2023 exceptional surveillance of Jaundice in newborns under 28 days (NICE guideline CG98)

HSIB report

The HSIB report details a baby who was initially assessed as a clinically stable premature baby. Subsequently, a routine blood sample taken 2 hours after birth indicated that bilirubin was present and the level was recorded. The clinical report was seen by one of the staff members, who observed the high level of bilirubin and possible need for treatment. This member of staff was then called to attend an emergency and no action was taken.

The baby was subsequently examined by the clinical team and was not noted to be jaundiced. Routine observations such as temperature, heart rate and skin colour were documented at approximately 2-hourly intervals. No visual signs of jaundice were documented.

Another blood sample was taken when the baby was 2 days old, again showing a high level of bilirubin, but the result was not acted upon. In the next 2 days, no visual signs of jaundice were documented.

At 5 days of age, a change in skin colour and visual signs of jaundice were documented. Bilirubin levels were checked and found to be high. Phototherapy was commenced. Over the next 3 days, bilirubin levels returned to acceptable levels and the baby was discharged home.

The HSIB report highlighted the issue of delay in the diagnosis of jaundice in newborns with black or brown skin-colour, in whom visual signs were not noted. This was attributed to the darker skin tone of the infant. The HSIB report also highlighted there is a need to explore other risk factors of jaundice including prematurity, to enable early identification.

As babies with darker skin tones were a significant subgroup in the 2016 update, this exceptional surveillance review also investigates whether there is new evidence on the accuracy of various tests (clinical history and examination, urine/stool examination, icterometer and transcutaneous bilirubin levels) in recognising neonatal jaundice or hyperbilirubinaemia in the subgroup of babies with darker skin tones (review question 3), in whom initial visual inspection could be difficult or unreliable.

NHS Race Health observatory report

In July 2023 the NHS Race Health observatory published a report into findings from a formal review of neonatal assessments and the potential for disadvantaging darker skin tones due to practice based on White European babies.

The report recommends that guidelines are reviewed with respect to neonatal assessment by skin colour specifically for jaundice to draw attention to differences in assessment techniques for Black, Asian and ethnic minority neonates.

Royal College of Paediatrics and Child Health (RCPCH) concerns

The Royal College of Paediatrics and Child Health contacted NICE about challenges in the screening and assessment of conjugated jaundice and the impact of the NICE guideline recommendations on practice. The British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) carried out a clinical audit involving 14 NHS trusts exploring the screening pathway for prolonged jaundice and concluded that the NICE guidelines do not sufficiently distinguish between early and prolonged jaundice which may inadvertently be leading to variable practices in the diagnostic work up of babies over 14 days of age with jaundice symptoms.