Transcutaneous bilirubin – comparing the accuracy of BiliChek®and JM 103®in a regional postnatal unit

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.

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

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

Transcutaneous bilirubinometry versus total serum bilirubin measurement for newborns

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Sixth-Hour Trancutaneous Bilirubin and Need for Phototherapy in DAT Positive Newborns

OBJECTIVES

To characterize the outcomes of ABO incompatible direct antiglobulin test (DAT) positive newborns and determine the predictive ability of a sixth-hour transcutaneous bilirubin (TcB for needing phototherapy ≤24 hours of age.

METHODS

Retrospective, cross-sectional study from May 2013 to March 2017. Of 10 942 consecutive newborns ≥35 weeks estimated gestational age, 829 were ABO incompatible and DAT positive. After excluding for antibodies other than ABO (51), missing data (4), miscategorization of blood type O (1), and duplicate record (1), 772 newborns remained. Of 772, a subsample of 346 newborns with both TcB and total serum bilirubin (TSB) tests within 1 hour of the sixth hour was analyzed to determine the predictive ability.

RESULTS

Phototherapy was required in 281 of 772 (36.4%); 156 (20.2%) in the first 24 hours. There were 10 (1.3%) admissions for hyperbilirubinemia to the NICU for intravenous immunoglobin. Birth weight, infant blood type B, TSB, reticulocyte count, and TcB were all significantly associated with phototherapy ≤24 hours. On multivariate analysis, significant predictors of phototherapy ≤24 hours were TSB and reticulocyte count if no TcB was done and TcB alone if no blood tests were done. TcB was highly predictive (odds ratio 3.1, 95% confidence interval: 2.4-4.0) and nearly as accurate as the TSB and reticulocyte count (area under the curve, 0.90 and 0.96, respectively). Low (<3.0 mg/dL) and high (≥5.3 mg/dL) risk TcB cutoffs demonstrated a negative predictive value of 98% and positive predictive value of 85%, respectively.

CONCLUSIONS

Among high-risk ABO incompatible DAT positive newborns, the sixth-hour TcB is highly predictive of the need for phototherapy ≤24 hours.

Noninvasive methods for bilirubin measurements in newborns: A report

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

Accuracy of Transcutaneous Bilirubin Versus Serum Bilirubin Measurement in Preterm Infants Receiving Phototherapy: A Systematic Review

BACKGROUND

Jaundice is a common condition among preterm infants in the neonatal intensive care unit (NICU). Total serum bilirubin (TSB) offers a gold standard tool for measurement, but blood sampling can be costly, time-consuming, and not without risks of infection and pain. Transcutaneous bilimeter (TcB) allows for noninvasive assessment of bilirubin. However, due to questions of accuracy the use of the TcB in preterm infants receiving phototherapy has not been widely adapted in the NICU.

PURPOSE

To systematically review studies that measure TcB versus TSB bilirubin in preterm infants who are receiving phototherapy.

METHODS

A systematic electronic search of databases (CINAHL, EMBASE, Cochrane, Medline, PubMed) was completed for English language publications. No date limitation was placed on the search. Inclusion criteria were based on preterm infants that were in the NICU receiving or had recently received phototherapy.

RESULTS

Nine studies of different quantitative study designs were reviewed. A good to strong correlation between TcB and TSB in preterm infants receiving phototherapy was demonstrated. There was a stronger correlation found in studies that examined TcB in unexposed skin areas during phototherapy.

IMPLICATIONS FOR PRACTICE

TcB may allow for a reduction in blood sampling, which would reduce painful procedures, reduce the risk of infection and anemia resulting from repeated blood sampling. It also acts as a more time and cost-efficient measurement tool.

IMPLICATIONS FOR RESEARCH

Larger scaled quantitative studies on the accuracy of TcB in preterm infants receiving phototherapy are needed to provide more evidence-based data and guide clinical practice on this topic.

Comparison of transcutaneous and serum bilirubin before, under, and after phototherapy in term and late-preterm infants

This study aimed to determine the correlation of transcutaneous bilirubin (TcB) with total serum bilirubin (TSB) in infants receiving phototherapy and the accuracy of TcB for deciding the time to discontinue phototherapy. Paired TcB and TSB levels were assessed in 52 term and 56 late-preterm infants receiving phototherapy. TcB was measured in the unexposed skin of the middle forehead using a noninvasive bilirubin analyzer, BiliChek. TSB was measured every morning, and TcB was measured 2 hours after TSB measurements. Bland-Altman plots, linear regression, multivariate pair wise correlation, and receiver operating characteristic curve (ROC) analyses were performed. Bland-Altman plots before, under, and 24 hours after phototherapy in term and late-preterm infants revealed that TcB and TSB have higher consistency. TcB and TSB showed positive linear correlation before, under, and after phototherapy in both infant groups. In the multivariate pair wise correlations, differences between TcB and TSB were negatively correlated with phototherapy duration in term (correlation coefficient = -0.233, P value = .001) and late-preterm (correlation coefficient = -0.198, P value = .002) infants. Cutoff levels of TcB for discontinuing phototherapy based on the ROC analysis were 13.8 (sensitivity of 90%, specificity of 84%, area under the curve [AUC] 0.94) and 11.8 mg/dL (sensitivity of 84%, specificity of 88%, AUC 0.92) in term and late-preterm infants, respectively. TcB and TSB before, under, and after phototherapy in both term and late-preterm infants showed good correlation and higher consistency with jaundice. To reduce repetitive blood sampling for TSB, TcB measurement may be a reliable method for term and late-preterm infants undergoing phototherapy.

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.

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.

Comparison of Transcutaneous and Serum Bilirubin Measurements in Neonates 30 to 34 Weeks' Gestation Before, During, and After Phototherapy

BACKGROUND

The use of noninvasive, transcutaneous bilirubin monitoring (TcB) as a jaundice screen in full-term infants is well established; however, there is a paucity of research evaluating the use of TcB in premature infants.

PURPOSE

To compare agreement and consistency of transcutaneous and serum bilirubin measurements in a multiracial premature infant population ranging from 30 to 34(Equation is included in full-text article.)weeks' gestation before, during, and after phototherapy.

METHODS

Forty-five neonates, 30 to 34(Equation is included in full-text article.)weeks' gestation, were enrolled in this prospective, correlational study over a 12-month period. One set of paired transcutaneous and serum bilirubin measurements, per neonate, was obtained before phototherapy, during therapy, and after phototherapy. Exclusion criteria included neonates with positive direct coombs test or evidence of hemolytic disease, major congenital anomalies, hydrops fetalis, and those not expected to survive.

RESULTS

There was a strong, positive correlation between TcB and total serum monitoring (TSB) measurements obtained pretherapy (r = 0.797, P < .001). A moderate correlation was noted between TcB and TSB measurements obtained during therapy (r = 0.588, P < .001). A strong correlation was noted between TcB and TSB measurements obtained posttherapy (r = 0.869, P < .001). There were no significant differences between paired samples across time (F = 0.891, P = .41, partial η = 0.01). The TSB measurements were consistently lower than TcB pretherapy, during, and posttherapy.

IMPLICATIONS FOR PRACTICE

The TcB measurements provide a reliable estimation, generally within 2 to 3 mg/dL of TSB levels, in premature infants 30 to 34(Equation is included in full-text article.)weeks' gestation.

IMPLICATIONS FOR RESEARCH

Investigation of consumption of time and nursing personnel required to perform TcB testing, compared with TSB testing, is indicated. Cost analyses comparing TcB-driven screening protocols and interval TSB measurements, among premature infants, are indicated. As newer generations of TcB devices are approved for use, additional studies using mixed-race populations of premature infants will be necessary to continue to evaluate the reliability and validity of this screening tool within the everyday neonatal intensive care unit.

Defining the limitations of transcutaneous bilirubin measurement in late preterm newborns

OBJECTIVE

The objective of this study is to determine the impact of postnatal age on the bias between transcutaneous (TcB) and total serum bilirubin (TSB), and evaluate a TcB screening protocol.

STUDY DESIGN

Preterm and term infants had paired TcB and TSB performed on days 1 to 3 of life; a subset of preterm infants had measurements on days 4 to 7. Sensitivity and specificity of TcB (plotted on an age-specific TSB nomogram) for prediction of high-intermediate (HIR) or high-risk TSB were calculated.

RESULTS

Median TcB bias was 2.6 and 2.5 mg dl^-1 for term and preterm infants in the first 3 days of life, respectively. However, median bias was 2.2 mg dl^-1 for preterm infants at 4 to 7 days of life. TcB in preterm infants predicted HIR or high-risk TSB with 94% sensitivity and 56% specificity.

CONCLUSION

TcB screening protocols developed for term infants can be used for late preterm infants in the first 3 days of life.

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 bilirubinometry is a reliably conservative method of assessing neonatal jaundice

OBJECTIVE

In order to reduce invasive testing in newborns prior to discharge, we tested the direction of the correlation between transcutaneous bilirubin (TcB) and total serum bilirubin (TSB), the likelihood of missing high TSBs with a raised threshold for confirmatory testing, and also calculated potential cost savings from fewer laboratory testing.

METHODS

We performed a cross-sectional analysis of single paired TcB and TSB results measured at 36 ± 2 h of life in neonates ≥37 weeks admitted only to the Level 1 nursery. TcB was measured using the BiliChek® meter.

RESULTS

Of the 552 infants, 512 (92.8%) had TSB levels below TcB values. Correlation between TcB and TSB was 0.69. If TSB confirmation was to be performed at 11.7 mg/dL (medium risk threshold for phototherapy), the negative predictive value was 99.4%, with a potential cost savings of $6555.00 ($1500.00 per 100 patients). Of the 495 infants with TcB <11.7 mg/dL, only 3 had TSB levels higher than 11.7 mg/dL, and none met phototherapy threshold for low risk infants.

CONCLUSIONS

TcB screening at our institution has a high negative predictive value, and can be used as a stand-alone test until values are close to phototherapy threshold, thus reducing invasive testing and cost.

Comparison of the transcutaneous bilirubinometers BiliCheck and Minolta JM-103 in preterm neonates

AIM

To investigate the trueness and uncertainty of two transcutaneous bilirubinometers BiliCheck and Minolta JM-103 in preterm infants; establish cut-off values for the transcutaneous bilirubin (TcB) level, indicating the need for total serum bilirubin (TsB) measurement; and estimate how many blood samples could be saved.

METHODS

In 133 neonates with gestational ages 28(+0) -34(+6) weeks, 239 measurements of TcB by BiliCheck (TcB(B)) and JM-103 (TcB(M)) and of TsB were performed.

RESULTS

Median TsB of the first samples was 160 (range, 53-293) μmol/L, whereas median TcB(B) was 12 μmol/L (8%) lower and TcB(M) 67 μmol/L (40%) lower. TcB(B) underestimated TsB for TsB ≥180μmol/L. All TcB(M) values, except one, underestimated TsB. The underestimation increased with increasing TsB. Multiple regression analysis showed that post-natal age and ethnicity were confounding factors for TcB(M); none were found for TcB(B). The uncertainty was the same for the two instruments. By using cut-off values of 70% of the phototherapy limit for TcB(B) and 35% for TcB(M), the sensitivity of the screening would be 95% and 97%, and 36% and 24% of the blood samples could be saved, respectively.

CONCLUSION

TcB determined with JM-103 gave values much lower than those obtained with BiliCheck. The underestimation of TsB increased with increasing concentrations. By using transcutaneous bilirubinometers in preterm neonates, 24-36% of the blood samples could be saved.

Measuring transcutaneous bilirubin: a comparative analysis of three devices on a multiracial population

Background

Hyperbilirubinemia can lead to potentially irreversible bilirubin-induced neurotoxicity. Transcutaneous bilirubin (TcB) determination has become a valuable aid in non invasive screening of neonatal jaundice.

The aim of this study is to compare the performance of three most widespread transcutaneous bilirubinometers on a multiracial population of term and late pre-term neonates.

Methods

Bilirubin concentration was determined using traditional photometric determination and transcutaneously with Bilicheck, BiliMed and JM-103, in random order.

Total serum bilirubin (TSB) was determined over a wide concentration range (15,8–0,7 mg/dl) with a mean of 9,5 mg/dl. Related TcB values using Bilicheck (TcB-BC), BiliMed (TcB-BM), and JM-103 (TcB-JM) are reported in Table 1.

Results

A multiracial population of 289 neonates was enrolled with a gestational age ranging from 35 to 41 weeks; birth weight ranging from 1800to 4350 grams; hours of life ranging from 4 to 424. In the total study population correlation analysis using Pearson coefficients showed good results for Bilicheck (r = 0.86) and JM-103 (r = 0.85) but poor for BiliMed (r = 0,70). Similar results were found for the non-Caucasian neonates subgroup. Bilicheck and JM-103 had a greater area under the curve than BiliMed when TSB =14 mg/dl was chosen as a threshold value both for the total study population and the non-Caucasian subgroup.

Conclusions

Bilicheck and JM-103, but not BiliMed, are equally reliable screening tools for hyperbilirubinemia in our multiracial neonatal population.