Accuracy of clinical judgment in neonatal jaundice

Concert: Recommendations for management of jaundice in newborns presume tha t jaundice is a reliable clinical finding and that the pattern and intensit y of jaundice reflects the degree of elevation of the serum bilirubin level . Objectives: To determine whether experienced observers agree in describing the extent of jaundice and to evaluate the reliability of visual assessment as an indication for the measurement of serum bilirubin levels. Design: Comparison of independent judgments of the extent of jaundice betwe en examiners and with actual serum bilirubin measurements. Setting: Well-newborn nursery in an urban public hospital. Participants: A convenience sample of 122 healthy term newborns whose bilir ubin concentration was measured in the course of standard newborn care. Obs ervers were experienced pediatric nurse practitioners, pediatric house staf f, and pediatric attending physicians. Results: Agreement was moderately good for whether an infant's skin was dar kly pigmented (kappa = 0.56). However, agreement between observers regardin g the presence of jaundice at each specific body site was poor (0%-23% agre ement beyond chance); correlation between estimated bilirubin concentration s was similarly poor (Pearson correlation coefficient, 0.37). Correlation b etween estimated and actual bilirubin values was slightly better (Pearson c orrelation coefficient, 0.43-0.54). Conclusions: Clinical examination with visual assessment for jaundice in ne wborns is neither reliable nor accurate. The decision to perform serum bili rubin testing should be based on additional factors.