A novel icterometer for hyperbilirubinemia screening in low-resource settings

Anne C.C. Lee, Lian V. Folger, Mahmoodur Rahman, Salahuddin Ahmed, Nazmun Nahar Bably, Lauren Schaeffer, Rachel Whelan, Pratik Panchal, Sayedur Rahman, Arun Dutta Roy, Abdullah H. Baqui

Research output: Contribution to journalArticlepeer-review

5 Scopus citations


BACKGROUND: Severe neonatal hyperbilirubinemia (.20 mg/dL) affects ∼1 million infants annually. Improved jaundice screening in low-income countries is needed to prevent bilirubin encephalopathy and mortality. METHODS: The Bili-ruler is an icterometer for the assessment of neonatal jaundice that was designed by using advanced digital color processing. A total of 790 newborns were enrolled in a validation study at Brigham and Women’s Hospital (Boston) and Sylhet Osmani Medical College Hospital (Sylhet, Bangladesh). Independent Bili-ruler measurements were made and compared with reference standard transcutaneous bilirubin (TcB) and total serum bilirubin (TSB) concentrations. RESULTS: Bili-ruler scores on the nose were correlated with TcB and TSB levels (r = 0.76 and 0.78, respectively). The Bili-ruler distinguished different clinical thresholds of hyperbilirubinemia, defined by TcB, with high sensitivity and specificity (score $3.5: 90.1% [95% confidence interval (CI): 84.8%–95.4%] and 85.9% [95% CI: 83.2%–88.6%], respectively, for TcB $13 mg/dL). The Bili-ruler also performed reasonably well compared to TSB (score $3.5: sensitivity 84.5% [95% CI: 79.1%–90.3%] and specificity 83.2% [95% CI: 76.1%–90.3%] for TSB $11 mg/dL). Areas under the receiver operating characteristic curve for identifying TcB $11, $13, and $15 were 0.92, 0.93, and 0.94, respectively, and 0.90, 0.87, and 0.86 for identifying TSB $11, $13, and $15. Interrater reliability was high; 97% of scores by independent readers fell within 1 score of one another (N = 88). CONCLUSIONS: The Bili-ruler is a low-cost, noninvasive tool with high diagnostic accuracy for neonatal jaundice screening. This device may be used to improve referrals from community or peripheral health centers to higher-level facilities with capacity for bilirubin testing and/or phototherapy.

Original languageEnglish (US)
Article numberY
Issue number5
StatePublished - May 2019

ASJC Scopus subject areas

  • Pediatrics, Perinatology, and Child Health


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