Clinical implication of the difference between transcutaneous bilirubinometry and total serum bilirubin for the classification of newborns at risk of hyperbilirubinemia
Introduction
The healthcare policy mandating early discharge of healthy, full-term infants combined with a higher prevalence of breast-feeding newborns has contributed to an increased number of neonatal hospital readmissions for hyperbilirubinemia, within days of being discharged [1]. The Canadian Pediatric Society (CPS) released new screening guidelines for jaundice with a recommendation that all infants should have their bilirubin measured in the first 72 h of life. Infants with a level consistent with increased risk should be carefully monitored and followed within 24 to 48 h of discharge [2]. Bilirubin concentration can be measured by capillary or venous blood sampling or by using transcutaneous devices.
Early detection and prevention of severe hyperbilirubinemia is essential to avoid bilirubin encephalopathy. Therefore, it is mandated that when infants go home, especially prior to 24 h of age, a follow up visit should be scheduled with a healthcare professional or a home visit arranged with a primary community provider who can perform a bilirubin test, as well as evaluate other potential health problems. Thus the primary responsibility for detecting significant post discharge jaundice rests within the healthcare system (family practitioners, midwives, and community nurses). In these settings, transcutaneous bilirubinometry seems to be a reasonable alternative to laboratory-based bilirubin testing to screen newborns for hyperbilirubinemia.
In recent years there have been major improvements in the assessment of bilirubin levels using transcutaneous bilirubinometry (TcB). At present two transcutaneous bilirubinometers are reputed to address the confounding effects of melanin and hemoglobin on TcB analysis; the Respironics BiliCheck™ and the Minolta Air-Shields JM-103® [3], [4]. The objectives of this study were 1) to determine whether transcutaneous bilirubin measurements, performed using the BiliCheck™ or JM-103 meters correlate with total serum bilirubin (TSB) levels, measured in our laboratory (VITROS 950) and 2) to evaluate the predictive accuracy of the TcB measurements pertinent to the risk classification of infants with jaundice based on the nomogram recommended by the CPS [2], [5].
Section snippets
Selection and description of participants
We selected healthy term or near term neonates from the nursery at McMaster Children's Hospital that were born in the period of July–August 2003 (BiliCheck™-Vitros (B-V) study) and December 2003 to February 2004 (Air-Shields-Vitros (AS-V)) who met the inclusion criteria. This was not designed as a 3-way comparison, and the Minolta Air-Shields JM-103® bilirubinometer was available in Canada at the end of 2003. Inclusion criteria were: i) healthy neonates greater than 35 weeks gestational age and
Population
A total of 154 admitted newborns met the inclusion criteria; 94 for Minolta Air-Shields JM-103®-Vitros (AS-V) and 60 for BiliCheck™-Vitros (B-V) comparisons. TSB values ranged from 69–343 µmol/L for the B-V infant group and 18–259 µmol/L for the AS-V. Mean gestational age was 39.2 ± 1.3 weeks for both cohorts and mean age and weight at the time when measurements were taken were 43.0 ± 31.9 h and 3391.6 ± 487.7 g for B-V and 40.6 ± 15.6 h and 3343.6 ± 399 g for the AS-V cohort. Slightly more vaginal
Discussion
Our results show a good correlation between both TcB devices (BiliCheck™ and Minolta Air-Shields JM-103®) and the laboratory method, in a study cohort representative of the population in Hamilton, Ontario. However, in both cases the TcB levels were lower than the serum bilirubin. Applying the risk classification developed by Bhutani et al. [5] and recommended by the CPS [2] we observed a 6% FN rate with BiliCheck™ and a FN rate of 62% with the Minolta Air-Shields JM-103® device. After
Conclusions
In summary, it is incorrect to plot TcB levels on a TSB based nomogram. The biases for these methods revealed in our study, have clinical implications for the classification of newborns at risk for hyperbilirubinemia and correction factors must be applied to the TcB measurements when used on the Bhutani nomogram. The first line healthcare professional must be aware of these limitations and work with the laboratory for optimal bilirubin level interpretation.
Acknowledgments
We are grateful to the patients who participated in the study. We thank the nurses on Ward 4C of the McMaster Hospital who performed the TcB measurements and Mr. M. Donahoe for help with the statistical analysis. We thank Trudell Canada for the loan of the BiliCheck™ and disposables and Hill-Rom Canada for the loan of the Minolta Air-Shields JM-103®. This paper is dedicated to the late Dr Keith Kim who assisted in the protocol preparation and performed this study during his training.
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