Validation of visual estimation of neonatal jaundice in low-income and middle-income countries: a multicentre observational cohort study

Abstract

ObjectiveDetermine the sensitivity and specificity of neonatal jaundice visual estimation by primary healthcare workers (PHWs) and physicians as predictors of hyperbilirubinaemia.DesignMulticentre observational cohort study.SettingHospitals in Chandigarh and Delhi, India; Dhaka, Bangladesh; Durban, South Africa; Kumasi, Ghana; La Paz, Bolivia.ParticipantsNeonates aged 1–20 days (n=2642) who presented to hospitals for evaluation of acute illness. Infants referred for any reason from another health facility or those needing immediate cardiopulmonary resuscitation were excluded.Outcome measuresInfants were evaluated for distribution (head, trunk, distal extremities) and degree (mild, moderate, severe) of jaundice by PHWs and physicians. Serum bilirubin level was determined for infants with jaundice, and analyses of sensitivity and specificity of visual estimations of jaundice used bilirubin thresholds of >260 µmol/L (need for phototherapy) and >340 µmol/L (need for emergency intervention in at-risk and preterm babies).Results1241 (47.0%) neonates had jaundice. High sensitivity for detecting neonates with serum bilirubin >340 µmol/L was found for ‘any jaundice of the distal extremities (palms or soles) OR deep jaundice of the trunk or head’ for both PHWs (89%–100%) and physicians (81%–100%) across study sites; specificity was more variable. ‘Any jaundice of the distal extremities’ identified by PHWs and physicians had sensitivity of 71%–100% and specificity of 55%–95%, excluding La Paz. For the bilirubin threshold >260 µmol/L, ‘any jaundice of the distal extremities OR deep jaundice of the trunk or head’ had the highest sensitivity across sites (PHWs: 58%–93%, physicians: 55%–98%).ConclusionsIn settings where serum bilirubin cannot be measured, neonates with any jaundice on the distal extremities should be referred to a hospital for evaluation and management, where delays in serum bilirubin measurement and appropriate treatment are anticipated following referral, the higher sensitivity sign, any jaundice on the distal extremities or deep jaundice of the trunk or head, may be preferred.

Community health worker-led household screening and management of neonatal hyperbilirubinemia in rural Bangladesh: a cluster randomized control trial protocol

“…The performance of CHW physical exams to detect clinical danger signs in newborns was validated and the exams had 81% sensitivity and 96% specificity to detect clinical danger signs 19 . This research has influenced the WHO guidelines to integrate seven newborn danger signs as a part of the Integrated Management of Childhood Illness guidelines and we used these danger signs as a part of our algorithm to manage neonatal hyperbilirubinemia 7,17 . We will use this validated screening method to identify newborns without danger signs and are otherwise healthy and can safely be treated with home phototherapy.…”

“…In many LMICs, more than half of newborns are born at home, where postnatal visits and physical exam screenings or laboratory screening for neonatal hyperbilirubinemia are rarely performed 5 . The World Health Organization (WHO) in the Integrated Management of Childhood Illness (IMCI) guidelines, recommend neonates in LMICs receive home or clinic-based physical exam screenings followed by a referral to a hospital if there is concern for hyperbilirubinemia 6,7 . Physical exam based screening by physicians prior to hospital discharge has been shown to be less effective in reducing cases of severe hyperbilirubinemia than transcutaneous bilirubin (TcB) screening 8 .…”

Antenatal jaundice instruction and acute bilirubin encephalopathy in Nigeria

“…44 TSB is frequently greater than 15–20 m/dL when hands and feet are jaundiced. 45 The listed danger signs reflect both early and advanced, often irreversible, ABE as defined by BIND score assessment. 33 , 34…”

“…Kramer scores are inaccurate in detecting significant jaundice, especially in deeply pigmented newborns. 45 …”

Acceptability and operational feasibility of community health worker-led home phototherapy treatment for neonatal hyperbilirubinemia in rural Bangladesh

“…CHWs conducted home visits to educate mothers and family members on the signs and symptoms of neonatal hyperbilirubinemia and the possible need for treatment with home or hospital-based phototherapy [ 31 , 41 , 42 ]. Each CHW was assigned 26 to 32 mother-neonate pairs over the implementation period of 4 months.…”