Diagnostic Accuracy of WHO IMCI Visual Inspection for Neonatal Jaundice: A Prospective Multi-Country Cohort
Year: 2026
Type: preprint
Study design: Observational Study
Abstract: BACKGROUND Adverse consequences of neonatal hyperbilirubinemia disproportionately affect babies in low- and middle-income countries. Laboratory measurement of total serum bilirubin is limited in low-resource settings, necessitating simpler alternatives. Our study aimed to evaluate the diagnostic accuracy of visual inspection of jaundice via the World Health Organization Integrated Management of Childhood Illnesses algorithm compared to transcutaneous bilirubinometry for the identification of hyperbilirubinemia in community settings. METHODS Hyperbilirubinemia was assessed by visual inspection for jaundice and transcutaneous bilirubinometry at 0-72 hours, 3-5 days, and 5-14 days postnatal in the PRISMA prospective cohort study in six sites in Asia and Africa. We assessed sensitivity, specificity, and positive and negative percent agreement. RESULTS We analyzed data from 14,331 infants, including 1,852 preterm infants. 15% had hyperbilirubinemia, as defined by transcutaneous bilirubin values and the NICE nomograms, at 3-5 days postnatal. Visual inspection had a sensitivity of 16%, specificity of 96%, positive percent agreement of 56%, and negative percent agreement of 86% at 3-5 days postnatal age, pooled across all sites and gestational ages, versus transcutaneous bilirubin defined by NICE nomograms. CONCLUSION The poor sensitivity of visual inspection underscores an urgent need for accurate, affordable screening tools to improve screening for hyperbilirubinemia. Impact Statement: We found poor sensitivity of visual inspection, identifying fewer than one in five neonatal jaundice cases, suggesting much worse diagnostic accuracy in this community-based context across five low- and middle-income countries (LMICs) as compared to the previous studies conducted in health facilities. Among preterm infants, sensitivity was modestly higher than in term infants but remained clinically inadequate, reinforcing that visual inspection alone is insufficient for this high-risk group. Despite standardized training and biannual refresher sessions, our study suggests that training for health care workers alone is unlikely to make visual inspection a reliable case-detection tool. Our findings suggest that the WHO should re-evaluate the IMCI recommendations to include tools with higher diagnostic accuracy to identify neonatal jaundice. Community-level jaundice screening should move beyond visual inspection alone towards validated, low-cost, objective tools; icterometers and smartphone apps with high diagnostic accuracy are promising alternatives.
Source: medRxiv
Authors: Amna Khan, Alyssa Shapiro, Nida Salman Yazdani, Sebin George Abrahim, Victor Akelo, Kwaku Poku Asante, Florence Aweyo, Anne George Cherian, Munita Jat, Fyezah Jehan, Indhumathi K, Kevin Kasadhe, Margaret P. Kasaro, Anne CC Lee, Azqa Mazhar, Sarmila Mazumder, Christopher N. Mores, Wilbroad Mutale, Humphrey Mwape, Sam Newton, Muhammad Imran Nisar, Linda Ogala, Nancy Ogola, Neeraj Sharma, M. Bridget Spelke, Jasmine Sugirtha, Yipeng Wei, Wen-Chien Yang, Zahra Hoodbhoy, Qing Pan, Emily R. Smith
Field: Medicine
Domain: Health Sciences
Open Access status: green
Awards: Collaborative Research and Innovation Organisation - To understand burden of adverse maternal and infant outcomes in LMIC settings., Aga Khan University - To understand burden of adverse maternal and infant outcomes in LMIC settings., University of North Carolina at Chapel Hill - to build a translational, data-generating and effectiveness-testing research platform focused on antenatal and postnatal care in the UNC-UNZA site ..., The Centre for Health Research and Development, Society for Applied Studies - To understand burden of adverse maternal and infant outcomes in Low- and Middle-Income Countries settings, Christian Medical College Vellore - to support pregnancy/postpartum surveillance infrastructure and data management/analysis at the CMC Vellore site., Liverpool School of Tropical Medicine - To understand burden of adverse maternal and infant outcomes in LMIC settings., Kintampo Health Research Centre - To understand burden of adverse maternal and infant outcomes in LMIC settings., The George Washington University - to support quality and rigor of ARC PRiSMA protocol implementation and data analysis through centralized processes and cross-site capacity building, The George Washington University - To support efficient and rigorous laboratory sample collection and analysis across the Preferred Reporting Items for Systematic Reviews and Meta-An...
OpenAlex ID: W7214047002
Cites:
Cited by:
Related to: