Quick reference guide

Issue date: May 2010

Neonatal jaundice

NICE clinical guideline 98 Developed by the National Collaborating Centre for Womens and Childrens Health

Open for a table on bilirubin thresholds for managing hyperbilirubinaemia

Treatment threshold graphs showing bilirubin thresholds for phototherapy and exchange transfusion in babies with hyperbilirubinaemia for different gestational ages are available in a separate file from www.nice.org.uk/guidance/CG98

Neonatal jaundice

Threshold table

Threshold table
Consensus-based bilirubin thresholds for management of babies 38 weeks or more gestational age with hyperbilirubinaemia Age (hours) 0 6 12 18 24 30 36 42 48 54 60 66 72 78 84 90 96+ Bilirubin measurement (micromol/litre) > 100 > 100 > 100 > 100 > 112 > 125 > 137 > 150 > 162 > 175 > 187 > 200 > 112 > 125 > 137 > 150 > 162 > 175 > 187 > 200 > 212 > 225 > 237 > 250 > 262 > 275 > 287 > 300 > 100 > 125 > 150 > 175 > 200 > 212 > 225 > 237 > 250 > 262 > 275 > 287 > 300 > 312 > 325 > 337 > 350 > 100 > 150 > 200 > 250 > 300 > 350 > 400 > 450 > 450 > 450 > 450 > 450 > 450 > 450 > 450 > 450 > 450

Action

Repeat bilirubin measurement in 612 hours

Consider phototherapy and repeat bilirubin measurement in 6 hours

Start phototherapy

Perform an exchange transfusion unless the bilirubin level falls below threshold while the treatment is being prepared

NICE clinical guideline 98

Quick reference guide

Neonatal jaundice

About this booklet

About this booklet

This is a quick reference guide that summarises the recommendations NICE has made to the NHS in Neonatal jaundice (NICE clinical guideline 98).

Who should read this booklet?

This quick reference guide is for all healthcare professionals and other staff who care for newborn babies with jaundice.

Who wrote the guideline?

The guideline was developed by the National Collaborating Centre for Womens and Childrens Health, which is linked with the Royal College of Obstetricians and Gynaecologists. The Collaborating Centre worked with a group of healthcare professionals (including consultants, GPs, midwives, and specialist and community nurses), parent members and technical staff, who reviewed the evidence and drafted the recommendations. The recommendations were finalised after public consultation. For more information on how NICE clinical guidelines are developed, go to www.nice.org.uk

Where can I get more information about the guideline?

The NICE website has the recommendations in full, reviews of the evidence they are based on, a summary of the guideline for parents and carers, and tools to support implementation (see back cover for more details).

National Institute for Health and Clinical Excellence, 2010. All rights reserved. This material may be freely reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the express written permission of NICE.

NICE clinical guidelines are recommendations about the treatment and care of people with specific diseases and conditions in the NHS in England and Wales. This guidance represents the view of NICE, which was arrived at after careful consideration of the evidence available. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. However, the guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, and informed by the summary of product characteristics of any drugs they are considering. Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Neonatal jaundice

Contents

Contents
Threshold table Key to terms Key priorities for implementation Information and support for parents and carers Investigation Phototherapy Exchange transfusion Further issues on treatment and management Further information 3 6 7 9 9 13 16 17 18

Introduction
Jaundice is one of the most common conditions needing medical attention in newborn babies. Jaundice refers to yellow colouration of the skin and the sclerae and is caused by a raised level of bilirubin in the circulation, a condition known as hyperbilirubinaemia. Approximately 60% of term and 80% of preterm babies develop jaundice in the first week of life, and about 10% of breastfed babies are still jaundiced at 1 month of age. In most babies early jaundice is harmless. However, a few babies will develop very high levels of bilirubin, which can be harmful if not treated. Clinical recognition and assessment of jaundice can be difficult, particularly in babies with dark skin tones. Once jaundice is recognised, there is uncertainty about when to treat, and there is widespread variation in the use of phototherapy and exchange transfusion. This guideline provides guidance on the recognition, assessment and treatment of neonatal jaundice in babies from birth to 28 days.

Patient-centred care
Treatment and care should take into account parents preferences. Good communication is essential, supported by evidence-based information, to allow parents to reach informed decisions about their babys care. Follow advice on seeking consent from the Department of Health or Welsh Assembly Government if needed. Families and carers should have the opportunity to be involved in decisions about treatment and care.

NICE clinical guideline 98

Quick reference guide

Neonatal jaundice

Key to terms

Key to terms
Conventional phototherapy Phototherapy given using a single light source (not fibreoptic) that is positioned above the baby Direct antiglobulin test (DAT) Also known as the direct Coombs test; this test is used to detect antibodies or complement proteins that are bound to the surface of red blood cells Fibreoptic phototherapy Phototherapy given using a single light source that comprises a light generator, a fibreoptic cable through which the light is carried and a flexible light pad, on which the baby is placed or that is wrapped around the baby Multiple phototherapy Phototherapy that is given using more than one light source simultaneously; for example two or more conventional units, or a combination of conventional and fibreoptic units Preterm Less than 37 weeks gestational age Prolonged jaundice Jaundice lasting more than 14 days in term babies and more than 21 days in preterm babies Significant hyperbilirubinaemia An elevation of the serum bilirubin to a level requiring treatment Term 37 weeks or more gestational age Visible jaundice Jaundice detected by visual inspection

NICE clinical guideline 98

Quick reference guide

Neonatal jaundice

Key priorities for implementation

Key priorities for implementation

Information
G

Offer parents or carers information about neonatal jaundice that is tailored to their needs and expressed concerns. This information should be provided through verbal discussion backed up by written information. Care should be taken to avoid causing unnecessary anxiety to parents or carers. Information should include: factors that influence the development of significant hyperbilirubinaemia how to check the baby for jaundice what to do if they suspect jaundice the importance of recognising jaundice in the first 24 hours and of seeking urgent medical advice the importance of checking the babys nappies for dark urine or pale chalky stools the fact that neonatal jaundice is common, and reassurance that it is usually transient and harmless reassurance that breastfeeding can usually continue.

Care for all babies

G

Identify babies as being more likely to develop significant hyperbilirubinaemia if they have any of the following factors: gestational age under 38 weeks a previous sibling with neonatal jaundice requiring phototherapy mothers intention to breastfeed exclusively visible jaundice in the first 24 hours of life. In all babies: check whether there are factors associated with an increased likelihood of developing significant hyperbilirubinaemia soon after birth examine the baby for jaundice at every opportunity especially in the first 72 hours. When looking for jaundice (visual inspection): check the naked baby in bright and preferably natural light examination of the sclerae, gums and blanched skin is useful across all skin tones.

Additional care
G

Ensure babies with factors associated with an increased likelihood of developing significant hyperbilirubinaemia receive an additional visual inspection by a healthcare professional during the first 48 hours of life.

Measuring bilirubin in all babies with jaundice

G

Do not rely on visual inspection alone to estimate the bilirubin level in a baby with jaundice.
continued

NICE clinical guideline 98

Quick reference guide

Neonatal jaundice

Key priorities for implementation

Key priorities for implementation continued

How to measure the bilirubin level
G

When measuring the bilirubin level: use a transcutaneous bilirubinometer in babies with a gestational age of 35 weeks or more and postnatal age of more than 24 hours if a transcutaneous bilirubinometer is not available, measure the serum bilirubin if a transcutaneous bilirubinometer measurement indicates a bilirubin level greater than 250 micromol/litre check the result by measuring the serum bilirubin always use serum bilirubin measurement to determine the bilirubin level in babies with jaundice in the first 24 hours of life always use serum bilirubin measurement to determine the bilirubin level in babies less than 35 weeks gestational age always use serum bilirubin measurement for babies at or above the relevant treatment threshold for their postnatal age, and for all subsequent measurements do not use an icterometer.

How to manage hyperbilirubinaemia

G

Use the bilirubin level to determine the management of hyperbilirubinaemia in all babies (see threshold table1 and treatment threshold graphs2).

Care of babies with prolonged jaundice

G

Follow expert advice about care for babies with a conjugated bilirubin level greater than 25 micromol/litre because this may indicate serious liver disease.

1 2

The threshold table is on the foldout page at the front of this quick reference guide. The treatment threshold graphs are available in a separate file from www.nice.org.uk/guidance/CG98

NICE clinical guideline 98

Quick reference guide

Neonatal jaundice

Information and support for parents and carers

Information and support for parents and carers

G

Offer parents or carers information about neonatal jaundice that is tailored to their needs and expressed concerns. This information should be provided through verbal discussion backed up by written information. Care should be taken to avoid causing unnecessary anxiety to parents or carers. Information should include: factors that influence the development of significant hyperbilirubinaemia how to check the baby for jaundice what to do if they suspect jaundice the importance of recognising jaundice in the first 24 hours and of seeking urgent medical advice the importance of checking the babys nappies for dark urine or pale chalky stools the fact that neonatal jaundice is common, and reassurance that it is usually transient and harmless reassurance that breastfeeding can usually continue. Encourage mothers of breastfed babies with jaundice to breastfeed frequently, and to wake the baby for feeds if necessary. Provide lactation/feeding support to breastfeeding mothers whose baby is visibly jaundiced.

Investigation
See the investigation pathway on pages 1011.

Inspection for jaundice

G

Parents, carers and healthcare professionals should all look for jaundice (visual inspection): check the naked baby in bright and preferably natural light examination of the sclerae, gums and blanched skin is useful across all skin tones. Do not rely on visual inspection alone to estimate the bilirubin level in a baby with jaundice. Do not use any of the following to predict significant hyperbilirubinaemia: umbilical cord blood bilirubin level end-tidal carbon monoxide (ETCOc) measurement umbilical cord blood direct antiglobulin test (DAT).

G G

NICE clinical guideline 98

Quick reference guide

Neonatal jaundice

Investigation

Investigation pathway
Care for all babies
Offer parents/carers information about neonatal jaundice (see page 9) Identify babies as being more likely to develop significant hyperbilirubinaemia if they have any of the following factors:
G G G G

gestational age under 38 weeks a previous sibling with neonatal jaundice requiring phototherapy mothers intention to breastfeed exclusively visible jaundice in the first 24 hours

Ensure adequate support is offered to all women who intend to breastfeed exclusively3

Does baby have suspected or obvious jaundice in the first 24 hours?

No

Does baby have any other factors?

G G G

gestational age under 38 weeks a previous sibling with neonatal jaundice requiring phototherapy mothers intention to breastfeed exclusively
No

Examine for jaundice at every opportunity, especially in first 72 hours

Examine the baby for jaundice at every opportunity, especially in the first 72 hours

The threshold table is on the foldout page at the front of this quick reference guide. The treatment threshold graphs are available in a separate file from www.nice.org.uk/guidance/CG98

Does baby have

No

Routine care

Manage hyperbilirubinaemia Interpret results using threshold table and treatment

Monitor bilirubin levels

Treat using phototherapy

Refer to Routine postnatal care of women and their babies (NICE clinical guideline 37) for information on breastfeeding support.

Go to phototherapy pathway (see page 15)

10

NICE clinical guideline 98

Quick reference guide

Neonatal jaundice

Investigation

Care for babies with signs of acute bilirubin encephalopathy

Check for signs of acute bilirubin encephalopathy

Go to exchange transfusion pathway (see page 16)

Urgent additional care for babies with jaundice in the first 24 hours Yes

Measure and record serum bilirubin level within 2 hours

Yes

Ensure babies receive an additional visual inspection by a healthcare professional within 48 hours

Additional care for babies who are more likely to develop hyperbilirubinaemia

Continue to measure the serum bilirubin level every 6 hours until the level is both:
G

below the treatment threshold stable and/or falling

visible jaundice?
Yes

Arrange a referral to ensure that an urgent medical review is conducted (as soon as possible and within 6 hours) to exclude pathological causes of jaundice

Measure and record bilirubin level within 6 hours

threshold graphs

Treat using exchange transfusion

Go to exchange transfusion pathway (see page 16)

NICE clinical guideline 98

Quick reference guide

11

Neonatal jaundice

Investigation

How to measure the bilirubin level

G

When measuring the bilirubin level: use a transcutaneous bilirubinometer in babies with a gestational age of 35 weeks or more and postnatal age of more than 24 hours if a transcutaneous bilirubinometer is not available, measure the serum bilirubin if a transcutaneous bilirubinometer measurement indicates a bilirubin level greater than 250 micromol/litre check the result by measuring the serum bilirubin always use serum bilirubin measurement to determine the bilirubin level in babies: N with jaundice in the first 24 hours of life N less than 35 weeks gestational age always use serum bilirubin measurement for babies at or above the relevant treatment thresholds for their postnatal age, and for all subsequent measurements do not use an icterometer. Do not measure bilirubin levels routinely in babies who are not visibly jaundiced.

See the threshold table on the foldout page at the front of this quick reference guide and the treatment threshold graphs (available from www.nice.org.uk/guidance/CG98) when managing hyperbilirubinaemia.

12

NICE clinical guideline 98

Quick reference guide

Neonatal jaundice

Phototherapy

Phototherapy
See the phototherapy pathway on page 15.

Information for parents or carers on phototherapy

G

Offer parents or carers verbal and written information on phototherapy including: why phototherapy is being considered why phototherapy may be needed to treat significant hyperbilirubinaemia anticipated duration of treatment the possible adverse affects of phototherapy including potential long-term adverse effects the need for eye protection and routine eye care reassurance that short breaks for feeding, nappy changing and cuddles will be encouraged what might happen if phototherapy fails rebound jaundice potential impact on breastfeeding and how to minimise this.

General care of the baby during phototherapy

G G G

Place the baby in a supine position unless other clinical conditions prevent this. Give the baby eye protection and routine eye care. Use tinted headboxes as an alternative to eye protection in term babies undergoing conventional blue light phototherapy. Ensure treatment is applied to the maximum area of skin. Monitor the babys temperature and ensure the baby is kept in a thermoneutral environment. Monitor hydration by daily weighing of the baby and assessing wet nappies. Support parents and carers and encourage them to interact with the baby.

G G G G

NICE clinical guideline 98

Quick reference guide

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Neonatal jaundice

Phototherapy

Starting phototherapy
G

Use serum bilirubin measurement and the treatment thresholds in the threshold table and treatment threshold graphs when considering the use of phototherapy. In babies with a gestational age of 38 weeks or more whose bilirubin is in the repeat bilirubin measurement category in the threshold table, repeat the bilirubin measurement in 612 hours. In babies with a gestational age of 38 weeks or more whose bilirubin is in the consider phototherapy category in the threshold table, repeat the bilirubin measurement in 6 hours regardless of whether or not phototherapy has subsequently been started. Do not use phototherapy in babies whose bilirubin does not exceed the phototherapy threshold levels in the threshold table and treatment threshold graphs.

Phototherapy equipment
G G G

Ensure all phototherapy equipment is maintained and used according to the manufacturers guidelines. Use incubators or bassinets according to clinical need and availability. Do not use white curtains routinely with phototherapy.

See the threshold table on the foldout page at the front of this quick reference guide and the treatment threshold graphs (available from www.nice.org.uk/guidance/CG98) when managing hyperbilirubinaemia.

14

NICE clinical guideline 98

Quick reference guide

Phototherapy pathway

Is serum bilirubin level: rising rapidly (more than 8.5 micromol/litre/hour) and/or within 50 micromol/litre below the threshold for which exchange transfusion is indicated after 72 hours (see the threshold table and treatment threshold graphs)?
No Yes

Neonatal jaundice

NICE clinical guideline 98 Start continuous multiple phototherapy

G G G G

Offer information to parents and carers about phototherapy (see page 13)

Perform formal assessment:

Start single phototherapy4

clinical examination serum bilirubin blood packed cell volume blood group of mother and baby DAT Do not interrupt for feeding Continue administering intravenous/enteral feeds Continue lactation/feeding support Monitor hydration by daily weighing of the baby and assessing wet nappies Using clinical judgement encourage short breaks for breastfeeding, nappy changing and cuddles Continue lactation/feeding support Do not give additional fluids or feeds routinely Monitor hydration by daily weighing of the baby and assessing wet nappies

Consider:

G G G

Check serum bilirubin level: 46 hours after starting phototherapy every 612 hours if bilirubin level is stable or falling

Check serum bilirubin level: 46 hours after starting phototherapy every 612 hours if bilirubin level is stable or falling

full blood count and examination of blood film blood glucose-6phosphate microbiological cultures of blood, urine and cerebrospinal fluid

Is serum bilirubin level stable or falling?

Yes No

Is serum bilirubin level stable or falling?

Yes No

Phototherapy

Is serum bilirubin level at least 50 micromol/litre below threshold for phototherapy?

No

Yes

Is serum bilirubin level 50 micromol/litre below threshold for exchange transfusion?

Yes

No

Quick reference guide

Stop phototherapy Check serum bilirubin for rebound after 1218 hours

Go to Manage hyperbilirubinaemia box in Investigation pathway (see pages 1011)

Step down to single phototherapy

Go to Manage hyperbilirubinaemia box in Investigation pathway (see pages 1011)

Continue multiple phototherapy and check serum bilirubin level every 612 hours

15

In term babies use conventional blue light phototherapy; in preterm babies use fibreoptic or conventional blue light phototherapy.

16 Initiate/maintain continuous multiple phototherapy Use IVIG (500 mg/kg over 4 hours) for babies with Rhesus or ABO haemolytic disease if serum bilirubin level rises by more than 8.5 micromol/litre/hour

Exchange transfusion pathway

Prepare for exchange transfusion

Offer information to parents and carers about exchange transfusions and intravenous immunoglobulin (IVIG) including:

Neonatal jaundice

NICE clinical guideline 98 Baby has:

G

Serum bilirubin level falls to below threshold for exchange transfusion

G

Exchange transfusion

why the treatment is being considered anticipated duration of treatment possible adverse effects when it will be possible for parents or carers to see and hold the baby the need to admit the baby to intensive care for an exchange transfusion (if needed) bilirubin level that remains above threshold for exchange transfusion and/or clinical signs of acute bilirubin encephalopathy Continue multiple phototherapy and perform exchange transfusion

During exchange transfusion do not:

Exchange transfusion

stop continuous multiple phototherapy perform a singlevolume exchange use albumin priming routinely administer intravenous calcium

Continue multiple phototherapy and measure bilirubin level within 2 hours of exchange transfusion and manage according to threshold table and treatment threshold graphs

Quick reference guide

Go to Manage hyperbilirubinaemia box in Investigation pathway (see pages 1011)

Neonatal jaundice

Further issues on treatment and management

Further issues on treatment and management

Management of hyperbilirubinaemia
G

When making decisions about the management of hyperbilirubinaemia: do not use the albumin/bilirubin ratio do not subtract conjugated bilirubin from total serum bilirubin.

Other therapies
G

Do not use any of the following to treat hyperbilirubinaemia: sunlight agar albumin barbiturates charcoal cholestyramine clofibrate D-penicillamine glycerin manna metalloporphyrins riboflavin traditional Chinese medicine acupuncture homeopathy.

Factors that influence the risk of kernicterus

G

Identify babies with hyperbilirubinaemia as being at increased risk of developing kernicterus if they have any of the following: a serum bilirubin level greater than 340 micromol/litre in term babies a rapidly rising bilirubin level of greater than 8.5 micromol/litre per hour clinical features of acute bilirubin encephalopathy.

Care for babies with prolonged jaundice

G

In

preterm and term babies with prolonged jaundice (see page 6 for definitions): look for pale chalky stools and/or dark urine that stains the nappy measure the conjugated bilirubin carry out a full blood count, blood group determination, DAT and urine culture ensure that routine metabolic screening has been performed.

Follow expert advice about care for babies with a conjugated bilirubin level greater than 25 micromol/litre.

NICE clinical guideline 98

Quick reference guide

17

Neonatal jaundice

Further information

Further information
Ordering information
You can download the following documents from www.nice.org.uk/guidance/CG98
G G

Implementation tools
NICE has developed tools to help organisations implement this guidance (see www.nice.org.uk/guidance/CG98).

The NICE guideline all the recommendations. A quick reference guide (this document) a summary of the recommendations for healthcare professionals. Understanding NICE guidance a summary for parents and carers. The full guideline all the recommendations, details of how they were developed, and reviews of the evidence they were based on.

Related NICE guidance

For information about NICE guidance that has been issued or is in development, see www.nice.org.uk Published G Diabetes in pregnancy: management of diabetes and its complications from pre-conception to the postnatal period. NICE clinical guideline 63 (2008). Available from: www.nice.org.uk/guidance/CG63
G

For printed copies of the quick reference guide or Understanding NICE guidance, phone NICE publications on 0845 003 7783 or email [email protected] and quote:
G G

N2143 (quick reference guide) N2144 (Understanding NICE guidance).

G

Antenatal care: routine care for the healthy pregnant woman. NICE clinical guideline 62 (2008). Available from: www.nice.org.uk/guidance/CG62 Intrapartum care: care of healthy women and their babies during childbirth. NICE clinical guideline 55 (2007). Available from: www.nice.org.uk/guidance/CG55 Routine postnatal care of women and their babies. NICE clinical guideline 37 (2006). Available from: www.nice.org.uk/guidance/CG37

Updating the guideline

This guideline will be updated as needed, and information about the progress of any update will be available at www.nice.org.uk/guidance/CG98

National Institute for Health and Clinical Excellence MidCity Place 71 High Holborn London WC1V 6NA www.nice.org.uk N2143 1P 67k 12 May 10 ISBN 978-1-84936-212-2