Early Neonatal Jaundice ( <14 Days )

Publication: 07/09/2011  --
Last review: 08/06/2018  
Next review: 08/06/2021  
Clinical Guideline
CURRENT 
ID: 2646 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2018  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Early Neonatal Jaundice (<14 Days)

Background

Jaundice is one of the most common conditions requiring medical attention in newborn babies. Jaundice refers to the yellow colouration of the skin and the sclera caused by the accumulation of bilirubin in the skin and mucous membranes, 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.

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Aims

To optimise and standardise the management of early neonatal jaundice and ensure practice consistent as far as possible with NICE guidance published May 2010 (Neonatal Jaundice CG98).

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Diagnosis

In all babies:

  • Identify any risk factors associated with an increased likelihood of developing significant hyperbilirubinaemia soon after birth.
    These risk factors include:
    • Prematurity
    • Infection
    • Previous sibling with neonatal jaundice requiring phototherapy
    • Visible jaundice in first 24 hours
  • Babies should be examined at every opportunity in the 1st 72 hours for jaundice.
    Record in the postnatal care plan or medical notes whether a baby is jaundiced <72 hours of age each time baby has cares or is examined.
    If a baby is not jaundiced - please document this clearly in the care plan.

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Investigation

Babies should be examined naked in good natural light. Examine sclera, gums and blanched skin. Be particularly aware that jaundice is more difficult to assess in babies with dark skin tones.

Risk factors

  • Blood group incompatibility
  • Previous sibling requiring phototherapy
  • Significant bruising e.g. cephalohaematoma
  • Weight loss greater than 10%
  • Family history

Measuring bilirubin level

  • Serum bilirubin should be measured. Use laboratory samples rather than the blood gas machine for measuring trends.
  • A discussion should take place with the parents/carers of all babies requiring treatment for jaundice from an appropriate health professional, regarding the implications of neonatal jaundice and their baby’s anticipated treatment regime.
  • Once a clinical decision has been made in the community that a baby (<14 days) needs a serum bilirubin checking they should then be managed as per the current guideline.
    nww.lhp.leedsth.nhs.uk/common/guidelines/detail.aspx?ID=407

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Treatment

Phototherapy
See appendix 2 - Phototherapy pathway

  • Use serum bilirubin and the treatment thresholds in the threshold table (see appendix 1) and treatment threshold graphs to determine whether phototherapy is needed.
  • Treatment threshold graphs can be found on clinical desktop computers in NICU, HDU, SCBU, postnatal wards and transitional care on both sides of the city.
  • Use conventional blue light single phototherapy in babies with a gestational age > 37 weeks.
  • Ensure positioning of phototherapy units & exposure of baby is optimal.
  • Do not use the biliblanket as first-line treatment in babies with a gestational age 37 weeks or more.
    However it can be used in conjunction with conventional phototherapy when multiple phototherapy is indicated.

Use multiple phototherapy treatment rather than single phototherapy if the serum bilirubin level

  • is rising rapidly (more than 8.5 mmol/l/hr)
  • fails to respond to single phototherapy.
  • is within 50 mmol/l of the threshold for exchange transfusion after 72 hours.

Monitoring response to phototherapy

  • Repeat serum bilirubin measurement 4–6 hours after initiating phototherapy, however, babies whose jaundice is not severe do not need bilirubin measurements taken outside normal lab hours.
  • Repeat serum bilirubin measurement every 6–12 hours when the serum bilirubin level is stable or falling.

Breast feeding

  • Short breaks from phototherapy for breastfeeding, nappy changing, cuddles and skin to skin contact should be encouraged.
  • Supplementation of breast feeds using formula should not be routinely prescribed.
  • In order to ensure adequate fluid intake, breastfeeding support should be prioritised and feeds observed in order to ensure that they are effective.
  • Mothers should be given information in order to ensure they are aware of the signs of adequate milk transfer and signs of good attachment including a reassuring suck-swallow pattern, and urine output and stooling appropriate to age.
  • Urine and stooling should be documented on the feed chart and output evaluated on a day to day basis.
  • Feed frequency should be monitored and documented, and mothers made aware that the baby should feed at least 8 times in a 24 hour period.
  • Where it is considered medically necessary to provide supplementation of breastfeeds, the use of mother’s breast milk should be prioritised above formula. Every attempt should be made to support mothers to express .
  • Supplements should be administered via a nasogastric tube or cup. Teats should not be introduced to babies establishing on breastfeeds without documented parental informed consent

Stopping phototherapy

  • Stop phototherapy once serum bilirubin has fallen to a level at least 50 mmol/l below the phototherapy threshold.
  • Check for rebound of significant hyperbilirubinaemia with a repeat bilirubin 12–18 hours after stopping phototherapy.

Intravenous immunoglobulin

  • Should be used in cases of Rhesus haemolytic disease or ABO haemolytic disease when the serum bilirubin continue to rise by more than 8.5 micromol/litre per hour despite continuous multiple phototherapy.
  • A dose of 500mg/kg over 4 hours should be given.
  • Immunoglobulin must be approved by a consultant immunologist within LTHT and the appropriate paperwork completed before it will be dispensed.

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Early Neonatal Jaundice (<14 days)

Exchange transfusion
See appendix 3 for flow sheet

  • Exchange transfusion should be used when bilirubin level indicates its necessity in the threshold table (see appendix 1) and treatment threshold graphs.
    and/or
    -Presence of Clinical features and signs of acute bilirubin encephalopathy.
  • There are circumstances (eg. antenatally diagnosed high antibody titres) where an exchange transfusion should be anticipated and prepared for prior to delivery.

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Prolonged Jaundice (>14 days):

See current guideline detail.aspx?ID=406

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Appendices

  1. Threshold table (≥ 38 weeks)
  2. Phototherapy pathway
  3. Exchange Transfusion Flowsheet
  4. Parent Information Leaflet

Links

References
National Institute for Health and Clinical Excellence – Neonatal jaundice NICE clinical guideline 98, issue date : May 2010

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Appendix 1: Threshold Table

Consensus-based bilirubin threshold for management of babies 38 weeks or more gestational age with hyperbilirubinaemia

Age (hours)

Bilirubin measurement (micromol/litre)

0

> 100

> 100

6

> 100

> 112

> 125

> 150

12

> 100

> 125

> 150

> 200

18

> 100

> 137

> 175

> 250

24

> 100

> 150

> 200

> 300

30

> 112

> 162

> 212

> 350

36

> 125

> 175

> 225

> 400

42

> 137

> 187

> 237

> 450

48

> 150

> 200

> 250

> 450

54

> 162

> 212

> 262

> 450

60

> 175

> 225

> 275

> 450

66

> 187

> 237

> 287

> 450

72

> 200

> 250

> 300

> 450

78

> 262

> 312

> 450

84

> 275

> 325

> 450

90

> 287

> 337

> 450

96+

> 300

> 350

> 450

Action

 

Repeat bilirubin level in 6 – 12 hrs

Consider phototherapy and repeat bilirubin level in 6 hrs

Start phototherapy

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

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Appendix 2

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Appendix 3

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Appendix 4


Provenance

Record: 2646
Objective:

To optimise and standardise the management of early neonatal jaundice and ensure practice consistent as far as possible with NICE guidance published May 2010 (Neonatal Jaundice CG98).

Clinical condition:

Jaundice

Target patient group: Newborn babies
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Midwives
Adapted from:

Evidence base

National Institute for Health and Clinical Excellence – Neonatal jaundice NICE clinical guideline 98, issue date : May 2010

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

Not supplied

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