Page 114 - 16Neonatal Jaundice_compressed

Recognition

baby. Therefore, it seems likely that a more intensive testing strategy would overcome some of
the limitations of visual examination, leading to better and earlier detection of cases which
would benefit from appropriate treatment. A threshold analysis was undertaken to estimate the
number of kernicterus cases that would have to be averted in order for the more intensive
testing strategies to be considered cost-effective.
The economic analysis suggested that, providing the testing strategy using transcutaneous
bilirubin measurement could be delivered with fewer than 9200 meters (without disposable
tips) in England and Wales, it would be more cost-effective than a strategy where all visually
jaundiced babies had a serum bilirubin. The threshold analysis suggested that a minimum of
1.52 kernicterus cases per annum would have to be avoided in order for more intensive testing
to be considered cost-effective, but that a smaller number of averted cases could be cost-
effective if fewer than 9200 meters were required.
Overall GDG translation from evidence (5.2.2)

Evidence shows that transcutaneous bilirubin measurements help with the assessment of the
degree of jaundice and are more accurate than visual inspection. Good-quality indirect
evidence shows that the BiliChek produces more accurate results than the Minolta JM-102 or
JM-103 in babies with dark skin tones but there are currently no published studies directly
comparing the BiliChek and the JM-103. The GDG understands that there are differences in the
design of these devices but is unable to recommend a particular device over another.

Studies have used the forehead or sternum as the primary site for transcutaneous bilirubin
measurement, and the results are comparable. The opinion of the GDG is that measurement
over the sternum is more acceptable to parents and babies. Sternal measurement avoids the
problem of failing to obtain a reading because the baby wrinkles his or her forehead when
crying. Measurement using the forehead carries a potential risk of injuring the eye if the baby
struggles.
The difference between transcutaneous bilirubin and serum bilirubin widens at levels above
250 micromol/litre and, as few babies with high levels were studied, transcutaneous bilirubin
cannot be recommended at levels above 250 micromol/litre. If a transcutaneous bilirubinometer
records a bilirubin level above 250 micromol/litre, a serum bilirubin level should be taken to
check the bilirubin level accurately. The GDG opinion is that transcutaneous bilirubin should
not be used in very preterm babies (gestational age < 35 weeks) because they are more
vulnerable than term babies to kernicterus at relatively low levels of bilirubin and therefore
need more accurate testing, and because the evidence for accuracy of transcutaneous
bilirubinometers in this group is unclear. The GDG has made research recommendations for
both the BiliCheck and JM-103 to be studies in these subgroups of babies with jaundice.
Based on the evidence reviewed in Section 5.1, the GDG is satisfied that visual inspection, by
parents or clinical staff, is effective in ruling out jaundice but is unreliable in assessing the depth
of jaundice. The GDG recognises that transcutaneous bilirubinometers are non-invasive and are
more acceptable than blood sampling. The GDG considers that transcutaneous bilirubinometers
should be used after 24 hours of age to avoid problems associated with taking and acting upon
blood samples in the community. However, if transcutaneous bilirubinometers are not
available, serum bilirubin levels should be monitored and recorded.
The NICE guideline on ‘Postnatal care’ recommends that if ‘jaundice develops in babies aged
24 hours and older, the intensity should be monitored and systematically recorded along with
the baby’s overall well-being with particular regard to hydration and alertness’
(www.nice.org.uk/CG37). The GDG considers that any healthcare professional can be
responsible for monitoring and recording the baby’s bilirubin.

Current practice is to perform serum bilirubin on a small minority of jaundiced babies, and there
are five to seven cases of kernicterus each year in the UK. The GDG is of the opinion that the
current practice of assessing the depth of jaundice by visual inspection in the majority of babies
is unacceptable in view of the evidence which shows that this is inaccurate. The GDG is of the
opinion that bilirubin measurement within 6 hours is required for all jaundiced babies. Options
include serum bilirubin testing in all term babies who are jaundiced, or transcutaneous bilirubin
in those of gestational age ≥ 35 weeks followed by serum bilirubin in appropriate subgroups.

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