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Home Health Nurse Clinical Assessment of Neonatal Jaundice
Comparison of 3 Methods
Diane J. Madlon-Kay, MD
Arch Pediatr Adolesc Med. 2001;155:583-586.
ABSTRACT
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Objective To compare 3 methods of clinical assessment of jaundice in newborns
by home health nurses.
Design Prospective clinical trial.
Setting Homes of newborns living within 10 miles of a 340-bed community hospital
where they were delivered.
Participants Home health nurses and newborn patients ( 2 weeks old).
Interventions The nurses examined the newborns and documented whether they detected
jaundice. In newborns thought to have jaundice, the nurses estimated bilirubin
levels, documented the extent of caudal progression of the jaundice, and determined
the Ingram (Cascade Health Care Products, Salem, Ore) icterometer readings
from the newborns' noses. Total serum bilirubin tests were obtained from all
newborns studied.
Outcome Measures Nurse assessment of the presence of jaundice and its caudal progression,
nurse estimates of bilirubin levels, icterometer readings, and bilirubin levels.
Results The nurses determined that 82 (50%) of the 164 newborns had jaundice.
Their estimates of bilirubin levels were most highly correlated with serum
bilirubin levels (Pearson correlation, 0.61). All 3 newborns with bilirubin
levels greater than or equal to 291 µmol/L ( 17 mg/dL) were recognized
by the nurses as having jaundice. These newborns had icterometer readings
greater than or equal to 3.5 and had estimated bilirubin levels of greater
than or equal to 274 µmol/L (16 mg/dL).
Conclusions The method of evaluation that each nurse was accustomed to using was
the most accurate in determining the severity of newborn jaundice. These results
suggest that postpartum home health nurses can effectively evaluate newborns
for the presence and severity of jaundice.
INTRODUCTION
JAUNDICE OCCURS in approximately 60% of newborns in the United States
and typically peaks during the first 3 to 5 days of life.1
Because most newborns stay in the hospital for 2 days at the longest, the
traditional clinic visit at age 2 weeks puts newborns at risk for delayed
diagnosis of jaundice and possible kernicterus. In 1995, the American Academy
of Pediatrics (AAP) recommended the following:
For newborns discharged in less than 48 hours after delivery,
a definitive appointment has been made for the baby to be examined within
48 hours of discharge. The follow-up visit can take place in a home or clinic
setting, as long as the personnel examining the infant are competent in newborn
assessment and the results of the follow-up visit are reported to the infant's
physician, or his designees, on the day of the visit.2(p
789)
One of the purposes of this visit is to assess the infant's degree of
jaundice.
In response to public and clinical concern about shorter postpartum
hospital stays, almost all states have passed maternity care legislation,
and federal legislation became effective in January 1998. Most state laws
include requirements for postdischarge follow-up services for mothers and
newborns discharged early. There is substantial variation in the types of
services specified and the extent to which insurers are responsible for covering
early follow-up care. In Minnesota, for example, legislation requires coverage
for at least 1 home visit by a registered nurse for a mother and newborn who
voluntarily leave the hospital before the minimum mandated stay and specifies
that the visit must occur within 4 days of the date of discharge. Neither
federal nor state legislation nor the AAP guidelines address routine postdischarge
follow-up after hospital stays longer than 48 hours.
Clinic visits within a few days of delivery are difficult for mothers
and families regardless of social and economic resources. Clinic no-show rates
as high as 26% have been noted.3 Moreover,
maternal satisfaction is markedly higher with postpartum home visits than
with pediatric clinic visits.4 However, the
assessment of jaundice is much more complex in the home setting than in the
hospital or clinic. The home health nurse must first decide whether the newborn
has jaundice. If the nurse believes that the newborn has jaundice, she must
then decide whether to recommend bilirubin testing. Then she must contact
the newborn's physician for permission to do the testing, obtain the blood
sample, and transport it to the laboratory. The test results are reported
to the physician who makes a recommendation. A key step in the process is
the nurse's ability to clinically assess whether the jaundice is serious enough
to warrant bilirubin testing.
The AAP guidelines on newborn hyperbilirubinemia management are rather
vague about the clinical evaluation of jaundice.1
Clinicians are advised to measure bilirubin levels when the jaundice is "‘clinically
significant' by medical judgment." No further definition of clinically significant
jaundice is given, and the AAP states that "adequate data are not available
from the scientific literature to provide more precise recommendations."1(p559) The AAP does suggest blanching the skin with
digital pressure to reveal the underlying color of the skin.1
The guidelines also state that clinical assessment must be done in a well-lighted
room, and that as the bilirubin level rises, the extent of caudal progression
may be helpful in quantifying the degree of jaundice.1
Several studies have documented that jaundice is first seen in the face and
progresses caudally to the trunk and extremities.5, 6, 7
These studies also found good correlation between serum bilirubin levels and
the advancement of dermal icterus. In contrast, a recent study concluded that
the clinical examination for jaundice had poor reliability and only moderate
correlation with bilirubin levels.8 However,
the authors did conclude that finding no jaundice caudal to the nipple line
reliably predicted a bilirubin concentration less than 205 µmol/L (12.0
mg/dL).
The AAP jaundice guidelines also state that the use of an icterometer
or transcutaneous jaundice meter may be helpful in the clinical assessment
of jaundice.1 These devices have not been used
in most US hospitals,9 perhaps because of the
ease of obtaining bilirubin tests, but are important for home health nurses'
evaluations of jaundice. A variety of instruments have been tested in differing
patient populations,10, 11, 12, 13, 14
and are useful in developing countries where few centers are equipped with
facilities for micromethods of bilirubin testing, and frequent blood sampling
is not feasible.12 Particularly promising because
of its low cost ($17) and simplicity is the Ingram (Cascade Health Care Products,
Salem, Ore) icterometer.11 Successful icterometer
use has been reported by 2 institutions that obtained serum bilirubin levels
only on newborns with icterometer readings of 3 or higher.12, 15
Because the use of home health nurses in the care of newborns after
discharge is increasing, the ability of home health nurses to clinically assess
jaundice is important to study. The purpose of this study was to examine the
accuracy of 3 methods of jaundice assessment by home health nurses of newborns
in the home: their usual methods of assessment, determining the caudal progression
of jaundice, and using the Ingram icterometer.
PARTICIPANTS AND METHODS
Home health nurses who visited newborns delivered at Regions Hospital
in St Paul, Minn, participated in the study. I interviewed the nurses individually
to determine their usual methods of assessing the presence and severity of
jaundice in newborns. I then instructed the nurses as a group how to determine
the caudal progression of jaundice by blanching the skin. The nurses were
also instructed on the use of the Ingram icterometer, and each nurse was given
one to use for the study.
Mothers in the postpartum department were invited to participate in
the study. Mothers were excluded if they were not proficient in English or
lived more than 10 miles from the hospital. Newborns were excluded if they
were in the intensive care nursery or received phototherapy. Participating
mothers were visited by the home health nurse before the newborn was 2 weeks
old. The nurse first assessed the newborn for jaundice in the usual manner.
If the nurse felt the newborn did not have jaundice, no further clinical assessment
was performed.
If the nurse felt the newborn had jaundice, the total serum bilirubin
level was estimated and it was documented whether bilirubin testing would
be recommended to the newborn's physician based on the usual assessment method.
In newborns with jaundice, the nurse then determined the caudal progression
of the jaundice and drew a horizontal line on an illustration of a newborn
corresponding to where the jaundice ended. The distance from the top of the
newborn's head to the line drawn by the nurse was used to determine the caudal
progression.
The nurse then used the Ingram icterometer to obtain a reading from
the newborn's nose. The Ingram icterometer is a simple handheld device made
of clear plastic on which are painted 5 transverse stripes of precisely graded
hues of yellow. The stripes and spaces in between are in 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 newborn infant's nose until the skin becomes blanched. The yellow color
of the blanched skin can then be matched with the yellow stripes and a jaundice
score assigned. If the color falls halfway between 2 stripes, for example
between 2 and 3, the number 2.5 is assigned.
Blood samples were obtained from all newborns and transported to Regions
Hospital for determination of the total serum bilirubin level. If the level
was greater than or equal to 239 µmol/L (14 mg/dL) the newborn's
physician was notified. The mothers received a $25 gift certificate for participating.
The HealthPartners (Bloomington, Minn) institutional review board approved
the study protocol.
Standard descriptive statistics were calculated for all variables. Pearson
product moment correlations were calculated to examine the relationship among
different quantitative measurements of jaundice. Accuracy of estimates was
calculated by subtracting the nurse estimate of the bilirubin level from the
actual total bilirubin level. Accuracy of different subgroups such as ethnicity
was assessed using 1-way analysis of variance techniques. Categorical relationships
were assessed using  and  2 statistics as appropriate.
All analyses were performed using SPSS for Windows version 10.0.5 (SPSS Inc,
Chicago, Ill).
RESULTS
One hundred sixty-four newborns and 12 home health nurses participated
in the study. The 6 nurses interviewed had provided home health care for newborns
for a length of time that ranged from 1 to 7 years, and in that time had cared
for 4 to 50 newborns each month. The nurses described a variety of methods
that they used to determine the severity of jaundice, including blanching
the skin to determine its caudal progression, looking for jaundice at the
nose, gum, or sclera, and judging "how yellow" the skin appeared. All of the
nurses reported obtaining bilirubin levels selectively on newborns with jaundice
in their usual practice. They considered several factors when deciding whether
to obtain a blood sample for a bilirubin determination, including the severity
of jaundice; the newborn's level of alertness; stooling; urination and feeding
patterns; concern about weight gain; parents perception of change in severity
of jaundice; and the newborn's age.
The mean (SD) age of the newborns at examination was 6.4 (2.5) days.
The race or ethnic group as determined by the nurses was 60% white, 18% black,
6% Asian, 7% Hispanic, and 9% other ethnicity.
When assessed in the nurses' usual manner, 82 (50%) of the newborns
were judged to have jaundice (Figure 1).
The nurses' estimates of the bilirubin levels of the newborns with jaundice
ranged from 34 to 325 µmol/L (2-19 mg/dL), with a mean (SD) of 176.0
(54.7) µmol/L (10.3 [3.2] mg/dL). The nurses judged that the jaundice
in these newborns extended between the forehead and the knees, with the mean
at the xiphoid area. The icterometer readings of the newborns with jaundice
ranged from 1 to 5, with a mean (SD) of 2.6 (0.8).
The actual total serum bilirubin levels of all the newborns ranged from
12 to 345 µmol/L (0.7-20.2 mg/dL), with a mean (SD) of 125.0 (80.4)
µmol/L (7.3 [4.7] mg/dL). Pearson correlations with actual bilirubin
levels were calculated among the 3 methods of jaundice assessment used. The
nurses' estimates of the bilirubin levels had a correlation of 0.61 (P<.01); the assessment of caudal progression had a correlation
of 0.47 (P<.01); and the icterometer had a correlation
of 0.48 (P<.01). The accuracy of the nurses' estimates
of bilirubin levels was unaffected by the race or ethnic group of the newborns
or by the different examiners.
The mean (SD) bilirubin level of newborns thought to have jaundice by
the nurses was 180.0 (68.4) µmol/L (10.5 [4.0] mg/dL), while the mean
(SD) bilirubin levels of newborns not thought to have jaundice was 71.8 (46.0)
µmol/L (4.2 [2.7] mg/dL) (P<.001). The nurses
would have recommended bilirubin testing in only 31 of the 82 newborns with
jaundice if they were not in a study. The mean (SD) bilirubin levels of the
newborns with jaundice they would have recommended testing for was 207.0 (66.7)
µmol/L (12.1 [3.9] mg/dL). The mean (SD) bilirubin levels of newborns
with jaundice they would not have tested was 164 (65) µmol/L (9.6 [3.8]
mg/dL) (P<.005).
Only 3 newborns had bilirubin levels greater than or equal to 291 µmol/L
(17 mg/dL), the level at which the AAP guidelines suggest considering
phototherapy for newborns older than 72 hours.1
The nurses judged that the progression of jaundice in these newborns extended
to the xiphoid in 2 and to the thigh in the third. The icterometer readings
were 3.5, 4.0, and 4.5. The nurses' estimates of the bilirubin levels were
greater than or equal to 291 µmol/L (17 mg/dL) in 2 of these newborns
and 274 µmol/L (16 mg/dL) in the third.
COMMENT
This study confirms that although jaundice is a common condition in
newborns, bilirubin levels requiring phototherapy are infrequently obtained.
Therefore, home health nurses providing care for newborns shortly after hospital
discharge must be skilled in assessing the presence of jaundice and determining
whether bilirubin testing is warranted. A recent study found equivalent clinical
outcomes in newborns receiving either home health nurse visits or pediatric
clinic visits on the third or fourth postpartum day.4
Although reassuring, the study did not provide specific information about
morbidity related to newborn jaundice.
In this study, bilirubin levels were more strongly correlated with the
nurses' estimates of bilirubin levels based on their usual method of assessing
jaundice than with their determination of the caudal progression of jaundice
or with icterometer readings. When interviewed about their usual methods of
evaluating jaundice, the nurses reported using caudal progression, checking
for jaundice at certain sites, and judging how yellow the skin was. Using
their usual methods of evaluation, the home health nurses correctly identified
newborns with the most severe jaundice and those without jaundice. The nurses
were also appropriately selective in determining which newborns with jaundice
they would recommend to receive bilirubin testing.
Although the nurses' usual methods of evaluation included determining
the caudal progression of jaundice, caudal progression alone was poorly correlated
with actual bilirubin levels. The reason for this is unclear. In my previous
study of newborns still in the nursery, the adjusted Pearson correlation of
nurse assessment of caudal progression with actual bilirubin levels was 0.48,
which is similar to the results of this study.16
In the previous study, however, correlation of the parental assessment of
caudal progression with actual bilirubin levels was much higher (0.71).
In a previous study, I investigated how well parents, nurses, physicians,
and an Ingram icterometer detected the presence and severity of jaundice in
newborns while they were still in the nursery.16
There was moderate agreement between examiners about the presence of jaundice
in the newborns (pairwise , 0.48) However, all newborns with bilirubin
levels greater than 205 µmol/L (12 mg/dL) were correctly identified
as having jaundice by all examiners. The parents' assessment of caudal progression
and the icterometer readings were most highly correlated with bilirubin levels
(adjusted Pearson correlations, 0.71 and 0.57, respectively). However, the
bilirubin levels in this study were relatively low, reflecting the brief hospital
stay of most of the newborns.
Another study found that the presence of visible jaundice extending
caudal to the nipple line had a sensitivity of 97% and a specificity of 19%
for identifying newborns with bilirubin levels greater than or equal to 205
µmol/L (12 mg/dL).8 The authors concluded
that finding no jaundice caudal to the nipple line reliably predicted that
a newborn would have a bilirubin concentration less than 205 µmol/L
(<12 mg/dL), which might be useful in determining which newborns do not
need serum bilirubin level determinations. In this study, the caudal progression
was not as useful in identifying newborns with bilirubin levels greater than
or equal to 205 µmol/L (12 mg/dL). The presence of jaundice caudal
to the nipple line had a sensitivity of only 76% and a specificity of 60%
for the identification of these newborns.
The correlation between Ingram icterometer readings and actual bilirubin
levels was not as high in this study as in prior ones. The adjusted Pearson
correlation in my previous study of newborns in the nursery was 0.57.16 A possible explanation for this difference is that
in the previous study the icterometer was used on all newborns, while in the
current study only newborns thought by the nurse to have jaundice had icterometer
readings obtained.
The icterometer readings were not as helpful as previously reported
in identifying newborns with bilirubin levels greater than or equal to 205
µmol/L (12 mg/dL). In my previous study, all 11 newborns with bilirubin
levels greater than 205 µmol/L (>12 mg/dL) had icterometer readings
greater than or equal to 2.5.16 In this study,
an icterometer reading greater than or equal to 2.5 had a sensitivity of 75%
and specificity of 72% for the identification of newborns with bilirubin levels
greater than or equal to 205 µmol/L (12 mg/dL). However, an icterometer
reading of greater than or equal to 3.5 was sensitive (100%) and quite specific
(85%) in identifying newborns with bilirubin levels greater than or equal
to 291 µmol/L (17 mg/dL).
A limitation of this study is the inability to further define the methods
used by the home health nurses to estimate bilirubin levels. Other home health
nurses may use different assessment methods that may in turn lead to a poorer
correlation with actual bilirubin levels. In my previous study of newborns
in the nursery, the nursery nurses' estimates of bilirubin did not correlate
as well with actual bilirubin levels (adjusted Pearson correlation, 0.52).
An additional limitation of the study is the relatively small number
of newborns having bilirubin levels high enough to require potential intervention.
Therefore, the sensitivites and specificities should be interpreted with caution.
However, it is reassuring that the home health nurses appropriately identified
the 3 newborns with bilirubin levels greater than or equal to 291 µmol/L
(17 mg/dL). Therefore, despite these limitations, this study indicates
that home health nurses have the clinical skills to appropriately evaluate
newborns for jaundice.
AUTHOR INFORMATION
Accepted for publication December 27, 2000.
This study was funded by grant N599 from the Ramsey Foundation, St Paul,
Minn.
From the Ramsey Family and Community Medicine Residency Program, St
Paul, Minn.
Corresponding author and reprints: Diane J. Madlon-Kay, MD, Ramsey
Family Community Medicine Residency Program, 640 Jackson St, St Paul, MN 55101
(e-mail: madlo001{at}tc.umn.edu).
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