Key messages
– Jaundice is a common newborn condition. If left undetected and untreated, it can lead to brain injury.
– Screening newborn babies by measuring jaundice levels through the skin (called transcutaneous bilirubin screening) probably leads to a reduction in readmission to hospital for light therapy and more babies having light therapy before discharge from hospital. It may have little or no effect on the number of babies who require an exchange blood transfusion to treat their jaundice or who have early brain injury.
– Further studies are needed that investigate the effect of transcutaneous bilirubin screening on newborns prior to hospital discharge.
What is jaundice?
Jaundice refers to yellowish discoloration of the skin and the white of the eyes. It occurs because of an increase in a pigment in the blood called bilirubin. When bilirubin levels in the blood increase, it gets deposited in the skin and eyes, and causes them to become yellow. Jaundice is a very common condition in newborns. In most cases, the condition is harmless and does not require any treatment. However, in some instances, the newborn requires treatment in the form of phototherapy (light therapy) or exchange blood transfusion (where some of the newborn's blood is removed and replaced with donor blood). Very high levels of bilirubin in the blood (called hyperbilirubinemia) can cause damage to the newborn's brain, resulting in permanent injury to the brain such as cerebral palsy. Early identification of jaundice is important to help prevent potential unwanted effects.
What is transcutaneous bilirubin screening?
Transcutaneous bilirubinometry is a test to detect hyperbilirubinemia in newborns. It works by directing light into the babies' skin and measuring the intensity of the light returned by gently pressing the meter against the sternum (breastbone) or forehead. This test is successful at detecting hyperbilirubinemia in newborns, and has been recommended as an appropriate screening tool for hyperbilirubinemia in newborns.
What did we want to find out?
In this systematic review we aimed to evaluate the effectiveness of transcutaneous bilirubin screening compared to visual inspection for high jaundice levels in newborns.
What did we do?
We searched for studies that looked at the use of transcutaneous bilirubin screening compared to visual inspection in newborns before they were discharged from the hospital. We summarized the results and rated our confidence in the evidence obtained.
What did we find?
We included one study (1858 babies) in this review. The study found that jaundice-related readmission to hospital is probably reduced in newborns who received transcutaneous bilirubin screening for jaundice compared to visual inspection. In addition, we found that this screening method may not affect the number of newborns who had an exchange blood transfusion, but it probably increased the number of newborns who received light therapy before discharge. We also found that this screening method compared to visual inspection for jaundice may have little effect on the rate of early brain injury caused by jaundice.
What are the limitations of the evidence?
More studies are needed to confirm these findings before widespread implementation of this transcutaneous method of bilirubin screening in newborns. However, we acknowledge that it will be unlikely that studies will be conducted to further evaluate this intervention, especially in advanced countries where this method is already widely used.
How up to date is this evidence?
This evidence is up to date to 21 June 2023.
Moderate-certainty evidence suggests that TcB screening probably reduces hospital readmission for hyperbilirubinemia compared to visual inspection. Low-certainty evidence also suggests that TcB screening may have little or no effect on the rate of exchange transfusion compared to visual inspection. However, moderate-certainty evidence suggests that TcB screening probably increases the number of newborns who require phototherapy before discharge compared to visual inspection. Low-certainty evidence suggests that TcB screening may have little or no effect on the rate of acute bilirubin encephalopathy compared to visual inspection.
Given that we have only identified one RCT, further studies are necessary to determine whether TcB screening can help to reduce readmission and complications related to neonatal hyperbilirubinemia. In settings with limited newborn follow-up after hospital discharge, identifying newborns at risk of severe hyperbilirubinemia before hospital discharge will be important to plan targeted follow-up of these infants.
The American Academy of Pediatrics and the Canadian Paediatric Society both advise that all newborns should undergo bilirubin screening before leaving the hospital, and this has become the standard practice in both countries. However, the US Preventive Task Force has found no strong evidence to suggest that this practice of universal screening for bilirubin reduces the occurrence of significant outcomes such as bilirubin-induced neurologic dysfunction or kernicterus.
To evaluate the effectiveness of transcutaneous screening compared to visual inspection for hyperbilirubinemia to prevent the readmission of newborns (infants greater than 35 weeks' gestation) for phototherapy.
We searched CENTRAL, MEDLINE, Embase, CINAHL, ClinicalTrials.gov, ICTRP, and ISRCTN in June 2023. We also searched conference proceedings, and the reference lists of included studies.
We included randomized controlled trials (RCTs), quasi-randomized, cluster-randomized, or prospective cohort studies with control arm that evaluated the use of transcutaneous bilirubin (TcB) screening for hyperbilirubinemia in newborns before hospital discharge.
We used standard methodologic procedures expected by Cochrane. We evaluated treatment effects using a fixed-effect model with risk ratio (RR) and 95% confidence intervals (CI) for categorical data and mean, standard deviation (SD), and mean difference (MD) for continuous data. We used the GRADE approach to evaluate the certainty of evidence.
We identified one RCT that met our inclusion criteria. The study included 1858 African newborns at 35 weeks' gestation or greater who were receiving routine care at a well-baby nursery, and were randomly recruited prior to discharge to undergo TcB screening. The study had good methodologic quality.
TcB screening versus visual assessment of hyperbilirubinemia in newborns:
– probably reduces readmission to the hospital for hyperbilirubinemia (RR 0.25, 95% CI 0.14 to 0.46; P < 0.0001; moderate-certainty evidence);
– may have little or no effect on the rate of exchange transfusion (RR 0.20, 95% CI 0.01 to 14.16; low-certainty evidence);
– probably increases the number of newborns who require phototherapy prior to discharge (RR 2.67, 95% CI 1.56 to 4.55; moderate-certainty evidence).
– may have little or no effect on the rate of acute bilirubin encephalopathy (RR 0.33, 95% CI 0.01 to 8.18; low-certainty evidence).
The study did not evaluate or report cost of care.