Investigating Prolonged Neonatal Jaundice: A Staged Approach is Superior and Conducive to Breastfeeding

Dear Editor,

In 2010, the National Institute for Health and Care Excellence (NICE) published guidance (CG98) for managing jaundice in neonates aged ≤ 28-days [1]. It recommended an extensive set of investigations for prolonged jaundice (PJ): conjugated bilirubin, full blood count, blood group determination and Coombs’ test, urine culture and verification of newborn metabolic screening (e.g. congenital hypothyroidism) [1].

A study from Glasgow, UK where 1.5% of 12,986 live births (n = 197) were referred for PJ assessment found no significant pathology [2]. Following the introduction of a rationalised investigation algorithm (split bilirubin and glucose-6-phosphate dehydrogenase [G6PD] where ethnically appropriate), the number of repeat investigations and return appointments significantly decreased [2].

In our secondary care centre with an average birth rate of 2300/year, PJ was investigated in all neonates who met the NICE CG98 [1] criteria in a dedicated clinic. Following a formal complaint about the impact of excessive investigations for PJ in a well neonate on breastfeeding, an audit to review our clinical practice was performed in 2018. The preceding 6-months period was audited, 93 neonates were assessed for PJ. Forty-two neonates required repeat blood tests due to borderline abnormalities that spontaneously resolved, and 41 had repeat urine cultures which were reported to have no growth. Only one case of Epstein-Barr virus related hepatitis was identified due to additional investigations for conjugated hyperbilirubinemia and required no treatment.

Since October’2018, we trialled a revised PJ assessment algorithm including clinical assessment, stool colour chart and conjugated bilirubin determination only. Following its introduction, we audited 3-months of sequential attendances. No infant discharged from the clinic re-presented in the next 6 months. Only 4/53 infants were recalled for repeat/additional tests as compared to 42/93 prior to change of practice (p-value 0.000003) leading to a significant reduction in over-medicalisation and parental inconvenience. An additional benefit is that average laboratory and clinic cost savings are estimated at £70 per child assessed using this approach.

An English survey showed that 63.6% of units (44/166 responses available) fully adhere to the NICE recommendations for blood tests; 20/44 include urine culture in their first-line investigations [3]. Some units include specialist liver investigations (G6PD, LFT, blood film, GAL1PUT, α − 1 antitrypsin) as their first-line [3].

Utility of urine culture [4], significance of borderline high thyroid stimulating hormone [5] and other blood abnormalities [6] for well babies with PJ have been questioned previously in the literature. In our and other cohort [2] these tests did not contribute to the detection of significant pathology.

Four previous studies from the UK involving 446 neonates who were being investigated for PJ have reported that majority of these neonates were either breast fed (70–80%) or received some additional supplementation with formula milk (7–18%) with no significant pathology identified and most cases were concluded to have breastmilk related physiological PJ [7–10]. This highlights the potential deleterious impact that excessive and often unnecessary investigations for physiological PJ in neonates may have on breastfeeding and the inappropriate message that it may impart to parents leading to discontinuation of breastfeeding.

A recent editorial published in the Archives of Disease in Childhood while discussing the issues of over investigations/diagnosis in child health, touched upon the validation of NICE jaundice guidelines (CG98) following which, results in babies with normal physiological jaundice ending up being labeled as having ‘pathology’ for which they must be ‘treated’ [11].

We conclude that investigating PJ in otherwise well babies results in significant cost and work force implications to the NHS with minimal yield. It causes heightened parental anxiety when babies undergo extensive/repeat investigations and may impact negatively on breast feeding. We would encourage other paediatric units in the UK and elsewhere to attempt similar service improvisation, much necessary especially in the context of developing countries.

Author Contribution

All the authors have contributed equally to the manuscript.

Funding

None.