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ORIGINAL ARTICLE
Year : 2021  |  Volume : 34  |  Issue : 2  |  Page : 644-648

Comparative study of total serum bilirubin levels measured via blood vs skin in neonates


1 Department of Pediatric, Faculty of Medicine, National Liver Institute, Menoufia University, Al Minufiyah, Egypt
2 Department of Pediatric, National Liver Institute, Menoufia University, Al Minufiyah, Egypt
3 Department of Pediatric, Shebin El-Kom Teaching Hospital, Al Minufiyah, Egypt

Date of Submission24-Nov-2019
Date of Decision02-Dec-2019
Date of Acceptance07-Dec-2019
Date of Web Publication30-Jun-2021

Correspondence Address:
Mostafa G Elsunsafty
MBBCH, Department of Pediatric, Shebin El-Kom Teaching Hospital, Al Minufiyah
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_355_19

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  Abstract 


Objective
The aim was to compare between total bilirubin levels measured via blood vs skin in neonates.
Background
Neonatal jaundice is a common clinical problem. total serum bilirubin (TSB) with transcutaneous bilirubin (TCB) measurement can be used for evaluating bilirubin levels in neonates.
Patients and methods
This cross-sectional study was conducted on 200 jaundiced neonates with indirect hyperbilirubinemia, in the neonatal intensive care unit of Menoufia University Hospital, and they were randomly divided into three groups: group 1 (n = 100) included full-term neonates with gestational age ranged from 37 to 42 weeks; group 2 (n = 35) included late preterm neonates with gestational age ranged from 34 to 36 weeks; and group 3 (n = 65) included early preterm neonates with gestational age ranged from 30 to 33 weeks. Complete blood count with reticulocyte count was obtained along with TSB, Rhesus factor, and ABO blood groups for both mothers and neonates.
Results
There was a strong positive significant correlation between TSB and TCB, but the correlation decreased as both levels advanced [Pearson correlation (r)=0.983]. The correlation was better in full tem with TSB-TCB difference of 1.88 ± 0.39 in comparison with late and early preterm, which was 2.27 ± 1.99 and 2.55 ± 0.64, respectively. There was a strong positive correlation between TSB and TCB regarding weight, gestational age, and postnatal ages, with Pearson correlation of 0.08, 0.404, and 0.505, respectively, for TSB and 0.477, 0.489, and 0.558, respectively, for TCB. TSB always overestimates TCB.
Conclusion
TCB is a reliable method in screening of neonatal jaundice in full-term babies, reducing the need for TSB, which is expensive and invasive. Reliability is lesser for the preterm.

Keywords: full term, neonatal jaundice, preterm, total serum bilirubin, transcutaneous bilirubin


How to cite this article:
Tawfik MA, Elahony DM, Abdulaziz SA, Salem ME, Elsunsafty MG. Comparative study of total serum bilirubin levels measured via blood vs skin in neonates. Menoufia Med J 2021;34:644-8

How to cite this URL:
Tawfik MA, Elahony DM, Abdulaziz SA, Salem ME, Elsunsafty MG. Comparative study of total serum bilirubin levels measured via blood vs skin in neonates. Menoufia Med J [serial online] 2021 [cited 2024 Mar 28];34:644-8. Available from: http://www.mmj.eg.net/text.asp?2021/34/2/644/319721




  Introduction Top


Bilirubin is a potentially toxic catabolic product of heme metabolism. Fortunately, there are elaborate physiologic mechanisms for its detoxification and disposition. Understanding these mechanisms is necessary for interpretation of the clinical significance of high serum bilirubin concentrations. Furthermore, because bilirubin shares its metabolic pathway with various other sparingly water soluble substances that are excreted in bile, understanding bilirubin metabolism also provides insight into the mechanisms of transport, detoxification, and elimination of many other organic anions [1]. Bilirubin is formed by breakdown of heme present in hemoglobin, myoglobin, cytochromes, catalase, peroxidase, and tryptophan pyrrolase. Overall, 80% of the daily bilirubin production is derived from hemoglobin, with the remaining 20% being contributed by other hemoproteins and a rapidly turning-over small pool of free heme. Enhanced bilirubin formation is found in all conditions associated with increased red cell turnover such as intramedullary or intravascular hemolysis (e.g., hemolytic, dyserythropoietic, and megaloblastic anemia) [2]. Neonatal jaundice (NJ) also known as neonatal hyperbilirubinemia means yellowish discoloration of the sclera and skin caused by an increase in bilirubin production or a defect in bilirubin elimination in the neonatal period [3]. Hyperbilirubinemia is a common and in most cases is a benign and physiological condition in the first month of life.Thus, intervention is not usually necessary. Jaundice appears during the first week of life in ∼60% of term and 80% of preterm infants [4]. Prompt management of NJ was the key in reducing the incidence of bilirubin-induced neurological dysfunction and permanent complications (kernicterus). Total serum bilirubin (TSB) level assessment in clinical laboratory is an objective method, but there is significant inter-laboratory and intra-laboratory variability. The necessary blood sampling is painful and associated with the possibility of local infection [5]. Transcutaneous bilirubin (TCB) testing has become more popular than visual assessment because of the known limitations of visual identification of hyperbilirubinemia, especially in nonwhite babies. TCB measurement appears to be reliable in identification of hyperbilirubinemia in neonates from a variety of ethnic backgrounds [6-10]. Maisels et al. [10] have confirmed the value of TCB measurement. The available literature on this topic demonstrates a high correlation between TCB measurements obtained using 2 bilirubin meters (Bili-check; Respironics Inc., Marietta, Georgia, USA and Konica-Minolta Air Shields JM-103; Dräger Medical Inc., Telford, Pennsylvania, USA). Although these devices seem accurate, underestimation and overestimation occur based on TSB level, measurement site, and race/ethnicity [7]. Transcutaneous readings are immediate, and they can indicate the need for TSB testing. Studies comparing the correlation between TSB and TCB yielded different results. Those studies were held in different places worldwide, where technology served in obtaining different devices for jaundice assessment [8]. Our study aimed to evaluate reliability of the Drager device to replace frequent invasive venous sampling among neonates of different districts of Menoufia Governorate. Owing to a lack of similar study in Egypt, we conduct it in NICU of Menoufia University.


  Patients and methods Top


After approval of the Local Institutional Ethical Committee of Menoufia University Hospital and after taking written consents from parents of studied neonates to participate in the work. This was a cross-sectional study conducted on 200 Egyptian neonates (114 males and 86 females) with symptoms, signs, and laboratory finding of neonatal indirect hyperbilirubinemia, randomly selected from those attending the NICU of Menoufia University Hospitals in a period from January 2018 to January 2019. They were classified into three groups: group 1 included full-term neonates (n = 100) with gestational age 37–42 weeks, group 2 included late preterm neonates (n = 35) with gestational age 34–36 weeks, and group 3 included early preterm (n = 65) with gestational age less than 33 weeks. Inclusion criteria were patients with clinical symptoms and signs of neonatal indirect hyperbilirubinemia, of both sexes. Exclusion criteria were neonates already on phototherapy and neonates diagnosed as having direct hyperbilirubinemia. All patients were subjected to complete detailed history in the form of the name, age, sex, residence, maternal history, history of the present illness, and family history. Full clinical examination, including gestational age (weeks) by new Ballard score, mode of delivery, and birth weight (kg), and laboratory investigations, including complete blood count (CBC), with the values of Hb% (g/dl), white blood cells (×103/l), platelets (×109/μl), reticulocyte count (%), and blood grouping of both mother and newborn were done. Blood for CBC was obtained either by venipuncture (the skin over the vein was sterilized by 70% alcohol) or through a central catheter. The samples were analyzed via the automated analyzer (PHONIX-NCC 3300; Bulevar sv. Cara Konstantina, Serbia, Europa). TSB was interpreted via venipuncture under complete aseptic conditions by Jendrassik-Grof's method and also determined automatically. Transcutaneous measurements were recorded at the same time using Drager Jaundice Meter JM 105 from forehead, sternum, and knee, as the device is programmed in our neonatal care unit not to yield bilirubin levels except after approval of being on three different sites to avoid calculation bias and ensure accuracy. All data were collected, tabulated, and statistically analyzed using SPSS 19.0 for windows (SPSS Inc., Chicago, Illinois, USA) and MedCalc 13 for windows (MedCalc Software BVBA, Ostend, Belgium). We used descriptive statistics in the form of percentage (%), mean and SD. Analytic statistics were incorporated in the study to include Pearson correlation for normally distributed quantitative variables and χ2-test to study association between two qualitative variables. Fisher's exact test was used in the analysis of 2 × 2 contingency tables when at least 25% of cells has expected number less than 5. P value was considered significant if it is less than 0.05.


  Results Top


Upon categorization of the most important clinical data, our study revealed that most neonates were born by CS (72.5%). Overall, males represented 57% and females 43%. Most babies (85%) weighed 2 kg or more. More than half of mothers (62.5%) had one to two children. It is also revealed that there is no statistically significant difference between newborns of different Gestational age (GA) regarding sex and mode of delivery, whereas there is a highly statistically significant difference regarding birth weight and parity in the three groups [Table 1].
Table 1: The frequency of the most important clinical data of the studied groups

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CBC results were categorized and revealed that there was a highly statistically significant correlation between the studied groups regarding reticulocyte, platelet, and white blood cell counts. Reticulocyte count was the highest in early preterm group with mean ± SD of 5.8 ± 2.9 and the least in full term group with mean ± SD of 2.9 ± 1.8, indicating that hemolysis was higher in preterm babies with higher bilirubin levels. There was no statistically significant correlation between studied groups regarding Hb% or RBC count [Table 2].
Table 2: Blood picture between the studied groups of different gestational ages

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Comparison between studied groups regarding TSB and TCB levels revealed that TSB and TCB are of the highest values in late preterm babies, with levels of 17.22 ± 3.3 and 14.66 ± 3.02, respectively. In relation to TSB-TCB differences, the early preterm had greater difference of 2.55 ± 0.64. With advancing gestational age, the difference became lesser [Table 3].
Table 3: Comparison between total serum bilirubin and transcutaneous bilirubin measurements among neonates of different GA

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There was a highly strong positive significant correlation regarding measures of TCB and TSB, with P value less than 0.0001. The correlation became weaker as both levels increased, as illustrated in [Figure 1]. We identified some risk factors and categorized them to establish their effects on TSB and TCB. There was a highly significant positive correlation between TSB and TCB with weight, gestational age, and postnatal ages, with Pearson correlation of 0.08, 0.404, and 0.505, respectively, for TSB and 0.477, 0.489, and 0.558, respectively, for TCB. Regarding maternal age, there was no significant correlation with TSB or TCB. Pearson correlation was 0.07 and 0.077, respectively, with P value greater than 0.05 [Table 4].
Figure 1: Relation between total serum bilirubin and transcutaneous bilirubin.

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Table 4: Correlation between total serum bilirubin, transcutaneous bilirubin and clinical findings

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  Discussion Top


Neonatal hyperbilirubinemia is a common condition and in most cases a benign problem in neonates. It is defined as a TSB above 5 mg/dl or a TSB greater than 95th percentile. It affects half of the full-term and almost all of the preterm infants [9]. Although most jaundiced infants are otherwise perfectly healthy, they make us anxious, because bilirubin is potentially toxic to the central nervous system [10]. So, the study aimed to find out reliability of TCB via Drager bilirubinometer, including neonates of different districts. Owing to a lack of similar study in Egypt, we conduct our work in NICU of Menoufia University Hospital. Although blood may be sampled routinely from ill preterm neonates, a relative accurate and precise noninvasive method of monitoring of jaundice in such babies would be desirable. TCB monitoring might enhance early detection of hyperbilirubinemia in this vulnerable population [11]. Reducing blood sampling and therefore a painful procedure is achieved [12]. We found that there was no statistically significant difference between different studied groups regarding mode of delivery [NVD represents 57 (28.5%) cases and CS represents 143 (71.5%) cases; P > 0.05]. In our study, there was a male predominance. American Academy of Pediatrics considered male sex as a minor risk factor for development of severe hyperbilirubinemia [13]. Our study showed that there was a highly statistically significant difference between TSB and TCB. Our results agreed with the study conducted by Şimşek et al. [14] who examined the correlation between TCB measurement (using the JM-103) and TSB measurement in 250 babies with a gestational age of greater than or equal to 36 weeks who were less than or equal to 15 days old. The mean ± SD of TSB level was 11.2 ± 4.6 mg/dl, and 17.2% of cases had TSB greater than 15 mg/dl. There was a good correlation between TCB and TSB measurements (P < 0.001). The TCB measurement tended to underestimate the value with increasing discrepancy at higher TSB values. Our results agreed with a study undertaken by Hesaraki [15] and carried out on 120 neonates diagnosed with indirect hyperbilirubinemia. They were selected using convenience nonprobability sampling. They were hospitalized in Amir Al-Momemin Hospital in Iran and concluded that TCB can be used as a screening tool for NJ. Rubaltelli et al. [16] and Kazmierczak et al. [17] reported that TCB is reliable enough to replace laboratory measurement of TSB entirely in term and near-term neonates. Wong et al. [18] had reported the limitation of this technique, and Engle et al. [19] reported that TCB may facilitate outpatient management of hyperbilirubinemia by reducing the number of TSB determinations required; however, it does not provide a reliable substitute for TSB. We disagreed with Neocleous et al. [20], who concluded that TCB and TSB values did not correlate well, and TCB values often proved imprecise in predicting actual TSB levels. In our study, there were some limitations. We did not compare between various devices. Another obstacle was the relative small size of the studied neonates. Opportunities to follow-up our cases was disabled. We did not take the color of the skin as an influencing factor on TCB readings. To the best of our knowledge, this study becomes one of the first to evaluate Drager JM105 in Egypt. Such device becomes one of the most recent and developing tool to approach TSB.


  Conclusion Top


Based on the results of the current study, it can be concluded that TCB using Drager JM105 device has a good correlation with TSB and can be used as a screening tool for evaluation of jaundice in full-term newborns, reducing the need for frequent blood sampling and to lesser extent for the preterm. However, it cannot be a definitive tool for accurate assessment, especially at high bilirubin levels.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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