The mothers of the 3 infants with bilirubin levels 17 mg/dL recognized that their infants were jaundiced and determined that the jaundice extended below the nipple line. The icterometer readings obtained by the mothers were 2.5, 3, and 3.5. The corresponding icterometer readings by the nurses were 4.5, 3.5 and 3.
The study booklet contained 6 questions about the mothers’ reactions to the study. Almost all of the mothers (98%) responded that the method for checking for caudal progression of jaundice was explained clearly, and even more (99%) felt the use of the icterometer was explained clearly. A total of 69% of the mothers felt it was “very easy” or “easy” to check for caudal progression, and 80% felt it was “very easy” or “easy” to use the icterometer. Forty-six percent of the mothers reported that checking their babies for jaundice made them “very worried” or “somewhat worried” about their babies’ health. Mothers with less education were significantly more likely to report being worried than mothers with higher education levels (P < .05). However, 93% of the mothers reported that checking their babies for jaundice made them “very reassured” or “somewhat reassured” about their babies’ health.
TABLE 1
Maternal assessment of jaundice, by caudal progression and icterometer readings, compared with serum bilirubin levels
| Maternal test result | Serum bilirubin level (mg/dL) | |||
|---|---|---|---|---|
| ≥ 12 | < 12 | ≥ 17 | < 17 | |
| Icterometer ≥ 2.5 | 11 | 14 | 3 | 22 |
| Icterometer < 2.5 | 4 | 26 | 0 | 30 |
| Caudal progression at or above nipple line | 11 | 9 | 3 | 17 |
| Caudal progression below nipple line | 5 | 31 | 0 | 36 |
TABLE 2
Diagnostic accuracy of maternal visual assessment of jaundice and of the Ingram icterometer
| Test | Cut-off (serum bilirubin level, mg/dL) | SN | SP | PV+ | PV- | LR+ | LR- |
|---|---|---|---|---|---|---|---|
| Maternal visual assessment below the nipple line | ≥12.0 | 69 | 77 | 55 (CI, 52-58) | 86 (CI, 84-88) | 3.1 | 0.4 |
| Ingram icterometer reading ≥ 2.5 | ≥12.0 | 73 | 65 | 44 (CI, 41-47) | 87 (CI, 85-89) | 2.1 | 0.4 |
| Maternal visual assessment below the nipple line | ≥17.0 | 100 | 68 | 15 (CI, 13-17) | 100 (CI, 67-100) | 3.12 | 0 |
| Ingram icterometer reading ≥ 2.5 | ≥17.0 | 100 | 58 | 12 (CI, 10–14) | 100 (CI, 67-100) | 2.4 | 0 |
| SN denotes sensitivity; SP = specificity; PV+ = positive predictive value; PV- = negative predictive value; LR+ = positive likelihood ratio; LR- = negative likelihood ratio; CI = 95% confidence interval. | |||||||
Discussion
The ability of mothers to detect and respond to jaundice in their newborns after discharge from the hospital has not been previously studied. Opinions about the value of parental education regarding jaundice vary markedly. The AAP recommends that all mothers be able to recognize signs of jaundice before discharge.9 Others are skeptical that such education will be helpful: “Experience suggests that asking mothers to observe infants for the development of jaundice is not satisfactory. Despite such instructions, it is difficult for many parents to recognize significant jaundice.”10
Several studies have documented that jaundice is first seen in the face and progresses caudally to the trunk and extremities.11-13 These studies also found good correlation between serum bilirubin levels and the advancement of dermal icterus. In a previous study, parents were able to accurately assess the caudal progression of jaundice while their babies were in the hospital.14 However, the bilirubin levels in that study were relatively low, reflecting the brief hospital stay of most of the infants. In contrast, a recent study concluded that the clinical examination for jaundice by nurses and physicians had poor reliability and only moderate correlation with bilirubin levels.15 The authors did conclude, however, that finding no jaundice below the nipple line reliably predicted that an infant would have a bilirubin concentration of less than 12.0 mg/dL. In this study, finding no jaundice below the nipple line reliably predicted that an infant would have a bilirubin concentration of less than 17.0 mg/dL.
Because of the relatively small number of infants having bilirubin levels high enough to require potential intervention, the measures of diagnostic accuracy in the tables should be interpreted with caution. However, the results of my study confirm several prior reports that restricting bilirubin testing to infants with icterometer readings 2.5 would have safely eliminated many unnecessary tests.6,14,16 Although most of the infants in my study were white, the efficacy of the icterometer has also been documented in Asian and black newborns.17
Previous studies have shown that neonatal jaundice and its treatments are associated with an increased risk of maternal behaviors consistent with the vulnerable child syndrome.18,19 This syndrome was originally described in 1964 in children whose parents believed that their child had suffered a “close call,” and thereafter perceived the child as vulnerable to serious injury or accident.18 Frequent blood tests to monitor bilirubin levels, supplementation or replacement of breast milk with formula, the physical separation of the mother and infant because of phototherapy, and prolonged hospitalization may create the impression that the infant is seriously ill, despite reassurances from medical personnel. Therefore, the mothers were asked whether the study itself served as a source of anxiety. Almost half of the mothers in this study reported that checking their babies for jaundice made them very or somewhat worried about their babies’ health. Some of the women must have felt ambivalent, however, because almost all of them (93%) also reported that checking their babies for jaundice made them very or somewhat reassured about their babies’ health. Most of the 48 comments written by the mothers in the study booklets were very positive.