Assessment, management, and incidence of neonatal jaundice in healthy neonates cared for in primary care: a prospective cohort study

Abstract

Jaundice caused by hyperbilirubinaemia is a common phenomenon during the neonatal period. Population-based studies evaluating assessment, management, and incidence of jaundice and need for phototherapy among otherwise healthy neonates are scarce. We prospectively explored these aspects in a primary care setting via assessing care as usual during the control phase of a stepped wedge cluster randomised controlled trial.We conducted a prospective cohort study embedded in the Screening and TreAtment to Reduce Severe Hyperbilirubinaemia in Infants in Primary care (STARSHIP) Trial. Healthy neonates were included in seven primary care birth centres (PCBCs) in the Netherlands between July 2018 and March 2020. Neonates were eligible for inclusion if their gestational age was ≥ 35 weeks, they were admitted in a PCBC for at least 2 days during the first week of life, and if they did not previously receive phototherapy. Outcomes were the findings of visual assessment to detect jaundice, jaundice incidence and management, and the need for phototherapy treatment in the primary care setting.860 neonates were included of whom 608 (71.9%) were visibly jaundiced at some point during admission in the PCBC, with 20 being 'very yellow'. Of the latter, four (20%) did not receive total serum bilirubin (TSB) quantification. TSB levels were not associated with the degree of visible jaundice (p = 0.416). Thirty-one neonates (3.6%) received phototherapy and none received an exchange transfusion. Five neonates did not receive phototherapy despite having a TSB level above phototherapy threshold.Jaundice is common in otherwise healthy neonates cared for in primary care. TSB quantification was not always performed in very jaundiced neonates, and not all neonates received phototherapy when indicated. Quality improvement initiatives are required, including alternative approaches to identifying potentially severe hyperbilirubinaemia.Trial registration: NL6997 (Dutch Trial Register; Old NTR ID 7187), registered 3 May 2018.

Figure 1

Phototherapy and exchange transfusion thresholds for neonates born after more than 35 weeks of gestation. TSB total serum bilirubin, PT phototherapy, ET exchange transfusion, AS Apgar score. Translated from Dutch. The Dutch nomogram is available at: http://babyzietgeel.nl/kinderarts/hulpmiddelen/diagnostiek/bilicurve35wkn.php.

Figure 2

Proportion of assessment resulting in TcB or TSB being quantified according to degree of visible jaundice. TcB transcutaneous bilirubin, TSB total serum bilirubin.

Figure 3

Difference between individual phototherapy treatment threshold and total serum bilirubin level according to degree of jaundice as visually assessed. The area above the red bar indicates a total serum bilirubin level above phototherapy treatment threshold.