Reliability of visual assessment of neonatal jaundice among neonates of black descent: a cross-sectional study from Tanzania

Abstract

Background Jaundice is common among neonates and if untreated can lead to kernicterus. Diagnosing neonatal jaundice (NJ) using Kramer’s method (visual assessment) is considered user-friendly in resource-limited areas. However, there are conflicting findings on reliability of the Kramer’s method in the diagnosis of NJ, particularly of black descent. Therefore, study aimed to determine the accuracy of Kramer’s method in comparison to the total serum bilirubin (TSB) test in the diagnosis of NJ among neonates of black descent in Tanzania. Methods A cross-sectional study was conducted between June and July 2020 at Muhimbili National Hospital (MNH) in Dar es Salaam Tanzania. A total of 315 neonates were recruited consecutively. In each neonate, jaundice was assessed using Kramer’s method and TSB test. NJ A total of 315 neonates were recruited i. A 2 X 2 table was created for the determination of sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive and negative likelihood ratios (+LR/−LR), and diagnostic accuracy (effectiveness) of Kramer’s method. Cohen kappa (κ) was used to analyze the agreement between Kramer’s method and TSB. Association between independent variables and presence of jaundice were assessed using the chi-square test and the p < 0.05 was considered to be statistically significant. Results The prevalence of NJ was 49.8% by Kramer’s method and 63.5% by TSB. The Sensitivity, Specificity, PPV, and NPV of Kramer’s method were 70.5, 86.1, 89.8, and 62.6%, respectively. The +LR and –LR were 5.07 and 0.34, respectively. The diagnostic accuracy of Kramer’s method was 76.1%. There was a moderate agreement between Kramer’s method and TSB results (κ = 0.524, P<0.001). No significant relationship was observed between the independent variables and the presence of NJ. Conclusion Kramer has a good positive predictive value. However, due to low sensitivity and NPV one cannot say that overall predictive ability is good. Also, clinical assessment by Kramer’s method should not be used for screening of NJ. Further studies are needed to investigate the utility of other non-invasive techniques in detecting NJ among neonates of black descent.

A review of the current policies and guidance regarding Apgar scoring and the detection of jaundice and cyanosis concerning Black, Asian and ethnic minority neonates

“…Within the guidance, healthcare professionals were advised that bilirubin levels should not be measured routinely, as visual inspection should be performed initially [ 29 , 32 , 38 ], which may disadvantage those with darker skin pigmentation. Visual inspection of jaundice has repeatedly been found to be unreliable [ 8 , 43 ], with instances of jaundice being missed by healthcare professionals, notably in those with darker skin pigmentation [ 44 ]. Indeed, the NICE guidance deemed the detection of jaundice in darker skin tones to be “almost impossible” [ 32 ].…”

Exploring the use of health technology in community-based midwifery care – An interview study

“…For example, in some NHS Trusts, midwives are trained and have the equipment needed to test babies for jaundice using transcutaneous monitors and blood testing (serum bilirubin (SBR)); others are only able to perform a transcutaneous reading, with babies who require subsequent blood testing being referred to the hospital; and some simply refer all the babies who appear jaundiced to a hospital to be tested there. More focused enquiry is needed to understand the reasons for these differences and the effects that they have on patient experience and health outcomes, particularly for women from lower socio-economic groups, where travel may be challenging, and for babies from non-white backgrounds, where visual inspection for jaundice is known to be less accurate [19].…”

Demystifying non-invasive approaches for screening jaundice in low resource settings: a review

“…Consequently, the clinical assessment based on Kramer's method should not be recommended for neonatal jaundice screening in this population. Further investigations are warranted to explore the efficacy of alternative non-invasive techniques in the detection of neonatal jaundice among this population ( 67 ). Limited Sensitivity: The rule's reliance on visual assessment alone to determine the cephalocaudal progression of jaundice may lack the sensitivity required to identify subtle or early signs of hyperbilirubinemia.…”

“…Consequently, the clinical assessment based on Kramer's method should not be recommended for neonatal jaundice screening in this population. Further investigations are warranted to explore the efficacy of alternative non-invasive techniques in the detection of neonatal jaundice among this population ( 67 ).…”

“…Additionally, the method's accuracy diminishes notably when applied to individuals with dark skin, owing to the inherent challenge of discerning skin yellowing ( 9 , 67 ). Consequently, this limitation may result in an underestimation of jaundice severity.…”