Management of late-preterm and term infants with hyperbilirubinaemia in resource-constrained settings.

Hyperbilirubinaemia is a ubiquitous transitional morbidity in the vast majority of newborns and a leading cause of hospitalisation in the first week of life worldwide. While timely and effective phototherapy and exchange transfusion are well proven treatments for severe neonatal hyperbilirubinaemia, inappropriate or ineffective treatment of hyperbilirubinaemia, at secondary and tertiary hospitals, still prevails in many poorly-resourced countries accounting for a disproportionately high burden of bilirubin-induced mortality and long-term morbidity. As part of the efforts to curtail the widely reported risks of frequent but avoidable bilirubin-induced neurologic dysfunction (acute bilirubin encephalopathy (ABE) and kernicterus) in low and middle-income countries (LMICs) with significant resource constraints, this article presents a practical framework for the management of late-preterm and term infants (≥ 35 weeks of gestation) with clinically significant hyperbilirubinaemia in these countries particularly where local practice guidelines are lacking. Standard and validated protocols were followed in adapting available evidence-based national guidelines on the management of hyperbilirubinaemia through a collaboration among clinicians and experts on newborn jaundice from different world regions. Tasks and resources required for the comprehensive management of infants with or at risk of severe hyperbilirubinaemia at all levels of healthcare delivery are proposed, covering primary prevention, early detection, diagnosis, monitoring, treatment, and follow-up. Additionally, actionable treatment or referral levels for phototherapy and exchange transfusion are proposed within the context of several confounding factors such as widespread exclusive breastfeeding, infections, blood group incompatibilities and G6PD deficiency, which place infants at high risk of severe hyperbilirubinaemia and bilirubin-induced neurologic dysfunction in LMICs, as well as the limited facilities for clinical investigations and inconsistent functionality of available phototherapy devices. The need to adjust these levels as appropriate depending on the available facilities in each clinical setting and the risk profile of the infant is emphasised with a view to avoiding over-treatment or under-treatment. These recommendations should serve as a valuable reference material for health workers, guide the development of contextually-relevant national guidelines in each LMIC, as well as facilitate effective advocacy and mobilisation of requisite resources for the optimal care of infants with hyperbilirubinaemia at all levels

Correlation between transcutaneous bilirubin and total serum bilirubin levels among preterm neonates at Groote Schuur Hospital

Includes abstract. Includes bibliographical references

A CORRELATION STUDY BETWEEN TRANSCUTANEOUS BILIRUBIN AND TOTAL SERUM BILIRUBIN LEVELS AMONG NEONATES

Objective: The availability of modern bilirubin meters that measure bilirubin concentration in dermal and subcutaneous tissues has made it possible to obtain serial, non-invasive (i.e., painless) TcB (transcutaneous bilirubin) measurements. However, concerns have been raised regarding the appropriateness of comparing these TcB values to serum bilirubin values. This study aims to find a correlation between transcutaneous bilirubin and total serum bilirubin. Methods: Prospective analytic study carried out in NICU of Govt. RDBP Jaipuria Hospital. Newborn babies up to the 10th postnatal day of life with visually found jaundice had been enrolled in the study. TcB was measured over mid-sternum with Dräger JM 105™ device. Simultaneous total serum bilirubin (TSB) measurements had been done. Pearson’s correlation coefficient and Bland–Altman analysis had been done. ROC curves of mean TcB at different TSB level had been constructed. Results: In the study, 120 babies had been included. A significant correlation was founded between TcB and TSB measured values. Pearson’s correlation coefficient was 0.892 (p<0.001). The average error in evaluating hyperbilirubinemia with TcB compared to TSB was 0.101, with limits of agreement between −3.73 and +3.55. The AUOC at three TSB levels (>10 mg/dl, >12 mg/dl, and >15 mg/dl) was 0.860, 0.892, and 0.849. Conclusion: In our study, TcB measurements correlated well with TSB measurements and validated its use as a screening tool for the evaluation of jaundice in newborns

Neonatal hyperbilirubinemia bilirubin encephalopathy: investigations into the diagnosis, epidemiology, pathogenesis, management and treatment of the jaundiced newborn

Jaundice is probably the most common newborn infant problem dealt with on a daily basis by the family practitioner and paediatrician. Jaundice occurs when the liver cannot clear a sufficient amount of bilirubin from the plasma. When the problem is excessive bilirubin formation or limited uptake or conjugation, unconjugated (i.e., indirect reacting) bilirubin appears in the blood and indirect hyperbilirubinemia is the predominant form of jaundice found in the newborn infant. In the vast majority of newborns, hyperbilirubinemia is transient and benign but, in rare cases, the serum bilirubin rises to a level that is toxic to the central nervous system. Understanding the pathogenesis and epidemiology of neonatal hyperbilirubinemia; recognizing, the problems involved in appropriate surveillance and monitoring of the jaundiced infant and the factors contributing to bilirubin encephalopathy; and implementing treatment of the jaundiced neonate in a timely fashion, are issues that have engaged clinicians and researchers for some 6 decades. This work will summarize my contributions to the field of neonatal hyperbilirubinemia and it includes papers published between 1971 and 2007. The description of this work will not follow its chronological sequence, but will be divided into the categories of diagnosis, epidemiology, pathogenesis, management, treatment, and bilirubin encephalopathy

Weight, Temperature, and Transcutaneous Bilirubin of the Term Neonate at Discharge: A Comparative Study Between a Traditional Nursery and Rooming-in Model of Care

Purpose: The purpose of this study was to examine day of discharge term neonate outcomes of percent weight change, body temperature, and transcutaneous bilirubin from a traditional nursery and a rooming-in model of care. Design: A retrospective, descriptive, comparative design was used, comparing two groups for differences between outcomes. Methods: A total of 102 electronic neonate records from one hospital in north Georgia were examined and divided based on when the model of neonate care changed from the traditional nursery care setting to full rooming-in, which was early November 2010: Group 1 (traditional care) consisted of 51 term neonates discharged from August 2010 through October 2010; Group 2 (rooming-in) consisted of 51 term neonates discharged from November 2010 through February 2011. Results: A one-way ANOVA revealed there was no statistically significant difference for neonates’ percent change in weight between the traditional nursery group and the rooming-in group, F(1, 100) = 1.70, p = .195. In addition, no significant difference was found for neonates’ discharge temperature or discharge transcutaneous bilirubin level between the two groups, F(1, 100) = 0.003, p = .953 and F(1, 100) = 0.000, p = .985, respectively. Conclusions: These study findings suggest term neonates cared for by their mothers in rooming-in settings have similar biometric measurements as neonates cared for by nurses in traditional nurseries. This strengthens the case for hospitals to either continue the practice of rooming-in or to transition to rooming-in if currently practicing within the traditional nursery setting

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. ImpactKey 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.Afdeling Klinische Chemie en Laboratoriumgeneeskunde (AKCL

Detection of hyperbilirubinaemia in jaundiced full-term neonates by eye or by bilirubinometer?

The aim of this study was to compare predictions of hyperbilirubinaemia by eye, performed by trained physicians and nurses, with predictions obtained using two commercial bilirubinometers. Jaundice was assessed in 92 white and 48 non-white healthy full-term neonates using three non-invasive methods and by total serum bilirubin as the reference method. Clinical assessment of cephalocaudal progression of jaundice was carried out independently by a physician and by nurses. Simultaneously, the Minolta Airshields JM-102 was applied on the sternum, the BiliCheck on both the forehead and the sternum, and finally, serum bilirubin concentrations were determined. The Minolta JM-102 showed the best performance with r2=0.90, an intraclass correlation coefficient (ICC) of 0.93, and a 95% confidence interval (CI) of ±4units (approx. 56µmol/l). The BiliCheck performed slightly better on the forehead than over the sternum with r2=0.90, an ICC of 0.88, and a CI of ±62µmol/l. Assessment of jaundice by eye was least accurate with r2=0.74, an ICC of 0.67, and a CI of ±1.5 zones (corresponding to ±75µmol/l). Skin pigmentation and ambient light both adversely affected non-invasive bilirubin estimation. Conclusion:All three non-invasive methods are well suited for estimation of serum bilirubin but show large confidence intervals. In healthy term newborns, hyperbilirubinaemia (>250µmol/l) can be safely ruled out by eye if jaundice does not reach the abdomen or the extremities (Kramer zones 1 and 2), with <22 units (<230µmol/l) for the Minolta JM-102, or with a cut-off of 190µmol/l for the BiliCheck. If these respective thresholds are exceeded, serum bilirubin concentrations should be measure

Smartphone screening for neonatal jaundice via ambient-subtracted sclera chromaticity

Jaundice is a major cause of mortality and morbidity in the newborn. Globally, early identification and home monitoring are significant challenges in reducing the incidence of jaundice-related neurological damage. Smartphone cameras are promising as colour-based screening tools as they are low-cost, objective and ubiquitous. We propose a novel smartphone method to screen for neonatal jaundice by imaging the sclera. It does not rely on colour calibration cards or accessories, which may facilitate its adoption at scale and in less economically developed regions. Our approach is to explicitly address three confounding factors in relating colour to jaundice: (1) skin pigmentation, (2) ambient light, and (3) camera spectral response. (1) The variation in skin pigmentation is avoided by imaging the sclera. (2) With the smartphone screen acting as an illuminating flash, a flash/ no-flash image pair is captured using the front-facing camera. The contribution of ambient light is subtracted. (3) In principle, this permits a device- and ambient-independent measure of sclera chromaticity following a one-time calibration. We introduce the concept of Scleral-Conjunctival Bilirubin (SCB), in analogy with Transcutaneous Bilirubin (TcB). The scleral chromaticity is mapped to an SCB value. A pilot study was conducted in the UCL Hospital Neonatal Care Unit (n = 37). Neonates were imaged using a specially developed app concurrently with having a blood test for total serum bilirubin (TSB). The better of two models for SCB based on ambient-subtracted sclera chromaticity achieved r = 0.75 (p250μmol/L (area under receiver operating characteristic curve, AUROC, 0.86), and 92% (specificity 67%) in identifying newborns with TSB>205μmol/L (AUROC 0.85). These results are comparable to modern transcutaneous bilirubinometers

Evaluation of the Bilicheck® transcutaneous bilirubinometer in jaundiced Nigerian term and preterm neonates

Background: Transcutaneous bilirubinometry has shown some promise as a safe, non-invasive method that correlates well with traditional laboratory methods of estimating serum bilirubin. However there is a paucity of studies done on neonates of African descent. Aim: The aim of the study was to evaluate the diagnostic performance of the Bilichek® transcutaneous bilirubinometer in jaundiced Nigerian term and preterm neonates. Methods: This was a cross-sectional study involving 169 jaundiced preterm and term neonates studied over a 4 month period. A total of 200 transcutaneous bilirubin (TcB) readings determined using the Bilichek® device were obtained simultaneously with total serum bilirubin (TSB) readings determined by the diazo method. Results: The mean (SD) difference between TcB and TSB was 1.5 (2.6) mg/dL (95% CI of 1.2 - 1.9 mg/dL); p= 0.000. There was strong correlation between T cB and TSB with a correlation coefficient (r) of 0.77 (p = 0.000). The 95% limits of agreement were between -3.5mg/dL and 6.6mg/dL. There was poor correlation between TcB and TSB of r= 0.43 at high TSB levels &gt;12mg/dl. The TcB cut-off that most accurately predicted TSB was 11.7mg/dL. Conclusion: Transcutaneous bilirubinometry is a reliable screening method for assessing severity of hyperbilirubinaemia in black African neonates. However, due to the occurrence of wide disparities, confirmatory serum bilirubin measurements should be done for TcB values above 11.7mg/dL