Prolonged jaundice Neonates (NHSGGC)

exp date isn't null, but text field is

Objectives

  1. To detect important disorders presenting as prolonged jaundice that require further evaluation
  2. To avoid over investigation of well babies
  3. To avoid unnecessary hospital visits for well babies and their families

Historically prolonged jaundice screening has been a common reason for attending hospital.  The great majority of those attending are well with simple breast milk jaundice and require no more than a split bilirubin as a screen for underlying disorders.  To avoid unnecessary hospital visits while ensuring appropriate safety, a new process that minimises the need for attendance has been developed in collaboration between the three GG&C neonatal units and Community Midwifery Colleagues.  This process has been successfully trialled and is now fully implemented.

The following pathways have been developed to ensure safe practice based on community lead screening based on three risk categories:

  • Well, thriving, breast fed term babies, not at risk of G6PD
  • Well, thriving, breast fed <37 week babies, not at risk of G6PD
  • Formula fed babies, babies with pale stools/dark urine, clinical concerns or at risk of G6PD

The process can simply be described as- well babies having bloods in the community rather than in hospital, with hospital appointments being reserved for babies with clinical concerns, a higher suspicion of underlying pathology (formula fed babies) and those requiring additional bloods (those at risk of G6PD).  Preterm babies are managed slightly differently to reflect the fact that acute jaundice issues can be more persistent in this group so additional sampling may be required for immediate jaundice management, and that jaundice may go on until day 21 in this group. These processes are described in boxes below, with flow charts as well for additional clarity

Applicability

Newborns 14- 21 days of life under the care of NHS GG&C Community Midwives, or in hospital settings in GG&C.  

For babies being cared for in the NHS Lanarkshire area, the usual process of seeing in hospital should be followed as blood taking is not currently possible in the community in those areas

Background

Prolonged jaundice is used to describe neonatal jaundice persisting beyond 14 days of life.  At this point the emphasis is no longer on prevention of kernicterus, but on investigation to rule out an underlying abnormality that is causing the jaundice to persist at this point.  The overwhelming majority of infants who remain jaundiced at 14 days of age will have benign self-resolving breast milk jaundice.  A small number will however have an underlying disorder which requires further evaluation and treatment, principle amongst those is extrahepatic biliary atresia for which the prognosis is improved by early diagnosis.  

The testing is based on a risk based clinical assessment followed by targeted investigations, which mean that well breast-fed infants with pigmented stools need just a “split bilirubin” to confirm that the jaundice is all unconjugated- with further investigations if a significant conjugated fraction is detected.  Unwell babies, particularly those with pale stools will require a more comprehensive evaluation.

The pathway described below should be used in conjunction with the West of Scotland MCN Neonatal Jaundice Guideline which describes in detail the management of neonatal jaundice including prevention of kernicterus.  All acute jaundice issues should be resolved before utilising this pathway.

Aims

  1. To detect important disorders presenting as prolonged jaundice that require further evaluation
  2. To avoid over investigation of well babies
  3. To avoid unnecessary hospital visits for well babies and their families
Prolonged Jaundice risk based screening

Well, thriving, breast fed term babies, not at risk of G6PD*: Community Management

37 weeks and over (see next box for <37 weeks)
Exclusively breastfed
Pigmented stools and pale urine
Thriving
No history of haemolysis
No relevant family history of  liver or haemolytic disorders
Family not from G6PD area
Clinically well, no parental
or midwifery concerns









Management: 

SBR from day 7 onwards showing total SBR < 250 umol/l and conjugated bilirubin <10umol/l

  • No further action required, document in Badger
  • If total >250 umol/l or conjugated >10 umol/l refer to neonatal service (number below)

No recent (after day 7) SBR?

Community Midwife takes SBR during scheduled visit - day 10 or more, day 14 ideally.
      If total SBR <250umol/l and conjugated bilirubin <10umol/l:
            ↳ No further action required, document in Badger.

      If total SBR >250umol/l or conjugated bilirubin >10umol/l:
            ↳ refer to neonatal service (number below)

Well, thriving, breast fed <37 week babies, not at risk of G6PD*: Assess as follows

<37 weeks but otherwise meeting the criteria above

Management:

Assess need for further SBR at 10-14 days:

  1. Review previous bilirubin measurements- look for evidence from serial transcutaneous or blood measurements that SBR is falling and now well away from the phototherapy line. 
          If this is not the case, take SBR:
                ↳ If total SBR <200umol/l and conjugated bilirubin <10umol/l:
                      ↳ No further action required, document in Badger.

                ↳ If total SBR >200umol/l or conjugated bilirubin >10umol/l:
                      ↳ refer to neonatal service (number below)

  2. If the bilirubin has clearly peaked and is falling but not gone by day 14:
    SBR from day 7 onwards showing total SBR <200umol/l and conjugated bilirubin <10umol/l
    • No further action required, document in Badger.
    • If total SBR >200umol/l or conjugated bilirubin >10umol/l refer to neonatal service (number below)
  3. No recent (after day 7) SBR and none required clinically (jaundice mild and fading):
    Refer to neonatal service (number below) for a deferred appointment (after day 21).
    • The neonatal team will call before the appointment to confirm that the jaundice persists at this point
    • When handing over to the Health Visitor request that they continue to monitor the jaundice when seeing the baby, and if the jaundice is clearing cancel the day 21 appointment by calling the number below.

Formula fed, pale stools/dark urine, clinical concerns, G6PD risk: Refer to Hospital

Babies not meeting the Community management criteria:

  • Formula fed
  • Pale stools and/or dark urine
  • Concerns regarding weight gain
  • Haemolysis (DAT/Coombs positive)
  • Family history of liver or haemolytic disorders
  • Mother's family from G6PD area (see map below)
  • Parental or midwifery concerns regarding general wellbeing

Management:

Refer to Neonatal services - number below

For babies with pale stools/dark urine, or concerns that they are unwell - see the same day
All other babies, see at next available clinic

For advice, or to make a referral, call the following numbers:

RHCG: 0141 452 4929

PRM: 0141 451 5222

RAH: 0141 314 7035

*G6PD Risk – If the mother’s family (or both parents, but not the father alone as G6PD is X linked) are from:

  • Sub-Saharan Africa
  • The Middle East
  • South East Asia

As denoted on the map below then the baby will require additional sampling for G6PD and so will be referred for hospital management.

Summary flow charts

Editorial Information

Last reviewed: 06 July 2021

Next review: 01 July 2022

Author(s): Allan Jackson, consultant neonatologist PRMH, Andrew Powls, consultant neonatologist PRMH, Lesley Jackson, consultant neonatologist RHCG, Anne Marie Heuchan, consultant neonatologist RHCG, Hilary Conetta, consultant neonatologist RAH, Jennifer Mitchell, Consultant Neonatologist RHCG, Veronica McArthur, community midwife (retired)

Co-Author(s): Other professionals consulted: Julie Boyd RCM representative