Queensland neonatal jaundice clincial guideline

Neonatal jaundice

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Queensland Maternity and Neonatal Clinical Guideline: Neonatal jaundice

Refer to online version, destroy printed copies after use Page 2 of 35

Document title: Neonatal jaundice

Publication date: November 2012

Document number: MN12.7-V4-R17

Replaces document: MN09.7-V3-R12 Neonatal jaundice: prevention, assessment and management

Author: Queensland Maternity and Neonatal Clinical Guidelines Program

Audience: Health professionals in Queensland public and private maternity services

Review date: November 2017

Endorsed by: Statewide Maternity and Neonatal Clinical Network

Contact: Queensland Maternity and Neonatal Clinical Guidelines Program Email: [email protected] URL: www.health.qld.gov.au/qcg

Disclaimer These guidelines have been prepared to promote and facilitate standardisation and consistency of practice, using a multidisciplinary approach. Information in this guideline is current at time of publication. Queensland Health does not accept liability to any person for loss or damage incurred as a result of reliance upon the material contained in this guideline. Clinical material offered in this guideline does not replace or remove clinical judgement or the professional care and duty necessary for each specific patient case. Clinical care carried out in accordance with this guideline should be provided within the context of locally available resources and expertise. This Guideline does not address all elements of standard practice and assumes that individual clinicians are responsible to:

• Discuss care with consumers in an environment that is culturally appropriate and which enables respectful confidential discussion. This includes the use of interpreter services where necessary

• Advise consumers of their choice and ensure informed consent is obtained. • Provide care within scope of practice, meet all legislative requirements and maintain

standards of professional conduct • Apply standard precautions and additional precautions as necessary, when delivering care • Document all care in accordance with mandatory and local requirements

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© State of Queensland (Queensland Health) 2010

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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. For further information contact Queensland Maternity and Neonatal Clinical Guidelines Program, RBWH Post Office, Herston Qld 4029, email [email protected] phone (07) 3131 6777.



Flow chart: Assessment and investigation of jaundice



Abbreviations

ALP Alkaline phosphatase ALT Alanine aminotransferase AST Aspartate aminotransferase CMV Cytomegalovirus DAT Direct antiglobulin test (Coombs test) EBM Expressed breast milk FBC Full blood count GGT Gamma glutamyl transpeptidase G6PD Glucose-6-phosphate dehydrogenase IVIg Intravenous immunoglobulin LED Light emitting diode LFT Liver function test MC&S Microscopy, culture and sensitivity test µW microwatts NBST Newborn screening test NNT Number needed to treat nm Nanometre ± Plus or minus PCR Polymerase chain reaction QCC Queensland Emergency Systems Coordination Centre QCMB Queensland Centre for Mothers and Babies RFDS Royal Flying Doctor Service Rh Rhesus Rh D Rhesus antibody type D RSQ Retrieval Services Queensland TcB Transcutaneous bilirubin T4 Thyroxine TFT Thyroid function test

TORCH Toxoplasmosis, rubella, cytomegalovirus, herpes simplex, human immunodeficiency virus

TSB Total serum bilirubin TSH Thyroid stimulating hormone



Definition of terms

ABO incompatibility

“ABO incompatibility describes an antibody reaction that occurs when mother and baby have different blood groups, typically maternal blood group O, and baby blood group A or B. Some mothers have naturally occurring anti-A and anti-B antibodies present in the circulation, which can pass across the placenta and bind to antigenic sites on fetal red cell[s]. Some mothers are sensitised by feto-maternal transfusion of ABO incompatible blood.”1

Conjugated bilirubin

Also known as direct bilirubin. The form of bilirubin after being processed by the liver. It is then transported by the biliary system to the intestine and excreted, although it can be broken down (de-conjugated) and reabsorbed from the gut. Bacterial breakdown of bilirubin in the intestine contributes to the colour of the faeces.1

Conventional phototherapy

Where the light source, either fluorescent or halogen but not fibreoptic, is positioned above the baby.1 When positioned 20 cm above the baby, spectral irradiance is should measure at 8-10 µW/cm2/nm over the waveband interval 430-490 nm.2

G6PD deficiency

Is familial. At risk babies include those of Mediterranean, Middle Eastern, African or Southeast Asian origin.3 It is of X linked recessive inheritance and is very rare in females.

Haemolysis Red blood cell breakdown. Hyper-bilirubinaemia Raised levels of bilirubin in the blood.1

Intensive phototherapy

Single or multiple phototherapy with spectral irradiance measuring at least 30 µW/cm2/nm over the waveband interval 460-490 nm.4

Irradiance Refers to the light intensity or energy output of the phototherapy unit and the number of photons (spectral energy) that are delivered per unit area (cm2) of exposed skin. Confounded by optical properties of skin and rates of bilirubin production and elimination.5

mg/dl Convert mg/dl to micromol/litre by multiplying by 17.1.1

Multiple phototherapy

Phototherapy that is administered by more than one light source simultaneously.1 Also known as intensive or double/triple phototherapy.

Opisthotonos Backward arching of the back.1 Sclera The white of the eye (plural sclerae).1 Significant hyper-bilirubinaemia

An elevation of the serum bilirubin to a level requiring treatment.1

Thermoneutral An environment that keeps the body temperature within a range that will minimise energy expenditure.1

Unconjugated bilirubin

Also known as indirect bilirubin. The form of bilirubin which has not been processed by the liver. As unconjugated bilirubin can penetrate the blood-brain barrier, it is potentially toxic and may result in short and/or long term neurological dysfunction.1

Unconjugated hyper-bilirubinaemia

Occurs when the liver cannot process the amount of unconjugated bilirubin presented to it. This may occur due to: • Excessive haemolysis and/or • Immaturity of liver enzymes involved in conjugation



Table of Contents

1 Introduction ..................................................................................................................................... 7 1.1 Bilirubin encephalopathy ........................................................................................................ 8

2 Prevention ...................................................................................................................................... 9 3 Assessment .................................................................................................................................. 10

3.1 All babies ............................................................................................................................. 10 3.2 Bilirubin measurement ......................................................................................................... 11 3.3 All jaundiced babies ............................................................................................................. 12 3.4 Additional assessment – jaundice visible at less than 24 hours of age .............................. 13 3.5 Additional assessment – jaundice first visible at 24 hours to 10 days of age ..................... 14 3.6 Additional assessment – onset of jaundice after 10 days of age and prolonged jaundice .. 15 3.7 Additional assessment – conjugated hyperbilirubinaemia ................................................... 16

4 Treatment ..................................................................................................................................... 16 4.1 Inter-hospital transfer ........................................................................................................... 16 4.2 Phototherapy........................................................................................................................ 17

4.2.1 Bilirubin monitoring .......................................................................................................... 17 4.2.2 Type of phototherapy equipment ..................................................................................... 18 4.2.3 Efficacy ............................................................................................................................ 18 4.2.4 Phototherapy care considerations ................................................................................... 19 4.2.5 Phototherapy observations and hydration ....................................................................... 20 4.2.6 Side-effects of phototherapy ............................................................................................ 21 4.2.7 Cessation of phototherapy ............................................................................................... 21

4.3 Exchange transfusion .......................................................................................................... 22 4.4 Adjunct therapy .................................................................................................................... 23

5 Discharge planning and follow-up ................................................................................................ 24 5.1 Follow-up assessment ......................................................................................................... 25

References .......................................................................................................................................... 26 Appendix A: Kramer’s rule ................................................................................................................... 28 Appendix B: Neonatal jaundice treatment graphs ............................................................................... 29 Acknowledgements .............................................................................................................................. 35 List of Tables

Table 1. Types of jaundice .................................................................................................................... 7 Table 2. Adverse jaundice sequelae ..................................................................................................... 8 Table 3. Prevention of jaundice ............................................................................................................. 9 Table 4. Care for all babies - clinical practice points ........................................................................... 10 Table 5. Types of bilirubin measurement ............................................................................................ 11 Table 6. Assessment for all babies with jaundice ................................................................................ 12 Table 7. Differential diagnosis and investigations for babies less than 24 hours of age ..................... 13 Table 8. Differential diagnosis and investigations for babies 24 hours to 10 days of age .................. 14 Table 9. Differential diagnosis and investigations for after 10 days of age ......................................... 15 Table 10. Differential diagnosis and investigations for conjugated hyperbilirubinaemia ..................... 16 Table 11. Serum bilirubin measuring and monitoring .......................................................................... 17 Table 12. Type of phototherapy equipment depending on gestation and serum bilirubin .................. 18 Table 13. Elements affecting phototherapy efficacy ............................................................................ 18 Table 14. Phototherapy care ............................................................................................................... 19 Table 15. Observations and hydration ................................................................................................. 20 Table 16. Side-effects of phototherapy ................................................................................................ 21 Table 17. Serum bilirubin measuring and monitoring – ceasing phototherapy ................................... 21 Table 18. Exchange transfusion .......................................................................................................... 22 Table 19. Adjunct therapy .................................................................................................................... 23 Table 20. Elements of discharge planning .......................................................................................... 24 Table 21. Follow-up assessment ......................................................................................................... 25



1 Introduction During the first week of life all newborns have increased bilirubin levels by adult standards, with approximately 50-60% of term1,6 and 80% of preterm1 babies developing jaundice. Neonatal jaundice refers to the yellow discolouration of the skin and sclera caused by the accumulation of bilirubin in the skin and mucous membranes. This is associated with hyperbilirubinaemia. Although most jaundice is physiologically normal [refer to Table 1], it is important to detect pathological causes of jaundice and those babies at risk of significant hyperbilirubinaemia with the aim of preventing bilirubin encephalopathy [refer to Table 2]. Table 1. Types of jaundice

Jaundice Explanation

Physiological

• Physiological jaundice occurs due to the1: o Higher concentration of red blood cells in newborns o Shorter life span of newborn red blood cells o Slower metabolism, circulation and excretion of bilirubin in newborns

• Usually appears 2 to 4 days after birth, resolving after 1 to 2 weeks6 (3 weeks if preterm)

• Frequently exacerbated by inadequate milk intake • Is not associated with underlying disease and is usually benign

Breast milk jaundice

• Develops 5 to 7 days after birth and peaks at 14 days7 • At one month of age, approximately 10% of breastfed babies remain

jaundiced1 • A suggested cause is an increased concentration of β-glucuronidase in

breast milk and the associated increase in deconjugation and reabsorption of bilirubin7

• Is benign

Pathological • Refer to Sections 3.3-3.7 for causes and investigations associated with time

of onset of jaundice • Refer to Section 1.1 Bilirubin encephalopathy



1.1 Bilirubin encephalopathy Unbound unconjugated bilirubin can penetrate the blood-brain barrier. It is potentially toxic and may result in short and/or long term neurological dysfunction1 [refer to Table 2]. There is a poor correlation between circulating bilirubin levels and severity of encephalopathy. Table 2. Adverse jaundice sequelae

Adverse sequelae Explanation

Risk factors

• Potential risk factors for neurotoxicity include: o Preterm birth1 o Rapid rate of rise of serum bilirubin1 o Hypoalbuminaemia o Other co-morbidities (sepsis, asphyxia and acidosis)

Acute bilirubin encephalopathy

• Refers to the clinical manifestations of bilirubin toxicity1 seen in the first few weeks after birth5

• Initial signs include: o Lethargy5 o Irritability1 o Apnoea1 o Hypotonia and poor suck progressing to3:

Hypertonia (opisthotonos) High pitched cry, and Eventually seizures and coma

Chronic bilirubin encephalopathy

• Refers to the pathogenic diagnosis of persistent brain dysfunction arising from hyperbilirubinaemia1

• Clinical findings of chronic bilirubin encephalopathy include3: o Athetoid cerebral palsy with or without seizures o Developmental delay o Hearing deficit o Oculomotor disturbances including paralysis of upward gaze

(Parinaud’s sign) o Dental dysplasia o Intellectual impairment

Kernicterus

• A pathology term, referring to the yellow staining of the basal nuclei of the brain1

• The term is frequently used to refer to the clinical syndrome and sequelae, including acute and [more commonly the] chronic brain effects, of bilirubin encephalopathy1



2 Prevention Table 3. Prevention of jaundice

Element Clinical practice points

Pregnancy, labour and birth

• Test all pregnant women for ABO, Rh (D) blood types and red cell antibodies5,3 during pregnancy: o If maternal red blood cell antibodies noted antenatally, test cord blood:

Blood group1 including Rh type Direct antiglobulin test (DAT/Coombs test)5,3 Full blood count (FBC) for haemoglobin and haematocrit Discuss with neonatologist3

• If the mother has not had antenatal blood tests send: o Maternal blood for blood group (ABO/Rh), and o Baby’s cord blood for blood group1, Rh type and DAT5,3

• Tests not predictive of severe hyperbilirubinaemia include1: o Umbilical cord blood total serum bilirubin o End-tidal carbon monoxide measurement (ETCOc) o Routine umbilical cord DAT

• Delayed cord clamping is recommended by the World Health Organization.8 It is associated with an increased risk of jaundice requiring phototherapy, which is offset by improved iron status of the newborn for up to 6 months9

Breastfeeding

• Support all women who choose to breastfeed1 • Encourage demand feeding or at least 3-4 hourly or as age appropriate • Consider referral to a midwife or Lactation Consultant (if available) to

provide the mother with feeding support3 • Promote the ingestion of colostrum to increase stooling to prevent

reabsorption of bilirubin o Use of suppositories and enemas to increase stooling is of no clinical

benefit3 • Supplementation with water and/or dextrose water does not affect bilirubin

levels and is not recommended3 o If supplemental fluids are indicated, then maternal expressed breast

milk (EBM) is the feed of choice • Refer to Guideline: Breastfeeding initiation10



3 Assessment

3.1 All babies Table 4. Care for all babies - clinical practice points

Element Clinical practice points

All babies

• Identify babies with risk factors associated with significant hyperbilirubinaemia1: o Gestational age less than 38 weeks o A previous sibling requiring phototherapy o Mother’s intention to breastfeed exclusively [refer to Section 2 and

Guideline: Breastfeeding initiation10] o Visible jaundice within the first 24 hours following birth

• If risk factor identified: o For visible jaundice within the first 24 hours following birth – an urgent

medical review is required within 6 hours [refer to Section 3.4] o For other risk factors – arrange an additional visual inspection, by a

healthcare professional, within the first 48 hours of the baby’s life • Examine all babies for jaundice at every opportunity especially in the first

72 hours1,3 • Educate and encourage parents and carers to observe for signs of

adequate hydration, feeding and jaundice [refer to Queensland Centre for Mothers and Babies (QCMB) Neonatal jaundice parent information sheet11]

• Ensure appropriate discharge planning and follow-up [refer to Section 1]

Visual examination

• Always assess the baby in a bright and preferably natural light1 (e.g. in daylight by a window5)

• Assess the sclerae, gums and blanch the baby’s skin with a finger to observe the underlying skin colour1

• Jaundice appears first in the face and progresses caudally to the trunk and extremities1 [Refer to Appendix A for associated information]

• Visual estimation of bilirubin levels can lead to errors2,3 particularly in babies1: o With darker skin tones o Who are preterm o Under 36 hours of age o Who are receiving phototherapy

• Visual examination is sufficient to exclude jaundice1 • Do not measure bilirubin levels routinely in babies who are not visibly

jaundiced1 • Consider a bilirubin measurement in any baby who is jaundiced [refer to

Table 5]



3.2 Bilirubin measurement Table 5. Types of bilirubin measurement

Visible jaundice Clinical practice points

Transcutaneous bilirubin (TcB)

• Only for babies1: o Gestational age of 35 weeks or more o More than 24 hours of age

• May be particularly useful in health care settings where total serum bilirubin level results are not expected to be available within 6 hours

• Prior to commencing phototherapy, consider a photo-opaque patch applied to the baby’s skin (e.g. the forehead)12 o TcB measurements have been shown to be accurate when taken on

skin that is not exposed to phototherapy12 Base clinical decisions on a TcB trend rather than a single value12

• If TcB is greater than 250 micromol/L – check serum bilirubin1 • Use according to the manufacturer’s information (e.g. calibration

requirements) • TcB measurements may decrease the numbers of heel pricks and/or

invasive blood tests required13

Total serum bilirubin

• If TcB is not indicated or available1 • For babies1:

o Gestational age of less than 35 weeks o Less than 24 hours of age

• Preferable to TcB for babies within treatment thresholds and for subsequent measurements1

• Treat venous and capillary total serum bilirubin levels the same5,3 • If collected in the community:

o Collect in heparinised, light protected blood tube Ensure sample is mixed well

o Protect from light (e.g. by using brown paper bag) o Avoid excessive heat (e.g. carry in esky/cooler box in the car) o Enable analysis as soon as practical o Consider collection of full blood count at the same time



3.3 All jaundiced babies Table 6. Assessment for all babies with jaundice

All jaundiced babies

Clinical practice points

• Measure and record bilirubin level in all babies within 6 hours of identifying obvious or suspected significant jaundice o Interpret bilirubin levels according to the baby’s postnatal age in hours

and manage hyperbilirubinaemia according to the Neonatal jaundice treatment graphs1 [refer to Appendix B]

• Do not use sunlight as a treatment for jaundice or hyperbilirubinaemia1 • Parents and carers:

o Provide information on treatment for hyperbilirubinaemia – if indicated o Breastfeeding babies [refer to Section 2]:

Encourage mother to breastfeed frequently (e.g. every 3 hours) and to wake their baby for feeds if necessary

Develop a feeding plan and provide lactation support

Assessment

• Jaundice may be a sign of serious illness • Review the history:

o Family history of significant haemolysis (including G6PD deficiency) • Clinical examination including:

o Feeding since birth o Weight o Hydration including elimination (number of wet nappies and stools) o Risk factors:

Preterm birth Onset of jaundice within 24 hours [refer to Table 7] Sepsis Asphyxia Acidosis Signs of illness (e.g. lethargy, poor feeding, fever/temperature

instability, vomiting, significant weight loss, irritability) Dark urine and light stools [refer to Table 9 and Table 10] Bilirubin is rising more than 8.5 micromol/L per hour Jaundice reappears after an initial improvement Jaundice persisting after 2 weeks in a term baby and 3 weeks in a

preterm baby [refer to Table 9] • Investigate the cause of jaundice if it is not explained by the history and

clinical examination5 [refer to Sections 3.4-3.7] • Do not use the albumin/bilirubin ratio when making decisions about the

management of hyperbilirubinaemia1 • Refer to neonatologist/paediatrician for management if results abnormal or

jaundice persisting without cause

Jaundice approaching exchange level

• Seek neonatologist/paediatrician advice • Consider further investigations

o Direct (conjugated) bilirubin – abnormal if greater than 25 micromol/L1 o Liver function test (LFT) o G6PD deficiency1 o Screen for Gilbert Syndrome



3.4 Additional assessment – jaundice visible at less than 24 hours of age Table 7. Differential diagnosis and investigations for babies less than 24 hours of age

Jaundice visible at less than 24 hours

Clinical practice point

• A medical emergency: o Measure and record the serum bilirubin within 2 hours of identifying

obvious or suspected jaundice1 Commence phototherapy whilst awaiting serum bilirubin results

o Urgent neonatology/paediatric/medical review required: Within 6 hours of identifying obvious or suspected jaundice To exclude pathological causes of jaundice

• Level 1-3 Neonatal services: o Organise transfer to nearest referral service [refer to Section 4.1]

Differential diagnosis

• Almost always pathological • Usually due to haemolysis:

o Rhesus disease o ABO incompatibility o Red cell enzyme defects (e.g. G6PD deficiency)

• Sepsis (e.g. acute/intrauterine infection) • Rarer causes may include:

o Other blood group incompatibilities (Kell, Duffy, anti-E) o Red cell membrane defects (hereditary spherocytosis)

Investigations

• Refer to Table 6. Assessment for all babies with jaundice • Routine1:

o TSB – for baseline level to assess response to treatment o Full blood count. Consider ± blood film o Blood group (maternal and baby)1 o DAT – consider strength of reaction1 (DAT may have a weak false

positive for mothers who received Anti D during pregnancy) • Consider1:

o G6PD deficiency o Microbiological cultures (MC&S) of:

Blood Urine Cerebrospinal fluid



3.5 Additional assessment – jaundice first visible at 24 hours to 10 days of age

Table 8. Differential diagnosis and investigations for babies 24 hours to 10 days of age

Jaundice first visible at 24 hours to 10 days

Clinical practice point

• Measure and record the transcutaneous or serum bilirubin level within 6 hours of identifying obvious or suspecting significant jaundice1

• Commence phototherapy if bilirubin higher than the Neonatal jaundice treatment graph threshold [refer to Appendix B]

• Medical review required • Level 1-3 neonatal services, consider phototherapy if results are unavailable

within 6 hours, and: o Baby has risk factors o TcB is greater than 250 micromol/L or above treatment threshold o Jaundice is below the nipple line13

• Consider transfer to a higher level facility if bilirubin not responding to treatment


• Most commonly benign physiological jaundice • Dehydration • Sepsis • Haemolysis • Polycythemia • Breakdown of extravasated blood (e.g. bruising) • Increased entero-hepatic circulation which may be due to gut obstruction • Metabolic disease including galactosaemia

Investigations

• Refer to Table 6. Assessment for all babies with jaundice • Routine1:

o TSB – for baseline level to assess response to treatment o Full blood count. Consider ± blood film o Blood group (maternal and baby)1 o DAT – consider strength of reaction1 (DAT may have a weak false

positive for mothers who received Anti D during pregnancy) o Newborn Screening Test (NBST) if not already taken

• Consider: o G6PD deficiency (at risk newborns include Mediterranean, Middle

Eastern, African or Southeast Asian origin)1,3 o MC&S1:

Blood Urine Cerebrospinal fluid

o TORCH screen



3.6 Additional assessment – onset of jaundice after 10 days of age and prolonged jaundice

Table 9. Differential diagnosis and investigations for after 10 days of age

Onset of jaundice after 10 days and prolonged jaundice Prolonged jaundice

• Obvious persisting clinical jaundice at greater than 2 weeks of age in term babies and greater than 3 weeks of age in preterm babies


• Sepsis • Hypothyroidism • Hypopituitarism • Hypoadrenalism • Haemolytic anaemia • Hereditary Spherocytosis • Pyloric stenosis or gastrointestinal obstruction • Breast milk jaundice

Investigations

• Requires investigation due to the risk of serious disease • Medical review including:

o Examination/enquiry regarding stool colour Pale stools and dark urine require urgent discussion with a

neonatologist/paediatrician/gastro-enterologist o Review of previous pathology results

• Routine: o Total and conjugated bilirubin

If conjugated bilirubin greater than 25 micromol/L refer to Table 10 o FBC + blood film o Reticulocyte count o Blood group o DAT – consider strength of reaction1 (DAT may have a weak false

positive for mothers who received Anti D during pregnancy) o Thyroid function test (TFT) (including TSH and T4) o Review NBST results*

• If the baby is unwell: o Discuss with a paediatrician/neonatologist o Consider further investigations

Septic screen • If above test results are normal, the baby is well and breastfeeding, it is

likely to be breast milk jaundice * Health Services Support Agency, Pathology Queensland, Central Laboratory, Chemical Pathology, Newborn screening: Email [email protected]; phone 3646 7171 or 3646 7051



3.7 Additional assessment – conjugated hyperbilirubinaemia Table 10. Differential diagnosis and investigations for conjugated hyperbilirubinaemia

Conjugated hyperbilirubinaemia


• Congenital obstruction and malformations of the biliary system (e.g. biliary atresia, choledochal cyst, bile duct stenosis)

• Idiopathic neonatal hepatitis • Infections (Hepatitis B, TORCH, sepsis, intrauterine) • Metabolic disorders (galactosaemia, hereditary fructose intolerance, Alpha-

1 antitrypsin deficiency, tyrosinaemia, glycogen storage disease type IV, hypothyroidism)

• Prolonged parenteral nutrition

Investigations

• Conjugated hyperbilirubinaemia requires urgent discussion with a neonatologist/paediatrician/gastro-enterologist

• Consider initiating investigations by requesting: o Total serum bilirubin and conjugated bilirubin levels o LFT (including: AST, ALT, GGT, ALP and albumin) o Coagulation screen o Blood gas (with blood glucose) o Liver ultrasound o Ferritin o TFTs (including TSH and T4) o Alpha-1-antitrypsin phenotype o Urine:

Cytomegalovirus (CMV) PCR Culture and sensitivity Reducing substances

• Additional investigations to consider include: o Urine:

Organic acids Amino acids

o Serum amino acids o Plasma:

Ammonia Pyruvate Lactate

4 Treatment Hyperbilirubinaemia can be treated with phototherapy, exchange transfusion and pharmacological agents.1, 3 Adequate hydration is also an important consideration in the baby with moderate to high bilirubin levels. It is important to also treat the underlying illnesses that may be causing jaundice (e.g. infection).

4.1 Inter-hospital transfer Management options will depend on the services available at each facility [refer to the Queensland Health Clinical Services Capability Framework14]. For management advice, contact the Queensland Emergency Medical Systems Coordination Centre (QCC) by calling 1300 799 127. Transfer or referral to a higher level facility for management and treatment options may be appropriate. This will be coordinated by the QCC via Retrieval Services Queensland (RSQ) and a Neonatal medical coordinator (phone: 1300 799 127) or the Royal Flying Doctor Service ((RFDS) as per local procedures). Refer to Guideline: Neonatal stabilisation for retrieval. Babies requiring inter-hospital transfer for management of jaundice by phototherapy or exchange transfusion, require phototherapy (at least a biliblanket) and IV fluids en-route (this can be provided by the retrieval team).



4.2 Phototherapy

4.2.1 Bilirubin monitoring Table 11. Serum bilirubin measuring and monitoring

Phototherapy Clinical practice point

Commencing

• When assessing the need for phototherapy, do not subtract the direct reacting or conjugated bilirubin level from the total serum bilirubin level5

• Interpret bilirubin levels according to the baby’s postnatal age in hours and manage hyperbilirubinaemia according to the Neonatal jaundice treatment graphs1 [refer to Appendix B] o For the first 14 days after birth, use the graph that reflects the baby’s

gestational age at birth • Do not commence phototherapy unless the bilirubin level exceeds the

threshold • For babies greater than 12 hours old with a serum bilirubin level 1-50

micromol/L below the phototherapy threshold: o Repeat the serum bilirubin in 6-24 hours as clinically indicated

• Document time and type of phototherapy commenced • Refer to Section 4.2.4 Phototherapy care considerations

During

• If the serum bilirubin is decreasing or unlikely to be significantly higher in the next 12-24 hours, then measure the serum bilirubin 12-24 hourly

• If after 24 hours, the serum bilirubin is stable or falling: o Measure the serum bilirubin every 24 hours until bilirubin is below

treatment threshold [refer to Table 17] • Increase frequency of serum bilirubin measurements as clinically indicated

o Consider measuring the bilirubin 4-6 hourly until the rise of serum bilirubin has stabilised

• Switch off phototherapy light during blood collection Continuous

multiple phototherapy

• Initiate if the serum bilirubin level1: o Is rising rapidly (greater than 8.5 micromol/L/hour) o Is less than 50 micromol/L below the exchange transfusion threshold o Does not fall in response to single phototherapy

• Reduce to single phototherapy when the serum bilirubin level: o Is at minimum 50 micromol/L below the threshold for which exchange

transfusion is indicated1 Ceasing • Refer to Section 4.2.7 Cessation of phototherapy



4.2.2 Type of phototherapy equipment As well as effectiveness, also consider the impact on maternal and baby bonding when choosing phototherapy equipment to treat neonatal jaundice. Table 12. Type of phototherapy equipment depending on gestation and serum bilirubin

Element Clinical practice point

Term babies (≥ 37 weeks)

• Conventional blue light1, overhead light emitting diodes (LED)15 and other modes of phototherapy are preferred to fibreoptic phototherapy as first line treatment

• Conventional compared to fibreoptic phototherapy is associated with: o A greater decrease in serum bilirubin o Shorter duration of phototherapy1,6

Preterm babies (< 37 weeks)

• Use either fibreoptic, conventional blue light or LED phototherapy • Conventional compared to fibreoptic phototherapy is associated with1:

o A longer duration of phototherapy • Early phototherapy is associated with a lower mean peak in serum bilirubin

level1

Continuous multiple phototherapy

• Usually requires at least 2 banks of phototherapy lights3 or the use of a combination of methods (e.g. conventional phototherapy plus biliblanket) o Single LED devices may deliver the same spectral irradiance as

multiple phototherapy4 • Use special blue fluorescent tubes or specially designed LEDs5 if available

4.2.3 Efficacy Table 13. Elements affecting phototherapy efficacy

Element Clinical practice point Equipment • Maintain and use according to manufacturers’ instructions

Light source • Wavelengths in the blue-green spectrum (~460-490 nm) are effective with special blue the most effective (~460 nm)4

Light (spectral) irradiance

• Energy output is usually measured in microwatts per cm2 (µW/cm2) and is normally marked on each phototherapy unit

• Conventional phototherapy – spectral irradiance should measure 8-10 µW/cm2/nm over the waveband interval 430-490 nm2

• Continuous multiple (intensive) phototherapy – spectral irradiance should measure least 30 µW/cm2/nm over the waveband interval 460-490 nm4

• Confirm spectral irradiance with an appropriate meter calibrated over the appropriate wavelength range4

• Check phototherapy units regularly using the method recommended by the manufacturer1, to ensure adequate irradiance is delivered: o Do not exceed recommended hours of use prior to technical service as

irradiance of all lamps decreases with use4 • Maintain distance from baby and orientation of light source according to

manufacturer’s instructions4 • Light rays should be perpendicular to the surface of the incubator to

minimise reflectance4



4.2.4 Phototherapy care considerations Table 14. Phototherapy care

Element Clinical practice point Equipment

Conventional • Incubator or open cot according to clinical need1 and unit policy Fibreoptic pad

(e.g. biliblanket) • Incubator or open cot according to clinical need

LED • Incubator or open cot according to clinical need and unit policy Phototherapy bed

(e.g. bilibed) • Open cot or as per manufacturer’s recommendation • Consider adding/changing to bank of lights if total serum bilirubin level

continues to rise

Clothing

• Maximise exposed body surface area1 o Total body surface area exposed to phototherapy is clinically more

important than the number of devices used • Remove all clothing (except ‘folded down’ disposable nappy)

o Remove nappy when serum bilirubin levels continue to rise or continuous multiple phototherapy is required

• Place fibreoptic pads15 or a LED mattress below the baby Fibreoptic pad

• Place fibreoptic pad between skin and singlet

o Writing side facing away from baby, illuminating side facing baby o Cable at baby’s feet, tip of the pad at the baby’s shoulders o Turn variable intensity knob to fully on (e.g. represented by sun)

• Parents are able to handle baby Phototherapy bed • Dress only in manufacturer’s jumpsuit to maximise exposure to light

Baby’s position

• Supine recommended1 • In intensive and special care nurseries, babies who are nursed in a prone

position (for clinical reasons) require continuous cardio respiratory monitoring16

Eye patches

• Required to protect immature retina3,17 • Remove with feeds/cares18

o Perform eye care as indicated o Replace before recommencing phototherapy

• Refer to manufacturers’ recommendations for fibreoptic pads and phototherapy beds, as eye patches are recommended by some manufacturers

Parents & carers

• Discuss and provide parents with information including: o Why phototherapy is being considered o The possible adverse effects of phototherapy o The need for eye protection and routine eye care o Reassurance that short breaks for feeding, nappy changing and

cuddles will be encouraged o What might happen if phototherapy fails o Rebound jaundice o Potential long-term adverse effects of phototherapy o Potential impact on breastfeeding and how to minimise this o Refer to QCMB Neonatal jaundice Parent information sheet11

• Where possible, enable mother and baby to remain together while baby receives phototherapy

• Provide support and encourage parental interaction with their baby1 • Consider home phototherapy for low risk babies

o Refer to local guidelines o Regular monitoring of serum bilirubin is essential5 o Refer to Section 5 Discharge planning and follow-up



4.2.5 Phototherapy observations and hydration Table 15. Observations and hydration

Element Clinical practice point

Temperature

• Ensure the baby is kept in a thermoneutral environment1 to minimise the side effects of temperature instability15

• Monitor the baby’s temperature1: o Hourly for the first 4 hours18, then 4-6 hourly (e.g. with feeds)

Incubator • Conventional phototherapy may lead to an elevated incubator temperature: o Do not turn the incubator off

It is not safe to nurse a baby in an incubator that has been turned off as air no longer circulates

• LED devices produce minimal heat15 • Cover temperature probe with reflective disc if servo control method is used

to monitor temperature o Servo control should only be used by experienced clinicians

Other observations

• As per clinical condition and/or maturity • With conventional blue light therapy it is difficult to distinguish cyanotic

colour changes in the baby – ensure an apnoea or saturation monitor is also used

• Check for skin rashes [refer to Photosensitivity row in Table 16] • Report dark urine and/or light (pale) stools

Hydration

• Provide lactation and feeding support1 o Monitor attachment, milk transfer (sucking and swallowing) and

maternal milk supply o Breastfeeding on demand at least 3-4 hourly or as age appropriate

Wake baby if necessary o Phototherapy often starts at the same time the breast milk supply is

increasing. Therefore additional feeds may not be necessary • Assess wet nappies1 • Document input and output • Daily weigh1 if required • Additional feeds may be indicated with:

o Excessive weight loss (e.g. greater than 12 percent of birth weight in breastfed babies19)

o Evidence of hypovolaemia or dehydration (e.g. decreased urine output) o Stool output is less than three small stools a day20

• If additional feeds are indicated: o Maternal EBM is the preferred choice1 o Do not supplement with water or dextrose water1,2 o Intragastric feeds with EBM and/or artificial formula (if parents/carers

are agreeable) may be required2 Discuss risk and benefits and obtain consent for the use of formula

o Intravenous therapy may be indicated in severe cases or preferred by some mothers to protect breastfeeding

Conventional ‘blue light’ and

LED phototherapy

• May be discontinued for shorts breaks (e.g. up to 30 minutes) for breastfeeding, nappy changing and cuddles1

• Does not routinely require additional fluids or feeds1

Fibreoptic • Remains in-situ during feeds Continuous

multiple phototherapy

• Do not interrupt for feeding1 – consider intragastric feeding • Continue lactation and feeding support to assist with breastfeeding when

treatment ceases1



4.2.6 Side-effects of phototherapy Table 16. Side-effects of phototherapy

Side effect Considerations

Insensible water loss

• Changes in the baby’s thermal environment leads to increased peripheral blood flow and insensible water loss17

• Likely to be more of an issue with conventional rather than LED phototherapy

Intestinal hypermotility • Associated with distended abdomen, loose stools and diarrhoea3

Photosensitivity

• Congenital porphyria or a family history of porphyria is a contraindication to the use of phototherapy.5,17 Babies with congenital erythropoietic porphyria can develop severe blistering and photosensitivity during phototherapy

• Concomitant use of photosensitising drugs or agents is a contraindication to phototherapy5,17

Bronze baby syndrome

• Babies with cholestatic jaundice may development bronze baby syndrome15 and rarely purpura and bullous eruptions5

Parental and carer anxiety

• Potential separation may cause interference in mother baby interaction5,3 • Some parents find eye patching disturbing5 • Refer to Table 14. Phototherapy care

4.2.7 Cessation of phototherapy Table 17. Serum bilirubin measuring and monitoring – ceasing phototherapy

Phototherapy Clinical practice points

Ceasing

• Cease phototherapy when serum bilirubin is at least 50 micromol/L below the phototherapy threshold1 o Inform the parents/carers about the possibility of rebound jaundice and

the potential need for follow-up serum bilirubin • Check for rebound with repeat serum bilirubin 12-24 hours after ceasing

phototherapy o Assess the need for the baby to stay in hospital during this time o Babies at increased risk of clinically significant rebound are those7:

Born at less than 37 weeks gestation With haemolytic disease Treated with phototherapy during the birth hospitalisation



4.3 Exchange transfusion A total serum bilirubin level at or above the exchange transfusion level should be considered a medical emergency. Commence continuous multiple phototherapy immediately1,2 and discuss further care with a neonatologist. Table 18. Exchange transfusion

Elements Considerations

Indications1

• 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 phototherapy1

• Immediate exchange transfusion is recommended if: o There are signs of bilirubin encephalopathy1

Preparing for exchange transfusion

• Exchange transfusion should only be performed by trained personnel in a Level 6 or Level 5 (in consultation with a Level 6) neonatal intensive care service14 o If immediate exchange transfusion is required discuss the management

of this situation with a neonatologist o Arrange transfer to an appropriate higher level facility as required [refer

to Section 4.1 and Guideline: Neonatal stabilisation for retrieval21] • Facilities undertaking exchange transfusions should ensure local guidelines

are in place • Initiate/maintain continuous multiple phototherapy1 • Consider Intravenous Immunoglobulin (IVIg)1:

o Refer to Table 19 for IVIg indications and clinical practice points • Discuss with parents or carers ensuring information is provided on1:

o Why the treatment is being considered o Anticipated duration of treatment o Possible adverse effects o When it would be possible for parents to see and hold their baby o The need to admit their baby to an intensive care nursery

• Consider collecting blood for investigation of the rare causes of severe hyperbilirubinaemia3: o Discuss with a neonatologist o There is no value in collecting blood for investigation of causes of

jaundice after an exchange transfusion

Possible adverse effects

• Thrombocytopenia1 • Hypocalcaemia1 • Catheter malfunction • Hypotension1 • Venous thrombosis1,22 • Hypokalaemia • Hypoglycaemia1 • Vasospasm22 • Apnoea22 • Bradycardia22 • Cyanosis22 • Necrotising enterocolitis22



4.4 Adjunct therapy Table 19. Adjunct therapy

Therapy Consideration and clinical practice points

Intravenous Immunoglobulin

• Maintain continuous multiple phototherapy • Consult with a neonatologist prior to treatment • Consider IVIg (500 mg/kg over 4 hours) in a baby with the following

exceptional circumstances1: o Rhesus haemolytic disease or ABO haemolytic disease, and o The serum bilirubin is rising by more than 8.5 micromol/L/hour despite

continuous multiple phototherapy • Refer to the National Blood Authority Australia and current product

information sheet7 for further administration information • Reduces the use of and number of exchange transfusions per baby in

Rhesus haemolytic disease (NNT = 2-3) or ABO haemolytic disease (NNT = 5-13)1

• The use of IVIg may be recommended in special circumstances such as23: o Parental refusal for exchange transfusion o Where appropriate blood components for exchange transfusion are

unavailable • Offer parents or carers information on IVIg including:

o Why IVIg is being considered o Why IVIg may be needed to treat significant hyperbilirubinaemia o The possible adverse effects of IVIg o When it will be possible for parents or carers to see and hold the baby

Other

• Evidence does not support the use of:1: o Agar o Albumin o Barbiturates o Charcoal o Cholestyramine o Clofibrate o D-penicillamine o Glycerin o Manna o Metalloporphyrins o Riboflavin o Traditional Chinese medicine o Acupuncture o Homeopathy o Sunlight



5 Discharge planning and follow-up Table 20. Elements of discharge planning

Elements Consideration and clinical practice points

Parents and carers

• Discuss and provide written information on the signs of jaundice, adequate hydration and feeding1

• Reassure that neonatal jaundice is common and usually transient o Refer to QCMB Neonatal jaundice Parent information sheet11

• Advise parents against exposure to sunlight as a treatment for jaundice • If the cause of jaundice is G6PD deficiency advise parents:

o Against the use of naphthalene o To wash all clothing/ bedding that may have been exposed to

Naphthalene • Advise parents and carers to seek urgent advice from a healthcare

professional if their baby becomes jaundiced within the first 24 hours of life • Parents and carers should also seek advice from a healthcare professional

if their baby: o Becomes jaundice o Has worsening jaundice o Has jaundice persisting beyond 14 days o Is passing pale chalky stools or dark urine o Is not feeding well o Shows signs of dehydration

Recommended follow-up

• Organise and/or advise parent(s) to have their baby examined by a qualified health care professional in the first few days after discharge to assess if the baby is well and for the presence of jaundice2,3

• Timing and location of this assessment is determined by2,3: o Length of hospital stay o Presence of associated risk factors for significant hyperbilirubinaemia

[refer to Table 4] o Risk of other neonatal problems

Baby discharged Should be seen by Number of visits

Before 24 hours of age

• 72 hours of age5 • If risk factor(s)

present, baby well and not visibly jaundiced – 48 hours1

• 2 visits5: 1. 24-72 hours 2. 72-120 hours

• Increase frequency if risk factors present or as indicated5 Between 24 and 48

hours of age • 96 hours of age5

Between 48 and 72 hours of age • 120 hours of age5

• Within the first 24 hours of life – do not discharge a baby with visible

jaundice – investigate as per Sections 3.3 and 3.4 • Never discharge a baby with conjugated hyperbilirubinaemia without

attempting to find the cause – investigate as per Sections 3.3 and 3.7 • If appropriate follow-up cannot be arranged and there are risk factors it may

be necessary to delay discharge until5: o Follow-up can be arranged o The greatest risk has passed (72-96 hours)

• Ensure discharge documentation includes a summary for parents and clinicians including any follow-up blood tests (e.g. repeat FBC and serum bilirubin levels) that are required



5.1 Follow-up assessment Table 21. Follow-up assessment

Elements Consideration and clinical practice points

Follow-up assessment

• Follow-up assessment must include2: o Baby’s weight and percentage change from birth weight o Review of feeding history to determine adequacy of intake o Voiding and stooling pattern o Presence or absence of jaundice o Clinical judgement to determine the need for total serum bilirubin level

measurement If there is any doubt measure the total serum bilirubin level2

• Other follow-up considerations include: o Healthy hearing o Encephalopathy – long term medical follow-up recommended o Haemolysis – follow-up for 4-6 weeks, due to potential for anaemia:

Advise weekly FBC and reticulocyte count Folic acid supplementation if continued haemolysis is suspected



References

1. National Institute for Health and Clinical Excellence. Neonatal jaundice. CG98. London: National Insititute for Health and Clinical Excellence; 2010.

2. Gregory MLP, Martin CR, Cloherty JP. Neonatal hyperbilirubinemia. In: Cloherty JP, Eichenwald EC, Hansen AR, Stark AR, editors. Manual of neonatal care. 7th ed. Philadelphia: Lippincott Williams & Wilkins 2012.

3. Canadian Paediatric Society. Position statement: (FN 2007-02). Guidelines for detection, management and prevention of hyperbilirubinemia in term and late preterm newborn infants (35 or more weeks' gestation). Paediatric Child Health. 2007; 12 Supplement B(May/June):1B-12B.

4. American Academy of Pediatrics. Technical report: Phototherapy to prevent severe neonatal hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics. 2011; 128:e1046-e52.

5. American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. Clinical Practice Guideline: Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics. 2004; 114:297-316. DOI: 10.1542/peds.114.1.297.

6. Woodgate P, Jardine LA. Neonatal jaundice. BMJ: Clinical Evidence. 2011; 09:319.

7. National Blood Authority Australia, Standing Council on Health. Criteria for the clinical use of intravenous immunoglobulin in Australia. Second edition. 2012 [cited 2012 August 25]. Available from: http://www.nba.gov.au/ivig/index.html.

8. World Health Organization, Department of Making Pregnancy Safer. WHO recommendations for the prevention of postpartum haemorrhage. 2007.

9. McDonald S, Middleton P. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database of Systematic Reviews. 2008; Issue 2. Art. No.: CD004074. DOI: 10.1002/14651858.CD004074.pub2.

10. Queensland Maternity and Neonatal Clinical Guidelines Program. Breastfeeding initiation. Guideline No. MN10.19-V2-R15. Queensland Health. 2010 [cited 2012 September 4]. Available from: http://www.health.qld.gov.au/qcg/.

11. Queensland Centre for Mothers and Babies, Queensland Maternity and Neonatal Clinical Guidelines Program. Parent information sheet. Neonatal jaundice. 2011 [cited 2012 August 25]. Available from: http://www.qcmb.org.au/parent_information_sheets

12. Zecca E, Barone G, Daniele DL, Marra R, Tiberi E, Romagnoli C, et al. Skin bilirubin measurement during phototherapy in preterm and term newborn infants. Early Human Development. 2009; doi:10.1016/j.earlhumdev.2009.05.010.

13. Maisels MJ. Noninvasive measurements of bilirubin. Pediatrics. 2012; 129(4):779-81.

14. Queensland Health. Clinical Services Capability Framework for Public and Licensed Private Health Facilities v3.0. Brisbane: Queensland Government Department of Health. 2011.

15. Kumar P, Chawla D, Deorari A. Light-emitting diode phototherapy for unconjugated hyperbilirubinaemia in neonates. Cochrane Database of Systematic Reviews. 2011; Issue 12. Art. No.: CD007969. DOI: 10.1002/14651858.CD007969.pub2.

16. Queensland Health. Safe infant care to reduce the risk of sudden unexpected deaths in infancy policy statement and guidelines. Queensland Government; 2008.

17. Maisels MJ, McDonagh AF. Phototherapy for neonatal jaundice. The New England Journal of Medicine. 2008; 358(9):920-8.

18. Truman P. Jaundice in the preterm infant: effective management. Journal of Neonatal Nursing. 2003; 9(1):22-6.

19. Wong R, Bhutani V. Treatment of unconjugated hyperbilirubinemia in term and late preterm infants. UpToDate. 2011 [cited 2012 April 27]. Available from: http://www.uptodate.com/contents/search.



20. Wong R, Bhutani V. Pathogenesis and etiology of unconjugated hyperbilirubinemia in the newborn. UpToDate. 2011 [cited 2012 April 27]. Available from: http://www.uptodate.com/contents/search.

21. Queensland Maternity and Neonatal Clinical Guidelines Program. Neonatal stabilisation for retrieval. Guideline No. MN11.18-V1-R16. Queensland Health. 2011 [cited 2012 September 4]. Available from: http://www.health.qld.gov.au/qcg/.

22. US Preventive Services Task Force (USPSTF). Screening of infants for hyperbilirubinemia to prevent chronic bilirubin encephalopathy: US Preventive Services Task Force recommendation statement. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2009.

23. Horn A, Kirsten G, Kroon S, Henning P, Moller G, Pieper C, et al. Phototherapy and exchange transfusion for neonatal hyperbilirubinaemia: neonatal academic hospitals' consensus guidelines for South African hospitals and primary care facilities. South African Medical Journal. 2006; 96(9):819-24.

24. Kramer LI. Advancement of dermal icterus in the jaundiced newborn. American Journal of Diseases of Children. 1969; 118(September):454-8.



Appendix A: Kramer’s rule Please note:

• Visual estimation of bilirubin levels can lead to errors particularly in babies1: o With darker skin tones o Who are preterm o Under 36 hours of age o Who have already commenced phototherapy

• Visual estimation should not be relied on to estimate the bilirubin level in a baby with jaundice1

Kramer recognised the cephalocaudal progression of jaundice with increasing total serum bilirubin levels and divided the baby into 5 zones, with a total serum bilirubin level measurement associated with each zone. This is known as Kramer’s rule (see Figure 1) and has traditionally been used to visually assess the severity of jaundice.24

Figure 1. Kramer’s Rule

Zone Definition TSB

(micromol/L)

1 Head and neck 100

2 Upper trunk 150

3 Lower trunk and thighs 200

4 Arms and lower legs 250

5 Palms and soles >250



Appendix B: Neonatal jaundice treatment graphs These example forms require approval for use by local health service.













Acknowledgements

The Queensland Maternity and Neonatal Clinical Guidelines Program gratefully acknowledge the contribution of Queensland clinicians and other stakeholders who participated throughout the guideline development process particularly:

Working Party Clinical Lead

Dr Peter Schmidt, Neonatologist, Gold Coast Hospital

Working Party Members

Mr Glen Alexander, Nurse Unit Manager, Logan Hospital

Ms Suzanne Bunker, Registered Nurse/Midwife, Royal Brisbane and Women’s Hospital

Ms Liz Chappell, Neonatal Educator, Gold Coast Hospital

Mrs Eileen Cooke, Consumer Representative, Preterm Infants’ Parents’ Association (PIPA)

Ms Anne-Marie Feary, Clinical Nurse Facilitator, Gold Coast Hospital

Ms Karen Hose, Neonatal Retrieval Project Officer, Royal Brisbane and Women’s Hospital

Ms Debra Humbley, Acting Nurse Unit Manager, Emergency Department and Maternity, Dalby Health Service

Dr Arif Huq, Paediatrician, Bundaberg Hospital

Mr Bruce Maybloom, Medical Student, Bond University

Ms Kristy Newnham, Acting Nurse Educator (Neonatal), Nambour General Hospital

Ms Elesha Toscano, Nurse Educator, Mater Children’s Hospitals

Ms Mary Tredinnick, Pharmacist, Royal Brisbane and Women’s Hospital

Ms Lorraine Turner, Lactation Consultant, Logan Hospital

Ms Cathy Van den Berg, Project Manager, Gold Coast Hospital

Queensland Maternity and Neonatal Clinical Guidelines Program Team

Associate Professor Rebecca Kimble, Director

Ms Jacinta Lee, Manager

Ms Lyndel Gray, Clinical Nurse Consultant

Steering Committee

Funding

This clinical guideline was funded by Queensland Health, Centre for Healthcare Improvement.

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Queensland neonatal jaundice clincial guideline

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