Article Text

Download PDFPDF
Visual assessment of jaundice in term and late preterm infants
  1. R Keren1,3,
  2. K Tremont1,
  3. X Luan2,
  4. A Cnaan2,3
  1. 1
    Division of General Pediatrics and the Center for Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
  2. 2
    Division of Biostatistics and Epidemiology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
  3. 3
    Department of Pediatrics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
  1. Correspondence to Ron Keren, The Children’s Hospital of Philadelphia, 3535 Market Street, Room 1524, Philadelphia, Pennsylvania 19104, USA; keren{at}


Objective: To determine the accuracy of predischarge visual assessment of jaundice for estimating bilirubin concentration and predicting risk of significant neonatal hyperbilirubinaemia.

Design: Prospective cohort study.

Setting: Well Baby Nursery at the Hospital of the University of Pennsylvania.

Patients: 522 term and late preterm newborns.

Interventions: Nurses used a 5-point scale to grade the maximum cephalocaudal extent of jaundice prior to discharge.

Main outcome measures: (1) Correlation between jaundice grade and bilirubin concentration. (2) Predictive accuracy of jaundice grade for identifying infants who developed significant hyperbilirubinaemia, defined as a bilirubin level that at any time after birth exceeded or was within 1 mg/dl (17 μmol/l) of the American Academy of Pediatrics-recommended hour-specific phototherapy treatment threshold.

Results: Nurses’ assessment of jaundice extent was only moderately correlated with bilirubin concentration and was similar in black and non-black infants (Spearman’s rho  =  0.45 and 0.55, respectively (p = 0.13)). The correlation was particularly weak among infants <38 weeks’ gestational age (rho = 0.29) compared with infants ⩾38 weeks’ gestation (rho = 0.53, p = 0.05). Jaundice extent had poor overall accuracy for predicting risk of significant hyperbilirubinaemia (c-statistic  =  0.65) but complete absence of jaundice had high sensitivity (95%) and excellent negative predictive value (99%) for ruling out the development of significant hyperbilirubinaemia.

Conclusions: Clinicians should not use extent of cephalocaudal jaundice progression to estimate bilirubin levels during the birth hospitalisation, especially in late preterm infants. However, the complete absence of jaundice can be used to predict with very high accuracy which infants will not develop significant hyperbilirubinaemia.

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Funding RK was supported by grant number K23 HD043179 from the National Institute of Child Health and Human Development, Bethesda, Maryland, USA. This study was also supported by Respironics (Murrysville, Pennsylvania, USA), which loaned us a BiliCheck device for bilirubin measurements during home visits and donated a limited supply of BiliCheck disposable tips.

  • Competing interests None.

  • Ethics approval The institutional review boards from the University of Pennsylvania School of Medicine and the Children’s Hospital of Philadelphia approved the study protocol.

  • Patient consent Parental consent obtained.

Linked Articles

  • Fantoms
    Ben Stenson
  • Perspective
    Donal Manning