The specific objectives were 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 serum bilirubin values. The purpose of this study was to reevaluate the importance of clinical observation in the management of neonatal icterus. No study that we found examined interobserver variability in the visual assessment of the extent of jaundice in newborns. She found a simple κ value of about 0.48 for this unitary judgment the adjusted correlation coefficient for the physician estimates of the bilirubin value was 0.55. Madlon-Kay 5 evaluated the accuracy and agreement of physicians, nurses, and parents in detecting jaundice in newborns by asking each observer to make a single subjective judgment of whether an infant was or was not jaundiced. He found that no infant whose jaundice did not progress below the knees (his region 3) had a bilirubin concentration greater than 188 µmol/L (>11 mg/dL). Ebbesen, 4 examining infants in daylight rather than in fluorescent light, found a similar correlation between the extent of dermal icterus and the serum bilirubin value but again noted a wide range of bilirubin values for each dermal zone. In that study, a single observer noted the presence or absence of jaundice in each of 5 "dermal zones" (progressing cephalocaudally) and found a correlation between the two, but with a wide range of bilirubin concentrations for jaundice in each of the dermal zones. The cephalocaudal progression of dermal icterus has long been noted, 2 but it was not until 1969 that Kramer 3 examined the correlation of clinical jaundice with serum bilirubin measurement. Davidson et al, 1 in 1941, noted wide variability among infants in the correlation between visible jaundice and serum bilirubin level. Decisions regarding the need for bilirubin testing in newborns are generally based on these assumptions, but confirmatory data are limited. The decision to perform serum bilirubin testing should be based on additional factors.ĬLINICIANS ASSUME that jaundice is a reliable clinical finding among examiners and that its pattern and intensity in newborns reflect the degree of elevation of the serum bilirubin concentration. Correlation between estimated and actual bilirubin values was slightly better (Pearson correlation coefficient, 0.43-0.54).Ĭonclusions Clinical examination with visual assessment for jaundice in newborns is neither reliable nor accurate. However, agreement between observers regarding the presence of jaundice at each specific body site was poor (0%-23% agreement beyond chance) correlation between estimated bilirubin concentrations was similarly poor (Pearson correlation coefficient, 0.37). Results Agreement was moderately good for whether an infant's skin was darkly pigmented (κ=0.56). Observers were experienced pediatric nurse practitioners, pediatric house staff, and pediatric attending physicians. Participants A convenience sample of 122 healthy term newborns whose bilirubin concentration was measured in the course of standard newborn care. Setting Well-newborn nursery in an urban public hospital. 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.ĭesign Comparison of independent judgments of the extent of jaundice between examiners and with actual serum bilirubin measurements. Shared Decision Making and CommunicationĬontext Recommendations for management of jaundice in newborns presume that jaundice is a reliable clinical finding and that the pattern and intensity of jaundice reflects the degree of elevation of the serum bilirubin level.Scientific Discovery and the Future of Medicine.Health Care Economics, Insurance, Payment.Clinical Implications of Basic Neuroscience.Challenges in Clinical Electrocardiography.
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