Skip to main content

Advertisement

SpringerLink
Log in

Clinical practices among healthcare professionals concerning neonatal jaundice and pale stools

  • Original Article
  • Published:
European Journal of Pediatrics Aims and scope Submit manuscript

Abstract

Jaundice and pale stools are major indicators of neonatal liver disease. Prognosis depends on timely diagnosis and management. We evaluated the clinical practices among healthcare professionals concerning jaundiced newborns and their ability to recognize pale stools. We supplied a questionnaire and a panel with eight photographs of stools, both locally validated, to physicians and nurses of the National Healthcare Service. Analysis was conducted according to professional status, specialization and years of experience of professionals and level of healthcare. Questionnaires were administered to 266 participants (100 physicians, 166 nurses). The decision to send patients to medical observation depended on the intensity of jaundice for a significant percentage of nurses. Concerning jaundiced newborns breastfed and otherwise healthy, 28.9% of physicians would never request a conjugated bilirubin assay, and only 43.3% would request it after 14 days old; for those with other signs/symptoms of disease, only 69.1% of physicians would request it immediately. Multiple linear regression analysis identified specialization as an independent variable significantly associated with the ability to recognize pale stools.

Conclusion: A significant percentage of healthcare professionals assumed clinical practices that preclude the timely recognition of cholestasis/pale stools, reinforcing the idea of educational needs. Specialization, rather than years of experience of professionals, was associated with better skills and practices.

What is Known:

• Neonatal cholestasis is a condition with some rare underlying entities having high mortality and morbidity. Early diagnosis is crucial to improve prognosis. Yet, many cases remain late recognized and referred.

• Studies evaluating the ability of healthcare professionals to recognize neonatal cholestasis are scarce.

What is New:

• In this study, a significant percentage of professionals assumed clinical practices that preclude timely recognition of neonatal cholestasis and pale stools, reinforcing the idea of educational needs.

• Specialization of professionals was associated with better skills and practices.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2

Similar content being viewed by others

Abbreviations

BA:

Biliary atresia

cBt:

Conjugated bilirubin

GP:

General practice

IQ:

Interquartile

NHS:

National Health Service

PHCUs:

Primary Health Care Units

UK:

United Kingdom

USA:

United States of America

References

  1. American Academy of Pediatrics Subcommittee on Hyperbilirubinemia (2004) Clinical practice guideline: management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Paediatrics 114:297–316

    Article  Google Scholar 

  2. Bakshi B, Sutcliffe A, Akindolie M, Vadamalayan B, John S, Arkley C, Griffin LD, Baker A (2012) How reliably can paediatric professionals identify pale stool from cholestatic newborns? Arch Dis Child Faetal Neonatal 97:385–387

    Article  Google Scholar 

  3. Benchimol EI, Walsh C, Ling S (2009) Early diagnosis of neonatal cholestatic jaundice: test at 2 weeks. Can Fam Physician 55(12):1184–1192

    PubMed  PubMed Central  Google Scholar 

  4. Chardot C (2006) Biliary atresia. Orphanet J Rare Dis 1(1):28

    Article  PubMed  PubMed Central  Google Scholar 

  5. Chen SM, Chang MH, Du JC, Lin CC, Chen AC, Lee HC, Lau BH, Yang YY, Wu TC, Chu CH et al (2006) Screening for biliary atresia by infant stool colour card in Taiwan. Paediatrics 117(4):1147–1154

    Article  Google Scholar 

  6. Dani C, Pratesi S, Raimondi F, Romagnoli C, and on behalf of the Task Force for Hyperbilirubinemia of the Italian Society of Neonatology (2015) Italian guidelines for the management and treatment of neonatal cholestasis. Ital J Pediatr 41:69. doi:10.1186/s13052-015-0178-7

    Article  PubMed  PubMed Central  Google Scholar 

  7. Davenport M, Puricelli V, Farrant P, Hadzic N, Mieli-Vergani G, Portmann B, Howard ER (2004) The outcome of the older (≥100 days) infant with biliary atresia. J Pediatr Surg 39(4):575–581

    Article  CAS  PubMed  Google Scholar 

  8. Davenport M, Ong E, Sharif K, Alizai N, McClean P, Hadzic N, Kelly DA (2011) Biliary atresia in England and Wales: results of centralization and new benchmark. J Pediatr Surg 46:1689–1694

    Article  PubMed  Google Scholar 

  9. De Bruyne R, Van Biervliet S, Vande Velde S, Van Winckel M (2011) Clinical practice: neonatal cholestasis. Eur J Pediatr 170:279–284

    Article  PubMed  Google Scholar 

  10. Feldman AG, Sokol RJ (2013) Neonatal cholestasis. NeoReviews 14(2). doi:10.1542/neo.14-2-e63

  11. Feldman A, Suchy FJ (2014) Approach to the infant with cholestasis. In: Suchy FJ, Sokol RJ, Balistreri WF (eds) Liver disease in children, 4rd edn. Cambridge University Press, Cambridge, pp 101–110

    Chapter  Google Scholar 

  12. Gilmour SM (2004) Prolonged neonatal jaundice: when to worry and what to do. Paediatric Child Health 9(10):700–704

    Google Scholar 

  13. Hagan JF, Shaw JS, Duncan PM (2008) Bright futures: guidelines for health supervision of infants, children, and adolescents, Third edn. American Academy of Paediatrics, Elk Grove Village, IL https://brightfutures.aap.org/Bright%20Futures%20Documents/1-BF-Introduction.pdf

    Google Scholar 

  14. Hoerning A, Raub S, Dechêne A, Brosch MN, Kathemann S, Hoyer PF, Gerner P (2014) Diversity of disorders causing neonatal cholestasis—the experience of a tertiary pediatric center in Germany. Front Pediatr 2:65. doi:10.3389/fped.2014.00065

    Article  PubMed  PubMed Central  Google Scholar 

  15. Hsiao CH, Chang MH, Chen HL, Lee HC, Wu TC, Lin CC, Yang YY, Chen AC, Tiao MM, Lau BH et al (2008) Universal screening for biliary atresia using an infant stool colour card in Taiwan. Hepatology 47(4):1233–1240

    Article  PubMed  Google Scholar 

  16. Jacquemin E (2007) Screening for biliary atresia and stool colour: method of colorimetric scale. Arch Pediatr 14:303–305

    Article  CAS  PubMed  Google Scholar 

  17. Kasai M, Kimura S, Asakura Y, Suzuki Y, Taira Y, Obashi E (1968) Surgical treatment of biliary atresia. J Pediatr Surg 3:665–675

    Article  Google Scholar 

  18. Lee WS (2008) Pre-admission consultation and late referral in infants with neonatal cholestasis. J Paediatr Child Health 44:57–61

    PubMed  Google Scholar 

  19. Maisels MJ, Bhutani VK, Bogen D, Newman TB, Stark AR, Watchko JF (2009) Hyperbilirubinemia in the newborn infant ≥35 weeks’ gestation: an update with clarifications. Paediatrics 124(4):1193–1198. doi:10.1542/peds.2009-0329 Epub 2009 Sep 28

    Article  Google Scholar 

  20. McKiernan PJ, Baker AJ, Kelly DA (2000) The frequency and outcome of biliary atresia in the UK and Ireland. Lancet 355:25–29

    Article  CAS  PubMed  Google Scholar 

  21. McKiernan PJ, Baker AJ, Lloyd C, Mieli-Vergani G, Kelly AD (2009) British paediatric surveillance unit study of biliary atresia: outcome at 13 years. Journal of Paediatric Gastroenterology and Nutrition 48(1):78–82

    Article  CAS  Google Scholar 

  22. Menezes B, Oliveira D, Sasseti L, Prazeres V (2013) Programa nacional de saúde infantil e juvenil. Norma da Direção Geral de Saúde n° 010/2013 de 31/05/2013. https://www.dgs.pt/directrizes-da-dgs/normas-e-circulares-normativas/norma-n-0102013-de-31052013.aspx

  23. Miethke AG, Balistreri WF (2008) Approach to neonatal cholestasis. In: Kleinman RE, Goulet OJ, Mieli-Vergani G et al (eds) Walker’s paediatric gastrointestinal disease: physiology, diagnosis, management, 5th edn. BC Decker Inc, Hamilton, pp 789–801

    Google Scholar 

  24. Morinville V, Ahmed N, Ibberson C, Kovacs L, Kaczorowski J, Bryan S, Collet JP, Schreiber R (2016) Home-based screening for biliary atresia using infant stool colour cards in Canada: Quebec feasibility study. J Pediatr Gastroenterol Nutr 62(4):536–541

    Article  PubMed  Google Scholar 

  25. Moyer V, Freese DK, Whitington PF, Olson AD, Brewer F, Colleti RB, Heyman MB (2004) Guideline for the evaluation of cholestatic jaundice in infants: recommendations of the north American Society for Paediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr 39:115–128

    Article  PubMed  Google Scholar 

  26. Nio M, Ohi R, Miyano T, Saeki M, Shiraki K, Tanaka K (2003) Five and 10-year survival rates after surgery for biliary atresia: a report from the Japanese biliary atresia registry. J Pediatr Surg 37(7):997–1001

    Article  Google Scholar 

  27. Palermo JJ, Joerger S, Tuemelle Y, Putman P, Garbutt J (2012) Neonatal cholestasis: opportunities to increase early detection. Acad Pediatr 12(4):283–288

    Article  PubMed  PubMed Central  Google Scholar 

  28. Porter ML, Dennis BL (2002) Hyperbilirubinemia in the term newborn. Am Fam Physician 65(4):599–607

    PubMed  Google Scholar 

  29. Santos Silva E, Pó I, Gonçalves I, and on behalf of the Portuguese Pediatric Gastroenterology Society (2010) Colestase neonatal—Protocolo de abordagem diagnóstica. Acta Pediátrica Portuguesa 41(3):141–143

    Google Scholar 

  30. Serinet MO, Broué P, Jacquemin E, Lachaux A, Gottrand F, Gauthierb F, Chardot C (2006) Management of patients with biliary atresia in France: results of a decentralized policy 1986–2002. Hepatology 44:75–84

    Article  PubMed  Google Scholar 

  31. Serinet MO, Wildhaber A, Broué P, Lachaux A, Sarles J, Jacquemin E, Gauthier F, Chardot C (2009) Impact of age at Kasai operation on its results in late childhood and adolescence: a rational basis for biliary atresia screening. Paediatrics 123(5):1280–1286

    Article  Google Scholar 

  32. Tseng JJ, Lai MS, Lin MC, Fu YC (2011) Stool colour card screening for biliary atresia. Paediatrics 128(5):1209–1215

    Article  Google Scholar 

  33. Wildhaber B (2011) Screening for biliary atresia: Swiss stool colour card. Hepatology 54(1):367

    Article  PubMed  Google Scholar 

  34. Wildhaber B, Majno P, Mayr J, Zachariou Z, Hohlfeld J, Schowoebel M et al (2008) Biliary atresia: Swiss National Study, 1994–2004. J Pediatrics Gastroenterol Nutr 46(3):299–307

    Article  Google Scholar 

  35. Winfield CR, MacFaul R (1978) Clinical study of prolonged jaundice in breast and bottle fed babies. Arch Dis Child 53:506–507

    Article  CAS  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgements

Many thanks are given to the healthcare institutions and their professionals who participated in this study (PHCUs of Póvoa de Varzim/Vila do Conde, PHCUs of Porto Oriental, Centro Hospitalar da Póvoa de Varzim/Vila do Conde and Centro Hospitalar do Porto). Also, the authors give many thanks to Professor Denise Mendonça for her contribution with suggestions and criticisms related to this work.

The master’s thesis in medicine (University of Porto) of the co-author Lia Azevedo Lijnzaat was based on this study.

Authors’ contributions

Ermelinda Santos Silva: Dr. Santos Silva conceptualized and designed the study, coordinated and supervised data collection, analysed and interpreted data, drafted the initial manuscript and approved the final manuscript as submitted.

Helena Moreira Silva: Dr. Moreira Silva carried out acquisition, analysis and interpretation of data; critically reviewed the manuscript and approved the final manuscript as submitted.

Lia Azevedo Lijnzaat: Dr. Lijnzaat carried out acquisition, analysis and interpretation of data; critically reviewed the manuscript and approved the final manuscript as submitted.

Cláudia Melo: Dr. Melo carried out analysis and interpretation of data, critically reviewed the manuscript and approved the final manuscript as submitted.

Elísio Costa: Prof. Costa carried out analysis and interpretation of data, critically reviewed the manuscript and approved the final manuscript as submitted.

Esmeralda Martins: Prof. Martins carried out analysis and interpretation of data, critically reviewed the manuscript and approved the final manuscript as submitted.

Ana Isabel Lopes: Prof. Lopes critically carried out analysis and interpretation of data, reviewed the manuscript and approved the final manuscript as submitted.

All the authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Author information

Authors and Affiliations

  1. Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Rua Jorge Viterbo Ferreira, nº 228, 4050-313, Porto, Portugal

    Ermelinda Santos Silva, Lia Azevedo Lijnzaat & Esmeralda Martins

  2. Gastroenterology Unit, Paediatrics Division, Departmento da Criança e do Adolescente, Centro Materno-Infantil do Norte, Centro Hospitalar do Porto, Largo da Maternidade Júlio Dinis, 4050-651, Porto, Portugal

    Ermelinda Santos Silva

  3. Paediatrics Division, Departamento da Criança e do Adolescente, Centro Materno-Infantil do Norte, Centro Hospitalar do Porto, Largo da Maternidade Júlio Dinis, 4050-651, Porto, Portugal

    Helena Moreira Silva

  4. Paediatrics Division, Unidade Hospitalar de Famalicão, Centro Hospitalar do Médio Ave, Rua de Cupertino de Miranda, 4764-958, Vila Nova de Famalicão, Portugal

    Cláudia Melo

  5. UCIBIO, Department of Biological Sciences, Faculdade de Farmácia, Universidade do Porto, Rua Jorge Viterbo Ferreira, nº 228, 4050-313, Porto, Portugal

    Elísio Costa

  6. Metabolic Diseases Unit, Paediatrics Division, Departmento da Criança e do Adolescente, Centro Materno-Infantil do Norte, Centro Hospitalar do Porto, Largo da Maternidade Júlio Dinis, 4050-651, Porto, Portugal

    Esmeralda Martins

  7. Gastroenterology Unit, Paediatrics Department, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Av. Prof. Egas Moniz, 1600-190, Lisboa, Portugal

    Ana Isabel Lopes

  8. Faculdade de Medicina, Universidade de Lisboa, Av. Prof. Egas Moniz, 1649-028, Lisboa, Portugal

    Ana Isabel Lopes

Authors
  1. Ermelinda Santos Silva
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Helena Moreira Silva
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Lia Azevedo Lijnzaat
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Cláudia Melo
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Elísio Costa
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Esmeralda Martins
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Ana Isabel Lopes
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Ermelinda Santos Silva.

Ethics declarations

Funding source

None.

Financial disclosure

None.

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This study involved human participants and all procedures performed were in accordance with the ethical standards of the participating healthcare institutions committees and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Clinical trial registration

Not applicable.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Additional information

Communicated by Peter de Winter

Electronic supplementary material

Below is the link to the electronic supplementary material.

ESM 1

(DOC 758 kb)

ESM 2

(DOC 752 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Santos Silva, E., Moreira Silva, H., Azevedo Lijnzaat, L. et al. Clinical practices among healthcare professionals concerning neonatal jaundice and pale stools. Eur J Pediatr 176, 361–369 (2017). https://doi.org/10.1007/s00431-016-2847-y

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00431-016-2847-y

Keywords

Search

Navigation