Published: 2019-08-23

Kramer’s scale or transcutaneous bilirubinometry: the ideal choice of a pediatrician? can we trust our eyes?

Pearl Mary Varughese


Background: Neonatal hyperbilirubinemia, though benign in 80% cases, can lead to kernicterus if not diagnosed and treated early. The golden method of estimation is measuring serum bilirubin levels. Both Kramer’s scale and Transcutaneous bilirubinometer are non -invasive methods. Its high time the pediatricians choose an ideal non-invasive and reliable method to detect hyperbilirubinemia. Objective of this study is to find out which has a better correlation with serum bilirubin - transcutaneous bilirubinometer reading (TcB) or Kramer's scale.

Methods: The study was conducted in a tertiary newborn center from November 2014 to June 2016. The inclusion criteria included all babies above 34 weeks gestation and exclusion criteria included babies with established direct hyperbilirubinemia, neonatal septicemia, major congenital/ gastrointestinal malformations and those on phototherapy. The sample size was 450 and the correlation was analyzed using ROC curves and plots of agreement was done using Bland Altman charts.

Results: The incidence of significant Hyperbilirubinemia is 12%. Transcutaneous bilirubin level had a better correlation and prediction level compared to Kramer at both 24 hours and 48 hours. Bland Altman analysis showed that transcutaneous values were closer to the total serum bilirubin level compared to Kramer values.

Conclusion: Transcutaneous bilirubinometry is a better and more ideal choice to replace serum bilirubin levels. In settings where TcB is not feasible, it’s always best to screen for jaundice using Kramer’s scale rather than estimating serum bilirubin values in all babies. In babies where TcB levels are above the cut off range, it’s better to do serum bilirubin levels.


Hyperbilirubinemia, Jaundice, Kramer scale, Newborns, Serum Bilirubin, Transcutaneous bilirubinometry

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Janjindamai W, Tansantiwong T. Accuracy of transcutaneous bilirubinometer estimates using BiliCheck in Thai neonates. J Med Assoc Thail Chotmaihet Thangphaet. 2005 Feb;88(2):187-90.

Yap SH, Mohammad I, Ryan CA. Avoiding painful blood sampling in neonates by transcutaneous bilirubinometry. Ir J Med Sci. 2002 Oct;171(4):188-90.

Stillova L, Matasova K, Mikitova T, Stilla J, Kolarovszka H, Zibolen M. Evaluation of transcutaneous bilirubinometry in preterm infants of gestational age 32-34 weeks. Biomed Pap. 2007 Dec 1;151(2):267-71.

Boo N-Y, Ishak S. Prediction of severe hyperbilirubinaemia using the Bilicheck transcutaneous bilirubinometer. J Paediatr Child Health. 2007 Apr;43(4):297-302.

Szabo P, Wolf M, Bucher HU, Fauchère J-C, Haensse D, Arlettaz R. Detection of hyperbilirubinaemia in jaundiced full-term neonates by eye or by bilirubinometer? Eur J Pediatr. 2004 Dec;163(12):722-7.

Nagar G, Vandermeer B, Campbell S, Kumar M. Reliability of transcutaneous bilirubin devices in preterm infants: a systematic review. Pediatrics. 2013 Nov;132(5):871-81.

Kurokawa D, Nakamura H, Yokota T, Iwatani S, Morisawa T, Katayama Y, et al. Screening for Hyperbilirubinemia in Japanese Very Low Birthweight Infants Using Transcutaneous Bilirubinometry. J Pediatr. 2016 Jan;168:77-81.

Thong YH, Rahman AA, Choo M, Tor ST, Robinson MJ. Dermal icteric zones and serum bilirubin levels in neonatal jaundice. Singapore Med J. 1976 Sep;17:184-5.

Knudsen A. The cephalocaudal progression of jaundice in new-borns in relation to the transfer of bilirubin from plasma to skin. Early Hum Dev. 1990 Apr;22(1):23-8.

Madlon-Kay DJ. Home health nurse clinical assessment of neonatal jaundice: comparison of 3 methods. Archives of pediatrics & adolescent medicine. 2001 May 1;155(5):583-6.

Riskin A, Kuglman A, Abend‐Weinger M, Green M, Hemo M, Bader D. In the eye of the beholder: how accurate is clinical estimation of jaundice in new-borns?. Acta Paediatri. 2003 May;92(5):574-6.

Moyer VA, Ahn C, Sneed S. Accuracy of clinical judgment in neonatal jaundice. Archives of pediatrics & adolescent medicine. 2000 Apr 1;154(4):391-4.

Davidson LT, Merritt KK, Weech AA. Hyperbilirubinemia in the newborn. American Journal of Diseases of Children. 1941 May 1;61(5):958-80.

Kramer LI. Advancement of dermal icterus in the jaundiced newborn. Am J Dis Child. 1969 Sep 1;118(3):454-8.

Riskin A, Tamir A, Kugelman A, Hemo M, Bader D. Is visual assessment of jaundice reliable as a screening tool to detect significant neonatal hyperbilirubinemia?. J Pediatr. 2008 Jun 1;152(6):782-7.

Keren R, Tremont K, Luan X, Cnaan A. Visual assessment of jaundice in term and late preterm infants. Archives of Disease in Childhood-Fetal and Neonatal Edit. 2009 Sep 1;94(5):F317-22.

Webster J. An appraisal of the use of the Kramer’s scale in predicting hyperbilirubinaemia in healthy full term infants. Birth Issues. 2006;14(3):83-9.

Panburana J, Boonkasidach S, Rearkyai S. Accuracy of transcutaneous bilirubinometry compare to total serum bilirubin measurement. J Med Assoc Thail Chotmaihet Thangphaet. 2010 Feb;93(2):S81-6.

Gunaseelan S, Devadas S, Pai N. Correlation of transcutaneous bilirubin and serum bilirubin concentration in term and late preterm new-borns. J Clin Neonatol. 2017 Jul 1;6(3):154.

Mishra S, Chawla D, Agarwal R, Deorari AK, Paul VK, Bhutani VK. Transcutaneous bilirubinometry reduces the need for blood sampling in neonates with visible jaundice. Acta Paediatr Oslo Nor. 1992. 2009 Dec;98(12):1916-9.

Kaplan M, Shchors I, Algur N, Bromiker R, Schimmel MS, Hammerman C. Visual screening versus transcutaneous bilirubinometry for predischarge jaundice assessment. Acta Paediatrica. 2008 Jun;97(6):759-63.

Gupta B, Chaudhary N, Bhatia B. Non invasive trans-cutaneous bilirubin as a screening test to identify the need for serum bilirubin assessment in healthy term neonates. J Univers Coll Med Sci. 2014 Jan;1(4):17-21.

Szabo P, Wolf M, Bucher HU, Haensse D, Fauchere JC, Arlettaz R. Assessment of jaundice in preterm neonates: comparison between clinical assessment, two transcutaneous bilirubinometers and serum bilirubin values. Acta Paediatrica. 2004 Nov;93(11):1491-5.

De Luca D, Zecca E, Zuppa AA, Romagnoli C. The joint use of human and electronic eye: visual assessment of jaundice and transcutaneous bilirubinometry. Turkish J pediatr. 2008 Sep 1;50(5):456.