Impact of delayed screening for prolonged jaundice in the newborn

M Tyrell; S Hingley; C Giles; J O Menakaya

doi:10.1136/adc.2008.145268

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Impact of delayed screening for prolonged jaundice in the newborn

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A rationalised protocol of selective screening for babies with prolonged jaundice is safe and practi
Michael O. Ogundele
Published on: 22 March 2016
Selective Screening for Prolonged Jaundice in Neonates: Reply to Letter Impact of Delayed Screening
Katy L Holden
Published on: 22 March 2016

Published on: 22 March 2016
A rationalised protocol of selective screening for babies with prolonged jaundice is safe and practi
- Michael O. Ogundele, Paediatric SpR
- Other Contributors:
  Jane Halliday
A rationalised protocol of selective screening for babies with prolonged jaundice is safe and practicable!
We have read with a keen interest the findings of the authors showing a significant reduction in the number of babies with prolonged jaundice requiring any further investigations by a simple protocol of one week delay (1). We suggest that even further savings on cost, prevention of undue distress to the pa...
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A rationalised protocol of selective screening for babies with prolonged jaundice is safe and practicable!
We have read with a keen interest the findings of the authors showing a significant reduction in the number of babies with prolonged jaundice requiring any further investigations by a simple protocol of one week delay (1). We suggest that even further savings on cost, prevention of undue distress to the patients and their parents, without any compromise to the quality and outcome of care of these babies can be achieved by reducing the number of investigations to the minimum of split bilirubin levels and others guided by the clinical assessment of risks.
In the UK there is no nationally agreed guideline for the management of prolonged jaundice. Several audits of local clinical practice have confirmed that there is insignificant yield from routine screening of babies with prolonged jaundice with a battery of tests including thyroid function test and full blood count since most of them have benign “breastmilk jaundice” (2). Our paediatric department at the Royal United Hospital in Bath has adopted a rationalised protocol of selective screening with split bilirubin levels and urine testing, supplemented with other tests based on clinical grounds for the past two years.
We have conducted a local audit of this simplified protocol over a six month period between January and June 2008. Briefly, the protocol requires a documentation of the patient’s demographic details, colour of stool and urine, feeding and family history, clinical examination including checking for liver or spleen enlargement. All babies had split bilirubin test only with specified additional tests recommended in cases of abnormal stool/urine colour, bottle-feeding, ethnic minority (G6PD status), failure to thrive, clinically unwell and or hepato-/splenomegaly.
A total of 50 patients were reviewed (21 girls, 29 boys), corresponding to 2.2% of the total live births (rate of 4875 annually). 80% of the referrals were seen within 72 hours of referral. Median birth weight was 3.336kg. 49/50 patients had a record of ethnicity, which varied from Caucasian, to British, white British and Polish. Appropriate number of tests based on the protocol were requested in 31 (62%) patients, while 4 (8%) had inadequate number of tests. 16 patients (32%) had 18 tests requested unnecessarily including 8 full blood count (FBC), 7 liver function tests (LFT), one each of glucose, thyroid function test (TFT) and electrolytes. No patient with biliary atresia was diagnosed within the audit period and no patient with any serious liver disease was missed since the introduction of the protocol for over two years.
The protocol has been further optimised by providing an appendix of recommended list of stool (pale/clay or any combination of yellow, green or brown) and urine (persistently yellow or brown, clear or light yellow) colours, ethnic group classifications and a list of countries/ethnicities with high risk for G6PD deficiency. Information required for risk assessment on the protocol has been expanded to include the mother's blood group or presence of antibodies, relevant family history of liver diseases, haemolytic disorders such as spherocytosis and history of consangunity. Enquiries about adequate dose(s) of vitamin K given at birth and about heel-prick neonatal screening were also considered useful.
The result of the audit shows that a rationalised protocol based on detailed clinical assessment of risk factors and limited screening tests for babies with prolonged jaundice is practicable, safe and cost- effective.
1. M Tyrell, S Hingley, C Giles and J O Menakaya. Impact of delayed screening for prolonged jaundice in the newborn. Archives of Disease in Childhood - Fetal and Neonatal Edition 2009;94:F154; doi:10.1136/adc.2008.145268 2. Ratnavel N, Ives NK. . Investigation of prolonged neonatal jaundice. Curr Paeds 2005:15;85-91.
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Conflict of Interest:
None declared.
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Published on: 22 March 2016
Selective Screening for Prolonged Jaundice in Neonates: Reply to Letter Impact of Delayed Screening
- Katy L Holden, Paediatric ST1
A recent audit conducted at Newham University Hospital on prolonged unconjugated jaundice supports the findings of Tyrell et al. in Hillingdon with regards to delayed screening in newborns [1], and in addition suggests the need for selected screening tests in babies who are otherwise well. Reducing the number of tests for initial screening is important for cost implications and for accurately detecting and treating the com...
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A recent audit conducted at Newham University Hospital on prolonged unconjugated jaundice supports the findings of Tyrell et al. in Hillingdon with regards to delayed screening in newborns [1], and in addition suggests the need for selected screening tests in babies who are otherwise well. Reducing the number of tests for initial screening is important for cost implications and for accurately detecting and treating the common causes of prolonged jaundice. The Children’s Liver Disease Foundation advise only testing split bilirubin in healthy term infants, and if the conjugated fraction is low then testing total bilirubin weekly until resolution.[2] Prolonged jaundice is rarely the marker for haematological, hepatobiliary, metabolic, endocrine, infectious and genetic disorders.[3] It would therefore seem sensible as first line testing to include a small number of laboratory tests with the focus on detecting conjugated hyperbilirubinaemia, hypothyroidism and sepsis. A larger range of tests could then be performed only if required.
A retrospective audit into screening for prolonged unconjugated jaundice in very low birthweight infants between November 2006 and November 2007 indicated that only certain tests would be necessary initially for detecting many causes of prolonged unconjugated jaundice. 11% (12/107) of very low birthweight infants underwent a prolonged jaundice screen during this period. Birthweight ranged from 1.2-1.47kg, and age at the time of the screen ranged from 13-62 days. 18 different types of tests were ordered totalling 103, and as well as basic blood tests included urine culture, urine for REDS and G6PD levels. No results in 2 years were positive for REDS, G6PD or hypothyroidism. Positive results were for anaemia (1), raised CRP (1) and urine cultures (4). 66% of urine cultures that were ordered were positive for bacteria. Results indicate that excluding certain tests would reduce unnecessary testing and cost and still detect a significant number of positive results appropriate for first line screening.
Findings from these audits suggest that screening for prolonged jaundice be delayed for 1 week longer than current practice1. In addition first line tests in well babies with no abnormal clinical signs should only include split bilirubin, FBC, CRP, TFT and urine culture. If further testing is required specialist tests can be directed by clinical findings and results from the initial screen.
1. Impact for delayed screening for prolonged jaundice in the newborn. Tyrell et al. Archives Dis Child Fetal Neonatal Ed 2009;94(2):F154
2. Jaundice Protocol Children’s Liver Disease Foundation March 2005 www.childliverdisease.org
3. N Ratnaval, N Kevin Ives. Investigation of prolonged neonatal jaundice. Current Paediatrics 2005;13(2):85-91.
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Conflict of Interest:
None declared.
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