Page 85 - 16Neonatal Jaundice_compressed

Neonatal jaundice

hospital between August 2002 and December 2003 were included. Since transcutaneous
bilirubin testing with BiliChek was introduced in the hospital in April 2003, babies born during
this month were excluded from the analysis. The study population was divided into two groups:
babies born in the 8 months before (August 2002 to March 2003), and those born in the
8 months after (May 2003 to December 2003) transcutaneous bilirubin testing was introduced.
The decision to measure transcutaneous bilirubin or serum bilirubin was made by the attending
physician, and Bhutani’s nomogram was used to decide whether to start phototherapy or obtain
additional blood samples. In all, 6603 babies were included in the study: 6.8% developed
significant hyperbilirubinaemia requiring phototherapy as determined by the attending clinician.
No baby was treated with home phototherapy or required exchange transfusion. The two groups
were similar with regard to gender and ethnicity. There was no statistically significant difference
in terms of total monthly births or the number of readmissions for hyperbilirubinaemia within
7 days of discharge. No statistically significant change was observed in the proportion of
newborns tested by serum bilirubin (31.8% versus 36.7%; P = 0.21) or in the mean number of
laboratory measurements per baby (1.51 versus 1.56; P = 0.33) after the introduction of
transcutaneous bilirubin testing. Similarly, no difference was seen in the mean length of hospital
stay, either for healthy babies or for babies treated with phototherapy. There was a statistically
significant increase in the total number of bilirubin measurements (transcutaneous bilirubin and
serum bilirubin) per baby (mean before transcutaneous bilirubin 0.37, mean after
transcutaneous bilirubin 0.61; P = 0.007). The mean number of readmissions for
hyperbilirubinaemia decreased statistically significantly from 4.5 to 1.8 per 1000 births per
month (P = 0.04), and the number of babies treated with phototherapy per month increased
from 5.9% to 7.7% (P = 0.014). The authors concluded that there appeared to be a trend
towards an increase in laboratory-based bilirubin testing associated with the introduction of
transcutaneous bilirubin measurement but, more importantly, it led to a reduction in the
number of hospital readmissions for significant hyperbilirubinaemia. [EL II]
Of the three studies which evaluated the impact of transcutaneous bilirubin measurement on the
need for blood sampling for serum bilirubin, the BiliChek device was used in two studies, from
Denmark and the UK, while the third study, also from the UK, used the Minolta JM-102. In the
Danish study, the BiliChek was evaluated both in sick babies in the neonatal intensive care
45
unit (NICU) and in healthy newborn babies. The authors used 70% of serum bilirubin limits
(defined by the Danish Paediatric Society guidelines) as a threshold for transcutaneous bilirubin.
A retrospective analysis of this transcutaneous bilirubin threshold showed that 35% (178 of 504)
of the NICU babies and 80% (254 of 317) of the healthy term and near-term babies would have
44
avoided blood sampling for serum bilirubin estimation, In the UK study using BiliChek, a
reduction of 55% in blood sampling was reported if serum bilirubin testing was limited to
babies with transcutaneous bilirubin levels > 195 micromol/litre only. The third study
46
evaluated the Minolta JM-102 in 285 healthy babies > 34 weeks of gestation in a UK setting.
In this study a reading of > 18 reflectance units was taken as an indicator for serum bilirubin,
resulting in a reduction of 34% in the number of blood samples taken.
Evidence summary

There is lack of good-quality prospective studies evaluating the impact of routine transcutaneous
bilirubin measurement on clinical outcomes. Results from a retrospective cohort study show a
reduction in the frequency of hospital readmissions after the introduction of transcutaneous
bilirubin measurement. However, there was an associated increase in the number of babies
treated with phototherapy and also in the proportion of babies tested for serum bilirubin,
although the difference was statistically not significant for the latter. Evidence from three other
studies suggests that routine use of transcutaneous bilirubin measurement may lead to a
reduction in the number of blood samples collected for bilirubin estimation.

GDG translation from evidence
Low-quality evidence suggests that routine pre-discharge transcutaneous bilirubinometer use is
accompanied by an increase in the use of phototherapy and a small reduction in the number of
hospital readmissions for significant hyperbilirubinaemia. Some studies suggest that the number
of serum bilirubin estimations is reduced, whereas others found an increase in the number of
these tests.

56