical jaundice.

Universal screening for hyperbilirubinemia in term healthy newborns at discharge: A systematic review and meta-analysis

Background

All term healthy neonates are screened for jaundice before hospital discharge as a standard clinical practice, but methods vary from clinical screening (visual inspection and/or risk factor assessment) to transcutaneous bilirubin (TcB) or total serum bilirubin (TSB) testing, depending on the setting.

Methods

This systematic review of randomized and non-randomized studies evaluated the effectiveness of universal TcB and universal TSB screening at discharge compared to clinical screening alone for term healthy neonates. The outcomes were neonatal mortality, readmission for jaundice, severe hyperbilirubinemia (>20 mg/dL), jaundice requiring exchange transfusion, and bilirubin-induced neurological dysfunction (BIND). We searched MEDLINE via Ovid, EBM reviews, Embase, CINAHL, clinical trials databases, and reference lists of retrieved articles. Two authors separately evaluated the risk of bias, extracted data, and synthesized effect estimates using relative risk (RR) for randomized and odds ratio (OR) for non-randomized studies.

Results

For universal TcB at discharge, we included one randomized trial enrolling 1858 participants and four non-randomized studies enrolling 375 956 participants. No study reported neonatal mortality. The randomized trial suggested that universal TcB at discharge may decrease readmission for jaundice (risk ratio (RR) = 0.24, 95% confidence interval (CI) = 0.13 to 0.46; low certainty evidence) and severe hyperbilirubinemia (RR = 0.27, 95% CI = 0.08 to 0.97; low certainty evidence), but the effect on jaundice requiring exchange transfusion (RR = 0.20, 95% CI = 0.01 to 41.6) and BIND (RR = 0.33, 95% CI = 0.01 to 8.17) was uncertain. Meta-analysis of non-randomized studies suggested that TcB may decrease severe hyperbilirubinemia (odds ratio (OR) = 0.25, 95% = CI 0.12 to 0.52; low certainty evidence) and jaundice requiring exchange transfusion (OR = 0.28, 95% CI = 0.19 to 0.42; low certainty evidence), but the effect on readmission for jaundice was uncertain (OR = 1.01, 95% CI = 0.38 to 2.7; very low certainty evidence). For universal TSB, we included three studies from the United States enrolling 490 426 participants. The effect on severe hyperbilirubinemia (OR = 0.37, 95% CI = 0.15 to 0.88), jaundice requiring exchange transfusion (OR = 0.53, 95% CI = 0.13 to 2.25) and readmission for jaundice (OR = 1.01, 95% CI = 0.62 to 1.67) was uncertain.

Conclusions

Universal TcB at discharge may improve clinical outcomes for term healthy neonates. Evidence for universal TSB is uncertain.

Registration

PROSPERO 2020 CRD42020187279.

Reducing Outpatient Infant Blood Draws with Transcutaneous Measurement of Bilirubin

Introduction:

Newborn jaundice is a common outpatient problem. Transcutaneous bilirubin (TcB) measurements correlate well with total serum bilirubin (SB) measurements below 15 mg/dl and are efficient and noninvasive. Some concern exists that TcB measurement may subsequently lead to an increase in the number of SB measurements performed in the outpatient setting. We aimed to implement the use of a TcB device in an outpatient clinic. By doing so, we sought to increase the number of newborns screened solely by TcB as opposed to SB, by 30%, within 12 months.

Methods:

We conducted plan-do-study-act cycles with targeted interventions to promote the use of TcB in an outpatient clinic for eligible newborns older than 35 weeks gestational age, aged 1–20 days, and without a history of transfusion, phototherapy, extensive bruising, or risk of hemolysis. We used statistical process control methods to measure proportions of newborns evaluated with TcB (run chart) and patients-between SB measurements (G-chart) over time in the outpatient clinic.

Results:

We collected preintervention data for 18-months and intervention data for 12 months. For newborns attending the outpatient clinic, the proportion of TcB measurements increased after implementation of the use of TcB measurement. There was an increase in patients-between SB measurements. At project inception, SB was drawn for every 8 eligible patients. By the end of the project, there were 98 eligible newborns between instances of SB testing.

Conclusion:

Implementation of a quality-improvement initiative to measure TcB in the outpatient clinic was feasible and reduced the number of SB tests.

Validation of transcutaneous bilirubinometry during phototherapy for detection and monitoring of neonatal jaundice in a low-income setting

Background: Severe neonatal jaundice (SNJ) and the associated long-term health sequelae are a significant problem in low-income countries (LIC) where measurement of total serum bilirubin (TSB) is often unavailable. Transcutaneous bilirubinometry (TcB) provides the opportunity for non-invasive, point-of-care monitoring. Few studies have evaluated its agreement with TSB levels during phototherapy in LIC.Aim: To determine agreement between TcB and TSB during phototherapy in a Haitian newborn population and to establish whether TcB can be safely used to guide treatment during phototherapy when TSB is unavailable.Methods: A single-centre prospective study (February to May 2017) in Cap Haïtien, northern Haiti was undertaken. Newborns <7 days of age with clinically detected jaundice were eligible for inclusion. A TcB device (JM-103) was used to screen for newborn jaundice along with a parallel TSB. A strip of black tape was placed across the sternum during phototherapy and uncovered for subsequent TcB measurements. Decisions about phototherapy treatment were based upon UK National Institute of Clinical Excellence (NICE) threshold criteria. Paired TSB and TcB measurements were compared using Bland-Altman methods.Results: The final analysis included 70 parallel TSB/TcB measurements from 35 infants within the first 5 days of life. Nineteen (54.3%) were male and 12 (34.3%) were <35 weeks. Thirty-two (91.4%) were receiving phototherapy. There was good agreement between TSB and TcB. Compared with TSB, TcB tended to over-estimate bilirubin (mean difference 11.1 µmol/L, 95% CI -10.2-32.5 µmol/L). However, at higher bilirubin levels (>250 µmol/L), TcB tended to under-estimate bilirubin compared with TSB and the difference increased.Conclusion: In an LIC setting in which serum bilirubin testing is not commonly available, TcB demonstrates good agreement with TSB and can be safely used to guide jaundice treatment during phototherapy but can lead to over-treatment at lower bilirubin levels and are more inaccurate at higher levels. For TcB levels >250 µmol, confirmation with serum bilirubin should be performed, if available, to avoid under-estimation.Abbreviations: LIC: low income countries; LMIC: low and middle income countries; TcB: transcutaneous bilirubinometry; TSB: transcutaneous serum biliubin.

Diagnosis of acute serious illness: the role of point-of-care technologies

Access to rapid diagnostic information is a core value of point-of-care (POC) technology. This is particularly relevant in acute, emergency, and critical care settings where diagnostic speed and precision directly guide the management of patients with potentially life-threatening conditions. Many POC diagnostics described in the literature, however, remain largely unproven and have yet to enter the market entirely. Only a few have traversed the translation and commercialization pathways to reach widespread clinical adoption. Moreover, even technologies that have successfully translated to the patient bedside still frequently lack an evidence base showing improvement of clinical outcomes. In this review, we present aspects of diagnosis of acute life-threatening diseases and describe the potential role of POC technologies, emphasizing the available evidence of clinical outcomes. Finally, we discuss what is needed to identify clinically meaningful new technologies and translate them toward the long-promised goal of better health through rapid POC diagnosis.

Transcutaneous bilirubin nomogram for Taiwanese newborns - A single center study

BACKGROUND

Hour-specific bilirubin nomogram has been recommended to predict postdischarge hyperbilirubinemia in newborns. However, it may not be applicable in Taiwan due to ethnic differences. The aim of this study was to construct a 12-h specific transcutaneous bilirubin (TCB) nomogram in newborns for clinical reference.

METHODS

We prospectively enrolled full term or late preterm neonates born in a tertiary care hospital between October 2013 and July 2014. The exclusion criteria included chromosome anomaly, glucose-6-phosphate dehydrogenase deficiency, and receiving phototherapy within 60 h after birth. TCB measurements were performed by a single technician using the Bilichek device, and measured every 12 h until neonates were discharged. Patient data including sex, delivery mode, gestational age, body weight with daily change, and feeding pattern were collected for analysis. A TCB nomogram was constructed with 40th, 75th, and 95th percentile lines.

RESULTS

A total of 498 newborns were enrolled, and the characteristics between the hyperbilirubinemia and nonhyperbilirubinemia groups were not different. The mean TCB curve revealed that the peak TCB level was 14.2 ± 2.9 mg/dL at 100.6 ± 3.6 h of age. The peak 95th percentile TCB level was 19.4 mg/dL at 121.9 ± 5 h of age. Mean TCB levels increased at a rate of 0.01-0.21 mg/dL/h initially, followed by a decrease after 96-108 h of age. Twenty newborns (4%) were diagnosed with hyperbilirubinemia. Regarding TCB distribution, 11 of 60 (18%) had peak TCB levels above the 95th percentile, 5 of 151 (3%) had TCB levels between the 75th and 95th percentile, 4 of 200 (2%) had levels between the 40th and 75th percentiles, and none had a level below the 40th percentile.

CONCLUSION

A 12-h specific TCB nomogram could be a useful reference for workup for hyperbilirubinemia, particularly when it is above the 95th percentile line.

A Prospective Comparison of Transcutaneous and Serum Bilirubin Within Brief Time Intervals

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.

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 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.

Reliability of transcutaneous bilirubinometry from shielded skin in neonates receiving phototherapy: a prospective cohort study

OBJECTIVE

To determine the agreement between transcutaneous bilirubin (TcB) measured from shielded skin and serum total bilirubin (STB) in infants (34 to 41 weeks of gestation) with hyperbilirubinemia receiving phototherapy (PT).

STUDY DESIGN

In this prospective cohort study, we shielded a small area of skin on sternum using a commercial photo-opaque patch (BilEclipseTM, Philips Respironics, Murrysville, PA, USA). The TcB from the shielded skin (TcBs) and STB were measured at four time points-before initiation, 12 and 24 h during and once after (12 h) cessation of PT. TcB was measured using multiwavelength transcutaneous bilirubinometer (BiliChek, Philips Children's Medical Ventures, Monroeville, PA, USA). The STB was measured in triplicate by spectrophotometry (Apel BR 5100, APEL, Japan). Bland and Altman plots were drawn to determine agreement between the TcBs and STB.

RESULTS

The gestation and birth weight of enrolled neonates were 37.0 (1.0) weeks and 2750 (458) g, respectively. The age at initiation and duration of PT were 75 (27 to 312) and 25.3 (4.4) h, respectively. Bland and Altman plot showed poor agreement between TcBs and STB at all time points. The gradient (median, range) between TcBs and STB at 0, 12, 24 h and 12 h after cessation of PT were -0.2 (-4.9 to 3.5), 1.4 (-4.7 to 4.0), 1.5 (-3.8 to 9.4) and 2 (-2.9 to 5.8) mg dl^-1. The proportions of TcBs values outside ±1.5 mg dl^-1 of STB ranged from 47 to 64% at four time points.

CONCLUSION

TcBs does not appear to be reliable for estimating serum bilirubin in late preterm and term neonates receiving PT.

[Management of jaundice in the newborn≥35 GW: From screening to follow-up after discharge. Guidelines for clinical practice]

Jaundice due to unconjugated bilirubin is an everyday condition in the neonatal period because it results from the adaptation of bilirubin metabolism at this time of life. Hyperbilirubinemia has a potential neurotoxicity and although it most often resolves spontaneously, it can lead to acute and sometimes chronic encephalopathy. The latter condition is called kernicterus and induces severe and irreversible neurological sequelae. This rare complication is still reported in all countries throughout the world even if severe hyperbilirubinemia can be prevented and critical points points of failure in jaundice management are identified. Jaundice management are identified, jaundice is the most frequent symptom during the first days of life and after discharge from the maternity ward but also the major cause of readmission in the 15 first days of life. Therefore in the past 20 years, numerous countries have written national practical guidelines for the management of neonatal jaundice using various methodologies. Most of the time, the guidelines resulted from expert consensus more than from an evidence-based argument. The Société française de néonatologie created a working group to provide the first French clinical guidelines for the management of jaundice in the near-term newborn (35 weeks and more). They were written following a physiopathological argument and taking into account both clinical risk factors for severe hyperbilirubinemia and interindividual variability in vulnerability to bilirubin neurotoxicity. Practical tools were also developed to facilitate implementation of the guidelines and are also included.

Use of Transcutaneous Bilirubin to Determine the Need for Phototherapy in Resource-Limited Settings

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.

Transcutaneous Bilirubinometry in Jaundiced Neonates: A Randomized Controlled Trial

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.

Transcutaneous bilirubin measurement to estimate serum bilirubin in neonates in a multi-ethnic cohort: a literature review

Neonatal jaundice (NNJ) is common in Singapore and is usually monitored with serum bilirubin (SB). This paper reviews literature on the accuracy of transcutaneous bilirubin (TcB) measurement compared to SB to monitor jaundice in neonates of major ethnic groups of Singapore, i.e. Chinese, Malay, and Indian. 15 studies with Chinese babies, 5 with Malay babies, and 15 with Indian babies were identified (total of 28 articles, some with more than one race). Correlation coefficient is good for all three races. Chest is a better site for TcB measurement than forehead, though both are good. Infants with TcB levels more than 160–200 μmol/L should have SB checked. While post-phototherapy infants may benefit from TcB 24 hours after cessation of phototherapy, more needs to be done to ascertain its usefulness. Premature babies should have SB measurements. TcB measurement is suitable to monitor NNJ in term and healthy Chinese, Malay, and Indian babies.

Implementation of a neonatal transcutaneous bilirubin screening programme in rural India

BACKGROUND

Universal pre-discharge assessment of risk for neonatal hyperbilirubinaemia is recommended by the American Academy of Pediatrics. A common algorithm is universal transcutaneous bilirubin (TcB) screening, followed by confirmatory total serum bilirubin (TSB) testing for results which cause concern. There is a paucity of data on the feasibility of TcB screening in low-income settings.

OBJECTIVES

To evaluate the acceptability and feasibility of implementing universal TcB screening at a resource-limited hospital in rural India, and to determine if it was associated with increased recognition of high-risk hyperbilirubinaemia.

METHODS

In December 2012 at Vivekananda Memorial Hospital, Karnataka, India, universal TcB screening at 24-48 hours of life was implemented, with TSB estimated if TcB was >75th percentile for age. The proportion of families that provided consent and the proportion of infants who underwent TcB and TSB testing were calculated. The rates of phototherapy pre- and post-implementation and the rate of high-risk hyperbilirubinaemia (TSB >95th percentile for age) post-implementation among infants ≥ 35 weeks gestation were determined.

RESULTS

Parents of 568 of 660 (86%) eligible infants consented to participation. All of these infants were screened with TcB. The proportion who had TSB testing was similar in the pre- (6%) and post-implementation (7%) periods. The rate of phototherapy was not significantly different after implementation (2% vs 3%). Five cases of high-risk hyperbilirubinaemia were identified post-implementation.

CONCLUSIONS

The study demonstrates the acceptability and feasibility of universal TcB screening at a resource-limited hospital in rural India. In settings in which early post-discharge follow-up cannot be assured, TcB can play a valuable role in identifying infants who need evaluation.

Pre-Discharge Screening Trans-Cutaneous Bilirubinometry in Healthy Newborns in Mahdieh Hospital, Tehran

BACKGROUND

Incidence of jaundice is high in newborn infants. Since well appearing newborns are rapidly and routinely discharged from hospital, performing an inexpensive noninvasive pre-discharge screening test for evaluation of jaundice seems to be necessary.

OBJECTIVES

This study was conducted to compare the accuracy of cutaneous v/s serum bilirubin measurements in this regard.

PATIENTS AND METHODS

This was a prospective cross sectional study conducted in Mahdieh hospital, Tehran. 613 neonates weighing ≥ 1,800 g with gestational age of ≥ 35 weeks were enrolled. A pre discharge transcutaneous bilirubin test (TcB) was performed in all. Serum samples were taken from neonates with TcB ≥ 5 mg/dL in first and > 8 mg/dL in second 24 hours. Decision for treatment or recheck of bilirubin level after discharge was made based on serum bilirubin results.

RESULTS

Based on the study protocol, among 613 studied neonates, 491 (80%) revealed high TcB, of them 240 (49%) cases showed TBC ≥ 5 mg/dL in first and 251 (51 %) in second pre-discharge 24 hours. TcB ranged 3.3 - 17.1, mean TcB in first 24 hours was 6.9 ± 1 .7 (mode 6) and in second 24 hours 9.1 ± 2.1 (mode 10). Of 491 neonates with high TcB, capillary serum sample was taken as the second step and 398 neonates revealed high total serum bilirubin (TsB) with the same protocol for TcB. 108 (27.1%) neonates showed TsB ≥ 5 mg/dL in first and 290 (72.9%) in second 24 hours. According to the study results TcB has a 81% positive predictive value (PPV) in diagnosis of hyperbilirubinemia. Correlation coefficient of TcB and TsB in highest rate is equal to 72% (P value < 0.001).

CONCLUSIONS

TcB is an inexpensive, noninvasive and precise pre-discharge screening test for evaluation of hyperbilirubinemia, with a high PPV. It is highly recommended to be performed routinely due to high incidence of hyperbilirubinemia in neonates.

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.

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.

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.

Predischarge non-invasive risk assessment for prediction of significant hyperbilirubinemia in term and late preterm neonates

OBJECTIVE

To evaluate efficacy of predischarge transcutaneous bilirubin (TcB) measurement and clinical risk assessment in predicting hyperbilirubinemia needing treatment.

STUDY DESIGN

A diagnostic test was performed in a prospective cohort study conducted at a teaching hospital in North India. Subjects included healthy neonates with a gestation period of ≥35 weeks or birth weight ≥2000 g. Maternal, neonatal and delivery risk factors for hyperbilirubinemia were prospectively collected. TcB was measured in all enrolled neonates at 24±6, 72 to 96 and 96 to 144 h of postnatal age and when indicated clinically. Neonates were followed up during hospital stay and after discharge till completion of the 7th postnatal day. The key outcome was significant hyperbilirubinemia defined as need of phototherapy on the basis of modified American Academy of Pediatrics guidelines. In neonates born at ≥38 weeks of gestation and in neonates born at ≤37 completed weeks of gestation, middle line and lower line of phototherapy thresholds were used to initiate phototherapy, respectively. Variables observed to be significantly associated with significant hyperbilirubinemia on multivariate analysis were used for construction of a clinical risk assessment tool. Predictive ability of the risk assessment tool was assessed by calculating sensitivity, specificity, positive predictive value and negative predictive value, by plotting receiver-operating characteristics curve and calculating c-statistic.

RESULT

A total of 997 neonates (birth weight: 2627±536 g, gestation: 37.8±1.5 weeks) were enrolled in the study, of which 931 completed follow-up. Among enrolled neonates, 344 (34.5%) were low birth weight. Overall, a total of 199 (20%) neonates developed significant hyperbilirubinemia. On stepwise logistic regression analysis, predischarge TcB percentile and gestation were significantly found to be associated with significant hyperbilirubinemia. A risk assessment graph was constructed to predict subsequent development of significant hyperbilirubinemia. Area under curve for this risk assessment strategy was 0.75.

CONCLUSION

A risk assessment graphical tool consisting of TcB and gestation accurately predicted subsequent need of phototherapy. Further studies are needed to validate performance of this risk assessment tool.

An evidence-based view on hyperbilirubinaemia

INTRODUCTION

We conducted a review of the evidence which contributes to the current care of jaundiced newborn infants.

METHODS

Literature was searched for reviews and randomized controlled trials (RCTs).

RESULTS

Six Cochrane reviews and eight other reviews and eighteen recent RCTs are discussed.

CONCLUSIONS

Many children still suffer life-long consequences of severe hyperbilirubinaemia, which could almost always have been prevented relatively easily. Up to date, guidelines summarizing the available evidence into unambiguous recommendations are needed to guide healthcare professionals in the prevention, diagnosis and treatment for infants with hyperbilirubinaemia.

Impact of a transcutaneous bilirubinometry program on resource utilization and severe hyperbilirubinemia

OBJECTIVES

Our goal was to assess the impact of programmatic and coordinated use of transcutaneous bilirubinometry (TcB) on the incidence of severe neonatal hyperbilirubinemia and measures of laboratory, hospital, and nursing resource utilization.

METHODS

We compared the neonatal hyperbilirubinemia-related outcomes of 14 796 prospectively enrolled healthy infants ≥35 weeks gestation offered routine TcB measurements in both hospital and community settings by using locally validated nomograms relative to a historical cohort of 14 112 infants assessed by visual inspection alone.

RESULTS

There was a 54.9% reduction (odds ratio [OR]: 2.219 [95% confidence interval (CI): 1.543-3.193]; P < .0001) in the incidence of severe total serum bilirubin values (≥342 µmol/L; ≥20 mg/dL) after implementation of routine TcB measurements. TcB implementation was associated with reductions in the overall incidence of total serum bilirubin draws (134.4 vs 103.6 draws per 1000 live births, OR: 1.332 [95% CI: 1.226-1.446]; P < .0001) and overall phototherapy rate (5.27% vs 4.30%, OR: 1.241 [95% CI: 1.122-1.374]; P < .0001), a reduced age at readmission for phototherapy (104.3 ± 52.1 vs 88.9 ± 70.5 hours, P < .005), and duration of phototherapy readmission (24.8 ± 13.6 vs 23.2 ± 9.8 hours, P < .05). There were earlier (P < .01) and more frequent contacts with public health nurses (1.33 vs 1.66, P < .01) after introduction of the TcB program.

CONCLUSIONS

Integration of routine hospital and community TcB screening within a comprehensive public health nurse newborn follow-up program is associated with significant improvements in resource utilization and patient safety.

Universal bilirubin screening for severe neonatal hyperbilirubinemia

To reduce the incidence of severe neonatal hyperbilirubinemia affecting newborns with jaundice in the United States and to prevent kernicterus, there is a need to implement proven prevention strategies for severe neonatal hyperbilirubinemia as recommended in the 2004 American Academy of Pediatrics Guidelines for newborns >35 weeks gestational age. The purpose of universal predischarge bilirubin screening is to identify infants with bilirubin levels >75th percentile for age in hours and track those with rapid rates of bilirubin rise (>0.2 mg per 100 ml per h). Early identification has been reported to predict severe hyperbilirubinemia and allow for evidence-based targeted interventions. A systems approach is likely to reduce the preventable causes of acute bilirubin encephalopathy. To do so, highest priority should be given to (i) designating extreme hyperbilirubinemia (total serum bilirubin >427 μmol l(-1) or >25 mg per 100 ml) as a reportable condition by laboratories and health-care providers through public health mandates; (ii) implementation of Joint Commission's Sentinel Report for kernicterus; (iii) nursing outreach to communities for education of prospective parents; (iv) development of clinical pathways to monitor, evaluate and track infants with extreme hyperbilirubinemia; and (v) societal awareness. These efforts should be monitored by a state and national surveillance system in order to critically improve the timeliness and completeness of notifications and to allow evaluation and interventions at the policy and individual family level.