Page 101 - 16Neonatal Jaundice_compressed

Neonatal jaundice

observers; P < 0.01). The presence of visible jaundice between the ‘nipple line and the
umbilicus’ (i.e. the lower chest) had the best diagnostic accuracy (among all the sites) for
detecting serum bilirubin levels > 205 micromol/litre with a sensitivity of 97% but a specificity
of 19% only. If visible jaundice was absent in the lower chest, it had an NPV of 94% in ruling
out serum bilirubin levels above 205 micromol/litre. [EL II]
The third study was conducted in a community setting in the USA and involved follow-up
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visits by 12 home nurses to babies (n = 164) delivered in a hospital setting. The sample
population was multi-ethnic: 60% of babies were white, 18% black, 6% Asian, 7% Hispanic
and 9% were of other ethnicity. Babies who were in the intensive care nursery, had received
phototherapy, whose mothers were not proficient in English or who lived more than 10 miles
from the hospital were excluded. The mean age of babies at examination was 6.4 ± 2.5 days. If
the baby was considered to be jaundiced, nurses obtained blood for serum bilirubin
measurement followed by assessment in three different ways: clinical assessment using their
usual method (e.g. blanching skin, looking for jaundice at sclera, nose), judging cephalo-caudal
progression, and taking an Ingram icterometer reading from the nose. Eighty-two babies were
judged to have jaundice. The nurses’ usual method of clinical assessment showed the best
correlation with serum bilirubin levels (r = 0.61; P < 0.01), while assessment of cephalo-caudal
progression and use of the icterometer showed lower levels of correlation (r = 0.47 and r = 0.48,
respectively; P < 0.01 for both). Only three babies had serum bilirubin > 291 micromol/litre
and nurses were able to predict the levels in two of them correctly. For detecting serum
bilirubin > 205 micromol/litre, the presence of jaundice caudal to the nipple line had a
sensitivity of 76% and specificity of 60%, while an Ingram icterometer reading ≥ 2.5 showed a
sensitivity of 75% and specificity of 72%. [EL II]

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The fourth study, from Israel, sought to determine whether clinical impression of jaundice
could be used as a primary screening tool for hyperbilirubinaemia in a sample of Jewish (76%)
and Arab (24%) babies. All full-term babies (n = 283) with jaundice were assessed by four
neonatologists before discharge regarding severity of jaundice (they were asked which
newborns were clinically jaundiced and to decide on whether to draw blood) and their
estimated serum bilirubin levels. Laboratory serum bilirubin levels were measured within
30 minutes. The physicians were unaware of the babies’ previous history and serum bilirubin
levels. Their clinical estimates of serum bilirubin were statistically significantly correlated with
the actual serum bilirubin values but with varying degree of linear correlation (correlation
coefficients ranging from 0.62 to 0.79). On combining the results of all the four physicians, the
correlation coefficient was 0.68 (P < 0.001). [EL II]
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In the fifth study, conducted in a newborn nursery in the USA, 171 babies over 2 days of age
were initially assessed for the severity of jaundice by nurses and physicians using both cephalo-
caudal progression and their clinical estimate. The maternal ethnic origins were described as
white (50%), black (24%), Asian (13%), Hispanic (9%) and ‘other’ (4%). The assessment was
done at the time of serum bilirubin estimation but serum bilirubin values were measured for
only 89 babies. The parents of these babies were then given written and verbal instructions on
how to assess jaundice using assessment of cephalo-caudal progression, and a researcher used
the Ingram icterometer to record readings from the nose. Only 11 babies had serum bilirubin
values above 205 micromol/litre. There was poor agreement between physicians, nurses and
parents about whether a baby was jaundiced (κ = 0.48 for all the three paired comparisons).
Parental assessment of cephalo-caudal progression of jaundice correlated best with the serum
bilirubin values (r = 0.71), followed by the icterometer (r = 0.57) and the nurses’ and physicians’
clinical estimates (r = 0.52 and 0.55, respectively). The nurses’ and physicians’ assessment of
cephalo-caudal progression correlated poorly with serum bilirubin values, the coefficients being
0.48 and 0.35, respectively. [EL II]
Two studies 55;56 with EL II conducted in the same setting in Switzerland compared the clinical
assessment of jaundice (Kramer method) and two transcutaneous bilirubinometers (Minolta JM-
102 and BiliChek) with serum bilirubin levels. The population in the first study included 140
healthy term babies, of whom 66% were white. In the second study the sample population
comprised healthy preterm babies (n = 69) with gestational age between 34 and 37 weeks, of
whom 87% were white. In both studies, babies with birthweight of at least 2000 g and age not
older than 6 days were included and evaluated for clinical jaundice at regular intervals. When

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