Transcutaneous bilirubinometry in neonates

In recent years, a new risk model for hyperbilirubinemia has emerged. There are several reasons for this. First, delivery of the health care system to the relatively healthy term or near-term infant and mother has changed, with earlier discharge and fewer routine tests (1). Second, physician awareness of the possibility of kernicterus in this population has changed, requiring increased vigilance (2). Third, the tendency toward demedicalization of the relatively healthy breastfed newborn has created the potential for development of severe hyperbilirubinemia (greater than 350 μmol/L). A recent study from Canada (2) concluded that severe hyperbilirubinemia continues to be observed in term and near-term neonates, with significant morbidity. Although jaundice occurs in the majority of newborns and most cases are benign, the newborn with severe jaundice must be identified, carefully followed and, if needed, treated appropriately because of the potential toxicity. Capillary collection of blood by heel puncture or blood collection from venous puncture has been the traditional method of screening and monitoring jaundice in neonates (3). This obviously causes pain and discomfort to infants and anxiety to parents. Transcutaneous bilirubin measurements using BiliChek (Respironics, USA) or other similar devices have been used sporadically in many countries, including the United States and Canada, for the screening of jaundiced infants. The clinical practice guideline that was recently published by the American Academy of Pediatrics (4) stated that there is an urgent need to improve the precision and accuracy of measurement of bilirubin in clinical laboratories. The Academy has called for additional studies on the cost-effectiveness and reproducibility of transcutaneous measurements of total serum bilirubin. Jaundice is first seen in the face of a newborn and generally progresses caudally to the body and the extremities. Visual estimation of jaundice will lead to errors; therefore, screening tools have been developed using noninvasive devices, such as BiliChek, to estimate bilirubin levels, and they have proven to be valid. Although studies are limited, they suggest a measurement within 34 μmol/L to 51 μmol/L when compared with serum bilirubin. A study by Jangaard et al (pages 79–83) evaluated the transcutaneous bilirubin device BiliChek by comparing transcutaneous bilirubin values with total serum bilirubin measurements in well term infants, ill term infants and preterm infants admitted to neonatal intensive care units, with and without phototherapy. The study consisted of two phases: in phase 1, 99 healthy, full-term infants who had not received phototherapy had transcutaneous bilirubin measurement performed simultaneously with heel puncture for serum bilirubin measurement. In phase 2, in 56 infants admitted to neonatal intensive care units, a total of 99 transcutaneous readings were performed at the time that serum bilirubin measurements were ordered for clinical reasons. The operators of the BiliChek device were blinded to the serum bilirubin levels. The authors found that transcutaneous bilirubin measurements were reasonably accurate for measuring bilirubin in term, jaundiced infants not undergoing phototherapy and in those receiving phototherapy if the area of skin was patched from the phototherapy. The BiliChek measurements were unreliable for preterm and ill infants. Jangaard et al should be congratulated for their work. Their study adds to the multiple other studies that are available comparing transcutaneous serum bilirubin measurements with capillary or venous bilirubin collection methods (5–7). Like others, they found that transcutaneous measurement has limitations. For instance, it becomes unreliable after initiation of phototherapy if the skin is not shielded from light because skin is bleached by the light. Their study did not address other important issues, such as varying degrees of skin thickness, skin colour and infants of different ethnic backgrounds, but the authors acknowledge these limitations. Future studies should include larger numbers of infants with larger numbers of measurements so that the reliability, specificity and sensitivity of such devices can be assessed. Infants in Canada are indeed from different ethnic backgrounds; therefore, variability, such as skin colour and thickness, becomes especially important in the Canadian population. Furthermore, it is crucial to investigate the cost-effectiveness of these instruments and the ability to use them for ongoing monitoring of jaundiced infants. If proven effective, these devices can be used to replace the traditional collection of serum from jaundiced infants for the measurement of bilirubin levels.

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