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The management of neonatal jaundice is a particular challenge to the neonatologist. Mild jaundice is a common and usually harmless feature of the neonatal period, seen on a daily basis by staff in a huge variety of settings. This is set against the occasional but devastating complication of kernicterus (with its long term implications) in those who are more severely affected.
Balancing the desire to avoid excessive intrusive investigations for the healthy majority against attempts to capture those who would go on to develop kernicterus if untreated is a significant challenge.
NICE has produced guidance for England and Wales on this subject 1. This gives detailed recommendations for recognition and management of neonatal jaundice. This has been the source of a great deal of discussion, with divergent opinions; some praising the approach2 for its thoroughness, others stating concerns that it is too permissive3 and many being concerned about the practicalities of implementing the guidance in disparate healthcare settings.
Whilst there is no statutory obligation to follow NICE guidance in Scotland, it was felt that local guidance should be developed that ensured that practice was not too divergent from that described. This document attempts to address these issues in a practical manner.
This section gives guidance on the management of jaundice noted in the first two weeks of life. Separate guidance on management of infants over 2 weeks old is contained in the prolonged jaundice section further into this document.
At delivery the midwife looking after the mother should check whether there are factors associated with an increased likelihood of developing significant hyperbilirubinaemia soon after birth:
Arrangements should be made for identification of infants in these categories, and particular attention made to assessing for jaundice. If visible jaundice is noted by any member of staff prior to this additional check taking place then immediate action should be taken rather than awaiting this additional check.
Measure and record the serum bilirubin level urgently (within 2 hours of detection) in all babies with suspected or obvious jaundice in the first 24 hours of life.
Continue to measure the serum bilirubin level every 6 hours for all babies with suspected or obvious jaundice in the first 24 hours of life until the level is below the treatment threshold and stable and/ falling (this decision should be made by a middle grade or consultant).
A bilirubin level should be measure in all jaundiced babies. When measuring the bilirubin level:
In addition to a full clinical examination by a suitably trained healthcare professional, carry out all of the following tests in babies with significant (i.e. requiring treatment) hyperbilirubinaemia as part of an assessment for underlying disease (see threshold chart in appendix 1)
When assessing the baby for underlying disease consider whether the following tests are clinically indicated:
In 2016 NICE revised their guidance around the timing of repeat samples for infants of 38 weeks gestation or more to the following:
Testing frequency guidance is not given for more immature infants. Given their greater susceptibility to kernicterus it would be prudent to ensure that they are retested within 18 hours, less where there are additional risk factors.
Where the bilirubin level is more than 50 micromols/l below the treatment line routine retesting is not required, unless the rate of rise based on serial measurements is a concern, or the clinical situation changes.
Timely and accurate measurement of bilirubin levels in the community is a particular practical challenge. With early discharge now the norm it must be recognised that a significant proportion of the assessment of jaundice occurs outwith the hospital setting and away from easy access to measurement resources.
At present the following is recommended:
Community teams should seek to improve access to transcutaneous bilirubinometers and/or ensure that staff are able to take, and have processed, blood samples for serum bilirubin.
Remote and rural areas should develop robust guidance with their referral neonatal units to facilitate this process.
Treatment should be commenced one a serum bilirubin has confirmed that the bilirubin level is over the treatment threshold. Exceptions to this would be where a transcutaneous bilirubin measurement is so high that there is concern about the time taken to confirm with a serum sample (a serum sample must be taken, treatment may be started without it), or where the rate of rise is clearly going to take the bilirubin level above the treatment threshold in the next 6 hours.
All level must be plotted on the treatment charts available in appendix 1. Care must be taken to ensure that the baby’s age in hours has been accurately calculated and plotted appropriately. Treatment thresholds will vary with gestation and postnatal age so it is vital that plotting is accurate.
Type of phototherapy
The effectiveness of phototherapy is dependent on the light output of the device and the exposure of the infant rather than whether it is an overhead or under baby device. Under-baby devices have advantages in terms of the ability to continue use when breastfeeding, less light pollution for others in the area and no need for the baby to be undressed etc, so where devices with appropriate outputs are available should be the first choice.
NICE suggests the following as evidence that the bilirubin is not coming under control and suggests moving to multiple phototherapy:
Care while receiving phototherapy
Monitoring the baby during phototherapy
During conventional ‘blue light’ phototherapy:
During multiple phototherapy:
Measuring bilirubin after commencing phototherapy.
NICE recommend checking an initial bilirubin 4-6 hours after commencing phototherapy, and 6-12 hourly thereafter if the bilirubin is falling. Decisions regarding the frequency and timing of repeat samples should take into account how far above the treatment line the bilirubin is, the age of the child and may include factors such as avoidance of overly frequent sampling overnight. Patient safety must be the priority however, and deviations from the recommended schedule should be done by an appropriately senior (middle grade level or above) member of staff after due consideration of all relevant factors
Stop phototherapy once serum bilirubin has fallen to a level at least 50 micromol/litre below the phototherapy threshold (see threshold table and treatment threshold graphs).
NICE recommend a check for rebound of significant hyperbilirubinaemia with a repeat serum bilirubin measurement 12–18 hours after stopping phototherapy. Babies do not necessarily have to remain in hospital for this to be done, but a clear plan will need to be made for this to happen, including where appropriate communication with the community midwifery team. It is recognised that a 12-18 hour wait is not always practical without unduly delaying discharge, particularly where arrangements for checking serum samples in the community are not in place. In these circumstances a sample can be taken earlier, but must be interpreted accordingly.
Use intravenous immunoglobulin (IVIG) (500 mg/kg over 4 hours) as an adjunct to continuous multiple phototherapy in cases of Rhesus haemolytic disease or ABO haemolytic disease when the serum bilirubin continues to rise by more than 8.5 micromol/litre per hour. The relevant request form will need to be completed to obtain IVIG.
Offer parents or carers information on IVIG including:
Use a double-volume exchange transfusion to treat babies:
During exchange transfusion do not :
measure serum bilirubin level within 2 hours and manage according to the threshold table
The introduction of routine antenatal anti D prophylaxis has resulted in many babies testing Coombs (more correctly Direct Antiglobulin Test or DAT) positive who are not at risk of haemolysis. This guideline has been developed in conjunction with blood transfusion services to facilitate identification of those at high risk without unnecessary intervention for those that are not.
This guideline does not replace clinical judgement, if there is a suspicion of active haemolysis in a neonate in any situation then they should be managed as such in the manner described in the section subsequent to this.
Where a mother has received routine antenatal anti D prophylaxis, only strongly positive DATs will be reported by the lab as Positive
Weakly positive DATs will no longer be reported as positive in this situation, though the lab will give this result if asked (e.g. if the baby has significant jaundice etc)
Current obstetric management of rhesus negative women (routine anti D prophlaxis) means large numbers of babies testing positive on cord Coombs/Direct Antibody testing (DAT). Local audit and national guidelines (British council for standards in haematology) show that these babies are not liable to significant haemolysis.
National guidelines (British council for standards in haematology) recommend that DAT/Coombs testing is not done in infants born to mothers who have received prophylactic anti D. Abandoning this altogether however runs the risk of missing a baby who has other haemolytic maternal antibodies (e.g anti-c), which could lead to brisk haemolysis in the days after birth with the associated morbidities that this brings. Therefore this risk analysis based approach has been developed.
The risk analysis is based on the fact that maternal antibodies that lead to haemolysis will develop prior to the start of the third trimester (2). All women receiving anti D will have an antibody screen taken before they receive anti D at 28 weeks gestation. Absence of haemolytic antibodies at this time means that there is no increased risk of postnatal haemolysis.
Maternal casenotes should be reviewed on presentation to labour suite for any paediatric alerts on the yellow sheet, and these communicated to the neonatal team.
If no specific action prompted by paediatric alert section or other correspondence, but the mother is rhesus negative cord bloods should be taken and sent for group and DAT/Coombs testing.
Those at highest risk where antibodies have been detected during pregnancy should have a paediatric alert on the yellow sheet in the maternal notes. Accompanying this should be a description of the antibodies detected including quantification and an estimate of the likely risk posed to the infant. The neonatal team should be advised of any women with irregular antibodies on presentation to labour suite to allow time for interpretation of the predicted severity of the situation and liaison with BTS where required.
If there is no alert and the cord bloods are DAT positive the neonatal team should be informed immediately and the result recorded clearly in the baby’s casenotes along with any other information from the lab. The neonatal team should then review the baby and casenotes for further information and manage as below.
Treat as per haemolytic jaundice below, ie take and send urgent FBC and SBR (or seek results from cord bloods if taken), consider commencing immediate phototherapy.
Haemolytic jaundice is a pathological condition. The baby with haemolytic jaundice is at risk of:
The cornerstone of management is close monitoring and the anticipation of treatment requirements.
The following are indications that the baby may require treatment either immediately upon delivery or shortly thereafter:
The following groups of babies should be investigated for haemolysis:
FBC, Blood group, Coomb’s test, Serum Bilirubin (SBR). These should be taken as cord bloods if haemolysis was anticipated antenatally, or from the baby in the case of early onset jaundice.
When haemolysis is confirmed, the following investigations are required to monitor the baby’s progress
FBC – repeat daily initially, reducing once trend is determined
SBR – repeated at 4 hours after the baseline test to determine the rate of rise. Thereafter, based on this rate of rise, the SBR should be repeated 4-8 hourly until the SBR is clearly under control N.B. All SBR results should be plotted accurately, by hour of sampling, on a phototherapy chart.
Treatment of haemolytic jaundice is by phototherapy. This may be commenced immediately if severe haemolysis is anticipated. Except where haemolysis is severe (bilirubin rising by> 8.5micromoles/l/hr) this should be by single phototherapy on the postnatal ward. It is important to ensure effective phototherapy i.e. maximal surface area exposure for most of the time. The baby should only come out for feeds, consider using a biliblanket during feeds if these are taking some time.
Where the SBR continues to rise despite effective phototherapy or where exchange transfusion is anticipated the baby should come to SCBU. Double phototherapy may be initiated on SCBU however it is important that the first unit is not moved away from the baby to accommodate the second unit. Units should ensure that they have up to date effective high luminescence devices.
Use intravenous immunoglobulin (IVIG) (500 mg/kg over 4 hours) as an adjunct to continuous intensified phototherapy in cases of rhesus haemolytic disease or ABO haemolytic disease when the serum bilirubin continues to rise by more than 8.5 micromol/litre per hour.
The appropriate request form will be required to obtain IVIG
Exchange transfusions are only performed with consultant approval. Exchange is indicated if one of the following criteria are met
For instructions on the performance of an exchange transfusion see transfusion protocol
Low grade haemolysis may continue in these infants, even in the absence of jaundice. Therefore:-
Early follow up should be arranged to monitor for anaemia. This should be 1-2 weeks after discharge if there is any noticeable decline in Hb levels leading up to discharge. If in any doubt then discuss follow up with the consultant.
Jaundice persisting beyond day 14 is common, occurring in 2-15% of all neonates and 15-40% of those who are breast fed.4,5 Rarely it can be the earliest manifestation of serious underlying pathology which may benefit from prompt diagnosis (Table 1).6 Biliary atresia (BA) is an uncommon cause of prolonged jaundice, having an incidence of 1 in 14000 to 1 in 21000 live births.7 Early detection and surgical intervention significantly improves outcome. 7-9 Late detection of infants with BA led to the UK “Yellow Alert Campaign”. This encouraged screening of all neonates with jaundice persisting beyond 14 days to facilitate prompt diagnosis.9 However this inevitably lead to the investigation of many normal babies. In addition complications of cholestatic liver disease are rare prior to the third week of life, leading the North American Academy of Pediatric Gastroenterology, Hepatology and Nutrition to recommend that well breast fed infants can have screening delayed until three weeks of age.10, 11 Throughout the UK marked heterogeneity exists in the evaluation of prolonged jaundice, with variation in both timing and laboratory assessment.10-13
Local audit demonstrated that infants identified as having prolonged jaundice were having extensive investigations many of which necessitated repeat appointments (26% of cases) to demonstrate the normalisation of initially abnormal results. However, none were identified as having liver related pathology. The intention of this guideline is to rationalise our approach to the infant with prolonged jaundice in keeping with the guidelines advocated by the “yellow alert” campaign
Table 1 - Conditions causing prolonged jaundice in newborns that require a specific treatment approach and therefore benefit from early diagnosis3
Bile duct abnormalities
Toxins / injury
Fig 1 - Stool chart
Please note that this chart is for guidance only as colours may reproduce differently on different monitors or printers. Please refer to charts available on the neonatal units (provided by the Yellow Alert campaign)
Fig 2. Distribution of G6PD worldwide
|Who to assess:||All newborns are at risk and should be assessed at every opportunity for the development of jaundice.|
|Who to measure:||
Anyone with visible jaundice
Babies with a family history of significant neonatal jaundice, DAT positive babies, breast fed babies and those under 38 weeks should receive special attention in looking for jaundice
|How to measure:||
Transcutaneous bilirubinometer (unless under 35 weeks, under 24 hours, DAT positive or previous phototherapy)
|When to take an SBR:||A serum bilirubin should be checked where the transcutaneous value is over 250micromol/l or within 25micomol/l of the treatment threshold.|
When to repeat bloods (>38wks):
Within 50micromol/l of the treatment line:
|When to treat:||
Use new gestation specific treatment lines- babies should stay on their gestation specific graph until they are 14 days old.
Treat when the serum bilirubin level is over the treatment line, or is clearly going to cross the line
When to recheck after treatment has been started:
|Recheck an initial level after 6 hours, then 6-12 hourly if falling.|
When to stop phototherapy:
Stop phototherapy when the serum bilirubin is at least 50micromol/l below the treatment threshold.
When to recheck after stopping phototherapy:
|Recheck an SBR 12-18 hours after stopping phototherapy.|
Last reviewed: 13 December 2016
Next review: 01 December 2019
Author(s): Dr Allan Jackson – Consultant Neonatologist – PRM