Jaundice Management in Neonates

The aim of this guideline is to support staff in ensuring the prompt assessment, recognition and treatment of jaundice, while minimizing the risks of unintended harm such as parental anxiety, decreased breastfeeding, and unnecessary costs or treatment.

Introduction

Jaundice is a common condition that can affect up to 60% of term neonates and 80% of preterm neonates. In the majority of cases, physiological jaundice resolves without intervention. However, some neonates can develop high levels of jaundice that can result in irreversible and permanent brain damage if not treated (NICE, 2010). The bilirubin level at which this damage occurs is lower in preterm neonates.

This guideline supports staff in the clinical management of neonatal jaundice due to unconjugated hyperbilirubinaemia at Great Ormond Street Hospital (GOSH) in accordance with NICE guidance CG98.

Aims and objectives

All medical and nursing staff who have contact with neonates should be trained in recognising, monitoring and treating neonatal jaundice, in accordance with Appendix 1. (Rationale 1)

The Neonatologists, General Paediatrician and Neonatal Nurse Advisor teams are available to provide advice and assist staff in dealing with jaundiced neonates.

Where there are any discrepancies between NICE guidance and this GOSH guideline, the NICE guidance should be followed and a query must be raised with the guideline owner to determine if the guideline requires amendment.

Duties and responsibilities

The Consultant in charge of the neonate’s care has ultimate responsibility for ensuring that neonatal jaundice is identified in a timely manner and treated in accordance with current NICE guidance and this guideline.

The registered bedside nurse caring for the neonate has responsibility to regularly check the patient for visual signs of jaundice, ensure that routine screening is carried out, and document their findings in the nursing notes.

Any registered nurse or doctor who suspects jaundice, whether through visual inspection or routine screening, is responsible for ensuring that either assessment using the transcutaneous bilirubinometer takes place or where this is not appropriate, blood tests should be carried out as soon as possible to determine the patient’s bilirubin level. They are also responsible for ensuring that results are provided by the laboratories in a timely manner and chasing these up if necessary.

The registered nurse or doctor who receives any blood tests back in relation to this patient is responsible for plotting the results on the correct NICE treatment chart (appendix 4) for the neonate’s gestational age. Other staff who suspect jaundice have an obligation to inform the registered nurse or doctor looking after the neonate.  

Where this plotting indicates treatment is required, the person who carried out the plotting is responsible for ensuring appropriate actions are taken rapidly to start phototherapy or discuss exchange transfusion with the Consultant in charge of the neonate’s care.

The guideline for detection and treatment of neonatal jaundice is part of mandatory training for clinical staff.

The Neonatologist, General Paediatric and Neonatal Nurse Advisor teams are available to provide advice and assist staff in dealing with neonates, however they are not solely responsible for identification and/or care of jaundiced neonates. Out of hours, further advice can be sought from on-call medical team for the relevant ward and the CSPs.  

Definitions

  • Conventional phototherapy: Phototherapy given using a single light source (not fibre optic) that is positioned above the neonate.
  • 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.
  • Exchange transfusion: procedure involving removing aliquots of the patient’s blood and replacing with donor blood in order to remove abnormal blood components and circulating toxins while maintaining adequate circulating blood volume
  • Fibre optic phototherapy: phototherapy given using a single light source that comprises a light generator, a fibre optic cable through which the light is carried and a flexible light pad, on which the neonate is placed or that is wrapped around the neonate.
  • Multiple/Intensified phototherapy: Intensifying the level of phototherapy delivered by switching to the double phototherapy option on the Natus blue lights and/or using more than one light source; for example, two or more conventional units, or a combination of conventional and fibre optic units.
  • Point of care testing (POCT): refers to any form of diagnostic testing undertaken outside of an accredited laboratory environment.
  • Preterm: less than 37 weeks completed gestational age.
  • Prolonged jaundice: jaundice lasting more than 14 days in term neonates and more than 21 days in preterm neonates.
  • Significant hyperbilirubinaemia: an elevation of the serum bilirubin to a level requiring treatment.
  • Term: Thirty-seven weeks or more gestational age.
  • Visible jaundice: Jaundice detected by visual inspection.
  • TSB: Total serum bilirubin level
  • TcB: Transcutaneous bilirubin level

Parent information

Medical and nursing staff caring for the neonate are responsible for offering parents or carers information about neonatal jaundice. This information should be tailored to individual needs and expressed concerns, taking care to avoid causing unnecessary anxiety. Information should be discussed verbally and backed up with written information. A leaflet is available to download via the Neonatal Jaundice section on the GOSH website.  

Assessment of jaundice

Jaundice within 24 hours of life is an emergency and needs urgent investigation and treatment. (Rationale 2)

For all neonates

All neonates should be examined for jaundice at every opportunity, especially within the first 72 hours of life. Colour assessment must be:

  • performed every time the neonate is examined, vital signs are recorded and cares are performed; and
  • documented daily as a minimum, recorded in the nursing notes by nursing staff and medical notes by medical staff.

Do not rely on visual inspection alone to estimate the bilirubin concentration.

On admission, all neonates <7 days (and all visibly jaundiced patients) should have their bilirubin measured (Rationale 3, Rationale 4)

Serum Bilirubin measurement is the most common method of assessing bilirubin levels. When printing request forms request a total and split bilirubin (rationale 5). The total bilirubin must be plotted on the appropriate treatment threshold chart

Other measurement methods are available throughout the trust: 

Squirrel ward (GOSH)

Transcuatneous bilirubinometer: This is currently only in use on Squirrel ward at GOSH and can be used for neonates over 24 hours postnatal age and over 35 weeks of gestational age. Result must be plotted on the appropriate neonatal jaundice treatment threshold chart. If for any reason, a transcutaneous bilirubinometer is not available or you are not trained in its use a serum bilirubin measurement should be obtained and plotted on the appropriate threshold chart

If the TcB level is more than 250 micromol/litre, then the result needs to be checked by measuring the serum bilirubin as the bilirubinometer becomes inaccurate at higher bilirubin levels.

TcB is not an appropriate measure of jaundice in the following situations when the serum bilirubin must be measured:

  • to determine the bilirubin level in neonates with jaundice in the first 24 hours of life (Rationale 6)
  • in a neonate less than 35 weeks of gestational age (Rationale 7)
  • in neonates who are at or above the relevant treatment threshold for their postnatal age and for all subsequent measurements (Rationale 8)
  • for assessment of jaundice after 14 days of age (Rationale 9)

For neonatesover 38 weeks of gestation, further management of jaundice can then be guided by the following threshold table (see Appendix 2).

The transcutaneous bilirubinometer should be cleaned with a sanitising wipe (e.g Clinel) between patients according to manufacturer’s guideline (A Transcutaneous bilirubinometer video is available on the GOSH Online Learning & Development portal). The Trancutaneous bilirubinometer must also be calibrated daily. 

If staff are trained in its use then transcutaneous bilirubinometer can also be used in other clinical areas for patients that meet the above criteria.

Use of blood gas analysers (ABL90 flex) for bilirubin measurement on NICU
  • The ABL90 blood gas analysers can be used for bilirubin monitoring trends during treatment of hyperbilirubinaemia in neonates up to one month of age or one month from term if premature. 
  • Serum from older children and adults contain potential interferents such as carotenoids and other pigments which may interfere with the bilirubin analysis. Serum from this age group has not been evaluated for use by this method and should therefore be sent to the laboratory for analysis.
  • The blood gas analysers have been evaluated for bilirubin levels of up to 300 μmol/L. Bilirubin concentrations greater than 300µmol/L should therefore be monitored using the laboratory method.
  • Prior to starting serum bilirubin monitoring, the initial diagnostic blood sample should be sent to the laboratory for split bilirubin analysis. Part of the same sample should also be measured on the blood gas analyser and the results compared. The results should be within 10% of each other.
  • If the difference between the results is greater than 10%, repeat the comparison. If the difference between the results of the repeat samples is still greater than 10%, do not use the blood gas analyser. Use the laboratory only for bilirubin monitoring.
  • Once the baseline has been established, it is recommended that a blood sample is sent to the Chemical Pathology for split bilirubin on a daily basis to ensure the ongoing accuracy of the blood gas analyser results. However it is recommended that trends should be monitored using the results from one method wherever possible, as this reveals trends in results more clearly.
  • If there are any unexpected results a blood sample should be sent to the laboratory for split bilirubin analysis.
  • If there is any concern over the blood gas analyser results, please contact Senior nursing staff or POCT team for further advice.
  • Blood gas analysers should only be used by those trained and certified as competent in accordance with the Trust’s POCT policy.

Plotting results

Whichever method is used for measuring the bilirubin the total must be plotted on an appropriate neonatal jaundice treatment threshold chart (Rationale 10). There are different charts for each week of gestation and the time of birth is needed to plot correctly (Rationale 11, 12), (see appendix 3 for quick reference guide) It is insufficient to solely rely on the bilirubin result to determine whether treatment is required; these results must be plotted.

The forms can be found on the GOSH web intranet (under clinical forms and then neonatal jaundice treatment threshold chart). 

There is a video on Gold LMS for GOSH staff showing how to plot a bilirubin on a threshold chart. Individual staff members are responsible for ensuring they know how to plot a treatment threshold graph correctly and this may form part of the mandatory training for clinical staff.

If a staff member suspects jaundice but for whatever reason is unable to measure the bilirubin themselves, they still remain responsible for ensuring that the measurement is taken, sent for testing and followed up.

If once plotted, the treatment threshold graph demonstrates that treatment is not required at that time, the person checking the results is responsible for discussing further management with medical staff responsible for neonate and following advice given by the NICE jaundice guideline (2010).

If once plotted, the treatment threshold graph demonstrates that treatment is required, the person checking the results is responsible for discussing treatment options with medical staff responsible for the neonate and for commencing treatment in line with NICE guidance (2010). The individual who identifies that treatment is required is responsible for ensuring that treatment is commenced as quickly as possible.

Patients with high levels of conjugated bilirubin have an entirely different disease process. Please discuss treatment options with consultant responsible for the neonate as this could suggest a serious liver disorder or metabolic disease and require referral to a specialist.

Determining need for phototherapy In neonates who are clinically well, have a gestational age of 38 weeks or more and are more than 24 hours old, and who have a bilirubin level that is below the phototherapy threshold but within 50 micromol/litre of the threshold (see the threshold table and the treatment threshold graphs from the full guideline), repeat bilirubin measurement as follows:

  • within 18 hours for neonates with risk factors for neonatal jaundice (those with a sibling who had neonatal jaundice that needed phototherapy or a mother who intends to exclusively breastfeed)
  • within 24 hours for neonates without risk factors.

In neonates who are clinically well, have a gestational age of 38 weeks or more and are more than 24 hours old, and have a bilirubin level that is below the phototherapy threshold by more than 50 micromol/litre (see the threshold table and the treatment threshold graphs), do not routinely repeat bilirubin measurement. 

Diagnosis

In neonates who require a clinical intervention due to jaundice such as phototherapy or an exchange transfusion, medical staff must ensure that the following are conducted:

  • clinical examination
  • split bilirubin 
  • blood group
  • direct antiglobulin test (DAT), also known as Coomb’s test
  • full blood count

The following tests should also be considered when assessing for underlying disease where there is significant hyperbilirubinaemia:

  • examination of blood film
  • glucose-6-phosphate (G6PD)
  • if sepsis is suspected - microbiological cultures of blood, urine and cerebrospinal fluid (CSF)

The individual who requested the blood test is responsible for ensuring that the result is obtained in a timely manner and plotted, whether plotted themself or delegated to another staff member. If the laboratory results are not forthcoming, they are responsible for chasing these up.

Once the laboratory results have been received, the individual who receives the test results is responsible for plotting the total bilirubin level on the correct NICE treatment threshold chart, available on the GOSH intranet

Treatment

The individual who identifies that phototherapy is required must commence this as quickly as possible. Medical staff must be informed of the need to commence phototherapy but this should not delay treatment.

Phototherapy treatment is given as follows:

Single phototherapy:
  • a Natus blue light; or
  • fibre optic blanket 
Intensified phototherapy:
  • Natus blue lights (with the double phototherapy switch on); and/or
  • Optional addition of a fibre optic blanket or additional Natus blue light/s.

Once phototherapy treatment has commenced, the NICE neonatal jaundice pathway must be followed in relation to escalating and reducing/stopping treatment. Any concerns about rising bilirubin levels must be escalated to the Consultant in charge of the patient’s care.

Three Natus blue lights are available from the central store and can be requested via the CARPS system and searched for using the asset tracking system. NICU also have two Natus blue lights and one fibre optic blanket which can be shared more widely if hospital wide equipment is in use or unavailable due to service. |Asset number 49646 is the number of the biliblanket.

Single phototherapy treatment:

Use conventional ‘blue light’ phototherapy as treatment for significant hyperbilirubinaemia in all neonates unless:

  • The serum bilirubin level is rising rapidly (more than 8.5 micromol/litre per hour)
  • The serum bilirubin is at a level that is within 50 micromol/litre nbelow the threshold for which exchange transfusion is indicated after 72 hours (see treatment threshold tables)
Continuous intensified phototherapy treatment:

Initiate continuous intensified phototherapy to treat all neonates if any of the following apply:

  • The serum bilirubin level is rising rapidly (more than 8.5 micromol/litre per hour)
  • The serum bilirubin is at a level within 50 micromol/litre below the threshold for which exchange transfusion is indicated after 72 hours
  • The bilirubin level fails to respond to single phototherapy (that is, the level of serum bilirubin continues to rise, or does not fall, within 6 hours of starting single phototherapy)
Care of the neonate receiving phototherapy

Staff must ensure that practices not endorsed by NICE, including the use of cling wrap over Babytherms, are not undertaken as they may pose a risk of harm. (Rationale 13)

See Quick reference guide for information on how to set up phototherapy for use with incubators and Babytherms (appendix 3). Note: Please note the different setup of the lights when used with Babytherm and ensure the light is angled ensuring it does not block the radiant heater.

Appropriate care must be given to a neonate undergoing phototherapy treatment, including:

  • ensuring adequate hydration - this includes providing advice and support to breastfeeding mothers. (Rationale 14)
  • extra fluids should not be given routinely. Hydration should be monitored by daily weighing of the neonate and assessing fluid balance; (Rationale 15)
  • ensuring the light source is at the correct distance from the neonate (follow the manufacturer’s guidance: 30cm for Natus blue lights); (Rationale 16)
  • ensuring treatment is applied to the maximum area of skin; (Rationale 17)
  • ensuring ointment or cream are not used on skin  
  • ensuring the neonate is clothed only in eye protection and a nappy to maximise surface area exposed roll nappy down rather than removing completely (Rationale 18); 
  • performing routine eye care; (Rationale 19)
  • placing the neonate in a supine position unless clinical condition dictates otherwise; (Rationale 20)
  • monitoring the neonate's temperature and ensure the neonate is kept in a thermoneutral environment (36.7-37.3) (Rationale 21)
  • supporting parents and carers and encouraging them to interact with the neonate.
Breaks and feeds while receiving phototherapy

Single phototherapy: use your clinical judgment to allow breaks of up to 30 minutes for neonates undergoing single phototherapy to allow for feeds, cuddles, cares etc.

ntensified phototherapy: Intensified phototherapy should be continuous and feeds should be provided either intravenously or via naso-gastric tube or bottle depending on the individual.

During phototherapy

Repeat serum bilirubin measurement 4–6 hours after initiating phototherapy and document on the appropriate chart.

Repeat serum bilirubin measurement every 6–12 hours when the serum bilirubin level is stable or falling, and document on the appropriate chart.

Stopping phototherapy

Stop phototherapy once serum bilirubin has fallen to a level at least 50 micromol/litre below the phototherapy threshold on the treatment threshold graphs.

Check for rebound of significant hyperbilirubinaemia with a repeat and record serum bilirubin measurement 12–18 hours after stopping phototherapy.

If the result plotted on the NICE treatment threshold chart indicates that exchange transfusion is required, this must be urgently escalated to the responsible Consultant.

Exchange transfusion is a Consultant decision and must be carried out in the intensive care environment by experienced staff familiar with the procedure.

Use intravenous immunoglobulin (IVIG) (500 mg/kg over 4 hours) for neonates with Rhesus or ABO haemolytic disease if serum bilirubin level rises by more than 8.5 micromol/litre/hour. (NICE Guidance CG98).

During the exchange transfusion, continue with intensified phototherapy.

Follow the NICE quick reference exchange transfusion pathway and local guidance on exchange transfusion.

Following exchange transfusion:
  • maintain continuous intensified phototherapy
  • measure and record serum bilirubin level within 2 hours and manage according to treatment threshold graphs

Prolonged Jaundice

Prolonged jaundice is defined as jaundice lasting over 14 days in a term neonate and over 21 days in a preterm neonate. Prolonged jaundice can be due to unconjugated or conjugated hyperbilirubinaemia. This must be investigated as some causes may need further treatment.

The following steps must be taken where prolonged jaundice occurs:

  • a full history and clinical examination should be performed;
  • weight should be plotted on an appropriate weight centile chart;
  • stool and urine should be examined: pale, chalky stools and dark urine
  • suggests cholestasis;
  • routine metabolic screening must be performed including screening of
  • congenital hypothyroidism; and
  • a serum bilirubin should be taken to establish whether the bilirubin is conjugated or unconjugated. Conjugated bilirubinaemia is defined as a conjugated bilirubin >17mmol/L if the total bilirubin is <85mmol/L or more than 20% of the total bilirubin if the total is >85mmol/L.

If the bilirubin is conjugated, consultation with a specialist should take place to determine further investigation and management

If the bilirubin is unconjugated a full blood count, liver function tests, thyroid function test and urine culture should be taken

Most commonly the diagnosis is unconjugated hyperbilirubinaemia due to breastmilk jaundice, but this is a diagnosis of exclusion.

If there are any concerns about prolonged jaundice, this must be escalated to the Consultant in charge of the patient’s care.

Quick link to related guidance

Rationale

Rationale 1: Timely and appropriate management of jaundice is essential to prevent the risk of bilirubin encephalopathy and kernicterus.
Rationale 2: Neonates that are jaundiced at <24 hours are at increased risk of developing significant hyperbilirubinemia 
Rationale 3: Internal audit shows that we need to improve identification of jaundice. Evidence suggests neonates that are unwell and/or premature are at greater risk of developing significant hyperbilirubinaemia
Rationale 4: Evidence suggests that visual estimation of jaundice is not reliable (NICE 2010)
Rationale 5: Jaundice presenting at <24 hours is more likely to have a pathological cause and require treatment
Rationale 6: All bilirubin samples sent on neonates <28 days at Great Ormond street when reported will include the total bilirubin and the conjugated and unconjugated bilirubin measurements. 

Rationale 7: There is limited evidence about the reliability of TcB measurement in preterm neonates <35/40
Rationale 8: The most accurate measurement method should be used in patient with high bilirubin levels requiring treatment and phototherapy may affect the reliability of the TcB measurement.
Rationale 9: Assessment of the levels of conjugated and unconjugated bilirubin is essential in assessment of prolonged jaundice and a TcB is not able to measure this.
Rationale 10: The treatment threshold charts guide treatment using acceptable bilirubin levels for each gestation and 
Rationale 11: The level at which bilirubin is toxic is lower at lower gestations. 
Rationale 12: Raised bilirubin levels <24 hours of age is a medical emergency knowing the time of birth and plotting the chart correctly is essential to identify neonates that require treatment and are < 24 hours of age.
Rationale 13: Using cling film or bubble wrap especially on neonates that are self-ventilating poses a risk of suffocation and is not advised.
Rationale 14: Mothers that intend to breastfeed should be supported in line with the Trust Breastfeeding Policy 
Rationale 15: The need for additional fluids should be assessed on an individual basis 
Rationale 16: Ensuring the light is at the optimal distance in relation to the neonate maximises irradiance and therefore maximises efficiency of the light source
Rationale 17: To maximise skin exposure to light source
Rationale 18: There is the potential for photochemical damage to eyes if eye protection is not used. 
Rationale 19: To reduce risk of conjunctivitis associated with wearing eye patches for prolonged periods.
Rationale 20: To ensure consistent advice is given in relation to reducing the risks associated with sudden neonate death syndrome.
Rationale 21: The neonate will be exposed for phototherapy so will require frequent monitoring of temperature and may need the temperature of the neonatetherm mattress to be increased or the use of the overhead heater. Any changes will be guided by regular temperature measurements.

References

National Institute for Health and Care Excellence (2010) Neonatal Jaundice: full guideline [CG98]. London: National Institute for Health and Care Excellence. [Last accessed on 27.07.2017].

National Insititue for Health and Care Excellence (2016) Addendum to Jaundice in newborn neonates under 28 days. London: National Insitute for Health and Care Excellence. [Last accessed on 27.07.2017].

Document control information

Lead Author(s)

Simon Hamman, Head of Neonatal Services and Consultant Neonatologist
Marie-Anne Kelly, Neonatal Nurse Advisor

Document owner(s)

Simon Hamman, Head of Neonatal Services and Consultant Neonatologist

Approved by

Guideline Approval Group

Reviewing and Versioning

First introduced: 
21 July 2017
Date approved: 
21 July 2017
Review schedule: 
Three years
Next review: 
21 July 2020
Document version: 
1.0