Diagnostic Accuracy of WHO IMCI Visual Inspection for Neonatal Jaundice: A Prospective Multi-Country Cohort
- 1Department of Global Health, Milken Institute School of Public Health, George Washington University (GWU), Washington, DC, United States
Abstract
BACKGROUNDAdverse 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.
METHODSHyperbilirubinemia 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.
RESULTSWe 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.
CONCLUSIONThe poor sensitivity of visual inspection underscores an urgent need for accurate, affordable screening tools to improve screening for hyperbilirubinemia.
Impact StatementO_LIWe 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. C_LIO_LIAmong 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. C_LIO_LIDespite 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. C_LIO_LIOur findings suggest that the WHO should re-evaluate the IMCI recommendations to include tools with higher diagnostic accuracy to identify neonatal jaundice. C_LIO_LICommunity-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. C_LI
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BibTeX
@misc{khan2026diagnostic,
title = {{Diagnostic Accuracy of WHO IMCI Visual Inspection for Neonatal Jaundice: A Prospective Multi-Country Cohort}},
author = {A. Khan and A. Shapiro and N. S. Yazdani and S. G. Abraham and V. Akelo and K. P. Asante and F. Aweyo and A. G. Cherian and M. Jat and F. Jehan and I. K and K. Kasadhe and M. Kasaro and A. C. Lee and A. Mazhar and S. Mazumder and C. Mores and W. Mutale and H. Mwape and S. Newton and M. I. Nisar and L. Ogala and N. Ogola and N. Sharma and M. B. Spelke and J. Sugirtha and Y. Wei and W.-C. Yang and Z. Hoodbhoy and Q. Pan and E. R. Smith},
howpublished = {medRxiv},
year = {2026},
month = sep,
doi = {10.64898/2026.09.16.26362263},
url = {https://www.medrxiv.org/content/10.64898/2026.09.16.26362263v1},
note = {CC BY},
}
RIS
TY - UNPB
TI - Diagnostic Accuracy of WHO IMCI Visual Inspection for Neonatal Jaundice: A Prospective Multi-Country Cohort
AU - A. Khan
AU - A. Shapiro
AU - N. S. Yazdani
AU - S. G. Abraham
AU - V. Akelo
AU - K. P. Asante
AU - F. Aweyo
AU - A. G. Cherian
AU - M. Jat
AU - F. Jehan
AU - I. K
AU - K. Kasadhe
AU - M. Kasaro
AU - A. C. Lee
AU - A. Mazhar
AU - S. Mazumder
AU - C. Mores
AU - W. Mutale
AU - H. Mwape
AU - S. Newton
AU - M. I. Nisar
AU - L. Ogala
AU - N. Ogola
AU - N. Sharma
AU - M. B. Spelke
AU - J. Sugirtha
AU - Y. Wei
AU - W.-C. Yang
AU - Z. Hoodbhoy
AU - Q. Pan
AU - E. R. Smith
PY - 2026
DA - 2026/09/16
PB - medRxiv
DO - 10.64898/2026.09.16.26362263
UR - https://www.medrxiv.org/content/10.64898/2026.09.16.26362263v1
AB - BACKGROUNDAdverse 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. METHODSHyperbilirubinemia 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. RESULTSWe 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. CONCLUSIONThe poor sensitivity of visual inspection underscores an urgent need for accurate, affordable screening tools to improve screening for hyperbilirubinemia. Impact StatementO_LIWe 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. C_LIO_LIAmong 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. C_LIO_LIDespite 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. C_LIO_LIOur findings suggest that the WHO should re-evaluate the IMCI recommendations to include tools with higher diagnostic accuracy to identify neonatal jaundice. C_LIO_LICommunity-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. C_LI
ER -