|Year : 2017 | Volume
| Issue : 1 | Page : 6-9
Twenty-four hours' transcutaneous bilirubin as a predictor of subsequent 3rd day neonatal hyperbilirubinemia
Krutika Arvind Kurhade, Sadhana Purandare
Department of Paediatrics, Acharya Vinoba Bhave Rural Hospital, DMIMS (DU), Wardha, Maharashtra, India
|Date of Web Publication||8-Feb-2017|
Dr. Krutika Arvind Kurhade
Plot No. 115, “Geeta,” Surendra Nagar, RPTS Road, Nagpur – 440 015, Maharashtra
Source of Support: None, Conflict of Interest: None
Context: Neonatal jaundice is the most common problem that can occur in over half of full term and most premature infants. Recently, due to the upcoming trend of early discharges, it is seen that these newborns are at increased risk for hospital readmission for jaundice. Hence, this study was designed to study the association between 1st day transcutaneous bilirubin (TcB) and subsequent significant neonatal hyperbilirubinemia (NNH) and to use it as a predictor for the same. Aim: This study aims to study the value of 1st day TcB as a predictor of subsequent NNH. Settings and Design: This was a descriptive correlational study conducted on 236 newborns born in our hospital which is a tertiary care center. Subjects and Methods: Inclusion criteria: Full term normal babies, ≥2.5 kg birth weight. Exclusion criteria: Rh incompatibility, babies with life-threatening conditions. After a baby was born, TcB was taken at 24 h of life and the newborn's bilirubin values were estimated on 24, 36, 48, and 72 h of life by measuring TcB; and total serum bilirubin was estimated whenever TcB was abnormal or at 72 h. TcB at 24 h >8 mg/dl and at 72 h >16 mg/dl was taken as significant. Serum bilirubin at 72 h >17 mg/dl was taken as significant as recommended by the AAP. Statistical Analysis Used: Statistical analysis was done using descriptive and inferential statistics using Chi-square test, receiver operating characteristic (ROC) analysis and the softwares used were IBM-SPSS version 17.0, graphpad prism 5.0 version developed by graphpad software inc. California, Epi Info a public domain software developed by Centers for Disease Control and Prevention in Atlanta, Georgia (USA). P < 0.05 was considered statistically significant. Results: A TcB >8 mg/dl at 24 h of life has a sensitivity of 79.71% and specificity of 96.41% to detect subsequent NNH. Area under ROC curve = 0.95.
Conclusions: TcB at 24 h has a very high correlation with the TcB, TSB, and thus NNH at 72 h of life with a P = 0.0001.
Keywords: First day bilirubin, neonatal hyperbilirubinemia, transcutaneous bilirubin
|How to cite this article:|
Kurhade KA, Purandare S. Twenty-four hours' transcutaneous bilirubin as a predictor of subsequent 3rd day neonatal hyperbilirubinemia. J Clin Neonatol 2017;6:6-9
|How to cite this URL:|
Kurhade KA, Purandare S. Twenty-four hours' transcutaneous bilirubin as a predictor of subsequent 3rd day neonatal hyperbilirubinemia. J Clin Neonatol [serial online] 2017 [cited 2019 Sep 21];6:6-9. Available from: http://www.jcnonweb.com/text.asp?2017/6/1/6/199752
| Introduction|| |
Neonatal Jaundice is the most common problem that can occur in over half of full term and most premature infants. All infants and especially preterm infants have higher rates of bilirubin production than adults because they have red cells with a higher turnover, shorter life span, and a larger early labeled bilirubin peak. Moreover, in newborn infants, unconjugated bilirubin is not readily excreted, and the ability to conjugate bilirubin is also limited. The risk for toxicity and acute encephalopathy progressively increases with a rise in serum bilirubin.
Recently due to the upcoming trend of early discharges it is seen that these newborns are at increased risk for hospital readmission for jaundice. Many neonates return with values as high as requiring exchange transfusions because they are not followed up adequately. Hence, this study was designed to study the association between 1st day transcutaneous bilirubin (TcB) and subsequent significant neonatal hyperbilirubinemia (NNH) and to use it as a predictor for the same.
| Subjects and Methods|| |
This was a descriptive correlational study conducted on 236 newborns born in our hospital which is a tertiary care center. Ethical clearance was sought and obtained from the JNMC Research and Ethics Committee before initiation of the study (Reference Number DMIMS (DU)/IEC/2014-15/838). Informed consent was taken from the mothers of the babies included in the study.
Inclusion criteria were full term normal babies with ≥2.5 kg birth weight and exclusion criteria were Rh incompatibility and babies with life-threatening conditions.
After a baby was born, TcB was taken at 24 h of life and the newborn's bilirubin values were estimated on 24, 36, 48, and 72 h of life by measuring TcB; and total serum bilirubin (TSB) was estimated whenever TcB was abnormal or at 72 h. TcB at 24 h >8 mg/dl and at 72 h >16 mg/dl was taken as significant. Serum bilirubin at 72 h >17 mg/dl was taken as significant as recommended by the AAP.
The TcB used was manufactured by DRAGER, Technology for Life, Germany Model JM-103 and TSB estimation required the RANDOX total bilirubin kit manufactured by Randox Laboratories Limited. Bilirubin estimation was done by Modified Jendrassik method.
Demographic profile and relevant maternal information was collected by interviewing the mother and from mother's case sheet. Gestational age was assessed using modified Ballard score.
To assess the serum bilirubin, 2 ml of blood was collected under all aseptic precautions in sterile sample bottle and sent to the biochemistry laboratory for measuring bilirubin levels at 72 h of life.
| Results|| |
Out of the total 236 newborns recruited in the study, 61 babies had significant NNH at 24 h of life. At 72 h of life, newborns with significant NNH by TcB were 69 in number while by TSB were 61 in number [Table 1] and [Graph 1].
|Table 1: Proportion of neonates developing neonatal hyperbilirubinemia at the end of 72 h|
Click here to view
The TcB at 24 h has a very high correlation with the TcB and thus NNH at 72 h of life with a P = 0.0001. A TcB >8 mg/dl has a sensitivity of 79.71%, specificity of 96.41%, positive predictive value of 90.16%, negative predictive value of 92.00% and a diagnostic accuracy of 91.50% for detecting subsequent NNH at 72 h [Table 2] and [Graph 2].
|Table 2: Correlation between 24 h transcutaneous bilirubin and 72 h transcutaneous bilirubin|
Click here to view
The TcB at 24 h has a very high correlation with the TSB and thus NNH at 72 h of life with a P = 0.0001. A TcB >8 mg/dl has a sensitivity of 81.96%, specificity of 93.71%, positive predictive value of 81.96%, negative predictive value of 93.71% for detecting subsequent NNH at 72 h.
The area under the receiver operating characteristic (ROC) curve was 0.95. This is an excellent value to calculate the accuracy of 24 h TcB to predict significant hyperbilirubinemia at 72 h [Graph 3].
Out of total 236 neonates, 70 (29.66%) received phototherapy and 2 (0.84%) received exchange transfusion at 72 h of life [Table 3] and [Graph 4] and [Graph 5].
|Table 3: Total number of neonates requiring phototherapy and exchange transfusion|
Click here to view
| Discussion|| |
Jaundice is observed during the 1st week of life in approximately 60% of term infants and 80% of preterm infants. NNH is one of the most common causes for readmission of the newborns.
Infants discharged in the first 2 days after birth are more likely to be readmitted to the hospital for jaundice compared with infants who have a longer postnatal hospital stay, particularly infants born “early term” at 37 and 38 weeks' gestation. In addition to hyperbilirubinemia, other health issues related to early discharge have been identified.
Significant hyperbilirubinemia in neonates can be predicted on the basis of predischarge TSB being plotted on the nomogram developed by Bhutani et al. However, the estimation of TSB levels is an invasive, risky, painful, and time-consuming procedure. On the other hand, recently introduced TcB measuring devices have been seen to be quite precise and time-saving for estimating bilirubin concentrations in neonates. TcB measurements are now being used with increasing frequency in the screening of newborn infants for significant hyperbilirubinemia despite TSB being the ultimate investigation of choice.
In the present study, we have determined a cutoff value of 8 mg/dl for the prediction of significant NNH at 24 h of life. A high serum bilirubin level at 24 h of life, has also predicted a high peak subsequently on day 3 of life. By demonstrating a significant difference in the 1st day serum bilirubin values of infants who subsequently did and those who did not develop significant hyperbilirubinemia, the present study has proved the usefulness of the test. Area under the curve was 0.95. This is an excellent value to calculate accuracy of 24 h TCB to predict significant hyperbilirubinemia at 72 h.
At 72 h, in a hyperbilirubinemic infant, the possibility that TcB at 24 h was >8 mg/dl, i.e., sensitivity is of 79.71%, while given a nonhyperbilirubinemic baby, the possibility of TcB <8 mg/dl, i.e. specificity is of 96.41%, positive predictive value, i.e., the possibility of a neonate developing significant NNH if TcB >8 mg/dl was 90.16%, negative predictive value, i.e., possibility of not developing hyperbilirubinemia when TcB is <8 mg/dl is of 92.00%, and a diagnostic accuracy is of 91.50% for detecting subsequent NNH at 72 h.
Bhutani et al. tested 1st day bilirubin in a large cohort in Philadelphia; USA. They proved that infants who develop hyperbilirubinemia have serum bilirubin levels which are in higher percentiles soon after birth (24 ± 6 h). The study patients were racially diverse. Predischarge, 6.1% of the study population had TSB values in the high-risk zone (≥95th percentile) at 18–72 h; of these, 39.5% remained in that zone. Predischarge, 32.1% of the population had TSB values in the intermediate-risk zone. In a clinically significant minority of these newborns (6.4%), the postdischarge TSB moved into the high-risk zone. They prospectively followed term newborns over the first 5 days of life by measuring serum bilirubin levels daily. In their series, out of 1097 newborns, no infant who had a bilirubin level of 5 mg/dl at 20–28 h of life developed significant hyperbilirubinemia (≥17 mg/dl), whereas 33% of those whose serum bilirubin level at the same hours was at least 8 mg/dl developed significant hyperbilirubinemia. Our study is in coordination with this.
In a study by Alpay et al., of about 500 term healthy newborns, it was observed that a serum bilirubin 6 mg/dl on the 1st day of life had a 90% sensitivity of predicting a subsequent TSB 17 mg/dl between 2nd and 5th day of life. At this critical serum bilirubin value, the negative predictive value was 97.9%. No cases with TSB of <6 mg/dl in first 24 h required a subsequent phototherapy treatment.
Agarwal et al. evaluated the predictive ability of TSB = 6 mg/dl at 24 ± 6 h of life and a sensitivity of 95%, specificity of 27.2% and negative predictive value of 99.3% were determined. They postulated that A TSB level of ≤6 mg/dl at 24 ± 6 h of life predicted neonates who would not develop hyperbilirubinemia.
In another study by Awasthi and Rehman, a value of 3.99 mg/dl was found to have a sensitivity of 64.2% and 67.4% for the subsequent requirement of phototherapy. However, the cutoff value was not determined using ROC analysis but rather the mean serum bilirubin at 18–24 h. Moreover, complete follow-up was conducted in infants who stayed in the hospital either for neonatal illness or some maternal reason. More than 50% of the neonates, who were healthy, thus discharged early, were not studied. If confirmed in other studies, these results suggest that there is a group of infants, who at least as far as significant hyperbilirubinemia is concerned, may not entail an early follow-up. Predischarge TSB levels may also alert the pediatrician to those infants who, because their TSB levels fall in the high-risk zone, require much more careful supervision and follow-up.
| Conclusions|| |
24 hours' TcB has a very high correlation with 72 hours' TcB and serum bilirubin. It can be safely used as a predictor for development of significant subsequent neonatal hyperbilirubinemia.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Mishra S, Agarwal R, Deorari AK, Paul VK. Jaundice in the newborns. Indian J Pediatr 2008;75:157-63.
MacDonald MG, Mullet MD, Seshia MM. Avery's Neonatology: Pathophysiology and Management of the Newborn. 6th
ed. Philadelphia: Lippincott Williams & Wilkins; 2005. p. 773.
Martin CR, Cloherty JP. Neonatal hyperbilirubinemia. In: Cloherty JP, Stark AR, editors. Manual of Neonatal Care. 7th
ed. Philadelphia: Lippincott; 2013. p. 304-38.
Grupp-Phelan J, Taylor JA, Liu LL, Davis RL. Early newborn hospital discharge and readmission for mild and severe jaundice. Arch Pediatr Adolesc Med 1999;153:1283-8.
Lain SJ, Roberts CL, Bowen JR, Nassar N. Early discharge of infants and risk of readmission for jaundice. Pediatrics 2015;135:314-21.
Catz C, Hanson JW, Simpson L, Yaffe SJ. Summary of workshop: Early discharge and neonatal hyperbilirubinemia. Pediatrics 1995;96 (4 Pt 1):743-5.
Bhutani VK, Johnson L, Sivieri EM. Predictive ability of a predischarge hour-specific serum bilirubin for subsequent significant hyperbilirubinemia in healthy term and near-term newborns. Pediatrics 1999;103:6-14.
Bhutani VK, Johnson LH, Sivieri EM. Universal newborn bilirubin screening. Pediatr Res 1997;41:191A. [Abstract].
Alpay F, Sarici SU, Tosuncuk HD, Serdar MA, Inanç N, Gökçay E. The value of first-day bilirubin measurement in predicting the development of significant hyperbilirubinemia in healthy term newborns. Pediatrics 2000;106:E16.
Agarwal R, Kaushal M, Aggarwal R, Paul VK, Deorari AK. Early neonatal hyperbilirubinemia using first day serum bilirubin level. Indian Pediatr 2002;39:724-30.
Awasthi S, Rehman H. Early prediction of neonatal hyperbilirubinemia. Indian J Pediatr 1998;65:131-9.
[Table 1], [Table 2], [Table 3]