Author Affiliations: Department of Pediatrics, Nanjing Maternity and Child Health Care Hospital of Nanjing Medical University, No. 123 Tian Fei Xiang, Mo Chou Road, Nanjing 210004, China (Yu ZB, Han SP); Department of Neonatology, Children's Hospital of Fudan University, No. 399 Wanyuan Road, Minhang District, Shanghai 201102, China (Chen C)

 

Corresponding Author: Shu-Ping Han, Department of Pediatrics, Nanjing Maternity and Child Health Care Hospital of Nanjing Medical University, No. 123 Tian Fei Xiang, Mo Chou Road, Nanjing 210004, China (Tel: +86-025-52226561; Fax: +86-025-52226561; Email: shupinghan@njmu.edu.cn)

 

doi: 10.1007/s12519-014-0495-8

 

 

 

 

 

 

 

 

Hyperbilirubinemia occurs in most healthy newborn infants, and must be monitored and promptly treated to prevent bilirubin encephalopathy.^[1] Recently, much attention has been paid to the damage caused by bilirubin encephalopathy which occurs in all countries, even in westernized countries.^[2] In developing countries with emerging medical systems, the problem is worsening. In China, 348 cases of bilirubin encephalopathy were reported from 28 hospitals from January to December in 2009.^[3] Therefore, identification of newborn infants at risk of developing significant hyperbilirubinemia and prevention of bilirubin encephalopathy remain a high priority among public health institutions.

The American Academy of Pediatrics (AAP) is highly concerned about the continuing appearance of bilirubin encephalopathy. Comprehensive guidelines to screen and identify newborn infants at risk of hyperbilirubinemia, and to treat those who develop hyperbilirubinemia, were implemented by the AAP in 2004.^[4] A 2009 update with clarifications of the 2004 AAP guideline recommended measurement of total serum bilirubin (TSB) or transcutaneous bilirubin (TcB) in a predischarge newborn population to identify severe hyperbilirubinemia.^[5] Universal implementation of this strategy in the US has improved outcomes of healthy newborns discharged early, which represents a valuable method to assess the risk of subsequent severe hyperbilirubinemia.^[6]

However, measurement of TSB remains an invasive, stressful and time-consuming procedure. Measurements of TcB are less time-consuming and can be used to screen for the need of blood sampling for serum bilirubin level, and reduce the need to measure TSB.^[7] The values of TcB after birth have also been plotted on an hour-specific TcB nomogram to predict severe hyperbilirubinemia in term and late-preterm infants.^[8] The availability of TcB estimation has made it possible to study the dynamic changes in bilirubin levels noninvasively; thus, TcB nomograms are being used with increasing frequency. Researchers from many countries have developed TcB hour-specific nomograms using their own race/ethnicity data for TcB levels.^[9,10] However, it is not clear whether the TcB nomogram is as accurate as the TSB nomogram, which may affect its predictive ability.^[11] TSB and TcB nomograms have been developed and validated to identify neonatal hyperbilirubinemia in some studies.^[12] This study aimed to review previously published studies and compare the TcB nomogram with the TSB nomogram, and to determine if the former has the same predictive value for significant hyperbilirubinemia as TSB nomogram does.

 

 

Methods

Search strategy

An electronic search of Medline, EMBASE, the Chinese Biomedical Literature Database, the Chinese National Knowledge Infrastructure database, and the Cochrane Library for any literature from January 1980 to July 2013 was performed. This search was limited to any study that developed and evaluated an hour-specific (TcB or TSB) bilirubin nomogram to identify significant hyperbilirubinemia in healthy term and late-preterm infants [gestational age (GA) ≥35 weeks]. The search key words were "jaundice" or "hyperbilirubinemia" combined with the terms "transcutaneous bilirubin", "hour-specific bilirubin", "nomogram", "curve" and "prediction", "diagnosis", "sensitivity", "specificity" and "newborn", "near term infant", and "late preterm infant". We used the "related articles" option and consulted the references of evaluated articles. No language restrictions were applied.

Study selection

Two investigators independently screened the results of the electronic searches to select potentially relevant studies. Discrepancies were resolved through consensus, and a third blinded investigator was consulted, when required, to resolve any discrepancies. The inclusion criteria were as follows: 1) the study population was healthy term or late-preterm newborn infants, the study population excluded all sick newborn infants who were admitted to the intensive care unit and those who required phototherapy before discharge; 2) TSB or TcB levels after birth in healthy term and late-preterm neonates were measured and an hour-specific TSB or TcB nomogram was developed; 3) the risk zone to identify neonatal hyperbilirubinemia was classified on the basis of different percentile values of TSB or TcB, four risk zones (high, high-intermediate, low-intermediate, low risk zone); 4) the predictive ability of TcB/TSB nomograms to identify significant hyperbilirubinemia was evaluated, the receiver operating characteristic (ROC) curves were constructed, and the area under the curve (AUC) of diagnostic accuracy could be calculated. The following criteria were applied to exclude inappropriate studies: 1) TcB/TSB nomograms were constructed, but their predictive abilities were not evaluated; 2) the AUC of diagnostic accuracy of the TcB/TSB nomograms could not be calculated; 3) if the same institution reported two or more studies for the same population, the study showing the larger number of patients was included.

 

Data extraction and assessment of study quality

Two independent reviewers extracted the study designs, total participants and entry criteria, the risk zone of the nomogram, diagnostic criterion for significant hyperbilirubinemia and AUCs from the included studies. A quality assessment scale was adopted, which was based on the criteria proposed by Strengthening the Reporting of Observational Studies in Epidemiology^[13] and Tooth et al^[14] to assess observational studies. Briefly, we assessed the quality of all included studies in accordance with the following items: study design, representativeness of target population, sample selection, sample size, included proportion of cohort samples, reasons for excluding samples, development and validation of nomograms, diagnostic criteria (significant hyperbilirubinemia), combining TSB/TcB nomograms and clinical risk factors, and follow-up. According to the score achieved (from 0 to 18), studies were classified as high (>14), medium (10-14) or low (<10) quality. Two reviewers independently assessed the quality and resolved differences through discussion. Assessment of multiple systematic reviews (AMSTAR) was used to assess the Kappa (inter-rater reliability), which measures the methodological quality of a systematic review. A Kappa higher than 0.8 indicated a high inter-rate reliability.^[15]

 

Statistical analysis

The diagnostic sensitivities and specificities for significant hyperbilirubinemia using TcB/TSB nomograms in the 40th, 75th and 95th percentile were extracted. The statistical pooling of sensitivity, specificity, and positive likelihood ratio (PLR) was done with the DerSimonian Laird method (random effects meta-analysis model) using Meta-Disc 1.4 analysis software (Madrid, Spain). Ninety-five percent confidence intervals (95% CIs) were calculated. Additionally, we created a summary ROC of the TcB/TSB nomograms in the 40th, 75th and 95th percentile using Meta-Disc 1.4. If a meta-analysis was inappropriate, data were summarized for each study.

 

 

Results

Search and selection results

A total of 187 publications were identified from electronic database searches and reference lists of eligible articles. Upon reviewing the titles and abstracts, 164 publications were excluded because they did not contain data on the predictive ability of TcB/TSB nomograms to identify significant hyperbilirubinemia. Twenty-three full-text articles were reviewed in detail.^[8-10,16-35]

 

Description of the excluded and included studies

Nine studies^[8,9,16-22] from seven countries were excluded based on the reasons listed in Fig. 1. The characteristics of the excluded studies are summarized in Table 1. Finally, 14 eligible studies^[10,23-35] were included for the systematic review and meta-analysis (Fig. 1). Eight studies^[8,9,16-21] had developed the TcB nomogram using the BiliCheck or JM-103 bilirubinometer based on their own race/ethnicity data for TcB levels; only one study^[22] validated the previously constructed TSB nomogram by Bhutani. Most of the studies (55.6%) were excluded because the diagnostic accuracy of the constructed TcB nomogram was not assessed.

Table 2 provides descriptive detail for the 14 studies that met the inclusion criteria for the systematic review and meta-analysis.^[10,23-35] These studies were from six countries: India, Israel, China, Italy, USA, and Turkey. Seven of these studies evaluated the diagnostic accuracy using the TcB nomogram;^[23,25-30] three nomograms were constructed using the JM-103 bilirubinometer,^[23,26,28] and four studies^{[25,27,29,30]} used the BiliCheck bilirubinometer. The diagnostic AUC values of the TcB nomograms ranged from 0.720 to 0.971. The remaining seven studies^{[10,24,31-35]} assessed the diagnostic accuracy using the TSB nomogram; the diagnostic AUC values ranged from 0.731 to 0.931 (Table 2).

 

Quality assessment of the included studies

Twelve included studies^{[10,23-29,31-34]} developed TSB/TcB nomograms based on the values of TSB or TcB at one center, which could not represent the entire national target population. The sample sizes of eight studies^{[10,25-27,29,31,33,34]} were less than 1000 neonates; only three studies^[23,28,32] had more than 5000 in the study population. Only five studies^{[23,30,33-35]} developed and validated a nomogram from a different study group using their own race/ethnicity data; the remaining nine studies^{[10,24-29,31,32]} developed and validated a nomogram from the same study group. Only five studies^{[23,29,32-34]} considered that the clinical risk factors that could improve the predictive accuracy of TSB/TcB nomogram. With these limitations, no study scored more than 14, which is necessary to be considered of high methodological quality. Eleven studies^{[10,23-25,27-30,33-35]} received scores between 10 and 14, and were considered to be of medium methodological quality. The remaining three studies^[26,31,32] received scores of <10 and were considered to be of low methodological quality. The methodological quality of the systematic review as assessed by AMSTAR, showed a kappa score of 0.82 indicating a high inter-rater reliability.

 

Meta-analysis

Based on the 40th, 75th, and 95th percentiles values, we pooled the data and assessed the diagnostic accuracy of the TSB/TcB nomograms. The sensitivity, specificity, PLR and AUC values are shown in Table 3. The summary PLR of the TcB nomograms increased gradually (1.67 for the 40th percentile; 3.61 for the 75th percentile; and 8.46 for the 95th percentile). The summary PLR of the TSB nomograms also increased gradually (1.76 for the 40th percentile; 3.34 for the 75th percentile; and 11.46 for the 95th percentile).

The summary AUC that was used to assess the accuracy of the 40th, 75th and 95th percentile is presented in Table 3. The AUC of the TcB nomograms increased gradually (0.512 for the 40th percentile; 0.864 for the 75th percentile; and 0.925 for the 95th percentile). The AUC of the TSB nomograms also increased gradually (0.591 for the 40th percentile; 0.875 for the 75th percentile; and 0.931 for the 95th percentile). Fig. 2 shows the comparison of the summary ROC curves between TcB and TSB nomograms. We found no difference between the predictive ability of summary TSB and summary TcB nomograms (0.819 vs. 0.817).

Discussion

The first hour-specific bilirubin nomogram based on TSB of healthy term and late-preterm infants was established by Bhutani et al^[24] in 1999. The nomogram could recognize infants at risk of developing significant hyperbilirubinemia. The AUC was 0.931. They found a steady and significant decline in readmission for significant hyperbilirubinemia (0.55%) after initiating the TSB nomogram in 2001 to 2003 compared with that in 1994 (1.4%).^[37] The incidence of exchange transfusion following failure of intensive phototherapy also decreased to 1:11 995 in 2001 to 2003, compared with 1:1827 in 1990 to 2000.^[37] Given the outstanding predictive ability of the TSB nomogram, its was widely accepted in clinical practice and is a crucial element of the clinical guidelines published by the AAP.^[4]

The Bhutani-based nomogram was used and validated by some studies in their own hospitals.^[32-34] These results showed that the AUC ranged from 0.830 to 0.880, which was lower than the value reported by Bhutani (0.931). This caused the use of the Bhutani nomogram as a screening tool to be questioned; however, the data were generated in a retrospective study that included newborn infants from a single urban Pennsylvanian hospital, and the demographic, racial, genetic and environmental features of that population may not adequately represent other newborn populations.^[11] Romagnoli et al^[35] developed and validated a TSB nomogram based on newborn infants in their own region, which showed the same predictive ability as the Bhutani-based nomogram; the AUC was 0.923. We identified seven studies^{[10,24,31-35]} that assessed diagnostic accuracy using the TSB nomogram; the diagnostic AUC values ranged from 0.731 to 0.931. The pooled AUC was 0.819. The summary result from the literature showed that a TSB nomogram was a simple and accurate method that identified subsequent significant hyperbilirubinemia.

However, measuring TSB is an invasive procedure that involves pain, neonatal stress and risk of infection. A noninvasive determination of TcB seems to be advantageous and suitable for universal neonatal screening.^[38] The new-generation, noninvasive, TcB-measuring devices (BiliCheck™ and JM-103) showed a good correlation with TSB (BiliCheck™ was 0.8212, JM-103 was 0.8686).^[39] In this study, we identified seven studies^[23,25-30] that assessed diagnostic accuracy using the TcB nomogram. Three nomograms were constructed using the JM-103 bilirubinometer and four studies used the BiliCheck bilirubinometer; the diagnostic AUC ranged from 0.766 to 0.971. The pooled AUC was 0.819, which was not significantly different to the summary TSB nomogram (0.817). The result showed that TcB nomograms were just as efficient as TSB nomograms for identifying subsequent significant hyperbilirubinemia.

The study has some limitations. Firstly, there are many countries (such as the USA, Greece, Italy, and Japan) which have developed TcB nomograms using their own race/ethnicity data for TcB levels; however, these nomograms are still not validated and were excluded from the systematic review.^[9,16-19,21] We were unable to assess their predictive ability. Secondly, twelve included studies^{[10,23-29,31-34]} developed TSB/TcB nomograms based on the values of TSB or TcB in one center, which could not represent the entire national target population. The relative limitations of previously constructed TSB/TcB nomograms have prompted us to carry out a multicenter study (ClinicalTrials.gov Identifier: NCT01763632), in which 17 hospitals in China will participate, to develop an hour-specific TcB nomogram from January to December 2013. Thirdly, combining the TcB nomogram with other clinical risk factors, such as GA and exclusive breastfeeding, could improve the prediction of subsequent hyperbilirubinemia. One included study evaluated the predictive performance of the predischarge bilirubin risk zone (AUC=0.88); however, combined clinical risk factors (GA, and percentage of weight loss per day over the first 2 days) showed better accuracy (AUC=0.96).^[34] Nine of the previously constructed TSB/TcB nomograms^{[10,24-29,31,32]} did not assess the combination; therefore, we could not perform sub-analysis of the data. Fourthly, theoretically, a predictive nomogram should be developed in one sample and validated in another; the after-effect evaluation of the constructed nomogram is very important for future clinical application. However, only five studies^{[23,30,33-35]} developed and validated a nomogram from a different study group using their own race/ethnicity data; the remaining nine studies^{[10,24-29,31,32]} developed and validated a nomogram from the same study group. Fifthly, the study subjects were healthy term and late-preterm infants, which represent a large group of populations. Only in our hospital, where there are 15 000 healthy term and late-preterm infants born every year, the sample size was large. The sample sizes of eight included studies^{[10,25-27,29,31,33,34]} were less than 1000 neonates; only three studies^[23,28,32] had more than 5000 in the study population. Most of the constructed TSB/TcBs could not represent the entire national target population. Given these limitations, none of the included studies were considered as being of high methodological quality. Eleven studies (78.6%)^{[10,23-25,27-30,33-35]} were considered to be of medium methodological quality. Sixthly, sources of bias in any meta-analysis are the selection and heterogeneity of the included studies. In this regard, a specific limitation of our systematic review and meta-analysis is related to the difficulty of combining studies that used different medical system (middle-income, developed), ethnicity and social background, and used different criteria of severe hyperbilirubinemia in the 2 groups; 5 of 7 AAP guideline (2004) in TcB group and 3 of 7 in TSB group. This is related directly to the lack of consensus about the criteria of severe hyperbilirubinemia in different countries.

 

 

Conclusions

This systematic review showed that a TcB nomogram has the same predictive value as a TSB nomogram, both of which could be used to identify subsequent significant hyperbilirubinemia. However, the included studies indicted some methodological limitations and should be interpreted cautiously, further studies are necessary to develop and validate an hour-specific nomogram in different study groups, using their own race/ethnicity data. The study group should represent the entire national target population. Combining TSB/TcB nomograms with clinical risk factors (such as GA, exclusive breastfeeding, cephalhematoma, significant bruising or previous sibling with jaundice) should also be evaluated.

 

 

Acknowledgements

We wish to thank Guo XR for technical guidance and valuable comments on this paper.

 

 

Funding: This work was supported by grants from the Key Medical Personnel Foundation of Jiangsu Province (Grant No. RC2011021), the Medical Youth Personnel Foundation of Nanjing Municipality (Grant No. QRX11107), Nanjing Municipal Medical Science Development Foundation (Grant No. ZKX12044, YKK13142), and Maternal and Child Health Foundation of Jiangsu Province (Grant No. F201308).

Ethical approval: Not applicable.

Competing interest: We declare no potential conflicts of interest involved in this article.

Contributors: Yu ZB was responsible for research design, data analysis, manuscript writing and revision. Han SP and Chen C assisted in completing the analysis interpretation.

 

 

References

1   Kaplan M, Bromiker R, Hammerman C. Severe neonatal hyperbilirubinemia and kernicterus: are these still problems in the third millennium? Neonatology 2011;100:354-362.

2   Sgro M, Campbell DM, Kandasamy S, Shah V. Incidence of chronic bilirubin encephalopathy in Canada, 2007-2008. Pediatrics 2012;130:e886-890.

3   Subspecialty Group of Neonatology, Society of Pediatrics, Chinese Medical Association; Chinese MulticenterStudy Coordination Group for Neonatal Bilirubin Encephalopathy. Clinical characteristics of bilirubin encephalopathy in Chinese newborn infants-a national multicenter survey. Zhonghua Er Ke Za Zhi 2012;50:331-335. [in Chinese]

4   American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics 2004;114:297-316.

5   Maisels MJ, Bhutani VK, Bogen D, Newman TB, Stark AR, Watchko JF. Hyperbilirubinemia in the newborn infant > or =35 weeks' gestation: an update with clarifications. Pediatrics 2009;124:1193-1198.

6   Bhutani VK, Stark AR, Lazzeroni LC, Poland R, Gourley GR, Kazmierczak S, et al. Predischarge screening for severe neonatal hyperbilirubinemia identifies infants who need phototherapy. J Pediatr 2013;162:477-482.

7   Rodríguez-Capote K, Kim K, Paes B, Turner D, Grey V. Clinical implication of the difference between transcutaneous bilirubinometry and total serum bilirubin for the classification of newborns at risk of hyperbilirubinemia. Clin Biochem 2009;42:176-179.

8   Varvarigou A, Fouzas S, Skylogianni E, Mantagou L, Bougioukou D, Mantagos S. Transcutaneous bilirubin nomogram for prediction of significant neonatal hyperbilirubinemia. Pediatrics 2009;124:1052-1059.

9  Kuboi T, Kusaka T, Kawada K, Koyano K, Nakamura S, Okubo K, et al. Hour-specific nomogram for transcutaneous bilirubin values in Japanese neonates. Pediatr Int 2013;55:608-611.

10 Pathak U, Chawla D, Kaur S, Jain S. Bilirubin nomogram for prediction of significant hyperbilirubinemia in north Indian neonates. Indian Pediatr 2013;50:383-389.

11 Fay DL, Schellhase KG, Suresh GK. Bilirubin screening for normal newborns: a critique of the hour-specific bilirubin nomogram. Pediatrics 2009;124:1203-1205.

12 Bhutani VK. Bilirubin nomogram, a prediction tool or natural history profile? Indian Pediatr 2013;50:365-366.

13 von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet 2007;370:1453-1457.

14 Tooth L, Ware R, Bain C, Purdie DM, Dobson A. Quality of reporting of observational longitudinal research. Am J Epidemiol 2005;161:280-288.

15 Shea BJ, Grimshaw JM, Wells GA, Boers M, Andersson N, Hamel C, et al. Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol 2007;7:10.

16 Sanpavat S, Nuchprayoon I, Smathakanee C, Hansuebsai R. Nomogram for prediction of the risk of neonatal hyperbilirubinemia, using transcutaneous bilirubin. J Med Assoc Thai 2005;88:1187-1193.

17 Engle WD, Lai S, Ahmad N, Manning MD, Jackson GL. An hour-specific nomogram for transcutaneous bilirubin values in term and late preterm Hispanic neonates. Am J Perinatol 2009;26:425-430.

18 Fouzas S, Karatza AA, Skylogianni E, Mantagou L, Varvarigou A. Transcutaneous bilirubin levels in late preterm neonates. J Pediatr 2010;157:762-766.

19 Romagnoli C, Tiberi E, Cardiello V, Priolo F, Zecca E. Validation of an hourly transcutaneous bilirubin nomogram in a population of term or late preterm newborn infants: preliminary results. Minerva Pediatr 2010;62:113-115. [in Italian]

20 Gonçalves A, Costa S, Lopes A, Rocha G, Guedes MB, Centeno MJ, et al. Prospective validation of a novel strategy for assessing risk of significant hyperbilirubinemia. Pediatrics 2011;127:e126-131.

21 Mantagou L, Fouzas S, Skylogianni E, Giannakopoulos I, Karatza A, Varvarigou A. Trends of transcutaneous bilirubin in neonates who develop significant hyperbilirubinemia. Pediatrics 2012;130:e898-904.

22 Bromiker R, Bin-Nun A, Schimmel MS, Hammerman C, Kaplan M. Neonatal hyperbilirubinemia in the low-intermediate-risk category on the bilirubin nomogram. Pediatrics 2012;130:e470-475.

23 Maisels MJ, Deridder JM, Kring EA, Balasubramaniam M. Routine transcutaneous bilirubin measurements combined with clinical risk factors improve the prediction of subsequent hyperbilirubinemia. J Perinatol 2009;29:612-617.

24 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.

25 Dalal SS, Mishra S, Agarwal R, Deorari AK, Paul V. Does measuring the changes in TcB value offer better prediction of Hyperbilirubinemia in healthy neonates? Pediatrics 2009;124:e851-857.

26 Bental YA, Shiff Y, Dorsht N, Litig E, Tuval L, Mimouni FB. Bhutani-based nomograms for the prediction of significant hyperbilirubinaemia using transcutaneous measurements of bilirubin. Acta Paediatr 2009;98:1902-1908.

27 Mishra S, Chawla D, Agarwal R, Deorari AK, Paul VK. Transcutaneous bilirubin levels in healthy term and late preterm Indian neonates. Indian J Pediatr 2010;77:45-50.

28 Yu ZB, Dong XY, Han SP, Chen YL, Qiu YF, Sha L, et al. Transcutaneous bilirubin nomogram for predicting neonatal hyperbilirubinemia in healthy term and late-preterm Chinese infants. Eur J Pediatr 2011;170:185-191.

29 Kaur S, Chawla D, Pathak U, Jain S. Predischarge non-invasive risk assessment for prediction of significant hyperbilirubinemia in term and late preterm neonates. J Perinatol 2012;32:716-721.

30 Romagnoli C, Tiberi E, Barone G, De Curtis M, Regoli D, Paolillo P, et al. Validation of transcutaneous bilirubin nomogram in identifying neonates not at risk of hyperbilirubinaemia: a prospective, observational, multicenter study. Early Hum Dev 2012;88:51-55.

31 Sarici SU, Serdar MA, Korkmaz A, Erdem G, Oran O, Tekinalp G, et al. Incidence, course, and prediction of hyperbilirubinemia in near-term and term newborns. Pediatrics 2004;113:775-780.

32 Newman TB, Liljestrand P, Escobar GJ. Combining clinical risk factors with serum bilirubin levels to predict hyperbilirubinemia in newborns. Arch Pediatr Adolesc Med 2005;159:113-119.

33 Keren R, Bhutani VK, Luan X, Nihtianova S, Cnaan A, Schwartz JS. Identifying newborns at risk of significant hyperbilirubinaemia: a comparison of two recommended approaches. Arch Dis Child 2005;90:415-421.

34 Keren R, Luan X, Friedman S, Saddlemire S, Cnaan A, Bhutani VK. A comparison of alternative risk-assessment strategies for predicting significant neonatal hyperbilirubinemia in term and near-term infants. Pediatrics 2008;121:e170-179.

35 Romagnoli C, Tiberi E, Barone G, Curtis MD, Regoli D, Paolillo P, et al. Development and validation of serum bilirubin nomogram to predict the absence of risk for severe hyperbilirubinaemia before discharge: a prospective, multicenter study. Ital J Pediatr 2012;38:6.

36 Practice parameter: management of hyperbilirubinemia in the healthy term newborn. American Academy of Pediatrics. Provisional Committee for Quality Improvement and Subcommittee on Hyperbilirubinemia. Pediatrics 1994;94:558-565.

37 Bhutani VK, Johnson LH, Schwoebel A, Gennaro S. A systems approach for neonatal hyperbilirubinemia in term and near-term newborns. J Obstet Gynecol Neonatal Nurs 2006;35:444-455.

38 Wainer S, Rabi Y, Parmar SM, Allegro D, Lyon M. Impact of skin tone on the performance of a transcutaneous jaundice meter. Acta Paediatr 2009;98:1909-1915.

39 Romagnoli C, Zecca E, Catenazzi P, Barone G, Zuppa AA. Transcutaneous bilirubin measurement: comparison of Respironics BiliCheck and JM-103 in a normal newborn population. Clin Biochem 2012;45:659-662.