Noninvasive Measurement of Total Serum Bilirubin in a Multiracial Predischarge Newborn Population to Assess the Risk of Severe Hyperbilirubinemia Correlation of transcutaneous bilirubinometry (TcB) and total serum bilirubin (TsB) levels after phototherapy Effectiveness of home versus hospital phototherapy for term infants with uncomplicated hyperbilirubinemia: a pilot study in Pahang, Malaysia. Visual assessment of jaundice in term and late preterm infants Transcutaneous bilirubinometry in the management of bilirubinemia in term neonates. Incidence, course, and prediction of hyperbilirubinemia in near-term and term newborns. Transcutaneous bilirubinometry during and after phototherapy Improvement of conventional transcutaneous bilirubinometry results in term newborn infants.
Background . Jaundice in near-term and term newborns is a frequent diagnosis that may prompt hospital readmission in the first postnatal week . Hyperbilirubinemia , when excessive , can lead to potentially irreversible bilirubin-induced neurotoxicity . Predischarge risk assessment ( at 24–72 hours of age ) for subsequent excessive hyperbilirubinemia is feasible by a laboratory-based assay of total serum bilirubin  ( TSB ) . Hypothesis . Noninvasive , transcutaneous , point-of-care measurement of transcutaneous bilirubin ( TcB ) predischarge by multiwavelength spectral analysis , using a portable BiliCheck device ( SpectRx Inc , Norcross , GA ) , is clinical ly equivalent to measurement of TSB in a diverse , multiracial term and near-term newborn population and predictive of subsequent hyperbilirubinemia . Methodology . We evaluated a h and -held device that uses multiwavelength spectral reflectance analysis to measure TcB ( BiliCheck ) . The study population ( 490 term and near-term newborns ) was racially diverse ( 59.1 % white , 29.5 % black , 3.46 % Hispanic , 4.48 % Asian , and 3.46 % other ) and was evaluated at 2 separate institutions using multiple ( 11 ) devices . The postnatal age ranged from 12 to 98 hours and the ranges of birth weights and gestational ages were 2000 to 5665 g and 35 to 42 weeks , respectively . All transcutaneous evaluations were performed contemporaneously and paired with a heelstick TSB measurement . All TSB assays were performed by high performance liquid chromatography , as well as by diazo dichlorophenyldiazonium tetrafluoroborate techniques . Results . TSB values ranged from .2 to 18.2 mg/dL ( mean ± st and ard deviation : 7.65 ± 3.35 mg/dL ) . The overall correlation of TSB ( by high performance liquid chromatography technique ) to TcB ( by BiliCheck devices ) was linear and statistically significant ( r = .91;r 2 = .83 ; TcB = .84 ; TSB = + .75 ; st and ard error of regression line = 1.38 ; P < .001 ; n = 490 infants ; 1788 sample s ) . Similar regression statistics were evident in subset population s categorized by race ( white : r = .91 [ n = 289 infants ] ; black : r = .91 [ n = 145 infants ] ) as well as by gestation ( term : r = .91 [ n = 1625 sample s ] ; near-term : r = .89 [ n = 163 sample s ] ) . Intradevice precision was determined to be .59 mg/dL ( 2–3 measurements per infant with 1 device ; n = 210 infants ; 510 sample s in a separate subset ) . Interdevice evaluation of 11 devices determined the precision to be .68 mg/dL ( 2–4 devices used for measurements per patient ) . In 23 of 419 of the study population infants who were in the 24- to 72-hour age range , the predischarge TSB values design ated them to be at high risk for subsequent excessive hyperbilirubinemia ( above the 95th percentile track on the hour-specific bilirubin nomogram ) . For these infants , the paired BiliCheck TcB values were all above the 75th percentile track ( negative predictive value = 100 % ; positive predictive value = 32.86 % ; sensitivity = 100 % ; specificity = 88.1 % ; likelihood ratio = 8.43 ) . Conclusions . Our data demonstrate the accuracy and reproducibility of the predischarge BiliCheck measurements in term and near-term newborn infants of diverse races and ethnicities . Infants with predischarge BiliCheck values above the 75th percentile of hour-specific TSB values on the bilirubin nomogram may be considered to be at high risk for subsequent excessive hyperbilirubinemia . Further studies are needed to assess the efficacy of this technique in preterm infants , those undergoing phototherapy , and those with TSB values of ≥15 mg/dL ( ≥256 μmol/L ) Abstract 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 prospect ively 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 A comparative pilot study was conducted to determine the difference in the reduction of total serum bilirubin in a group of infants who had phototherapy at home compared to an in-patient group on hospital phototherapy . Eighteen infants with unconjugated hyperbilirubinaemia who fitted the selection criteria were put under the mobile home unit ( Bluelite Portable Light ) placed in the home . A control group of 18 infants with the same matching characteristics had intense phototherapy in the hospital using a unit with top and bottom light sources . The infants were matched for race , starting total serum bilirubin level , birth weight ( up to 250 grams ) and age of baby at initiation of phototherapy ( up to one-day difference ) . It was observed that the mean daily decrease in serum bilirubin concentration was significantly more in the home group as compared to the hospital group ( t=2.95 , df=17 , P<0.05 ) . The mean duration of treatment was significantly less for the home group as compared to the hospital group ( t=2.84 , df=17 , P<0.05 ) . None of the infants who had home phototherapy were re-hospitalized . Phototherapy related complications were mild and comparable in both groups . The result suggests that home phototherapy is safe and effective in bringing down the concentration of serum bilirubin for term babies with uncomplicated hyperbilirubinaemia Objective : To determine the accuracy of predischarge visual assessment of jaundice for estimating bilirubin concentration and predicting risk of significant neonatal hyperbilirubinaemia . Design : Prospect i ve cohort study . Setting : Well Baby Nursery at the Hospital of the University of Pennsylvania . Patients : 522 term and late preterm newborns . Interventions : Nurses used a 5-point scale to grade the maximum cephalocaudal extent of jaundice prior to discharge . Main outcome measures : ( 1 ) Correlation between jaundice grade and bilirubin concentration . ( 2 ) Predictive accuracy of jaundice grade for identifying infants who developed significant hyperbilirubinaemia , defined as a bilirubin level that at any time after birth exceeded or was within 1 mg/dl ( 17 μmol/l ) of the American Academy of Pediatrics-recommended hour-specific phototherapy treatment threshold . Results : Nurses ’ assessment of jaundice extent was only moderately correlated with bilirubin concentration and was similar in black and non-black infants ( Spearman ’s rho = 0.45 and 0.55 , respectively ( p = 0.13 ) ) . The correlation was particularly weak among infants < 38 weeks ’ gestational age ( rho = 0.29 ) compared with infants ⩾38 weeks ’ gestation ( rho = 0.53 , p = 0.05 ) . Jaundice extent had poor overall accuracy for predicting risk of significant hyperbilirubinaemia ( c-statistic = 0.65 ) but complete absence of jaundice had high sensitivity ( 95 % ) and excellent negative predictive value ( 99 % ) for ruling out the development of significant hyperbilirubinaemia . Conclusions : Clinicians should not use extent of cephalocaudal jaundice progression to estimate bilirubin levels during the birth hospitalisation , especially in late preterm infants . However , the complete absence of jaundice can be used to predict with very high accuracy which infants will not develop significant hyperbilirubinaemia One hundred full term babies of both sexes were r and omly selected for transcutaneous bilirubin index ( TcBI ) estimation at the forehead at 12 - 24 h intervals from the time of appearance of clinical jaundice till the serum bilirubin levels fell within safe limits . TcBI was correlated with serum bilirubin estimated by conventional diazo method .  Forty babies required phototherapy , in 20 an area of 2.5 cm2 over the forehead was covered during phototherapy to make an unexposed ' window ' for TcBI estimation . The other 20 newborns received phototherapy as such and TcBI was estimated on the forehead . There was a linear relationship between serum bilirubin level and TcBI estimated at the forehead ( r = 0.9090 ; P < 0.001 ) . Further a significant linear correlation between prephototherapy and post-phototherapy ( covered and uncovered groups ) TcBI and serum bilirubin levels also existed ( r = 0.7979 ; P < 0.001 ) . There was no significant difference between post-phototherapy TcBI estimated at the covered and uncovered areas of forehead . However , post-phototherapy values of TcBI were significantly lower than corresponding prephototherapy values at higher serum bilirubin levels ( > 16 mg/dl ) OBJECTIVE In this study , we investigated prospect ively the incidence of significant hyperbilirubinemia and demographic and laboratory characteristics and pattern of  serum bilirubin levels of near-term newborns ( 35 - 37 weeks ' [ 245 - 265 days ' ] gestation ) by comparing them with those of term newborns ( 38 - 42 weeks ' [ 266 - 294 days ' ] gestation ) longitudinally in the first 7 days of life ; we also aim ed to determine the value of an early ( 6th-hour ) serum bilirubin measurement in predicting the development of significant hyperbilirubinemia later during the first week of life in near-term newborns . METHODS  Serum total bilirubin measurements  were initially made at the 6th hour of life and repeated daily for the next 4 days , and a last measurement was performed on the 7th day ( 150th hour ) in 219 term newborns ( term group ) and 146 near-term newborns ( near-term group ) . Newborns with serum total bilirubin levels of > or = 8 and > or = 12 mg/dL on day 2 , > or = 12 and > or 15 mg/dL on day 3 , and > or = 14 and > or = 17 mg/dL on days 4 , 5 , and 7 for birth weights 2000 to 2500 g and > 2500 g , respectively , were defined to have significant hyperbilirubinemia , and phototherapy treatment was started . The predictive ability of the 6th-hour serum total bilirubin value in determining the development of significant hyperbilirubinemia in the near-term group was assessed on the basis of the placement of any of the first week 's serum bilirubin measurements in the > or = 95th percentile of the study population . A Gaussian distribution curve , the 5th , 30th , 60th , and 95th percentiles , and 4 percentile tracks were obtained from mean serum total bilirubin values . On the basis of the percentile tracks with various sensitivity , specificity , and negative and positive predictive values , a nomogram demonstrating the 4 percentile tracks as risk-zone demarcators with divided risk zones was produced . RESULTS Twenty-three newborns ( 10.5 % ) in the term group and 37 newborns ( 25.3 % ) in the near-term group had significant hyperbilirubinemia and required phototherapy . When the daily mean serum bilirubin levels of the 2 groups were compared , the first 4 days ' values did not significantly differ between the 2 groups , whereas the 5th and 7th days ' values were significantly higher in the near-term group . There were significant differences between the 2 groups with respect to the incidence of significant hyperbilirubinemia , hematocrit , Apgar score , and mode of delivery . On the age-specific nomogram , the zone > 95th percentile was labeled as high risk , and that < 5th percentile was labeled as low risk . Serum total bilirubin values between the 5th and 30th , 30th and 60th , and 60th and 95th percentiles were design ated as being in the low-intermediate , intermediate , and high-intermediate risk zones , respectively . The 5th and 95th percentiles on the nomogram had the highest sensitivity ( 100 % ) and specificity ( 98.2 % ) , respectively , in predicting the subsequent development of significant hyperbilirubinemia . CONCLUSIONS Near-term newborns should not be treated as term newborns in the approach to management of hyperbilirubinemia , because infants of 35 to 37 weeks ' gestation had significantly lower birth weights , significantly higher serum total bilirubin levels on days 5 and 7 , and were 2.4 times more likely to develop significant hyperbilirubinemia than those of 38 to 42 weeks ' gestation in the present study . In near-term newborns of 35 to 37 weeks ' ( 245 to 265 days ' ) gestation , the decision to diagnose and treat significant hyperbilirubinemia should be made on the basis of risk status ( percentile distribution of the serum bilirubin values on postnatal age ) rather than using birth-weight-based thresholds . A nomogram constructed from daily serum bilirubin values of each population , as we present herein , can be used in assessing the age (hour)-specific jaundice risk ( high , intermediate , or low ) of each near-term newborn Aim : To evaluate the reliability of  transcutaneous bilirubinometry ( TcB ) during and after phototherapy . Methods : TcB was performed on the forehead and chest of infants with neonatal jaundice when capillary blood was sample d for bilirubin determination in a control group of 240 neonates . In a second group of 70 neonates exposed to phototherapy  the same procedure was performed after at least 24 h of exposure ; on the forehead , TcB was done in the centre of the unexposed area and also on the adjacent exposed area , and the exposed chest . During the post‐phototherapy period , TcB was again done during the first and second days , at least 18–24 h after cessation of phototherapy . The results were then statistically evaluated and regression curves were plotted . Results : A close correlation between TcB values and bilirubin levels was observed in the control group . In the phototherapy group , a correlation was also found between the TcB and the bilirubin values , but this correlation was significantly poorer than that of the controls ; the correlation for the covered part of the forehead was significantly better than that of the exposed part but still poorer than that of the controls , though the difference was no longer significant . Skin colour recovered during the post‐phototherapy period and correlation was better than that during exposure and no longer significantly different from that of the controls This prospect i ve study was performed to determine a way to improve conventional transcutaneous bilirubinometry results in healthy term newborn infants . In 118 infants during phototherapy ( group A ) , and in 118 infants without phototherapy ( group B ) ,  bilirubin determinations were done in duplicate using the Minolta AirShields Jaundice Meter type 101 ( transcutaneous bilirubin index [ TcB ] ) , and the diazometric method on the Hitachi 717 Automated Analyzer ( total reacting serum bilirubin [ SeB ] ) . In 112 infants ( group C ) ,  bilirubin determinations  were done in triplicate , using simple direct-reading photometry on the Moltronic Bilirubinometer ( direct serum bilirubin [ BiB ] ) . A close correlation between TcB and SeB values was observed in group A ( r = 0.69 ; p < 0.001 ) and in group B ( r = 0.59 ; p < 0.001 ) . The 95 % confidence intervals of TcB readings corresponding to SeB were + /- 80.7 micromol/L in group A and + /- 76.9 micromol/L in group B , respectively . In group C , using a correctly calibrated BiB with adult sera containing bilirubin concentration in the range 271 to 344 micromol/L , the 95 % confidence intervals of parallel TcB and BiB readings corresponding to SeB were + /- 28 micromol/L. Parallel determinations of the TcB and the BiB in healthy term newborn infants give results almost identical to those of bilirubin determination by the laboratory method
Background : Transcutaneous bilirubin ( TcB ) devices are commonly used for screening of hyperbilirubinemia in term and near-term infants not exposed to phototherapy .
However , the accuracy of TcB devices in infants exposed to phototherapy is unclear .
Objectives : To conduct a systematic review of studies comparing TcB devices with  total serum bilirubin ( TSB ) in infants receiving phototherapy or in the postphototherapy phase .