Maternal assessment of neonatal jaundice after hospital discharge

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Original Research

Maternal assessment of neonatal jaundice after hospital discharge

J Fam Pract. 2002 May;51(5):445-448

By

Diane J. Madlon-Kay, MD

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References

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ABSTRACT

OBJECTIVE: To determine whether mothers can accurately assess the presence and severity of jaundice in their newborns, both visually and with an icterometer, after hospital discharge.

STUDY DESIGN: Mothers were taught how to examine their infants for jaundice by determining the extent of caudal progression of jaundice and by using an Ingram icterometer. The mothers documented the examinations for 7 days after discharge. Home health nurses examined the babies for jaundice after discharge and obtained serum bilirubin levels.

POPULATION: Mothers of infants cared for in the normal newborn nursery of a 340-bed community hospital.

OUTCOME MEASURED: Maternal assessment of the presence of jaundice and its caudal progression.

RESULTS: Jaundice extending below the nipple line had a positive predictive value of 55% and a negative predictive value of 86% for identifying infants with bilirubin levels of 12 mg/dL. Icterometer readings of 2.5 had a positive predictive value of 44% and a negative predictive value of 87% for identifying infants with bilirubin levels of 12 mg/dL. The 3 infants with bilirubin levels 17 mg/dL were recognized by their mothers as having jaundice below the nipple line and had icterometer readings of 2.5.

CONCLUSIONS: Further study is needed to determine the optimum method of parental education about newborn jaundice. However, maternal use of the Ingram icterometer and determination of jaundice in relation to the infant’s nipple line are both potentially useful methods of assessing jaundice after hospital discharge.

KEY POINTS FOR CLINICIANS

Although kernicterus, or bilirubin encephalopathy, is preventable, it is still occurring.
Parents should be provided with educational materials about newborn infants that include information about jaundice.
It may be useful for parents to be instructed how to assess the level of jaundice in their infant or to be given an Ingram icterometer to monitor their infants for jaundice after discharge.

From 1% to 4% of full-term infants are readmitted to the hospital for jaundice in the first week of life, representing as many as 109,000 admissions¹ Delayed diagnosis of jaundice puts babies at risk for kernicterus, which had virtually disappeared in the United States but is now on the rise. There are anecdotal reports of 22 full-term infants born in the early 1990s who developed kernicterus after discharge from the hospital within 48 hours of birth.¹ The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recently issued a Sentinel Event Alert recommending that organizations take steps to raise awareness among neonatal caregivers of the potential for kernicterus and its risk factors by reviewing their current patient care processes with regard to the identification and management of hyperbilirubinemia in newborns and by identifying risk reduction strategies that could enhance the effectiveness of these processes.²

The JCAHO alert cites the American Academy of Pediatrics (AAP) Practice Parameter for Management of Hyperbilirubinemia in the Healthy Term Newborn, which is based on available data and expert consensus, as an example of a guideline for identifying at-risk newborns and their diagnosis and treatment. The AAP guideline suggests checking for jaundice by blanching the skin with digital pressure to reveal its underlying color. The guideline states that clinical assessment must be done in a well-lighted room and suggests that as the bilirubin level rises, the extent of caudal progression may be helpful in quantifying the degree of jaundice.³

The AAP jaundice guideline suggests that the use of an icterometer (transcutaneous jaundice meter) may be helpful in the clinical assessment of jaundice.³ A variety of instruments have been tested in different patient populations.^4-8 A potential role for such devices is their use by parents. The Ingram icterometer (Cascade Health Care Products, Salem, Ore.) is particularly promising because of its low cost ($17) and simplicity.⁵ It is a simple handheld device, made of clear plastic, on which are painted 5 transverse stripes of precise and graded hue. The stripes and spaces between them are 3/16 inch wide and are numbered from 1 (lightest in color) to 5 (darkest). When the icterometer is used, the painted side is pressed against the tip of the infant’s nose until the skin becomes blanched. The yellow color of the blanched skin can then be matched with the yellow stripes on the instrument, and a jaundice score assigned.

The purpose of my study was to determine whether mothers can accurately assess the presence and severity of jaundice in their newborns, both visually and with an icterometer, after hospital discharge. Maternal assessments were compared with bilirubin levels and home health nurse assessments to determine their accuracy. Serum bilirubin levels were used as the reference standard. Maternal comfort with the examination techniques was also assessed.