Transcutaneous Bilirubinometry Research Articles

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.

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

To assess the accuracy of transcutaneous bilirubin (TcB) measurements at 5 different body sites in Japanese very low birthweight (VLBW) infants and to determine a cut-off value of TcB to detect total serum/plasma bilirubin (TB) levels ≥10mg/dL (171μM). In a prospective multicenter study, 85 Japanese VLBW infants were enrolled from 5 neonatal intensive care units during the study period. A total of 383 blood samples from infants not receiving phototherapy or ≥24hours postphototherapy were analyzed. TcB was measured at the forehead, sternum, upper back, lower abdomen, and waist within 1hour of blood collection. Linear regression analysis and Bland-Altman plots were used to compare TcB values at each site with TB levels. The TcB cut-off value for detecting TB ≥10mg/dL was determined by receiver operating characteristics curve analysis. TcB significantly correlated with TB, but the coefficient of determination varied among the sites (forehead: 0.5294, sternum: 0.6488, upper back: 0.6321, lower abdomen: 0.5430, waist: 0.7396). At a TcB value ≥8, the sensitivity was 100% at the sternum and upper back, 85% at the waist, 84% at the forehead, and 64% at the lower abdomen to detect TB ≥10mg/dL. In Japanese VLBW infants, the accuracy of TcB measurements varies according to body site. TcB ≥8 on the sternum or upper back is more reliable than that on the forehead, lower abdomen, or waist to detect TB levels ≥10mg/dL.

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.

A Comparison between Transcutaneous Bilirubin (TcB) and Total Serum Bilirubin (TSB) Measurements in Term Neonates

Background: Transcutaneous bilirubinometry (TCB) is a simple method for estimating bilirubin levels in neonates. This method is noninvasive, quick, and painless. We aimed to compare serum and cutaneous bilirubin measurements in term neonates.Method: In this descriptive cross-sectional study, 200 neonates with icter with birth weights of at least 2500 grams were studied. TCB was measured using a bilirubinometer three times on the forehead and mean levels were calculated. Then, during the subsequent 30 minutes blood samples were obtained and sent to the laboratory for determining the total serum bilirubin (TSB) levels. Findings: Of the 200 neonates, 124 (62%) were boys and 76 (38%) were girls, with an age range of 1-22 days. The mean±SD serum and cutaneous bilirubin levels were 18.75±5.38 and 17.85±4.46 mg/dl, respectively. A high correlation (r=0.89) was observed between TSB and TCB. The sensitivity and specificity of cutaneous bilirubin measurement were 95.1% and 68%, respectively.Conclusions: Because of its high sensitivity, TCB can be a suitable tool for predicting neonatal icter. However, it is not a suitable substitute for TSB measurement in neonates at a high risk of jaundice.

Evaluation of Early Transcutaneous Bilirubinometry to Predict Subsequent Hyperbilirubinemia in Neonates Admitted to a Well-Baby Nursery.

The aim of this study is to determine whether a transcutaneous bilirubin (TcB) value obtained within 6 hours of birth (early transcutaneous bilirubin [ETcB]) either alone, or used to calculate an early rate of rise (E-ROR) in TcB, will identify those neonates who are at a higher risk for subsequent jaundice. ETcB values were obtained from a convenience sample of neonates admitted to the newborn nursery. E-ROR was calculated as the average hourly increase between ETcB and subsequent TcB obtained at 18 to 36 hours of age. TcB percentile values at various ages were obtained from a previously published and cross-validated nomogram. The predictive values relating ETcB, E-ROR, and TcB at 18 to 36 hours of age to TcB at 42 to 66 hours of age were determined, and receiver-operator characteristic curves were compared. A total of 516 late preterm and term neonates were studied. ETcB was higher (p = 0.003) in those neonates who subsequently received phototherapy (n = 15), and negative predictive value was always ≥ 0.96; positive predictive value (PPV) ranged from 0.04 to 0.06. Compared with ETcB, TcB at 18 to 36 hours was more likely to predict significant jaundice at 42 to 66 hours of age. Given the observed low PPV, ETcB is not useful in identifying infants who develop subsequent hyperbilirubinemia. However, it may be helpful in identifying those neonates at a low risk of subsequent hyperbilirubinemia.

Correlation of transcutaneous bilirubinometry (TcB) and total serum bilirubin (TsB) levels after phototherapy

Aim: To investigate the correlation between transcutaneous bilirubinometry (TcB) and total serum bilirubin (TsB) in jaundiced infants before and after, but not during phototherapy. Methods: This study prospectively investigated the correlation between TcB and TsB in term and near term infants before and after phototherapy. Results: Overall 673 pairs of measurements (TcB and TsB) were performed on 371 infants of ≥35 weeks gestation and with birth weight above 2000 g. Of these 337 sets were from 200 infants who had not been treated with phototherapy (Group 1) and 336 measurements from 171 infants taken between 1 h and 5 d after phototherapy (Group 2). The correlation coefficient between TcB and TsB in the whole cohort was r = 0.72. The correlation was low during the first 8 h after phototherapy (r = 0.56), but thereafter the correlation returned to the range of 0.65–0.8. Using the Sobel test, no significant difference was found between the correlation coefficients at the different time periods, with the possible exception of the difference between 1 and 8 h and 9 and 16 h which was of borderline significance with a p value of 0.06. Conclusion: This study demonstrates good correlation between TcB and TsB by 8 h after phototherapy. This adds validity to community-based screening programs employing TcB measurements plotted on TsB nomograms. Such programs may contribute to prevention of tragic cases of bilirubin-induced neurologic damage.

Transcutaneous bilirubinometry is not influenced by term or skin color in neonates

BackgroundThe utility of transcutaneous bilirubin measurements (TcB) in screening for hyperbilirubinemia in preterm infants (<34weeks) and in non-white infants remains a matter of debate. AimTo evaluate accuracy of TcB in preterm and term infants of different ethnic backgrounds, using a second generation bilirubinometer. Study designThe Draeger JM-103® device was used to measure TcB. Eighty five measurements of TcB and total serum bilirubin (TSB) were retrospectively compared. Neonates were stratified into groups according to gestational age: <34weeks (group 1, n=44) and >34weeks (group 2, n=41), and according to ethnic origin: Caucasians (group A, n=49) and non-Caucasians (group B, n=36).Statistical analysis, using Pearson's correlation coefficient (r) and Bland–Altman analysis were performed to evaluate correlation and agreement between TSB and TcB values. Multiple linear regression was used to control for confounders for TSB values. ResultsCorrelation between TSB and TcB was high. Pearson's correlation coefficients were over 0.9 in all groups (0.910, 0.908, 0.916 and 0.934, p<0.0001 in groups 1, 2, A, and B respectively). Bland–Altman plots showed acceptable and close limits of agreements (56.8/−57.7, 54.2/−67.2, 57.7/−55.8, and 51.3/−69.9μmol/L in groups 1, 2, A and B respectively) with a trend for TcB to overestimate TSB in groups 2 and B. Birth term and skin color were not identified as confounding factors for predicting TSB in multiple linear regression. ConclusionsTcB measurements using the Draeger JM-103® device correlate significantly with TSB, regardless of term and skin color. Transcutaneous bilirubinometry seems to be a safe and cost-effective screening method for severe hyperbilirubinemia in newborns of different terms and ethnic origins.

Interscapular site for transcutaneous bilirubin measurement in preterm infants: a better and safer screening site

To prevent bilirubin induced brain injury in the newborn, repeated blood withdrawals are necessary to ascertain bilirubin levels and institute care. Noninvasive, painless and bloodless screening using transcutaneous bilirubinometry is the standard of care for term and near term neonates but there is still debate about its use with preterm neonates. The aims of this study were to determine how transcutaneous bilirubin (TcB) level measured from the interscapular site related to total serum bilirubin (TSB) level and to compare performance of TcB from the forehead, sternum and interscapular sites in identifying preterm neonates in need of phototherapy. This was a cross sectional study conducted at Groote Schuur level III neonatal unit. Over a 5-month period 122 consecutive preterm neonates <35 weeks gestational age were enrolled. TcBs were measured over the forehead, sternum and interscapular area. Pearson's correlation coefficients and differences between TSB and TcBs were computed. P-value <0.05 was considered significant. The median gestational age of the study participants was 31 weeks (range: 24 to 34 weeks), the median TSB level was 81.5 μmol l(-1) (range: 25 to 229 μmol l(-1)) and 45% had a TSB at the phototherapy threshold. The correlation coefficients for TcBs ranged from 0.859 to 0.929 (P<0.001). The difference between TSB and TcBs ranged from -86 to +51 μmol l(-1). With respect to initiating phototherapy, the interscapular site had the highest sensitivity of 94% and lowest false negative rate of 6%. Using transcutaneous bilirubinometry, the interscapular site is superior and safer for screening preterm neonates.

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

BackgroundTranscutaneous 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.MethodsTranscutaneous 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.ResultsA 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 60th 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.ConclusionsOur study shows that both BC and JM-103 can exclude subsequent significant hyperbilirubinemia when the measurements are performed after the 60th 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.

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...

Influence of Changes in the Evaluation of Neonatal Jaundice

To study the influence of policy changes in the evaluation of neonatal hyperbilirubinemia on discharge process from the nursery. Changes included early assessment of risk factors by universal umbilical blood sampling for blood type, Coombs test, and glucose-6-phosphate dehydrogenase (G6PD) and universal noninvasive transcutaneous bilirubinometry at discharge. The 1,569 newborns (≥ 36 weeks' gestation) admitted after the implementation of changes were compared with the 1,822 born before. Policy changes improved the diagnosis of G6PD deficiency and ABO incompatibility and decreased the number of referrals from the community for jaundice follow-up. The average number of needlesticks per baby as well as the time required for the analysis of serum bilirubin levels on discharge day decreased. Changes did not significantly increase costs. Changes seem to have improved the quality of medical care, including early identification of risk factors and better follow-up of neonatal hyperbilirubinemia with reduction of pain and increased efficiency.

1327 Audit on Management of Neonatal Jaundice

BackgroundNeonatal jaundice is a common medical problem in postnatal wards. With the introduction of NICE guidelines in UK, the management of jaundice of newborn infants has achieved clarity.AimsAn audit was...

Neonatal Transcutaneous Bilirubin Measurements: An Opportunity to Enhance Laboratory Utilization and Improve Patient Care

By far the most common clinical problem addressed by family practitioners and pediatricians in the first weeks of an infant's life is hyperbilirubinemia. With the exception of the standard metabolic screen, the measurement of a total serum bilirubin (TSB)2 concentration is the most common laboratory test ordered for a newborn infant. That is not surprising because the clinical sign, jaundice, is seen in approximately 80% of infants in a well-baby nursery during the first few days (1). The process of observation, clinical monitoring, and laboratory testing that continues throughout the infant's first week of life has a single objective—to prevent extreme hyperbilirubinemia [a TSB concentration >25–30 mg/dL (>428–513 μmol/L)] and its rare but dreaded consequence, bilirubin encephalopathy. Data from most of the Western world suggest that chronic bilirubin encephalopathy, or kernicterus, is currently occurring at an incidence of approximately 0.5–2 per 100 000 live births (2). Thus, of approximately 4 × 106 infants born annually in the US, perhaps 20–40 will develop kernicterus, a permanently disabling condition characterized by athetoid cerebral palsy, severe sensorineural hearing loss, paralysis of upward gaze, and dental dysplasia. For decades practitioners have relied on the appearance and intensity of jaundice as a means of deciding when to obtain a TSB measurement, but recognizing that estimating TSB by eye is difficult and on occasion grossly misleading (3) has prompted the development of transcutaneous bilirubinometry. The instruments that measure the transcutaneous bilirubin (TcB) concentration operate by transmitting light that penetrates the blanched skin and transilluminates the subcutaneous tissues. The …

Transcutaneous bilirubinometry during phototherapy

Transcutaneous bilirubinometry during phototherapy

Noninvasive Measurements of Bilirubin

* Abbreviations: TcB — : transcutaneous bilirubin TSB — : total serum bilirubin The relationship between the total serum bilirubin (TSB) concentration and the intensity of neonatal jaundice was documented almost 100 years ago,1 and although practitioners have long used this clinical sign to help them decide whether to measure the TSB, the difficulty of accurately estimating the TSB by eye2–6 has led to the development of transcutaneous bilirubinometry. When light is transmitted to the skin, the yellowness of the reflected light can be measured to provide an objective measurement of skin color7 and, taking into account the contributions of hemoglobin, melanin, and dermal thickness, current transcutaneous bilirubinometers provide a readout that estimates the TSB.8–11 Because measuring the yellowness of the skin is not equivalent to measuring the TSB,12–15 experts recommend that transcutaneous bilirubin (TcB) measurements should be used as a screening tool and not as a substitute for the TSB.13–17 In this edition of the journal, Bosschaart et al18 describe a new method of measuring bilirubin noninvasively that raises the possibility of improving the technique to the point where transcutaneous bilirubin (TcB) measurements … Address correspondence to M. Jeffrey Maisels, MB, BCh, DSc, Beaumont Children's Hospital and Department of Pediatrics, Oakland University William Beaumont School of Medicine, 3601 W. 13 Mile Rd, Royal Oak, MI 48073. E-mail: jmaisels{at}beaumont.edu

Impact of a Transcutaneous Bilirubinometry Program on Resource Utilization and Severe Hyperbilirubinemia

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. 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. 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. 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.

Ins and Outs of Transcutaneous Bilirubin Monitoring

The American Academy of Pediatrics recommends transcutaneous bilirubinometry in the management of hyperbilirubinemia in newborns (JW Pediatr Adolesc Med Aug 9 2004). This method measures bilirubin levels in the skin without painful blood sampling, but does it reliably estimate the total serum bilirubin (TSB) concentration, the gold standard for clinical decision making? Researchers in the Netherlands tested a new bilirubinometer that measures the skin's absorption coefficient across a range of wavelengths and determines the contributions …

Evaluation of the Effectiveness of Transcutaneous Bilirubinometry in Reducing the Number of Serum Bilirubin Tests in Neonatal Jaundice

Background: Bilicheck is a non-invasive device that uses multiwavelength spectral reflectance analysis to measure bilirubin levels transcutaneously. Previous work in our institution predicted that using bilicheck in jaundiced babies born after 34 weeks may reduce the number of serum bilirubin tests (SBR's) needed by up to 55%. On the basis of this work, the use of Bilicheck was introduced into clinical practise in 2003. Aim: To determine whether clinical use of Bilicheck has resulted in a reduction of SBR's in clinical practice and quantify that reduction. Methods: A retrospective evaluation of all SBR's taken in 2002 (pre Bilicheck) and 2009 (post Bilicheck) compared the frequency of blood sampling for bilirubin estimation and values obtained. Results: Table Conclusions: Since the introduction of Bilicheck, there has been a significant decrease in the number of SBR tests undertaken as well as the proportion of babies having SBR measurements. The use of Bilicheck exposes fewer neonates of >34 weeks gestation to painful invasive blood taking procedures. As SBRs measurements are both time and resource consuming, Bilicheck is likely to provide a more cost effective approach to the traditional method of management of jaundice.

Transcutaneous bilirubinometry: comparison of two multiwavelength devices in healthy term newborns

The correlation coefficient for fair, dark intermediate, and dark skin was r=0.91, 0.89, and 0.72 respectively with JM103 and r=0.87, 0.90, and 0.70 respectively with BiliCheck. The sensitivity to predict significant hyperbilirubinemia is 98.7% for JM-103 and 85.7% for BiliCheck. Both devices are reliable, accurate, and sensitive to be used clinically distinguishing those babies who need further assessment and follow-up. JM-103 was more accurate, and the measurements can be assessed with this monogram with high accuracy to predict significant hyperbilirubinemia.

Reply to the correspondence letter: “Transcutaneous bilirubinometry: comparison of two devices in healthy term newborns”

Dear Editor, We would like to thank Teran C et al. for their comment on our article. We and Varvarigou et al. chose different transcutaneous bilirubinometers (JM-103 and BiliCheck, respectively), provided data on transcutaneous bilirubin (TcB) levels of neonates after birth and developed two different hour-specific TcB nomograms to predict significant hyperbilirubinemia [3, 4]. It is difficult for physicians to decide which device should be used to determine TcB levels, whereas the JM-103 (a two-wavelength measurement) and the BiliCheck (a multiwavelength measurement) are both approved by the U.S. Food and Drug Administration for estimating bilirubin concentrations in neonates. So, it is important to study simultaneous TcB by the two devices and total serum bilirubin (TSB) measurements from the same neonatal population in order to assess the different TcB nomograms for predicting significant hyperbilirubinemia. Carlos et al. have offered a novel perspective with a small study, which show that the two devices (JM-103 and BiliCheck) are both reliable, accurate and the measurements can be assessed on the basis of these nomograms with high accuracy to predict significant hyperbilirubinemia. Their results have further supplemented our study. Application of the two devices could both allow us for a noninvasive, risk-based approach for neonatal hyperbilirubinemia, but we should notice that TcB readings above 250 μmol/L should be interpreted with care because of the observed underestimation at high concentrations; all TcB values above the levels should be confirmed with a TSB measurement [2]. In addition, when we analyzed the sensitivity of TcB measurement to predict significant hyperbilirubinemia, we should consider the risk zone of TcB values in the hourspecific TcB nomogram. The TcB values in the different risk zone showed different detection sensitivity. In our study, when the TcB values by JM-103 were in high-risk zone (HRZ), intermediate-risk zone (IRZ), and low-risk zone (LRZ), the sensitivity was 26.9%, 78.7%, and 100%, separately. In the study by Dalal et al., when the TcB values by BiliCheck were in HRZ, IRZ, and LRZ, the sensitivity was 39.2%, 80.4%, and 98%, separately [1], which was consistent with our results. So, both devices (JM-103 and BiliCheck) are reliable, accurate, and suitable screening tools to identify jaundiced infants; in order to improve the detection sensitivity of TcB devices, we should combine the use of these devices with using the hour-specific TcB nomogram.