Detection of jaundice in newborn babies

This investigation was carried out by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.

This report explored the detection and diagnosis of jaundice in newborn babies, in particular babies born prematurely (before 37 weeks of pregnancy). Specifically, it explored delayed diagnosis due to there being no obvious visual signs of jaundice apparent to clinical staff.

Jaundice is a condition caused by too much bilirubin in a person’s blood. Bilirubin is a yellow substance produced when red blood cells are broken down. If left undiagnosed and untreated, high bilirubin levels in newborn babies can lead to significant harm. Newborn babies have a higher number of red blood cells in their blood which increases their risk of jaundice. Jaundice can cause yellowing of the skin and whites of the eyes; however, sometimes the visual signs of jaundice are not obvious, particularly for premature or newborn babies with brown or black skin.

To explore this issue, the investigation used an example case, referred to as ‘the reference event’, which involved the delayed diagnosis of jaundice in Baby Elliana, a baby girl of black African ethnicity who was born prematurely.

The investigation’s findings, safety recommendations and safety observations aim to facilitate the timely diagnosis of jaundice in newborn babies. Some of the findings and conclusions may also be applicable to other conditions in newborn babies.

Baby Elliana was born at 32 weeks and 1 day via a forceps delivery (a type of assisted vaginal delivery). Because Baby Elliana was born prematurely, she was transferred to the Trust’s special care baby unit (SCBU).

Baby Elliana was assessed on admission to the SCBU by staff as a clinically stable premature baby. A routine blood sample was taken from Baby Elliana by SCBU staff at approximately 2 hours after her birth to establish a baseline. Analysis of the blood sample indicated bilirubin was present and so the level was measured. This result was uploaded onto the Trust’s computer system alongside the results of the blood tests that had been requested by the clinical team.

The bilirubin result was seen by a SCBU member of staff who recognised that the level was high, indicating the possible need for treatment. However, this member of staff was then required to attend an emergency and the bilirubin result was not acted upon.

Another blood sample was taken when Baby Elliana was 2 days of age. The result was uploaded to the Trust’s computer system. It is unclear if this bilirubin result was seen by staff; it was not documented in clinical records and was not acted upon.

Over the next 2 days Baby Elliana continued to show no visible signs of jaundice that were detected by staff and she was documented to be developing well.

When Baby Elliana was 5 days of age, a change in her skin colour was observed and visible signs of jaundice were detected. A further blood sample was taken and bilirubin levels were requested by the clinical team. As previously, this confirmed a high level of bilirubin and treatment was started accordingly. Baby Elliana’s bilirubin levels returned to within acceptable levels over the next 3 days and she was subsequently discharged home.

High bilirubin levels can cause significant harm including brain damage. It is therefore important that jaundice is diagnosed and treated in a timely way. This relies on visual signs of jaundice being present and observed by clinical staff. It is nationally acknowledged that the recognition and assessment of jaundice can be difficult, particularly in babies with black or brown skin, increasing the risk of delayed diagnosis.

HSIB contacted the hospital where the reference event took place. The Trust welcomed HSIB’s involvement and collaborated with information gathering. After initial information had been gathered and evaluated against a set of patient safety risk criteria, HSIB’s Chief Investigator authorised a national safety investigation.

• The assessment of visual signs of jaundice in newborn babies is subjective and more challenging with babies who have black or brown skin.
• Stakeholders have differing opinions about the reliability of visual signs to detect jaundice in newborn babies.
• Some neonatal units have introduced safety measures to mitigate the risk of reliance on visual signs of jaundice.
• National guidance does not recommend routinely measuring bilirubin levels in babies who are not visibly jaundiced.
• National guidance for jaundice in newborn babies maybe more applicable to term babies (those born after 37 weeks of pregnancy) than those born prematurely.
• National guidance does not contain information on how to address the challenges of detecting jaundice in newborn babies with black or brown skin.
• Some universities providing education to NHS students on the detection of jaundice are seeking to ensure that teaching aids and literature represent the diversity of the population.
• Levels of bilirubin can vary according to the gestational age of a baby (how long the baby was in the womb). Laboratory staff do not calculate the gestational age of a baby and therefore whether their bilirubin level is within the expected range.
• Laboratory practice varies in terms of whether they set specific reference ranges for bilirubin in newborn babies; whether they have a defined threshold for communicating results to neonatal units; and whether the telephone alert limit (the level of bilirubin that triggers laboratory staff to report the result to clinical staff by telephone) reflects the thresholds in national guidance.
• Neonatal staff may be unaware that laboratories analyse blood samples to see if they are icteric (indicate jaundice). These staff will not know to look for a comment about this on blood test reports.