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  • Question on Consultation

    1. Do you agree with the proposed addition in recommendation 1.2.5 ‘jaundice may be difficult to detect visually in neonates with darker skin tones’?
    Do you agree or disagree (yes/no) and provide a rationale if you disagree.
  • Question on Consultation

    1. Do you agree with the proposal to make recommendation 1.7.1 more flexible around urine culture?
    Do you agree or disagree (yes/no) and provide a rationale if you disagree.
  • Question on Consultation

    1. Have you come across any evidence that could potentially indicate differential diagnostic accuracies of bilirubin measurement in neonates of varying skin tones and that has been missed in the surveillance review?
    Please could you provide a link/reference with your comments.
  • Question on Consultation

    1. Are you aware of any evidence on the diagnostic value of urine culture in the management of prolonged jaundice?
    If so please provide details.
  • Question on Consultation

    1. Do you have any comments on any additional equality issues except the concerns raised for health inequalities in surveillance review?
  • Question on Consultation

    1. Are you aware of any evidence on risk factors for neonatal jaundice that this surveillance review has missed?
    Please could you provide a link/reference with your comments .
The content on this page is not current guidance and is only for the purposes of the consultation process.

Surveillance proposal

We will amend:

  • Recommendation 1.2.5 to include text to acknowledge that jaundice may be harder to detect visually in darker skin tones.

  • Recommendation 1.7.1 to be more flexible around urine culture.

No further areas of the guideline will be updated at this time.

This surveillance proposal does not impact on the previous decision to update the guideline on total serum bilirubin (TSB) thresholds for starting phototherapy or exchange transfusion in all term babies with neonatal hyperbilirubinaemia due to variability between assays from different manufacturers please see 2023 exceptional surveillance.

Reason for the Surveillance Review

This exceptional surveillance review is triggered by an HSIB report on the detection of jaundice in newborn babies following an incident of delayed diagnosis due to visual inspection not detecting clinical jaundice in a premature newborn of black African ethnicity.

While considering the impact of the HSIB report two further triggers were identified: NHS Race and Health Observatory Review of neonatal assessment and concerns from the Royal College of Paediatrics and Child Health as to the extent to which the guideline covers conjugated Jaundice.

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.