Transcutaneous Bilirubinometry in Jaundiced Neonates: A Randomized Controlled Trial

Transcutaneous bilirubinometry for detecting jaundice in term or late preterm neonates

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Neonatal jaundice detection in low-resource Mexican settings: possibilities and barriers for innovation with mobile health

BACKGROUND

Neonatal jaundice is a common condition that can lead to brain damage and disabilities when severe cases go undetected. Low- and middle-income countries often lack accurate methods for detecting neonatal jaundice and rely on visual assessment, resulting in a higher incidence of adverse consequences. Picterus Jaundice Pro (Picterus JP), an easy-to-use and affordable smartphone-based screening device for the condition, has demonstrated higher accuracy than visual assessment in Norwegian, Philippine and Mexican newborns. This study aimed to identify the barriers and facilitators to implementing Picterus JP in public health services in low-income settings in Mexico by exploring the current process of neonatal jaundice detection and stakeholders' perspectives in that context.

METHODS

Qualitative data collection techniques, including one focus group, 15 semi-structured interviews and four observations, were employed in urban and rural health facilities in Oaxaca, Mexico. The participants included medical doctors, nurses and health administrators. The data were analysed by thematic analysis guided by the Consolidated Framework for Implementation Research.

RESULTS

The analysis yielded four main themes: (I) the current state of neonatal care and NNJ detection, (II) the needs and desires for enhancing NNJ detection, (III) the barriers and facilitators to implementing Picterus JP in the health system and (IV) HCWs' expectations of Picterus JP. The findings identify deficiencies in the current neonatal jaundice detection process and the participants' desire for a more accurate method. Picterus JP was perceived as easy to use, useful and compatible with the work routine, but barriers to adoption were identified, including internet deficiencies and costs.

CONCLUSIONS

The introduction of Picterus JP as a supporting tool to screen for neonatal jaundice is promising but contextual barriers in the setting must be addressed for successful implementation. There is also an opportunity to optimise visual assessment to improve detection of neonatal jaundice.

Skin color influences transcutaneous bilirubin measurements: a systematic in vitro evaluation

OBJECTIVE

Concerns have been raised about the effect of skin color on the accuracy of transcutaneous bilirubin (TcB) measurements, a widely used method for hyperbilirubinemia diagnosis in newborns. Literature is inconclusive, with both reported under- and overestimations of the TcB with increasing skin pigmentation. Therefore, the influence of skin color on TcB measurements was systematically evaluated in a controlled, in vitro setting.

METHODS

A bilirubin meter (JM-105) was evaluated on layered phantoms that mimic neonatal skin with varying dermal bilirubin concentrations (0-250 µmol/L) and varying epidermal melanosome volume fractions (0-40%; light-dark skin color).

RESULTS

TcB measurements were influenced by skin pigmentation. Larger mimicked melanosome volume fractions and higher bilirubin levels led to larger underestimations of the measured TcB, compared to an unpigmented epidermis. In the in vitro setting of this study, these underestimations amounted to 26-132 µmol/L at a TcB level of 250 µmol/L.

CONCLUSION

This in vitro study provides insight into the effect of skin color on TcB measurements: the TcB is underestimated as skin pigmentation increases and this effect becomes more pronounced at higher bilirubin levels. Our results highlight the need for improved TcB meter design and cautious interpretation of TcB readings on newborns with dark skin.

IMPACT

Key message: Skin color influences transcutaneous bilirubin measurements: the darker the skin, the larger the underestimation. What this study adds to existing literature: Existing literature is inconclusive regarding the influence of skin color on transcutaneous bilirubin measurements. This study systematically evaluates and clarifies the influence of skin color on transcutaneous bilirubin measurements in a controlled, in vitro setting.

IMPACT

This study aids to better interpret the measured TcB level in patients with varying skin colors, and is particularly important when using TcB meters on patients with dark skin colors.

Transcutaneous Bilirubin Accuracy Before, During, and After Phototherapy: A Meta-Analysis

CONTEXT

Transcutaneous bilirubinometry (TcB) is used as a valid screening to identify neonates requiring measurement of total serum bilirubin (TSB) before phototherapy. Its use during and after phototherapy is not advised yet because of unknown reliability.

OBJECTIVES

To determine the agreement of TcB and TSB measurements before, during, and after phototherapy.

DATA SOURCES

PubMed Medline, Cochrane Library, and references of eligible studies were searched.

STUDY SELECTION

Prospective and retrospective cohort and cross-sectional studies reporting Bland-Altman statistics of paired TcB and TSB measurements in term and preterm newborns.

DATA EXTRACTION

Meta-analysis was performed using the Mantel-Haenszel weighted approach. The agreement between TcB and TSB in μmol/L was described by pooled mean differences (MDs) and limits of agreement (LoA).

RESULTS

Fifty-four studies were included. The pooled MD before phototherapy is 2.5 μmol/L (LoA -38.3 to 43.3). The pooled MD during phototherapy is -0.3 μmol/L (LoA -34.8 to 34.2) on covered skin and -28.6 μmol/L (LoA -105.7 to 48.5) on uncovered skin. The pooled MD after phototherapy is -34.3 μmol/L (LoA -86.7 to 18.1) on covered skin and -21.1 μmol/L (LoA -88.6 to 46.4) on uncovered skin. Subgroup analysis revealed the best agreement at the forehead. We did not find any difference in agreement between term and preterm neonates.

LIMITATIONS

Language restriction.

CONCLUSIONS

TcB measurements before and during phototherapy on covered skin show good agreement compared with TSB in term and preterm newborns. More studies are needed to evaluate the accuracy after phototherapy.

Transcutaneous bilirubin levels in extremely preterm infants less than 30 weeks gestation

OBJECTIVE

The primary objective of this study was to determine the relationship between transcutaneous bilirubin (TcB) levels and total serum bilirubin (TSB) levels in extremely preterm infants.

STUDY DESIGN

We conducted a prospective multicenter study of extremely preterm infants less than 30 weeks gestation in California. Difference between paired TcB and TSB values were compared based on gestational age, birth weight, maternal race/ethnicity, chronological age as well as during and after phototherapy.

RESULTS

TSB values ranged from 0 to 12.6 mg/dl and the TcB values ranged from 0 to 14.2 mg/dl. TSB was predicted with a high degree of accuracy at TSB = 2.37 + 0.54 (TcB) with r = 0.786. There was good correlation across gestational age, birth weight, race/ethnic, chronological age subgroups as well as during and after phototherapy.

CONCLUSION

Our study supports the use of TcB as a screening tool for monitoring jaundice in extremely preterm infants.

Quantification of cephalocaudal progression of jaundice in preterm infants

BACKGROUND

The cephalocaudal progression (CCP) of neonatal jaundice is a well-known phenomenon, but quantitative information on CCP in preterm infants is absent. In this study, CCP was quantified in preterm infants as a function of postnatal age and body location.

METHODS

5.693 transcutaneous bilirubin (TcB) measurements were performed in 101 preterm infants from birth until postnatal day seven at five body locations (forehead, sternum, hipbone, tibia, ankle). Multi-level linear regression analysis was performed to evaluate the CCP as a function of body location and postnatal age. TcB measurements at all body locations and postnatal days were compared to total serum bilirubin (TSB) levels (N = 1.113).

RESULTS

The overall average change in ratio of TcB compared to forehead was for sternum +0.04 [95% CI -0.02;0.09]; hipbone +0.05 [0.00;0.01]; tibia -0.33 [-0.38;-0.27] and ankle -0.62 [-0.68;-0.57]. No effect modification of CCP by sex, gestational age, birthweight, phototherapy, and TSB was found. The TcB maximally underestimated the TSB at the ankle -79.5 µmol [-0.1;159.2].

CONCLUSIONS

CCP is present in preterm infants and is relatively stable over time. Since TcB measurements on the tibia and ankle underestimate TSB significantly, we advise to use only measurement locations cephalic from the tibia; i.e., hipbone, sternum, and forehead.

IMPACT

Cephalocaudal progression (CCP) of jaundice in preterm infants, assessed by transcutaneous bilirubin (TcB) measurements, is substantial and rather stable over postnatal day 0 to 7. To the best of our knowledge, this study is the first to investigate CCP of jaundice in preterm infants as a function of postnatal age in preterm infants. Our results demonstrate that TcB measurements at the tibia and ankle differ from the TSB beyond the clinically used TcB safety margins. We advise to perform TcB measurements only at locations cephalic from the tibia; i.e., hipbone, forehead, and sternum.

Better assessment of neonatal jaundice at home (BEAT Jaundice @home): protocol for a prospective, multicentre diagnostic study

INTRODUCTION

Severe neonatal hyperbilirubinaemia can place a neonate at risk for acute bilirubin encephalopathy and kernicterus spectrum disorder. Early diagnosis is essential to prevent these deleterious sequelae. Currently, screening by visual inspection followed by laboratory-based bilirubin (LBB) quantification is used to identify hyperbilirubinaemia in neonates cared for at home in the Netherlands. However, the reliability of visual inspection is limited. We aim to evaluate the effectiveness of universal transcutaneous bilirubin (TcB) screening as compared with visual inspection to: (1) increase the detection of hyperbilirubinaemia necessitating treatment, and (2) reduce the need for heel pricks to quantify bilirubin levels. In parallel, we will evaluate a smartphone app (Picterus), and a point-of-care device for quantifying total bilirubin (Bilistick) as compared with LBB.

METHODS AND ANALYSIS

We will undertake a multicentre prospective cohort study in nine midwifery practices across the Netherlands. Neonates born at a gestational age of 35 weeks or more are eligible if they: (1) are at home at any time between days 2 and 8 of life; (2) have their first midwife visit prior to postnatal day 6 and (3) did not previously receive phototherapy. TcB and the Picterus app will be used after visual inspection. When LBB is deemed necessary based on visual inspection and/or TcB reading, Bilistick will be used in parallel. The coprimary endpoints of the study are: (1) hyperbilirubinaemia necessitating treatment; (2) the number of heel pricks performed to quantify LBB. We aim to include 2310 neonates in a 2-year period. Using a decision tree model, a cost-effectiveness analysis will be performed.

ETHICS AND DISSEMINATION

This study has been approved by the Medical Research Ethical Committee of the Erasmus MC Rotterdam, Netherlands (MEC-2020-0618). Parents will provide written informed consent. The results of this study will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

Dutch Trial Register (NL9545).

Cephalocaudal progression of neonatal jaundice assessed by transcutaneous bilirubin measurements

OBJECTIVE

The cephalocaudal progression in neonatal jaundice is a well-known phenomenon. Since transcutaneous bilirubin measurements (TcB) are increasingly applied, for which different body site can be used, we aimed to quantify the cephalocaudal progression of neonatal jaundice through TcB and to assess the influence of gestational age, postnatal age and the degree of hyperbilirubinemia on this cephalocaudal progression.

STUDY DESIGN

In jaundiced neonates ≥32 weeks of gestational age, TcB was measured on 5 sites: forehead, sternum, hipbone, proximal tibia and foot, during the first two weeks of life.

RESULTS

58 neonates were included. Mean ratios of TcB on the 5 sites compared to the forehead were: sternum 1,03 (SD 0,14), hipbone 0,80 (SD 0,16), proximal tibia 0,63 (SD 0,14) and foot 0,44 (SD 0,15). Gestational age, postnatal age nor the degree of hyperbilirubinemia were associated with the cephalocaudal progression (ANOVA p > 0,05).

CONCLUSION

The cephalocaudal progression of neonatal jaundice is evident, with caudal levels of TcB being less than half of cephalic measurements. This implicates that TcB measurements caudal from the sternum are less reliable, and should be avoided. The degree of cephalocaudal progression is not associated with gestational or postnatal age, nor with height of bilirubin levels.

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

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

Inter-device reproducibility of transcutaneous bilirubin meters

BACKGROUND

Transcutaneous bilirubinometry is a widely used screening method for neonatal hyperbilirubinemia. Deviation of the transcutaneous bilirubin concentration (TcB) from the total serum bilirubin concentration (TSB) is often ascribed to biological variation between patients, but variations between TcB meters may also have a role. This study aims to provide a systematic evaluation of the inter-device reproducibility of TcB meters.

MATERIALS AND METHODS

Thirteen commercially available TcB meters (JM-105 and JM-103) were evaluated in vitro on phantoms that optically mimic neonatal skin. The mimicked TcB was varied within the clinical range (0.5-181.3 μmol/L).

RESULTS

Absolute differences between TcB meter outcomes increased with the measured TcB, from a difference of 5.0 μmol/L (TcB = 0.5 μmol/L phantom) up to 65.0 μmol/L (TcB = 181.3 μmol/L phantom).

CONCLUSION

The inter-device reproducibility of the examined TcB meters is substantial and exceeds the specified accuracy of the device (±25.5 μmol/L), as well as the clinically used TcB safety margins (>50 µmol/L below phototherapy threshold). Healthcare providers should be well aware of this additional uncertainty in the TcB determination, especially when multiple TcB meters are employed in the same clinic. We strongly advise using a single TcB meter per patient to evaluate the TcB over time.

IMPACT

Key message: The inter-device reproducibility of TcB meters is substantial and exceeds the clinically used TcB safety margins. What this study adds to existing literature: The inter-device reproducibility of transcutaneous bilirubin (TcB) meters has not been reported in the existing literature. This in vitro study systematically evaluates this inter-device reproducibility.

IMPACT

This study aids in a better interpretation of the measured TcB value from a patient and is of particular importance during patient monitoring when using multiple TcB meters within the same clinical department. We strongly advise using a single TcB meter per patient to evaluate the TcB over time.

Volatile organic compounds as disease predictors in newborn infants: a systematic review

Volatile organic compounds (VOC) detected in human breath, urine, stool, sweat, saliva, and blood result from metabolic processes in the body during health or disease. Using sophisticated measurement systems, small amounts of these compounds can be detected in the above bodily fluids. Multiple studies in adults and children have shown the potential of these compounds to differentiate between healthy individuals and patients by detecting profiles of compounds in non-invasively collected samples. However, the detection of biomarkers in VOCs from neonates is particularly attractive due to the non-invasive nature of its approach, and its ability to track disease progress by longitudinal sampling. In this work we have reviewed the literature on the use of VOCs in neonates and identified areas for future work.

The accuracy of transcutaneous bilirubin to identify hyperbilirubinemia in jaundiced neonates

OBJECTIVE

To compare transcutaneous bilirubin (TcB) to total serum bilirubin (TSB) in jaundiced neonates by using a JM-103 bilirubinometer.

METHODS

We conducted a retrospective study in jaundiced infants ≥35 weeks' gestation. Infants' and maternal information, TcB measurements, and TSB levels were collected. The correlation and consistency between TcB and TSB were analyzed by Pearson's correlation analysis and the Bland-Altman plot. Multivariate regression analysis was used to identify characteristics associated with the difference between TcB and TSB, underestimation by TcB and overestimation by TcB.

RESULTS

A total of 787 paired samples were collected. There was a strong correlation between TcB and TSB with a Pearson correlation coefficient of 0.708 (p < .001). In preterm infants, outpatients and infants with high TSB levels, the TcB measurements were less precise. The TcB-TSB difference was significantly associated with gender, maternal hypertension disease, ABO hemolytic disease, and outpatient setting (p < .05). Only the outpatient setting had statistical significance in the underestimation of TSB ≥2 mg/dL.

CONCLUSIONS

Generally, TcB by a JM-103 bilirubinometer had a good correlation and consistency with the TSB values. However, small for gestational age, postnatal age of hour, ABO hemolytic disease, and outpatient setting may lead to inconsistencies between the TcB and TSB.

Predictability of transcutaneous bilirubinometry in late preterm and term infants at risk for pathological hyperbilirubinemia

BACKGROUND

The aim was to assess the predictability of transcutaneous bilirubinometry in late preterm and term neonates at risk for pathological hyperbilirubinemia, and to identify the neonatal population in which transcutaneous bilirubin most accurately predicts serum bilirubin level (SB, mg/dl).

METHODS

The correlations between transcutaneous bilirubin (TCB, mg/dl) and SB in different neonatal population subsets; and between ΔTSB (TCB-SB) and relevant neonatal variables and clinical groups were analyzed.

RESULTS

TCB correlated with SB (r = 0.82, p < 0.05) in the cohort (n = 350) and in population subsets (r = 0.81-0.9, p < 0.001). Black infants with gestational age (GA) >35 weeks and chronological age (CA) >3 days recorded strongest correlation (r = 0.9, p < 0.001) followed by Blacks, and non-Black infants with CA >3 days and GA >35 weeks. ΔTSB was positive in Blacks, and in infants with CA <3 days, or with no phototherapy. ΔTSB was negative in non-Blacks, in infants with positive direct Coombs test (DC+) or those receiving phototherapy. Black race [beta (SE) = 1.3(0.33), p < 0.001] had positive, while CA [beta (SE) =-1.74 (0.36), p < 0.001], DC + status [beta (SE) =-0.72 (0.25), p = 0.004] and receipt of phototherapy [beta (SE) =-0.84 (0.21), p < 0.001] each had negative correlation with ΔTSB. ΔTSB for Blacks was >Whites, Hispanics and Asians.

CONCLUSION

SB is best predicted by TCB in Black infants with CA over 3 days and GA over 35 weeks. Variability in SB estimation by TCB is race, CA and immune mediated hemolysis specific.

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.

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.

How skin anatomy influences transcutaneous bilirubin determinations: an in vitro evaluation

BACKGROUND

Transcutaneous bilirubinometry is an effective screening method for neonatal hyperbilirubinemia. Current transcutaneous bilirubin (TcB) meters are designed for the "standard" situation of TcB determinations on the forehead or sternum of term newborns. We hypothesize that skin anatomy can considerably influence TcB determinations in non-standard situations-e.g., on preterm newborns or alternative body locations.

METHODS

A commercially available TcB meter (JM-105) was evaluated in vitro on phantoms that accurately mimic neonatal skin. We varied the mimicked cutaneous hemoglobin content (0-2.5 g/L), bone depth (0.26-5.26 mm), and skin maturity-related light scattering (1.36-2.27 mm^-1) within the clinical range and investigated their influence on the TcB determination. To obtain a reference frame for bone depth at the forehead, magnetic resonance head scans of 46 newborns were evaluated.

RESULTS

The TcB meter adequately corrected for mimicked hemoglobin content. However, TcB determinations were influenced considerably by clinically realistic variations in mimicked bone depth and light scattering (deviations up to 72 µmol/L). This greatly exceeds the specified accuracy of the device (±25.5 µmol/L).

CONCLUSION

As bone depth and light scattering vary with gestational maturity and body location, caretakers should be cautious when interpreting TcB measurements on premature newborns and non-standard body locations.

Quality improvement initiative using transcutaneous bilirubin nomogram to decrease serum bilirubin sampling in low-risk babies

BACKGROUND

Screening for neonatal hyperbilirubinaemia in the postnatal ward has traditionally been performed using serum bilirubin sampling, but this has significant drawbacks such as risk of infection and slower reporting time.

OBJECTIVE

We aimed to assess the impact of introducing transcutaneous bilirubin (TcBR) testing using TcBR nomogram on the number of serum bilirubin samples sent.

METHODS

A before-and-after study was performed following the introduction of a protocol integrating the use of the Dragger JM-105 transcutaneous bilirubinometer in the postnatal ward. Only babies born at ≥37 weeks of gestation, weighing ≥2500 g who presented with jaundice after the first 24 hours and within the first 7 days of life were included in the study. The number of total serum bilirubin samples (TSBRs) sent were compared for the 6-month periods before and after (a total of 12 months) implementation of the new protocol.

RESULTS

In the pre-implementation phase, a total of 882 (49%) out of 1815 babies had at least one serum bilirubin sample taken as opposed to a total of 236 (17%) out of 1394 babies in the post-implementation phase. The odds of performing TSBRs at least one time among babies in post-implementation phase were 79% lower than in pre-implementation phase (OR 0.21, 95% CI 0.18 to 0.25). We also estimated a significant cost saving of approximately US$1800 over a period of 6 months.

CONCLUSION

TcBR testing used in conjunction with our proposed nomogram significantly reduces the need for serum bilirubin sampling.

Implementing evidence-based medicine in a busy general hospital department: results and critical success factors

Implementing evidence-based medicine (EBM) in a busy hospital department is challenging, but when successful, may contribute to quality of care. This paper is a narrative review of the successes and challenges of deliberate implementation of EBM in a paediatric department in a general teaching hospital in Zwolle, the Netherlands. Key elements in this project were providing basic EBM education to the entire team of consultants and nurse practitioners, structurally embedding EBM activities into our weekly schedule and development of local practice guidelines. This deliberate practice of EBM principles has changed the way we treat common paediatric problems. It likely reduced unwarranted practice variation and promoted a reserved attitude towards the use of unnecessary diagnostics, which might improve delivery of effective, cost-conscious care. The project also positively influenced our group culture and learning environment. In accordance with previous reports, lack of time and reluctance to change routines and habits hindered the practice of EBM in our department. In our experience, these barriers can be overcome by promoting a team-wide endorsement of EBM, a willingness to acknowledge uncertainty and by deliberate practice. If these can be achieved, systematic application of EBM principles in a busy hospital department is feasible and worthwhile.

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.

Effectiveness of transcutaneous bilirubin measurement in managing neonatal jaundice in postnatal ward of a tertiary care hospital in Pakistan

INTRODUCTION

Neonatal jaundice is a common cause of concern in immediate newborn period for parents as well as for the caregivers. Babies with visible jaundice are identified by the healthcare provider, and blood samples are sent for confirmation. Clinical expertise varies from person to person and may lead to sending excessive blood sampling. Obtaining blood bilirubin samples is a painful procedure; it predisposes the baby to infections and requires skilled health personnel. Moreover, laboratory tests are costly and time consuming, leading to unnecessary delays in commencing phototherapy and discharge from hospital. Transcutaneous bilirubinometer has been in use for a long time as screening tool in postnatal wards. With passage of time, its accuracy and validity have improved tremendously.

METHODOLOGY

We aim to implement a quality improvement initiative to reduce the number of blood bilirubin samples using transcutaneous bilirubin (TcBR) nomogram in full-term, low-risk babies who are born at our hospital and are admitted in postnatal ward after birth. Using preanalysis and postanalysis study design, this study will be performed in two phases of 6 months each. Data regarding total number of admissions in postnatal wards, demographics, serum bilirubin(TSBR) samplings and need for phototherapy will be recorded in both phases. TcBR will be done and recorded in postimplementation phase.

ANALYSIS AND RESULTS

Comparisons between the two groups will be made. Primary outcome will be reduction in blood bilirubin samples for TSBR after the implementation of TcBr protocol. The proportion of infants having TSBR performed in both periods will be compared. Crude sampling cost of TSBR will be obtained from laboratory, and cost comparison between two phases will be done to look for difference.