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Original Article ›››

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

ABSTRACT
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.

Key words:
First day bilirubin, neonatal hyperbilirubinemia, transcutaneous bilirubin

INTRODUCTION Recently due to the upcoming trend of early discharges it is

Neonatal Jaundice is the most common problem that can
occur in over half of full term and most premature infants.[1]
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.[2] 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.[3]
Address for correspondence:
Dr. Krutika Arvind Kurhade,
Plot No. 115, “Geeta,” Surendra Nagar, RPTS Road,
Nagpur – 440 015, Maharashtra, India.
E‑mail: krutika_88@hotmail.com
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seen that these newborns are at increased risk for hospital
readmission for jaundice.[4] 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
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DOI: How to cite this article: Kurhade KA, Purandare S. Twenty-four

10.4103/2249-4847.199752 hours' transcutaneous bilirubin as a predictor of subsequent 3rd day
neonatal hyperbilirubinemia. J Clin Neonatol 2017;6:6-9.

6 © 2017 Journal of Clinical Neonatology | Published by Wolters Kluwer - Medknow

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Kurhade and Purandare: Twenty‑four hours TcB as a predictor of NNH at 72 h

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.
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].
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 Graphs 4 and 5].

Demographic profile and relevant maternal information Table 1: Proportion of neonates developing neonatal
was collected by interviewing the mother and from mother’s hyperbilirubinemia at the end of 72 h
case sheet. Gestational age was assessed using modified Total neonates Neonates with significant Percentage
Ballard score. NNH at the end of 72 h
236 61 25.84
To assess the serum bilirubin, 2 ml of blood was collected NNH – Neonatal hyperbilirubinemia
under all aseptic precautions in sterile sample bottle and
sent to the biochemistry laboratory for measuring bilirubin
Table 2: Correlation between 24 h transcutaneous
levels at 72 h of life. bilirubin and 72 h transcutaneous bilirubin
24 h TcB 72 h TcB Total χ2 P
RESULTS
Not significant Significant
Out of the total 236 newborns recruited in the study, 61 Not significant 161 14 175 147.59 0.0001, S
babies had significant NNH at 24 h of life. At 72 h of life, Significant 6 55 61
Total 167 69 236
newborns with significant NNH by TcB were 69 in number
TcB – Transcutaneous bilirubin
while by TSB were 61 in number [Table 1 and Graph 1].

120%
Neonates with
significant NNH at 96.41%
100% 90.16% 92.00% 91.50%
end of 72 hrs, 79.71%
Percentage(%)

25.84% 80%

60%

40%

20%

0%
Sensitivity Specificity PPV NPV Accuracy
Total Neonates,
100% Binary Classification

Graph 2: Binary classification. Sensitivity = 79.71%, specificity = 96.41%,

positive predictive value = 90.16%, negative predictive value = 92.00%,
Graph 1: Out of total 236 newborns recruited in the study, 61 newborns diagnostic accuracy  =  91.50%. NPV  –  Negative predictive value,
developed hyperbilirubinemia. The incidence of this study was 25.84% PPV – Positive predictive value

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Kurhade and Purandare: Twenty‑four hours TcB as a predictor of NNH at 72 h

No of
neonates
requiring
phototherapy,
29.66%

Total no of
neonates,
100%

Graph 3: Receiver operating characteristic curve for correlation between

24 h transcutaneous bilirubin and 72 h neonatal hyperbilirubinemia.
Area under the curve was 0.95. This is an excellent value to calculate
accuracy of 24  h transcutaneous bilirubin to predict significant
hyperbilirubinemia at 72 h
Area under the curve
Area SE P Asymptotic 95% CI
Lower bound
0.950 0.018 0.0001 0.915
CI – Confidence interval; SE – Standard error
Table 3: Total number of neonates requiring
phototherapy and exchange transfusion
Procedure Number of neonates
Phototherapy 70
Exchange transfusion 2 0.84
DISCUSSION
Jaundice is observed during the 1 week of life in st
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.[5] In addition to hyperbilirubinemia, other health
issues related to early discharge have been identified.[6]
Significant hyperbilirubinemia in neonates can be predicted
on the basis of predischarge TSB being plotted on the
nomogram developed by Bhutani et  al.[7] 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
Graph 4: Total number of neonates requiring phototherapy
being used with increasing frequency in the screening of
newborn infants for significant hyperbilirubinemia despite
TSB being the ultimate investigation of choice.
Upper bound In the present study, we have determined a cutoff value of
0.985 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
Percentage develop significant hyperbilirubinemia, the present study
29.66 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.[7] They

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Kurhade and Purandare: Twenty‑four hours TcB as a predictor of NNH at 72 h
No of
neonates
requiring
exchange
transfusion,
0.84%
Total no of
neonates,
100%
Graph 5: Total number of neonates requiring exchange transfusion
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.[8] 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.[9]
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.[10]
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
Journal of Clinical Neonatology | Vol. 6 | Issue 1 | January-March 2017
were healthy, thus discharged early, were not studied.[11]
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
Nil.
Conflicts of interest
There are no conflicts of interest.
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