RPA Newborn Care Guidelines

Royal Prince Alfred Hospital

Transcutaneous Bilirubinometers
Introduction
The incidence of clinical jaundice in newborn infants is reported to be as high as 60 to
1
80 per cent during the first days following birth . Jaundice is safe for most term infants
but high levels of unconjugated bilirubin can cause brain damage in susceptible
newborns. Preventative, screening and management strategies therefore remain a
significant practice issue during the early postnatal period.
This high incidence of jaundice combined with a relatively low incidence of adverse
outcomes and the shortening of postnatal stay means that peak serum bilirubin levels
2
(SBRs) often occur after discharge . Thus effective screening and surveillance are
essential to ensure that infants with severe hyperbilirubinaemia are not missed.
Importantly it is still not known at what level bilirubin can cause a significant risk of
1, 3, 4, 5, 6, 7,
however SBRs over 450 micromol/L have been associated
brain damage
4
with kernicterus in the term infant with co morbidities such as sepsis or haemolysis .
This guideline was developed to improve our screening for significant jaundice and
reduce the need for invasive and painful blood tests through the use of new generation
bilirubinometers.

Use of Transcutaneous Bilirubinometers

(TcBs)
The proposed benefits of using this technology include non-invasive and accurate
screening for clinically significant jaundice. TcB readings are instant and results can
avoid delay with discharge and / or indicate the need for formal SBR testing.
Reduction in invasive blood tests will have an associated reduction in pain and
discomfort for the newborn and a reduction in health costs.
TcB measurements have demonstrated linear correlation with SBRs and several
investigators have recommended their use as a screening device to detect clinically
significant jaundice and thus decrease the need for frequent blood sampling in the well
2, 3, 4, 20, 24, 25, 26, 27
term infant
. In addition, both the BiliChek and the Konica Minolta
JM-103 have been trialed in ethnically diverse populations and have had good
2
correlations with SBRs .
The results of a recent audit at RPA Women and Babies demonstrated that both the

BiliChek (Respironics, Inc. Murrysville, PA USA) see figure one and the Konica
Minolta JM-103 (Drger Air-Shields, USA) see figure two have sufficient accuracy
in the term population when compared with traditional SBR blood tests to justify their
use. At this time the use of TcB measurements for infants less than 37 weeks
gestation has not been validated in our population. Further evaluation of the
technology in this high-risk group is currently underway.

Serum bilirubin blood test (SBRs)

Aside from almost universal screening for rare inborn errors of metabolism, the most
frequently ordered blood test on well newborns is the measurement of SBRs. Although
frequency of testing has a poor correlation with the number of infants diagnosed with
8
moderate to severe hyperbilirubinaemia , the total SBR remains the gold standard
for jaundice screening in most maternity units.
Most protocols used to identify infants at risk for moderate severe
hyperbilirubinaemia rely on clinical observation of increasing jaundice and blood tests
20
. Importantly clinical assessment of jaundice is not predictive, reliable or accurate
21, 22, 23
and can lead to over testing
.
It is important to balance the potential harms of over diagnosing and over treating
infants with safe levels of jaundice and under treating that very small number of infants
with jaundice that can potentially cause harm.
The potential harms associated with using invasive blood tests to measure SBRs and
over diagnosing jaundice include:

9, 10, 11

infant pain and discomfort

12, 13
infection
11
maternal distress
14, 15
interruption to breast feeding
and
16
maternal infant separation

The potential harms associated with under diagnosis of moderate to severe jaundice
include:

17

sensorineural hearing loss

bilirubin encephalopathy (hypertonia, arching, opisthotonos, high pitched cry)

18

kernicterus

Indications for SBR blood tests

preterm infants with clinically significant jaundice

all infants less than 24 hours of age who present with jaundice
all infants with haemolysis or other significant risk factors for jaundice
term infants 24 48hours of age where the TcB reading is greater than 140

mol/L
term infants 48 72 hours of age where the TcB reading is greater than 200
mol/L
term infants greater than 72 hours of age where the TcB reading is greater
than 260 mol/L
first jaundice level after initiation of phototherapy on the postnatal ward or in
the home
all infants receiving overhead phototherapy

Risk factors for jaundice in the term infant

8, 19

Several factors increase the risk for jaundice in the otherwise well term infant
.
These include a history of hyperbilirubinaemia in a previous sibling, infants less than
8
38 weeks gestation, Asian ethnicity and infants who are breast feeding . Asian race
and a gestational age less than 38 weeks are strong predictors for maximum SBRs
8
over 428 micromol/L . Maisels et al (1988) also reported a strong relationship between
breast feeding (p < .0001) and greater than seven per cent weight loss (p = .0001) and
19
hyperbilirubinaemia .
The list of complex factors that advance bilirubin toxicity in the at risk newborn include
high levels of unconjugated bilirubin (excessive bruising, increased entero hepatic
bilirubin production, or haemolysis - Rh or ABO incompatibility and glucose-6phosphate dehydrogenase deficiency), low serum albumin levels (prematurity) and / or
impaired binding of bilirubin to albumin (acidosis, sepsis, hypothermia, hypoglycaemia)
and decreased bilirubin solubility / increased bilirubin deposition (acidosis, anaemia,
sepsis, poor perfusion or respiratory distress) see Jaundice policy for a detailed list
of risk factors, consequences and investigation of jaundice.

TcB Measurements
TcB measurements are used to screen the otherwise well term infant who is greater
than 24 hours of age to determine the need for a formal SBR. In addition to the TcB
reading it is essential to consider the presence of any risk factors associated with
moderate to severe jaundice in the term infant.
Using the current clinical practice guidelines for the initiation of phototherapy in the
28
term infant (RPA Newborn Care 2003 see jaundice poliy) that is a SBR greater
than 320 mol/L on day three, the correlations for the Konica Minolta JM-103 and
SBRs were examined. On the scatter plot for the Konica Minolta JM-103 TcB
measurements and corresponding SBRs (n = 95) there was only one TcB reading
under 260 mol/L that had a corresponding SBR over the phototherapy limit of 320
mol/L (JM-103 220 mol/L / SBL 330 mol/L) - see figure two.

(Drger Air-Shields, USA)

Procedure (postnatal wards / midwifery discharge programme)

TcB measurements are performed to determine the need for a formal SBR
TcB measurements can be used to facilitate newborn discharge where
appropriate
Serial TcB readings are used to evaluate the effect of phototherapy after
formal SBRs have demonstrated falling bilirubin levels. Transcutaneous
bilirubin measurements can only be used to monitor efficacy of phototherapy
when the Medela Bilibed (Fischer & Paykel) is in use. This method of
phototherapy does not expose the forehead to therapeutic light.
Take two single TcB readings if there is a difference in readings of less than
60mol/L document the higher reading. Repeat procedure if readings are
outside this range.
All clinicians require accreditation with use of the Konica Minolta JM-103 and
associated QI guidelines.
The Konica Minolta JM-103 requires calibration daily - prior to the morning
round. The midwives (night shift) will calibrate the Konica Minolta JM-103,
document and sign in the JM-103 Resource Manual. Both the values for the
long and short optical paths should read within 1.0 of the reference value on
the unit cover see resource folder.
To take a measurement the device is positioned on the forehead flush with the
infants skin and below the hairline. Avoid any bruising or discoloured areas of
skin. The tip is cleaned with an alcohol wipe between infants. The devices are
2
set to take a single measurement . While in hospital all TcB readings are
taken on the forehead to ensure a standardised technique. Accuracy of both
2
the forehead and sternum has been validated .

The Konica Minolta JM-103 Jaundice Meter (reproduced with permission of Drger
Air-Shields, USA)

BiliChek (Respironics, Inc. Murrysville, PA

USA)
The domiciliary midwives have used The BiliChek to screen for hyperbilirubinaemia
in term infants for the last 18 months. To take a measurement using the BiliChek, the

device is calibrated prior to each measurement; the disposable probe (BiliCal ) is

applied on the forehead level below the hairline and five readings are used to generate
26
one measurement that is displayed in mol/L . When correct pressure is applied a
green light alerts the operator to take a reading, if a faulty measure is taken an error
message is displayed and the last reading must be repeated. This device uses more
advanced technology than the Konica Minolta JM-103 and is currently being
evaluated at RPA Newborn Care for use in the sick and preterm infant.

The BiliChek in use (reproduced with permission Respironics, Inc. Murrysville, PA

USA)

Figure one - correlation between SBRs and BiliChek

measurements term babies

Figure two - correlation between SBRs and Minolta JM103 measurements term babies

Screening for hyperbilirubinaemia in

term infants: Summary
Signs of jaundice < 24 hours
of age

Do SBR see jaundice

policy
for additional
investigations

Signs of jaundice > 24 hours

of age +
Risk factors (maternal
antibodies; history of G6PD)

Do SBR see jaundice

policy
for additional
investigations

Signs of jaundice 24-48 hours

of age
Well infant / no risk factors

If TcB measurement >

140mol/L
Do SBR

Signs of jaundice 48-72 hours

of age
Well infant / no risk factors

If TcB measurement >

200mol/L
Do SBR

Signs of jaundice >72 hours

of age
Well infant / no risk factors

If TcB measurement >

260mol/L
Do SBR

Phototherapy using the

Medela Bilibed
Well infant / no other risk
factors

Do SBR if level falling

Monitor jaundice using
TcB

References:
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Jackson C, Talbot D & Huang R. Evaluation of a new transcutaneous bilirubinometer.
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http://www.cs.nsw.gov.au/rpa/neonatal/default.htm

Created January 2006