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In May 2016, the National Institute for Health and Care Excellence (NICE) published updated guidelines entitled ‘Jaundice in newborn babies under 28 days’ (box 1).1 The guideline covers diagnosis and treatment of neonates with jaundice, aiming ‘to help detect and prevent very high levels of bilirubin’. New recommendations focus on measuring and monitoring bilirubin levels and the type of phototherapy. Here, we summarise the guideline, highlighting updates and relevance to clinical practice.
The original NICE guideline CG98, published in May 2010, was jointly developed with the National Collaborating Centre for Women and Children's Health (now part of the National Guideline Alliance) to encourage more uniform, evidence-based practice.
Care for all babies: use every opportunity in the first 72 hours to visually inspect babies for jaundice, particularly in the first 48 hours for those at higher risk (table 1). Examine in bright, natural light, pressing gently to look for jaundice on ‘blanched’ skin, and checking sclera and gums particularly in darker skinned babies. Do not measure bilirubin level routinely in babies who do not appear visibly jaundice, equally do not use visual inspection alone to estimate bilirubin level. Always keep parents/carers well informed (box 2).Box 2
What do I need to do to inform the families in my care?
In identifying jaundice
Listen to parents/carers expressed concerns; provide them with verbal and written information on neonatal jaundice without causing unnecessary anxiety. Educate them on how to look for jaundice and what to do if suspected.
Provide safety netting advice on when to seek urgent medical advice, for example, if signs of conjugated hyperbilirubinaemia with pale stool or dark urine, or if jaundice suspected in first 24 hours.
In managing hyperbilirubinaemia
Continue to provide breast feeding support to mothers. Encourage frequent feeds for breastfed babies, waking them if necessary.
Reassure that breast feeding, nappy changing and cuddles can usually continue. Explain when parents can hold their babies if requiring intensive phototherapy or exchange transfusion and how feeding will be supported, including the option to give expressed breast milk via nasogastric tube.
When considering any treatment option provides information on why that option is being considered and possible adverse effects.
Bilirubin levels: measure with a transcutaneous bilirubinometer and/or serum bilirubin levels, and monitor until the baby is no longer at risk of developing kernicterus (box 3).Box 3
Measuring and monitoring of bilirubin levels
How to measure bilirubin levels:
For babies under 24 hours of life or gestational age under 35 weeks:
Use serum bilirubin levels.
For babies over 24 hours of life and gestational age over 35 weeks:
Use transcutaneous bilirubinometer
If >250 μmol/L, or above treatment threshold, confirm and monitor further levels with serum bilirubin measurements.
How to monitor bilirubin levels:
For babies under 24 hours of life:
If jaundice is suspected urgently measure bilirubin levels within 2 hours
Repeat every 6 hours until levels stable or falling.
For babies over 24 hours of life:
If bilirubin is <50 μmol/L from treatment threshold repeat levels within 24 hours, or within 18 hours if risk factors for neonatal jaundice (table 1)
If bilirubin is >50 μmol/L from treatment threshold in a baby who is clinically well and gestational age over 38 weeks, bilirubin levels do not need to be routinely repeated.
Phototherapy: use to treat hyperbilirubinaemia according to threshold graph. Consider intensified phototherapy if serum bilirubin level is rising rapidly (>8.5 μmol/L/hour), is not falling after 6 hours of phototherapy, or if within 50 μmol/L of exchange transfusion threshold after 72 hours of life. Intensify phototherapy by increasing the irradiance of the light or adding a further light source. During phototherapy measure serum bilirubin levels 4–6 hours after initiation, then every 6–12 hours once levels are stable or falling. Stop phototherapy when levels are at least 50 μmol/L below treatment line and check for rebound hyperbilirubinaemia 12–18 hours later.
Care during phototherapy: position the baby supine with maximal exposed skin, provide eye protection and monitor hydration status and temperature. Breaks of up to 30 min for breast feeding, nappy changing and cuddles should be encouraged, unless using intensified phototherapy when treatment should not be interrupted and expressed breast milk via nasogastric tube would be feed of choice.
Intravenous immunoglobulin: for those with rhesus haemolytic disease or ABO haemolytic disease and a rapidly rising serum bilirubin of >8.5 μmol/L/hour use immunoglobulin (500 mg/kg over 4 hours) as an adjunct to continuous intensified phototherapy.
Exchange transfusion: use double volume exchange transfusion when clinical features of acute bilirubin encephalopathy are present, or when serum bilirubin level indicates its necessity from threshold graph. During the transfusion, continue intensified phototherapy. Once transfusion is complete, continue intensified phototherapy and check serum bilirubin levels within 2 hours to determine need for further therapy.
Consider underlying disease in babies with significant and/or prolonged hyperbilirubinaemia: perform a full clinical examination and, if infection is suspected, take microbiological cultures of blood, urine and cerebrospinal fluid. For unconjugated hyperbilirubinaemia check full blood count with blood film, blood packed cell volume, mother's and baby's blood group and direct antiglobulin test (DAT). Check heel prick test result, screening for metabolic abnormalities particularly hypothyroidism and consider checking glucose-6-phosphate levels. Look for pale, chalky stool with dark urine and check conjugated bilirubin levels, seek expert advice if conjugated bilirubin is over 25 μmol/L due to the possibility of serious underlying liver pathology.
Underlying evidence base
The NICE recommendations are based on systematic reviews of the best available evidence. New recommendations for 2016 have predominantly come from targeted consultations with topic experts and the Clinical Guideline Update Committee, due to a lack of good quality evidence.2
What do I need to know?
What can I continue to do as before?
For babies under 24 hours of life or gestational age <35 weeks, measure serum bilirubin levels if jaundice suspected from visual inspection.
For babies over 24 hours of life or gestational age over 35 weeks, measure bilirubin levels with a transcutaneous bilirubinometer if jaundice is suspected. If levels exceed 250 μmol/L or above treatment threshold, confirm bilirubin level by measuring serum bilirubin.
What should I do differently?
For babies who are clinically well, over 24 hours of life and with a gestational age over 38 weeks:
No need to measure repeat serum bilirubin level routinely if the bilirubin level is >50 μmol/L under the phototherapy treatment threshold, even if within 100 μmol/L of treatment threshold as previously recommended.
Measure a repeat level within 24 hours if the bilirubin is <50 μmol/L under the phototherapy treatment threshold, or within 18 hours for babies with risk factors for neonatal jaundice (table 1). It is no longer necessary to consider starting phototherapy in these babies or repeating serum bilirubin levels earlier.
What should I start doing?
Phototherapy can be delivered with light-emitting diode, fibre optic or fluorescent lamps, tubes or bulbs, no specific device is recommended.
Intensify phototherapy by increasing irradiance of a light source or adding an additional light source. This is indicated when serum bilirubin level is rising rapidly, close to threshold for exchange transfusion or not responding to initial phototherapy.
Clinical bottom line
Jaundice in neonates is common, while kernicterus is rare. These guidelines provide a framework to identify and effectively treat those at risk and to prevent kernicterus developing, with new recommendations on when bilirubin levels should be rechecked and how to best deliver phototherapy.
Contributors RA: initial manuscript draft. RA, HJ and WL: manuscript revisions.
Competing interests None declared.
Provenance and peer review Commissioned; externally peer reviewed.
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