Commentary Limited resources lead to newer approach in jaundice therapy Gregory L. Jackson, William D. Engle Department of Pediatrics, University of Texas Southwestern Medical Center, USA
Invited commentary on ‘Can transcutaneous bilirubinometry safely guide phototherapy treatment of neonatal jaundice in Malawi?’, Rylance et al. Neonatal jaundice remains a tremendous issue worldwide, and in developing nations the presentation of neonates late in the first week of life with extremely high bilirubin levels is not uncommon.1 The predominance of G6PD deficiency may be a partial explanation for this problem,2 but limited resources for screening and logistical issues in travelling to an early follow-up visit are more likely to be the real hurdles. Although the use of transcutaneous bilirubinometry (TcB) has been shown to be a helpful tool in screening for and managing hyperbilirubinemia in developed countries, its use in developing nations is less well described.3 In this issue of the journal, Rylance and colleagues present the results of their study of the use of TcB in a 1000-bed government-run tertiary referral hospital in Blantyre, Malawi.4 Health-care in Malawi, a landlocked, south-eastern democratic African rural country of nearly 16 million people, is complicated by a high incidence of HIV (y12% of the population) and increased infant mortality (53/1000 infants ,1 year of age). Using a donated TcB device (Dra¨ger JM-103TM), the authors investigated the relationship between TcB determinations (forehead and sternum) and laboratory bilirubin (TSB), and whether TcB was accurate in assessing the need for initiation and/or continuation of phototherapy. Of note, although the hospital laboratory was able to perform serum bilirubin tests, for this study the investigators used a research laboratory because ‘financial and human resource constraints limit availability and results are not timely’ with the hospital laboratory. In general, this study found that correlation between TcB and TSB and the predictive ability of Correspondence to: G L Jackson, Department of Pediatrics, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390–9063, USA. Email: [email protected]
ß W. S. Maney & Son Ltd 2014 DOI 10.1179/2046905514Y.0000000120
using TcB were quite acceptable. Similar to previous studies in dark-skinned populations,5,6 Rylance et al. found that the TcB reading was more likely than not to over-estimate the corresponding TSB value.4 As noted by the authors, this tendency to slightly increase the use of phototherapy is preferable to the alternative, an increased risk of damage to the central nervous system. Their finding that TcB was relatively accurate during phototherapy is interesting and differs from the prevailing view that only patched areas of skin should be used when TcB is performed in an infant undergoing phototherapy.7 The authors note that in at least some instances, a forehead reading may have been influenced by the light-shielding effect of the eye patch, and this may at least partly explain their findings. This important study raises larger issues relating to the availability in less developed countries of reliable, current technology to assist in the reduction of the devastating effects of bilirubin-induced neurological dysfunction and kernicterus.8 As the authors point out, in a tertiary government hospital, a test as basic as TSB was not considered to be generally available. Given this situation, TcB was considered to be the reasonable alternative. Although TcB may be costeffective, its use still requires what might be considered a significant capital outlay. Given the ability to modify an internal algorithm of a TcB device, it seems likely that, with additional study, a TcB device could be developed and be financially feasible for widespread use in these settings. Slusher et al.9 and Vreman et al.10 have described a low-tech phototherapy system that safely uses sunlight. The onus is now on physician scientists and industry to develop cost-effective methods to screen for hyperbilirubinemia in low-income countries, and to determine when phototherapy is or is not indicated.
References 1 Slusher T, Zipursky A, Bhutani V. A global need for affordable neonatal jaundice technologies. Semin Perinatol. 2011;35:185– 91. 2 Slusher T, Vreman H, McLaren D, Lewison L, Brown A, Stevenson D. Glucose-6-phosphate dehydrogenase deficiency and carboxyhemoglobin concentrations associated with bilirubin-related morbidity and death in Nigerian infants. J Pediatr. 1995;126:102–8. 3 De Luca D, Engle WD, Jackson GL. Transcutaneous Bilirubinometry. New York: Nova Science, 2013. 4 Slusher T, Angyo I, Bode-Thomas F, Akor F, Pam S, Adetunji A, et al. Transcutaneous bilirubin measurements and serum total bilirubin levels in indigenous African infants. Pediatrics. 2004;113:1636–41. 5 Rylance S, Yan J, Molyneux E. Can tanscutaneous bilirubinometry safely guide phototherapy treatment of neonatal jaundice
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in Malawi? Paediatr Int Child Health. 2014; remaining details to be added later 6 Maisels MJ, Ostrea EM, Touch S, Clune SE, Cepeda E, Kring E, et al. Evaluation of a new transcutaneous bilirubinometer. Pediatrics. 2004;113:1628–35. 7 Maisels MJ. Historical perspectives in transcutaneous bilirubinometry. NeoReviews. 2006;7:e217–25. 8 Fonseca R, Kyralessa R, Malloy M, Richardson J, Jain S. Covered skin transcutaneous bilirubin estimation is comparable with serum bilirubin during and after phototherapy. J Perinatol. 2012;32:129–31.
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9 Slusher T, Olusanya B. Neonatal jaundice in low- and middleincome countries. In: Care of the Jaundiced Neonate. New York: McGraw-Hill Medical, 2012; pp 263–73. 10 Slusher T, Olusanya, BO, Vreman H, Wong R, Brearley A, Vaucher Y, et al. Treatment of neonatal jaundice with filtered sunlight in Nigerian neonates: study protocol of a non-inferiority, randomized controlled trial. Trials. 2013;14:446. 11 Vreman H, Slusher T, Wong R, Schulz S, Olusanya B, Stevenson D. Evaluation of window-tinting films for sunlight phototherapy. J Trop Pediatr. 2013;59:496–501.
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Invited commentary on ‘Can transcutaneous bilirubinometry safely guide phototherapy treatment of neonatal jaundice in Malawi?’, Rylance et al. Neonatal jaundice remains a tremendous issue worldwide, and in developing nations the presentation of neonates late in the first week of life with extremely high bilirubin levels is not uncommon.1 The predominance of G6PD deficiency may be a partial explanation for this problem,2 but limited resources for screening and logistical issues in travelling to an early follow-up visit are more likely to be the real hurdles. Although the use of transcutaneous bilirubinometry (TcB) has been shown to be a helpful tool in screening for and managing hyperbilirubinemia in developed countries, its use in developing nations is less well described.3 In this issue of the journal, Rylance and colleagues present the results of their study of the use of TcB in a 1000-bed government-run tertiary referral hospital in Blantyre, Malawi.4 Health-care in Malawi, a landlocked, south-eastern democratic African rural country of nearly 16 million people, is complicated by a high incidence of HIV (y12% of the population) and increased infant mortality (53/1000 infants ,1 year of age). Using a donated TcB device (Dra¨ger JM-103TM), the authors investigated the relationship between TcB determinations (forehead and sternum) and laboratory bilirubin (TSB), and whether TcB was accurate in assessing the need for initiation and/or continuation of phototherapy. Of note, although the hospital laboratory was able to perform serum bilirubin tests, for this study the investigators used a research laboratory because ‘financial and human resource constraints limit availability and results are not timely’ with the hospital laboratory. In general, this study found that correlation between TcB and TSB and the predictive ability of Correspondence to: G L Jackson, Department of Pediatrics, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390–9063, USA. Email: [email protected]
ß W. S. Maney & Son Ltd 2014 DOI 10.1179/2046905514Y.0000000120
using TcB were quite acceptable. Similar to previous studies in dark-skinned populations,5,6 Rylance et al. found that the TcB reading was more likely than not to over-estimate the corresponding TSB value.4 As noted by the authors, this tendency to slightly increase the use of phototherapy is preferable to the alternative, an increased risk of damage to the central nervous system. Their finding that TcB was relatively accurate during phototherapy is interesting and differs from the prevailing view that only patched areas of skin should be used when TcB is performed in an infant undergoing phototherapy.7 The authors note that in at least some instances, a forehead reading may have been influenced by the light-shielding effect of the eye patch, and this may at least partly explain their findings. This important study raises larger issues relating to the availability in less developed countries of reliable, current technology to assist in the reduction of the devastating effects of bilirubin-induced neurological dysfunction and kernicterus.8 As the authors point out, in a tertiary government hospital, a test as basic as TSB was not considered to be generally available. Given this situation, TcB was considered to be the reasonable alternative. Although TcB may be costeffective, its use still requires what might be considered a significant capital outlay. Given the ability to modify an internal algorithm of a TcB device, it seems likely that, with additional study, a TcB device could be developed and be financially feasible for widespread use in these settings. Slusher et al.9 and Vreman et al.10 have described a low-tech phototherapy system that safely uses sunlight. The onus is now on physician scientists and industry to develop cost-effective methods to screen for hyperbilirubinemia in low-income countries, and to determine when phototherapy is or is not indicated.
References 1 Slusher T, Zipursky A, Bhutani V. A global need for affordable neonatal jaundice technologies. Semin Perinatol. 2011;35:185– 91. 2 Slusher T, Vreman H, McLaren D, Lewison L, Brown A, Stevenson D. Glucose-6-phosphate dehydrogenase deficiency and carboxyhemoglobin concentrations associated with bilirubin-related morbidity and death in Nigerian infants. J Pediatr. 1995;126:102–8. 3 De Luca D, Engle WD, Jackson GL. Transcutaneous Bilirubinometry. New York: Nova Science, 2013. 4 Slusher T, Angyo I, Bode-Thomas F, Akor F, Pam S, Adetunji A, et al. Transcutaneous bilirubin measurements and serum total bilirubin levels in indigenous African infants. Pediatrics. 2004;113:1636–41. 5 Rylance S, Yan J, Molyneux E. Can tanscutaneous bilirubinometry safely guide phototherapy treatment of neonatal jaundice
Paediatrics and International Child Health
2014
VOL.
34
NO.
2
73
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Commentary
in Malawi? Paediatr Int Child Health. 2014; remaining details to be added later 6 Maisels MJ, Ostrea EM, Touch S, Clune SE, Cepeda E, Kring E, et al. Evaluation of a new transcutaneous bilirubinometer. Pediatrics. 2004;113:1628–35. 7 Maisels MJ. Historical perspectives in transcutaneous bilirubinometry. NeoReviews. 2006;7:e217–25. 8 Fonseca R, Kyralessa R, Malloy M, Richardson J, Jain S. Covered skin transcutaneous bilirubin estimation is comparable with serum bilirubin during and after phototherapy. J Perinatol. 2012;32:129–31.
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9 Slusher T, Olusanya B. Neonatal jaundice in low- and middleincome countries. In: Care of the Jaundiced Neonate. New York: McGraw-Hill Medical, 2012; pp 263–73. 10 Slusher T, Olusanya, BO, Vreman H, Wong R, Brearley A, Vaucher Y, et al. Treatment of neonatal jaundice with filtered sunlight in Nigerian neonates: study protocol of a non-inferiority, randomized controlled trial. Trials. 2013;14:446. 11 Vreman H, Slusher T, Wong R, Schulz S, Olusanya B, Stevenson D. Evaluation of window-tinting films for sunlight phototherapy. J Trop Pediatr. 2013;59:496–501.
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