Neonatal Jaundice Clinical Guideline Education Presentation V2.0
30 minutesTowards your CPD Hours
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
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
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
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
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/ ]
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
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/]
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
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
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
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
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
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/]
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/ ]
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
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
Neonatal jaundice treatment graph
Queensland Maternity and Neonatal Clinical Guidelines Program: Neonatal jaundice 18
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
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
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
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]
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
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
Queensland Maternity and Neonatal Clinical Guidelines Program: Neonatal jaundice 25
Treatment• Phototherapy• Exchange transfusion• Pharmacological agents
• Adequate hydration is important
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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
hours of starting
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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
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
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
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
• 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
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