Neonatal jaundice

Introduction

This is an illustrative case story based on clinical negligence cases involving neonatal jaundice. The aim is to share the learning from these claims and highlight national guidance. NHS Resolution is sharing this insight to help prevent similar occurrences from happening to babies, their parents and families, and staff.

As you read through this illustrative case story, please ask yourself:

• Could or does this happen in my organisation?
• Who could I share this with?
• What can we learn from this?

What is neonatal jaundice?

Neonatal jaundice is a common condition in newborn babies which is usually harmless and is resolved within 10-14 days after birth. Some of the symptoms include yellowing of the skin and the whites of the eyes; this is caused by accumulation of the pigment bilirubin in the skin and mucous membranes. Some babies with jaundice develop high levels of bilirubin and if not treated it is harmful, as it may cause a type of brain damage known as Kernicterus.

For more information on neonatal jaundice please refer to the NICE guidance¹.

Case Story: Pauline

Antenatal

Pauline is in her third pregnancy; she is a Black British mother and had two previous spontaneous vaginal deliveries (SVD) with no complications and breast fed both successfully. No concerns were identified at booking.

Apart from one episode of reduced fetal movements (RFM) at 36+5 weeks her pregnancy was uneventful. Pauline called maternity triage and was advised to attend for a review. A brief assessment and CTG was commenced within 15 minutes of arrival, followed by a review by the obstetric team. Pauline was discharged home with appropriate safety netting advice to call Triage with any concerns.

Intrapartum

At 37+5 weeks gestation Pauline was admitted to hospital in the early hours of the morning with contractions. She had a SVD within two hours of arriving and no complications. A baby girl weighing 3.25kg was born with Apgar score 7 at 1 minute, 9 at 5 minutes and 9 at 10 minutes. Her baby breastfed but only for a few minutes.

Postnatal

Pauline was discharged home the same day, and at the Newborn and Infant Physical Examination (NIPE) the outcome was nothing abnormal detected (NAD). She was seen on day 2 at home by the community midwife. Pauline reported that she felt her baby had jaundice and was breast feeding less than her first two children.

The baby was seen by the community midwife, but was not undressed to complete a full physical examination. The records stated that the baby was well perfused, warm, and alert with good tone, passing urine and bowels opened and there was a plan for a review the next day. There was no detailed documented assessment for jaundice, and no breast feeding assessment despite Pauline’s concerns.

No visit occurred the next day due to staff shortages and a visit occurred on day 4. Again, Pauline stated she was concerned about jaundice and that her baby was not feeding well but now very sleepy also. The midwife advised that the baby should be taken to the hospital for a serum bilirubin (SBR) check as no transcutaneous bilirubinometer (TCB) was available.

The midwife did not state that the SBR was urgent, and Pauline waited for childcare before taking her baby to hospital some six hours later. On arrival, her baby was approximately 107 hours old, and a SBR test was performed. The result was 404mmols/litre and was plotted on the treatment graph for babies born above 38 weeks.

This incorrectly indicated that the results were below the exchange transfusion line. Had this result been plotted on the correct chart for babies of 37 weeks gestation the results would have been 34mmol/litre above the exchange transfusion level.

Double light phototherapy was commenced immediately as indicated by the 38-week treatment chart and the continuation of breastfeeding with nasogastric top-up formula feeds. The SBR level was repeated six hours later on the same 38-week treatment chart, and it had decreased but was still within the treatment zone. The baby was subsequently diagnosed with kernicterus and cerebral palsy. Cerebral palsy is caused by ‘an acquired pathology within the developing brain’ that affects movement and posture⁵.

Points for improvement outlined within the claim identified that the care provided:

1. Did not respond appropriately to parental concerns.
2. Did not provide an adequate neonatal examination in community.
3. No record of a breastfeeding assessment⁶.
4. Did not measure bilirubin levels when jaundice was first noted.
5. Did not convey the urgency of the need for a SBR test.
6. Did not plot the SBR level on the correct chart for the baby’s gestational age.

Advice and resources

What could you do?

• Have you had an event or claim in your service related to neonatal jaundice/kernicterus? Find out and discuss with colleagues what learning was identified to prevent future similar events from reoccurring.
• Familiarise yourself with NICE guidance CG98, Jaundice in newborn babies under 28 days
  (updated Oct 2023).
• Familiarise yourself with local policies for the management of jaundice and neonatal re-admissions.

Related guidance and information

References

_¹ NICE (2023) CG98 Jaundice in newborn babies under 28 days

² WHO (2022) Meeting report of the technical consultation to review the classification of glucose-6-phosphate dehydrogenase (G6PD)

³ RCOG (2023) Maternity Triage (Good Practice Paper No. 17)

⁴ NHS Race & Health Observatory (2023) Review of neonatal assessment and practice in Black, Asian and minority ethnic newborns: Exploring the Apgar score, the detection of cyanosis, and jaundice.

⁵ NICE (2019) What is Cerebral Palsy?

⁶ UNICEF Breastfeeding Assessment Tool (maternity) – How you and your midwife can recognise that your baby is feeding well

⁷ NHSE (2022) SEIPS quick reference guide and work system explorer