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Neonatal jaundice education presentation

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Neonatal Jaundice Clinical Guideline Education Presentation V2.0 30 minutes Towards your CPD Hours
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Page 1: Neonatal jaundice education presentation

Neonatal Jaundice Clinical Guideline Education Presentation V2.0

30 minutesTowards your CPD Hours

Page 2: Neonatal jaundice education presentation

References: The Queensland Maternity and Neonatal Clinical Guidelines Program clinical guideline Neonatal jaundice is the primary reference for this package.

Recommended citation:Queensland Maternity and Neonatal Clinical Guidelines Program. Neonatal jaundice. Clinical Guideline Education Presentation V2.0. Queensland Health. 2013.

Disclaimer: This presentation is an implementation tool and should be used in conjunction with the published guideline. This information does not supersede or replace the guideline. Consult the guideline for further information and references.

Feedback and contact details: M: GPO Box 48 Brisbane QLD 4001 | E: [email protected] | URL: www.health.qld.gov.au/qcg

Funding:The Queensland Maternity and Neonatal Clinical Guidelines Program is supported by the Clinical Access and Redesign Unit, Queensland Health.

Copyright: © State of Queensland (Queensland Health) 2013

This work is licensed under a Creative Commons Attribution Non-Commercial No Derivatives 3.0 Australia licence. In essence, you are free to copy and communicate the work in its current form for non-commercial purposes, as long as you attribute the Queensland Maternity and Neonatal Clinical Guidelines Program, Queensland Health and abide by the licence terms. You may not alter or adapt the work in any way. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/3.0/au/deed.en

For further information contact Queensland Maternity and Neonatal Clinical Guidelines Program, RBWH Post Office, Herston Qld 4029, email [email protected], phone (+61) 07 3131 6777. For permissions beyond the scope of this licence contact: Intellectual Property Officer, Queensland Health, GPO Box 48, Brisbane Qld 4001, email [email protected], phone (07) 3234 1479.

Queensland Maternity and Neonatal Clinical Guidelines Program: Neonatal jaundice 2

Page 3: Neonatal jaundice education presentation

Queensland Maternity and Neonatal Clinical Guidelines Program: Neonatal jaundice 3

Objectives• To gain an understanding of neonatal

jaundice:◦ Definition◦ Primary prevention strategies◦ Assessment and investigations ◦ Treatment options

Phototherapy Exchange transfusion Pharmacological therapy

◦ Discharge planning

Page 4: Neonatal jaundice education presentation

Queensland Maternity and Neonatal Clinical Guidelines Program: Neonatal jaundice 4

Definition• Neonatal jaundice

◦ Refers to the yellow discolouration in the skin and mucous membranes

◦ Associated with hyperbilirubinaemia Raised levels of bilirubin in the blood

• Significant hyperbilirubinaemia ◦ Serum bilirubin elevated to a level that

requires treatment

Page 5: Neonatal jaundice education presentation

Queensland Maternity and Neonatal Clinical Guidelines Program: Neonatal jaundice 5

Incidence• Term babies: 50-60%• Preterm babies: 80%• Physiological

◦ Most common• Pathological

◦ Significant because the cause requires investigation

◦ Aim to prevent bilirubin encephalopathy

Page 6: Neonatal jaundice education presentation

Physiological jaundice• Occurs in newborns due to a:

◦ Higher concentration of red blood cells◦ Shorter life span of newborn red blood cells◦ Slower metabolism, circulation and excretion of bilirubin

• Frequently exacerbated by inadequate milk intake• Not associated with underlying disease • Usually benign• Breast milk

jaundice is benign

Queensland Maternity and Neonatal Clinical Guidelines Program: Neonatal jaundice 6

Source: Mamatoto midwves [accessed 2013 March 18; http://mamatotomidwives.com.au/ ]

Page 7: Neonatal jaundice education presentation

Queensland Maternity and Neonatal Clinical Guidelines Program: Neonatal jaundice 7

Pathological jaundice

• Investigate:◦ Jaundice occurring within 24 hours of age◦ Increase of bilirubin > 8.5 micromol/L/hour◦ Jaundice persisting after 2 weeks in term or 3

weeks in preterm babies◦ Clay or white coloured stools◦ Conjugated bilirubin > 25 micromol/L

• Seek paediatrician / neonatology advice

Page 8: Neonatal jaundice education presentation

Queensland Maternity and Neonatal Clinical Guidelines Program: Neonatal jaundice 8

Bilirubin encephalopathy• Risk factors:

◦ Preterm birth◦ Rapid rate of rise of

serum bilirubin◦ Hypoalbuminaemia◦ Other co-morbidities,

e.g. Sepsis Asphyxia Acidosis

Source: Stanford School of Medicine [accessed 2013 March 5http://newborns.stanford.edu/PhotoGallery/]

Page 9: Neonatal jaundice education presentation

Queensland Maternity and Neonatal Clinical Guidelines Program: Neonatal jaundice 9

Acute bilirubin encephalopathy• Clinical manifestations of bilirubin toxicity

seen in the first few weeks after birth• Initial signs:

◦ Lethargy◦ Irritability◦ Apnoea◦ Hypotonia and poor suck

Page 10: Neonatal jaundice education presentation

Queensland Maternity and Neonatal Clinical Guidelines Program: Neonatal jaundice 10

Chronic bilirubin encephalopathy• Persistent brain dysfunction

◦ Athetoid cerebral palsy◦ Hearing deficit◦ Oculomotor disturbances◦ Dental dysplasia◦ Intellectual impairment

• Kernicterus◦ Pathological term◦ Clinically used to refer to the syndrome and sequelae

of bilirubin encephalopathy

Page 11: Neonatal jaundice education presentation

Queensland Maternity and Neonatal Clinical Guidelines Program: Neonatal jaundice 11

Prevention• Test all pregnant women:

◦ ABO and Rh (D) blood types ◦ Red cell antibodies:

If present → test cord blood:– Blood group including the Rh type– Direct antiglobulin test (DAT/Coombs test)– Full blood count for haemoglobin and haematocrit– Discuss with neonatologist

• Ensure adequate support for all breastfeeding women◦ Refer to Guideline: Breastfeeding initiation

Page 12: Neonatal jaundice education presentation

Queensland Maternity and Neonatal Clinical Guidelines Program: Neonatal jaundice 12

Care for all babies• Assess risk factors for significant

hyperbilirubinaemia:◦ Gestational age < 38 weeks ◦ Sibling with neonatal jaundice who required

phototherapy ◦ Mother's intention to breastfeed exclusively◦ Visible jaundice in the first 24 hours following birth

• Early visual inspection for jaundice• Educate and encourage parents to observe

for signs of adequate hydration, feeding and jaundice

Page 13: Neonatal jaundice education presentation

Queensland Maternity and Neonatal Clinical Guidelines Program: Neonatal jaundice 13

Care for all babies

Risk factors identified?

· An additional inspection by a healthcare professional within 48 hours

· Offer adequate support to women who intend to breastfeed

All babies· Examine for jaundice at every

opportunity especially in the first 72 hours

Yes

No

Page 14: Neonatal jaundice education presentation

Queensland Maternity and Neonatal Clinical Guidelines Program: Neonatal jaundice 14

Parent education• Educate and

encourage parents to observe for signs of adequate hydration, feeding and jaundice

• Seek advice if concerned

Source: Stanford School of Medicine [accessed 2013 March 5http://newborns.stanford.edu/PhotoGallery/]

Page 15: Neonatal jaundice education presentation

Queensland Maternity and Neonatal Clinical Guidelines Program: Neonatal jaundice 15

Visual examination• Check the naked baby in bright and preferably

natural light• Examination of the sclerae, gums and blanched

skin is useful across all skin tones• Cephalo-caudal progression of jaundice• Can lead to errors, particularly in babies:

◦ With darker skin tones◦ Who are preterm◦ Under 36 hours of age◦ Receiving phototherapy

Source: Mamatoto midwves [accessed 2013 March 18;http://mamatotomidwives.com.au/ ]

Page 16: Neonatal jaundice education presentation

Queensland Maternity and Neonatal Clinical Guidelines Program: Neonatal jaundice 16

Transcutaneous bilirubin

• For babies◦ Gestational age of 35

weeks or more◦ More than 24 hours of age

• May decrease the number of heel pricks and/or invasive blood tests

• If not available → measure serum bilirubin• If TcB level greater than 250 micromol/litre

→ measure serum bilirubin

Page 17: Neonatal jaundice education presentation

Queensland Maternity and Neonatal Clinical Guidelines Program: Neonatal jaundice 17

Total serum bilirubin• If TcB not available or indicated• For babies

◦ Gestational age < 35 weeks◦ < 24 hours of age

• If bilirubin level > 250 micromol/L• Preferred once baby is at the relevant

treatment threshold and for subsequent measurements

Page 18: Neonatal jaundice education presentation

Neonatal jaundice treatment graph

Queensland Maternity and Neonatal Clinical Guidelines Program: Neonatal jaundice 18

Page 19: Neonatal jaundice education presentation

Queensland Maternity and Neonatal Clinical Guidelines Program: Neonatal jaundice 19

All jaundiced babies• Do not use sunlight as treatment for

hyperbilirubinaemia • Discuss with and provide parent and carer

information• Encourage mother to breastfeed every 3

hours and wake baby if necessary• Do not subtract conjugated bilirubin from

total serum bilirubin when making decisions about the management of hyperbilirubinaemia

Page 20: Neonatal jaundice education presentation

Queensland Maternity and Neonatal Clinical Guidelines Program: Neonatal jaundice 20

< 24 hours of age• A medical emergency• Measure and record serum

bilirubin within 2 hours◦ Manage as per Neonatal

jaundice treatment graphs• Neonatology/paediatric/

medical review within 6 hours

• Commence phototherapy whilst awaiting serum bilirubin results

• Level 1-3 Neonatal Services:◦ Organise transfer to

nearest referral service

Visible jaundice?

YesIs baby less than 24

hours old?

Yes

Page 21: Neonatal jaundice education presentation

Queensland Maternity and Neonatal Clinical Guidelines Program: Neonatal jaundice 21

24 hours-10 days • Visual estimation of jaundice can lead to errors

• Measure and record TcB or serum bilirubin within 6 hours of suspecting significant jaundice◦ Manage as per Neonatal

jaundice treatment graphs• Level 1-3 Neonatal Services –

consider phototherapy if:◦ Results are unattainable for > 6

hours and: Baby has risk factors TCB > 250 micromol/L or

above treatment threshold Jaundice is below the nipple

line• Medical review is required –

consider transfer to a higher level service if bilirubin not responding to treatment

Is onset of jaundice 24 hours to 10

days of age?

Yes

Page 22: Neonatal jaundice education presentation

Queensland Maternity and Neonatal Clinical Guidelines Program: Neonatal jaundice 22

Investigation· Investigate the cause if not

explained by history and clinical examination

· Individualise fluid management and other care as indicated

· Routine blood tests:o Total serum bilirubino FBC ± filmo Blood group (maternal and baby)o DATo NBST (if applicable)

· Additional investigations may be required [refer to Guideline]

Page 23: Neonatal jaundice education presentation

Queensland Maternity and Neonatal Clinical Guidelines Program: Neonatal jaundice 23

Late onset or prolonged jaundice

Isonset of

jaundice after 10 days of age or

prolonged?

After 10 days of age or prolonged· Usually breastfeeding related· Requires investigation due to

risk of serious disease · Routine:o Total and conjugated bilirubin o Full blood count + blood filmo Reticulocyte counto Blood groupo DATo Thyroid function testso Review NBST results

· Investigate the cause and/or seek expert advice if indicated, for example: o Conjugated bilirubin > 25

micromol/Lo Pale stools, dark urine

· Additional investigations may be required [refer to Guideline]

Yes

Page 24: Neonatal jaundice education presentation

Queensland Maternity and Neonatal Clinical Guidelines Program: Neonatal jaundice

Conjugated hyperbilirubinaemia

Is conjugated bilirubin

>25 micromol/L?

• Requires urgent discussion with a neonatologist / paediatrician / gastroenterologist

Yes

24

Page 25: Neonatal jaundice education presentation

Queensland Maternity and Neonatal Clinical Guidelines Program: Neonatal jaundice 25

Treatment• Phototherapy• Exchange transfusion• Pharmacological agents

• Adequate hydration is important

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Page 26: Neonatal jaundice education presentation

Queensland Maternity and Neonatal Clinical Guidelines Program: Neonatal jaundice 26

Phototherapy

• Fibreoptic phototherapy isnot recommended for babies > 37 weeks

• Use fibreoptic, LED or conventional lights in babies < 37 weeks

• Initiate continuous multiple lights if SBR: ◦ Is rising rapidly (>8.5mmol/L per hour)◦ Is < 50 micromol/L below the exchange

transfusion threshold◦ Fails to respond to single bank of lights within 6

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Page 27: Neonatal jaundice education presentation

Queensland Maternity and Neonatal Clinical Guidelines Program: Neonatal jaundice 27

Phototherapy parent information• Why treatment is necessary• Maximum area of skin exposed• Need for eye protection and eye care• Temperature monitored (thermoneutral

environment)• Potential impact on breastfeeding –

reassure cuddle time allowed• Need for additional fluids – not routine

Page 28: Neonatal jaundice education presentation

Queensland Maternity and Neonatal Clinical Guidelines Program: Neonatal jaundice 28

Ceasing phototherapy· Measure serum bilirubin 4-6

hourly until the rise of the serum bilirubin is known to be controlledo Then measure 12-24 hourly

· Cease phototherapy when serum bilirubin is ≥ 50 micromol/L below the phototherapy thresholdo Repeat serum bilirubin 12-24

hours after cessation of phototherapy

Page 29: Neonatal jaundice education presentation

Exchange transfusion• Recommended if the serum bilirubin level is

above the exchange transfusion threshold and is not expected to be below the threshold after 6 hours of continuous multiple phototherapy

• Immediate exchange transfusion is recommended if there are clinical features and signs of bilirubin encephalopathy

• Offer parents or carers information on exchange transfusion

Queensland Maternity and Neonatal Clinical Guidelines Program: Neonatal jaundice 29

Page 30: Neonatal jaundice education presentation

Intravenous immunoglobulin• Rhesus haemolytic disease or ABO

haemolytic disease◦ An adjunct to continuous multiple

phototherapy when the serum bilirubin continues to rise by more than 8.5 micromol/litre per hour

• 500 mg/kg over 4 hours • Discuss and offer parents and carers

information

Queensland Maternity and Neonatal Clinical Guidelines Program: Neonatal jaundice 30

Page 31: Neonatal jaundice education presentation

• Do not discharge baby with:◦ Visible jaundice in the first 24 hours◦ Conjugated hyperbilirubinaemia without attempting to

find a cause◦ Risk factors if follow up is not available

• Provide written information to parents • Advise parents to seek advice if baby:

◦ Becomes jaundiced/worsening jaundice◦ Dark urine or pale chalky stools◦ Not feeding well/signs of dehydration

Queensland Maternity and Neonatal Clinical Guidelines Program: Neonatal jaundice 31

Discharge planning

Page 32: Neonatal jaundice education presentation

Queensland Maternity and Neonatal Clinical Guidelines Program: Neonatal jaundice 32

Follow-upBaby discharged

Should be seen by

Number of visits

Before 24 hours of age

72 hours of age If risk factor(s)

present, baby well and not visibly jaundiced – 48 hours

2 visits:1. 24-72 hours2. 72-120 hours Increase

frequency if risk factors present or as indicated

Between 24 and 48 hours of age

96 hours of age

Between 48 and 72 hours of age

120 hours of age


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