A “jaundiced” eye toward clinical assessments of bilirubin

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Elevated bilirubin levels are normal in term newborn infants. The risk of very high bilirubin levels can be predicted by clinical factors such as gestational age, growth, and feeding practices. Recently, nomograms were developed for screening infants prior to discharge to identify the infants at risk and to arrange for closer follow-up. These assessments require bilirubin measurements on blood, which are time-consuming and expensive. In this issue of The Journal, Riskin et al evaluated the ability of physicians and nurses to visually assess bilirubin levels. Although the overall correlations between the clinical estimates and laboratory assessments were quite good, 62% of infants in a high-risk zone were misclassified as lower risk. The problem was most evident for infants scheduled for early discharge or for near-term infants. The clinical assessments of bilirubin were made under optimal conditions with consistent lighting. Therefore, in practice, clinical estimates of bilirubin levels are likely to be more problematic. Surprisingly, in 2008, the management of bilirubin in newborn infants remains an area of active research.