DO NOT USE FOR CLINICAL PRACTICE
Please use current guidelines available on the UHNM intranet for patient treatment
Please use current guidelines available on the UHNM intranet for patient treatment
Based on NICE CG98 Jaundice in newborn babies under 28 days
RECOGNITION AND ASSESSMENT
Risk factors for hyperbilirubinaemia
- <38 weeks’ gestation
- Previous sibling required treatment for jaundice
- Mother intends to breastfeed exclusively
- Visible jaundice in baby aged <24 hr
Risk factors for kernicterus
- High bilirubin level (>340 micromol/L in term baby)
- Rapidly rising bilirubin level (>8.5 micromol/L/hr)
- Clinical features of bilirubin encephalopathy
Symptoms and signs
- When looking for jaundice (visual inspection):
- check naked baby in bright and preferably natural light
- examine the sclerae and gums, and press lightly on skin to check for signs of jaundice in 'blanched' skin
Assess
- Pallor (haemolysis)
- Poor feeding, drowsiness (neurotoxicity)
- Hepatosplenomegaly (blood group incompatibility or cytomegalovirus)
- Splenomegaly (spherocytosis)
Causes
- Physiological
- Prematurity
- Increased bilirubin load:
- blood group incompatibility (Rhesus or ABO)
- G6PD deficiency and other red cell enzyme deficiencies
- congenital spherocytosis
- cephalhaematoma, bruising
- Rarely infection (e.g. UTI, congenital infection)
- Metabolic disorder
Persistent jaundice after aged 14 days (see Liver dysfunction in preterm babies) guideline
- Breast milk jaundice
- Hypothyroidism
- Liver disease (e.g. extra hepatic biliary atresia and neonatal hepatitis)
- Alpha-1-antitrypsin deficiency
- Galactosaemia
- TPN-induced cholestasis
Investigations
Assessment of jaundice
- Babies aged <72 hr, at every opportunity (risk factors and visual inspection)
- do not routinely measure bilirubin in babies not visibly jaundiced
- Babies with suspected or obvious jaundice, measure and record bilirubin level urgently
- <24 hr: within 2 hr
- ≥24 hr: within 6 hr
- If serum bilirubin >100 micromol/L in first 24 hr
- measure 6-hrly until level is both below treatment threshold and stable/falling
- interpret result in accordance with baby’s age and gestation see threshold graph (http://www.nice.org.uk/guidance/CG98 under 'Tools and resources' then 'CG98 Neonatal Jaundice: treatment threshold graphs')
- urgent medical review as soon as possible (and within 6 hr, or 2 hr if baby aged <24 hr)
- Interpret bilirubin result in accordance with baby’s gestational and postnatal age according to threshold graph
Use of transcutaneous bilirubinometer
- May be used for initial bilirubin measurement for babies aged >24 hr and gestation ≥35 weeks
- If reading >250 micromol/L check serum bilirubin
- If serum bilirubin ≥ treatment threshold, use serum bilirubin for all subsequent measurements
Jaundice approaching treatment level
- If baby well, ≥38 weeks, aged >24 hr and
- serum bilirubin ≤50 micromol/L below treatment threshold, repeat measurement in 18 hr if risk factors and 24 hr if no risk factors
- serum bilirubin >50 micromol/L below treatment threshold, no further routine measurements required
Jaundice requiring treatment
- Total bilirubin
- Baby’s blood group and direct Coombs test (interpret result taking into account strength of reaction and whether mother received prophylactic anti-D immunoglobulin during pregnancy)
- Mother’s blood group and antibody status (should be available from maternal healthcare record)
- PCV
Plus (if clinically indicated)
- Full infection screen (in an ill baby)
- G6PD level and activity (if indicated by ethnic origin: Mediterranean, Middle Eastern, South East Asian)
- FBC and film
Persistent jaundice >14 days term baby; >21 days preterm baby (see Liver dysfunction in preterm babies) guideline
- Total and conjugated bilirubin
- Examine stool colour
- FBC
- Baby’s blood group and direct Coombs test (interpret result taking into account strength of reaction and whether mother received prophylactic anti-D immunoglobulin during pregnancy) [see Blood group incompatibilities (including Rhesus disease) guideline]
- Ensure routine metabolic screening performed (including screening for hypothyroidism)
- Urine culture
Baby with conjugated bilirubin >25 micromol/L, refer urgently to a specialist centre
Second line investigations (not in NICE guideline)
- Liver function tests (ALT, AST, albumin, GGT)
- Coagulation profile
- G6PD screen in African, Asian or Mediterranean babies
- Thyroid function tests: ask for ‘FT4 priority and then TSH’
- Congenital infection screen
- Urine for CMV PCR, toxoplasma ISAGA-IgM and throat swab for HSV culture/PCR
- Metabolic investigations e.g:
- blood galactose-1-phosphate
- urine for reducing substances
- alpha-1-antitrypsin
TREATMENT <7 DAYS
Do not start treatment if serum bilirubin is below treatment threshold
Babies ≥38 weeks' gestation
- Use conventional blue light phototherapy (not fibre optic) as treatment of choice
- Use continuous multiple phototherapy for babies who:
- fail to respond to conventional phototherapy (bilirubin does not fall within 6 hr of starting treatment)
- have a rapid rise in bilirubin (>8.5 micromol/L/hr)
- have a bilirubin level within 50 micromol/L of exchange transfusion threshold at 72 hr
- when level falls to >50 micromol/L below exchange transfusion threshold reduce intensity of phototherapy
- If exchange transfusion threshold crossed see (see Exchange transfusion guideline)
Babies <38 weeks’ gestation
- Use fibre optic or conventional blue light as first line treatment
- based on gestational age and postnatal age, use threshold graphs (http://www.nice.org.uk/guidance/CG98 under ‘Tools and resources’ then 'CG98 Neonatal Jaundice: treatment threshold graphs') to determine threshold for phototherapy
- use gestational age at birth, not corrected gestational age
- Indications for multiple phototherapy as term babies
Management during phototherapy
- Offer parents information on procedure (www.nice.org.uk/guidance/cg98/resources/jaundice-in-newborn-babies-318006690757)
- Unless other clinical conditions prevent, place baby in supine position
- Ensure treatment applied to maximum area of skin
- Monitor baby’s temperature
- Monitor hydration by weighing baby daily and assessing wet nappies
- Use eye protection and give routine eye care
- Provided bilirubin not significantly elevated, encourage breaks of up to 30 min for breastfeeding, nappy change and cuddles
- Do not give additional fluids routinely
- During multiple phototherapy:
- do not interrupt for feeds
- continue lactation/feeding support so that breastfeeding can recommence when treatment stops
Monitoring during phototherapy
- Repeat serum bilirubin 4–6 hr after starting treatment
- Repeat serum bilirubin 6–12 hrly when bilirubin stable or falling
- Stop phototherapy once serum bilirubin has fallen to at least 50 micromol/L below threshold
- Check for rebound jaundice with repeat serum bilirubin 12–18 hr after stopping phototherapy. Babies do not necessarily need to remain in hospital for this to be done
DISCHARGE AND FOLLOW-UP
- GP follow-up with routine examination at 6–8 weeks
- If exchange transfusion necessary or considered, request developmental follow-up and hearing test
- In babies with more than weakly positive Coombs test who require phototherapy:
- check haemoglobin at aged 2 and 4 weeks due to risk of continuing haemolysis
- give folic acid 1 mg daily
- Treatment graphs giving the phototherapy and exchange transfusion limits for each gestational age can be printed from http://www.nice.org.uk/guidance/CG98 under 'Tools and resources' then 'CG98 Neonatal Jaundice: treatment threshold graphs'