Contents



Canberra Health ServicesGuideline Jaundice in the Newborn Contents TOC \h \z \t "Heading 1,1,Heading 2,2" Contents PAGEREF _Toc68167662 \h 1Guideline Statement PAGEREF _Toc68167663 \h 2Scope PAGEREF _Toc68167664 \h 2Section 1 – Introduction PAGEREF _Toc68167665 \h 2Section 2 – Assessment and screening of infants ≥35 weeks of gestational age PAGEREF _Toc68167666 \h 4Section 3 – Assessment and screening of jaundice in preterm infants <35 weeks of gestational age PAGEREF _Toc68167667 \h 7Section 4 – Treatment of Jaundice PAGEREF _Toc68167668 \h 7Section 5 – Follow up of infants with jaundice PAGEREF _Toc68167669 \h 14Section 6 – Management of Jaundiced Infants in the Community PAGEREF _Toc68167670 \h 15Section 7 – Prolonged jaundice PAGEREF _Toc68167671 \h 17Evaluation PAGEREF _Toc68167672 \h 17Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc68167673 \h 18References PAGEREF _Toc68167674 \h 18Definition of Terms PAGEREF _Toc68167675 \h 19Search Terms PAGEREF _Toc68167676 \h 20Attachments PAGEREF _Toc68167677 \h 20Attachment A. How to perform transcutaneous bilirubin measurement (TcB) PAGEREF _Toc68167678 \h 21Attachment B: Commencing Phototherapy and Caring for infants under Phototherapy PAGEREF _Toc68167679 \h 23Attachment C: Phototherapy and Exchange Transfusion Charts PAGEREF _Toc68167680 \h 25Guideline StatementThe purpose of this clinical guideline is to assist Canberra Health Services (CHS) staff in recognising and treating infants with jaundice.Alerts Clinically visible jaundice in the first 24 hours of age is always pathological until proven otherwise. Perform an urgent Serum Bilirubin Level (SBR) and refer to the neonatal medical team immediately.A conjugated bilirubin of >20% of the total bilirubin or >30micromol/L is pathological and requires neonatal medical review.Prolonged jaundice >14 days is pathological until proven otherwise and requires further evaluation via the neonatal team, paediatric team, or general practitioner.To avoid the possibility of burns, do not use lotions or creams on the infant’s skin during phototherapy.Phototherapy lights need to be turned off during blood collection for a Serum Bilirubin Level (SBR).Do not use a Transcutaneous Bilirubinometer in infants who are receiving phototherapy via conventional phototherapy lights as the skin is exposed to the therapeutic light which may result in inaccurate measurement of the bilirubin level. Back to Table of ContentsScopeThis document applies to the following staff working within their scope of practice:Medical OfficersNurses and Midwives Student nurses and midwives, and medical students under supervision.Back to Table of ContentsSection 1 – IntroductionDefinitionJaundice is the yellow discoloration of skin, sclera, and mucous membranes that is caused by tissue deposition of bilirubin.Jaundice is a common clinical sign in newborns and indicates hyperbilirubinemia. Physiological jaundice:Physiological jaundice is common and usually benign. Approximately 60% of term infants and 85% of preterm babies will develop clinically apparent jaundice. Physiological jaundice typically becomes apparent on day 2-3 of age, peaks on day 5-7 of age and resolves over the second week of life.Some babies with physiological jaundice require treatment with phototherapy. There are several risk factors that can predispose newborns to needing treatment for jaundice. These include:The presence of bruising or bleeding (cephalohaematoma, subgaleal haemorrhage, bruising) or polycythaemiaPotentiation of the enterohepatic circulation through poor feeding and gut stasis (poor feeding, >10% weight loss, delayed passage of meconium)A family history of siblings or parents requiring phototherapy for jaundice.Non-physiological jaundice:Jaundice associated with an underlying condition is non-physiological jaundice.Different patterns of jaundice (timing of onset, rate of rise of SBR) suggest that a pathological process may be causing jaundice. Although the timing of the appearance of jaundice can provide clues about whether it is pathological of physiological it’s important to note that pathological jaundice can present on day 2-3 as well (during the period that physiological jaundice commonly presents):Clinical jaundice in the first 24 hours: this is uncommon and is almost always pathological. It is usually caused by haemolysis. Causes of newborn haemolysis include alloimmune blood group incompatibilities (ABO or rhesus incompatibility), G6PD deficiency, hereditary cell membrane defects (spherocytosis, elliptocytosis) or sepsis amongst others. This needs urgent assessment and treatment.Rapid progression of jaundice: this is often also associated with haemolysis.Prolonged jaundice (jaundice for more than 14 days for term infants and more than 21 days for premature babies): whilst breast milk jaundice is a common cause of prolonged jaundice this is diagnosis of exclusion. Prolonged jaundice always requires further investigation and follow up. Conjugated jaundice >20% of the total bilirubin or >30micromol/L is pathological and requires neonatal medical review.Risk factors for pathological jaundice include:Infants of mothers that have known red cell antibodies during the pregnancyInfants of a Rhesus negative mother and DCT positive in cord bloodFamily history of haemolytic disease of the newborn, G6PD deficiencySibling with ABO incompatibility or a history of severe jaundiceInfants with accumulation of extra-vascular blood (cephalohaematoma, subgaleal haemorrhages or severe bruising)Prematurity (<37 weeks)Unwell infants (sepsis/viral infections/metabolic disease/asphyxia)Elevated haemoglobin and haematocrit/plethoricDehydration/poor feeding, delayed passage of meconium.High level jaundiceHigh levels of unconjugated bilirubin are neurotoxic when they exceed the capacity of albumin binding in the blood. In this situation the unconjugated bilirubin can cross the blood brain barrier and cause brain injury. The areas of the brain that are most affected by bilirubin are the auditory nerve and the basal ganglia which can lead to future hearing impairment and/or cerebral palsy. High levels of unconjugated bilirubin can cause an acute bilirubin encephalopathy and chronic irreversible neurological damage (Kernicterus). Infants at risk of Kernicterus are:Term infants with bilirubin level >450 micromol/LInfants with rapid rise of bilirubin level > 8.5micromol/L/hourInfants with clinical features of acute bilirubin encephalopathy. This includes:LethargyHypotoniaPoor suckHigh pitched crySeizuresImportant points:Clinical jaundice in the first 24 hours of life is considered pathological until proven otherwise. Perform an urgent SBR and refer to the neonatal medical team for review.A conjugated bilirubin of >20% of the total bilirubin or >30micromol/L is pathological and requires neonatal medical review.Prolonged jaundice >14 days is pathological until proven otherwise and requires further evaluation.Back to Table of Contents Section 2 – Assessment and screening of infants ≥35 weeks of gestational ageAll infants should have a risk assessment performed at birth by their midwife and have cord bloods sent if indicated (see Flowchart 1).During each routine midwifery review, every infant needs to be visually assessed for jaundice. Jaundice usually begins on the face and progresses in a cephalon-caudate fashion. Infants who should routinely have cord blood sent for blood group and direct Coomb’s test (DCT) are those born to: Rhesus negative mothersMothers with a positive antibody screen during pregnancyBlood group ‘O’ mothersInfants are also at risk of haemolysis if they have:A family history of severe jaundice or G6PD deficiencyA sibling with severe jaundice in the newborn periodA sibling with a history of ABO incompatibilityTranscutaneous Bilirubin Measurement (TcB)Every infant needs to be visually assessed for jaundice during each routine midwifery review.Many studies show that a visual assessment for jaundice is very inaccurate and can both under and overestimate the true incidence of jaundice in a newborn (even when performed by clinically experienced individuals).The use of a Transcutaneous Bilirubinometer helps healthcare professionals accurately determine which newborns need to have a SBR performed. The TcB is not a tool that is intended to replace the SBR. Both the TcB and SBR are recorded and plotted on the jaundice flowchart in different ways. The TcB is plotted using a black “X” and the SBR is plotted with a black “dot” to differentiate them on the chart.TcB should not be used in babies that are receiving phototherapy and its use is not recommended in premature babies <35 weeks. If a TcB indicates a level ≥ 250 micromol/L, always perform a formal SBR as at this level there is a discrepancy between TcB and SBR.Refer to Attachment A to check “how to perform a TcB”.When to measure TcB?In any infant ≥ 35 weeks of GA in whom there is clinical jaundice (see Flowchart 1)Routinely in high risk infants ≥ 35 weeks of GA (see Flowchart 1)Flow Chart 1: Assessment and screening of jaundice in infants ≥35 weeksImportant points: If a DCT is sent at birth, it is the responsibility of the midwifery team to review the results. Any infant who is DCT positive must be reviewed by/discussed with the neonatal medical team.Note that a DCT negative result has a good negative predictive value for haemolysis, which helps to identify newborns with low risk of haemolysis. However, a DCT positive result has a low positive predictive value for haemolysis. Because of this, performing a FBC and reticulocytes with the first SBR will help to determine which babies are likely to be haemolysing. Any newborn with clinical jaundice in the first 24 hours of life should have an SBR performed urgently and should be referred to the neonatal team for further investigations (blood group, DCT, FBC, reticulocytes) irrespective of their risk factors for haemolysis.Have a low threshold for performing a TcB for preterm infants (35 and 36 weeks of gestational age) as they are at a high risk of jaundice.Always measure SBR if a TcB indicates a level ≥ 250 micromol/LNote: If TcB is not available, perform SBRBack to Table of Contents Section 3 – Assessment and screening of jaundice in preterm infants <35 weeks of gestational ageMeasure SBR in any clinically jaundiced preterm infant <35 weeks gestation. Do not use a TcB in infants <35 weeks of gestational age. Measure SBR at 12 hours of age in preterm infants <32 weeks of gestational age or those who have high risk of haemolysis. Consider performing SBR with the first set of electrolytes blood test performed in preterm infants.Plot the SBR result in the correspondent chart for the gestational age of the infant.A repeat SBR should be organised by the neonatal team as indicated. Back to Table of Contents Section 4 – Treatment of JaundicePhototherapy is the first line of treatment for unconjugated hyperbilirubinemia. Phototherapy light converts the unconjugated bilirubin to a less toxic water-soluble photo-isomer that can be excreted in the bile and urine. Phototherapy light is not the same as ultra-violet light.The efficacy of phototherapy depends of the wavelength and luminance of the light source and the skin surface area illuminated by the light.The decision to start phototherapy is based on the infant’s gestational age at birth and postnatal age (in hours), risk factors and SBR levels. The initiation of the treatment is needed when the SBR is above the line for phototherapy on the appropriate chart (see Attachment C). The Neonatal Intensive Care Unit at the Canberra Hospital has two types of phototherapy device: Biliblanket: fibre-optic blanket that is located under the infant in contact with the skin. This device uses a standard light source that passes through a fibre-optic bundle into a pad of woven optic fibres. The pad can be placed next to the infant’s skin, therefore infants under fibre-optic phototherapy can be nursed close to their parents without mother-newborn separation. This kind of phototherapy is less effective in reducing the bilirubin level than conventional phototherapy in term infants, therefore should not be used alone as a first line treatment. However, it’s use as a sole treatment could be considered when phototherapy is weaned in an infant with adequate response to initial treatment. LED-light treatment: the device is located above the infant. The LED is a special type of semiconductor diode which emits light when connected to an electrical circuit. This light source emits high-intensity light while generating little heat and can be placed closer to the infant. LED-light phototherapy is more efficient reducing bilirubin levels than fibre-optic devices in term infants. The distance recommended for effective treatment is 30 cm from the baby. Intensity of phototherapy: Irradiance is the measure of the treatment with light provided by phototherapy systems. Irradiance is measured in ?W/cm?/nm. Different phototherapy devices and different levels of intensity in these devices provide different levels of irradiance.The Neonatal Department at the Canberra Hospital has the following phototherapy systems and the irradiance that they provide are: Phototherapy System Level Irradiance uW/cm2/nm (with overhead lights at 30 cm)NeoBlue Natus(LED light treatment)High level35BiliLux Drager (LED light treatment)Level 1 18Level 233Level 350Level 465Level 585Bilisoft LED Phototherapy System (Biliblanket)Large Pad35Phototherapy is prescribed as Standard or Intensive. Standard phototherapy provides an irradiance of 35 to 50 ?W/cm?/nm and Intensive phototherapy provides an irradiance of 70 to 85 ?W/cm?/nm.For babies ≥35 weeks of gestational age at birth: Type of PhototherapyIrradiance (uW/cm2/nm)Phototherapy systems to useStandard 35 + Biliblanket1 overhead light NeoBlue Natus at high level + Biliblanket50 + Biliblanket1 overhead light BiliLux at level 3 + BiliblanketIntensive70 + Biliblanket2 devices for overhead light NeoBlue Natus at high level + Biliblanket85+ Biliblanket1 overhead light BiliLux at level 5 + BiliblanketFor babies <35 weeks of gestational age at birth:Type of PhototherapyIrradiance (uW/cm2/nm)Phototherapy systems to useStandard351 overhead light NeoBlue Natus high level 501 overhead light BiliLux at level 3The use of Biliblanket can be considered by the neonatal team on a case by case basis.Intensive70 + Biliblanket2 devices for overhead light NeoBlue Natus at high level + Biliblanket85+ Biliblanket1 overhead device BiliLux at level 5 + BiliblanketRefer to Attachment B to check “how to start phototherapy”Flow Chart 2: Treatment of Jaundice in infants ≥35 weeksPhototherapy and supportive care on the Postnatal ward/SCN/NICU for babies ≥35weeks of gestational ageStart phototherapy as indicated on the above flowchart.Standard light phototherapy includes overhead LED-light phototherapy above the infant providing an irradiance of 35-50 ?W/cm?/nm AND Biliblanket (fibre-optic light) under the infant next to the infant’ skin.The infant should wear a nappy with no clothes on, to maximise skin exposed to the light. All infants under phototherapy should wear the appropriate eye cover/protector during the treatment. The Biliblanket should stay under the infant in contact with the skin when breastfeeding whilst on phototherapy.SBR should be monitored after phototherapy is started. Usually the SBR should be repeated after 12-24 hours (this time frame may vary in some cases, the repeat SBR should be organised by the neonatal medical team).Increase observation frequency (as per NEWS chart) whilst on phototherapy paying attention to the risk of hyperthermia or hypothermia and the positioning of the protective eye mask.Blood collection for SBR must be done with phototherapy devices turned off so that the phototherapy does not falsely reduce the SBR in the tube.TcB must not be used on infants receiving phototherapy treatment.Note: If the SBR level is rising rapidly (≥8.5 micromol/L/hour) and/or the SBR level is within 50 micromol/L below the threshold for exchange transfusion and/or the baby is clinically jaundiced under 24 hours of age, request an urgent transfer to the NICU (if the baby is in PNW/SCN) for intensive treatment.Phototherapy in the NICU/SCN for infants <35 weeks of gestational ageCheck SBR level at 12-24 hours in premature babies.Plot SBR result in the appropriate chart for gestational age at birth and postnatal age.Standard phototherapy in infants <35 weeks of gestational age includes overhead LED light providing an irradiance of 35-50 ?W/cm?/nm (device above the infant). The need for Biliblanket under the infant could be considered by the neonatal team in a case by case base. Repeat SBR test as clinically indicated.TcB should not be used on infants <35weeks of gestational age at birth. Intensive Phototherapy in the NICU (for babies ≥35weeks of gestational age and <35 weeks of gestational age)Intensive phototherapy is indicated in infants with:SBR level above the threshold for exchange transfusion, while resources and preparation for exchange transfusion are organised (see “Exchange transfusion/use Immunoglobulin IVIG” section below).SBR level within 50 micromol/L below the threshold for exchange transfusion after 72 hours of age. SBR level is increasing rapidly (≥8.5 micromol/L/hr).SBR level fails to respond to standard phototherapy. This means that the SBR level continues to rise or does not fall within 6-12 hours of starting standard phototherapy.Intensive treatment includes overhead LED-light device(s) providing an irradiance of 70-85 ?W/cm?/nm above the baby AND a Biliblanket under the baby.The exposure of the skin should be maximised. This involves removing all clothes and the newborn’s nappy to increase the skin area exposed to light. Aluminium foil or white cloth placed on either side of the infant to reflect light could increase irradiance and surface exposure and could be considered on a case by case basis by the neonatal team. Infants that need intensive phototherapy should receive continuous phototherapy unless otherwise advised by the neonatal medical team. The decision to restart breastfeeds should be made by the neonatal team. Lactation support is recommended so that breastfeeding can start again when indicated.Aim to offer enteral feeds rather than IV fluids to infants with jaundice unless an exchange transfusion is imminent.Jaundice in exchange range should receive prompt treatment. The repeat SBR after commencement of the lights needs to be done at 4-6 hours. Phototherapy device(s) should be turned off during blood sample collection. TcB must not be used on infants receiving phototherapy treatment. Discontinuation of phototherapyIntensive phototherapy can result in a decrease of SBR values of 30 to 40% in the first 24 hours of treatment with the most pronounced decline occurring in the first 4 to 6 hours.It is recommended to stop phototherapy when the bilirubin levels fall more than 50 micromol/L below the treatment line in the appropriate chart for gestational age and postnatal age. Special consideration should be taken in infants with jaundice due to haemolysis. In these cases, ceasing phototherapy should be undertaken in consultation with the neonatal fellow or consultant on call.Rebound bilirubin levelsA rebound in SBR level can occur after phototherapy is ceased.Premature infants and infants with known haemolysis are at increased risk of significant rebound.Perform a repeat SBR level 12-24 hours after ceasing phototherapy. Premature infants and infants with haemolytic jaundice that needed treatment with phototherapy should have a rebound SBR level 12 hours after phototherapy was ceased.Continue to monitor SBR level until it has started to show a static or decreasing trend without phototherapy.Side effects of phototherapy There are few significant short- or long-term side effects of phototherapy. Starting phototherapy can potentially interfere with mother infant bonding, which is why, where possible, phototherapy treatment is conducted on the postnatal ward. Newborns can become hypothermic, hyperthermic or dehydrated whilst undergoing phototherapy. Short-term effects:Interference with maternal-infant interactionHypothermia or hyperthermiaDehydrationBenign skin rashesIleusLoose watery stoolsBronze baby syndrome (in babies with conjugated hyperbilirubinemia)Exchange transfusion/use of Immunoglobulin (IVIG):When the SBR level is above the exchange transfusion threshold in the chart for the appropriate gestational age and postnatal age, exchange transfusion should be considered.SBR level above the threshold for exchange transfusion confers a risk of bilirubin encephalopathy and kernicterus after 72 hours of age and exchange transfusion is recommended if intensive phototherapy does not decrease the SBR quickly. The threshold prior the 72 hours of age reflects the need to consider exchange transfusion taking into consideration the absolute level of bilirubin and the rate of rise.Use double-volume exchange transfusion in these cases (see exchange transfusion protocol/guideline).In infants at risk of needing an exchange transfusion:Start intensive phototherapy in NICU and inform consultant/fellow on call.Send a DCT (if not done), full blood count, reticulocytes, SBR on admission. Perform G6PD screen if required.Perform neurological examination looking for evidence of bilirubin encephalopathy and document the assessment.Start IV fluids if exchange transfusion is imminent.Contact blood bank and request blood for exchange transfusion in cases of severe jaundice that may require exchange transfusion if the intensive phototherapy is not successful.Consider intravenous immunoglobulin (IVIG) as a coadjutant to the treatment in infants who may need exchange transfusion. Consider intravenous immunoglobulin when:DCT positive iso-immune haemolytic anaemia (Rhesus, ABO, and other antibodies) ANDSBR is rising more than 4 micromol/L/hour (at any time after delivery) AND SBR is within 50micromol/L of exchange transfusion threshold despite intensive phototherapy treatment (after 24 hours of age)The dose is 1 g/Kg and it can be repeated in 12-24 hours if required. The indication of intravenous immunoglobulin will be decided by the neonatologist/fellow on call.In infants with clinical features and signs of bilirubin encephalopathy (independent of the cause of jaundice):Start intensive phototherapy in NICU.Optimise hydration.Perform double-volume exchange transfusion. Follow protocol/guideline of exchange transfusion to perform this procedure.Supportive care: FeedingEnteral feeding is preferred in infants that are receiving phototherapy. Feeding is beneficial reducing the reabsorption of unconjugated bilirubin from the gastrointestinal system.Suck feeds (breastfeeds/feeds by bottle) should be encouraged in infants receiving treatment on the postnatal ward (and NICU/SCN when appropriate). Breaks of a maximum of 30 minutes (every 3 hours) for feeding are recommended when infants are receiving phototherapy in the postnatal ward (while continuing phototherapy on a Biliblanket).Nasogastric feeds are an option for infants receiving intensive phototherapy in the first 4 to 6 hours of treatment. When the SBR level is trending down effectively, suck feeds can be restarted, and the infant can have breastfeeds using the Biliblanket. Feeding time should be limited to 20-30 minutes to reduce the time out of overhead phototherapy.The indication of top-ups with expressed breast milk (EBM) or/and formula, or the need for additional fluids during phototherapy should be considered on an individual clinical basis by the neonatal team.Back to Table of Contents Section 5 – Follow up of infants with jaundiceWell infants that needed phototherapy in the postnatal ward:Follow up will be done by mid-call/continuity midwife/maternal and child health (MACH) or/and General Practitioner. SBR sample can be taken in the community if clinically indicated. The result should be discussed with the neonatal team.Monitor SBR level until static or falling trend without treatment.Infants with haemolytic jaundice that needed phototherapy:Routine follow up with mid-call/continuity midwife/MACH or/and General Practitioner.Monitor SBR level until static or falling trend without treatment. If the SBR sample is taken in the community, the result should be discussed with the neonatal team.Follow up at 6 weeks of age with full blood count (FBC) and reticulocyte count. This is done through the postnatal follow-up calendar with NICU registrar/SRMO contacting parents regarding the results. Parents are to be advised to seek medical advice if the infant remains visibly jaundice for more than 14 days (>3weeks if premature) and/or has dark urine or pale stools. Infants with SBR level in the range of exchange transfusion: Routine follow up with mid-call/continuity midwife/MACH or/and General Practitioner.Monitor SBR level until static or falling trend without treatment. If the SBR sample is taken in the community, the result should be discussed with the neonatal anise long term follow up in the Growth and Development Clinic in infants with SBR level in the exchange transfusion range for gestation age after the first 48 hours of age.Back to Table of Contents Section 6 – Management of Jaundiced Infants in the Community AssessmentThe maternal and child health (MACH) nurse, mid-call or continuity midwife program will monitor all newborns under their care for evidence of jaundice. They will consider the risk factors for jaundice in each case. Clinical historyConsider the risk factors as per Section 1 and 2 of this document when assessing and screening for jaundice. Check in every infant:Clinical jaundiceFeeding Volume and colour of urine and stoolsWeight HydrationPresence of cephalohaematoma/bruisesLevel of vigourBehaviourAssessment of JaundiceJaundice is assessed in natural light by blanching the baby’s skin with a finger and observing the underlying skin colourThere is evidence that visual assessment for jaundice is inaccurate and can both under and overestimate the true incidence of jaundice in an infant (even in clinically experienced individuals). Therefore, we recommend performing SBR level in babies with clinical jaundice.If a Transcutaneous Bilirubinometer is available, this can help health professionals to accurately determine which infants need to have a SBR test performed. However, the TcB is not a tool that is intended to replace the SBR. If Transcutaneous Bilirubinometer is available:Refer to Attachment A to check “how to perform a TcB”. Refer to Section 2 “Transcutaneous Bilirubin Measurement (TcB)”, “When to measure TcB” and “Flow Chart 1”. When assessing an infant with jaundice also check presence of cephalohaematoma/bruises and DCT statusMaternal Assessment/HistoryBlood group and presence of antibodiesFamily history Lactation assessment Psychosocial assessmentInterventionA jaundiced infant must have a SBR level taken and must be referred for treatment if the SBR is above the line for phototherapy treatment in the appropriate chart for gestational age.A jaundiced infant must have an SBR taken and must be referred for further medical assessment if any of the following is evident (irrespective of clinical degree of jaundice):Indicators of dehydration.Indicators of a poor feeding effort or pattern.The infant is lethargic or/and has abnormal behaviour.The infant has fever.Jaundice is prolonged (>14 days).The infant has pale chalky stools/dark urine.The infant has abnormal neurological examination/behaviour.Ongoing management Address any feeding issues. Ensure infant is receiving adequate hydration from breast or bottle. Consider increasing frequency of feeds and consider complement breastfeeds with top-ups with EBM or/and formula if necessary.Document nature and duration of concern regarding jaundice, assessment and plan. Document discussion with neonatal team and plan decided.Ensure parents or carers know to follow up if concerns persist or if condition worsens.Provide information regarding jaundice to parents.Referral ProcessPatients <14 days old with jaundice that are on mid-call/midwifery continuity program/MACH should be discussed with the NICU registrar/fellow or consultant on call. If the infant needs admission for treatment with phototherapy, inform the parents and advise them to bring the infant to the hospital immediately. The phototherapy treatment should be commenced promptly on admission.Document in the clinical records and follow up according to agreed plan. Alert the Clinical Nurse Consultant (CNC) if concerns are identified. Back to Table of Contents Section 7 – Prolonged jaundiceTerm infants with jaundice lasting ≥14 days and premature infants with jaundice lasting ≥21 days should be referred for medical review and further investigation due to prolonged jaundice.Clinical examination of these infants is crucial.Request the following investigation:Total SBR, conjugated SBRLiver function testFull blood count with reticulocytesBlood group and DCTThyroid function TestUrine CultureEnsure that Newborn Screening Test has been performed.G6PD (if appropriate)Urinary Metabolic Screening (if appropriate)Abdominal Ultrasound (if appropriate)First clinical assessment and investigations of this group of patients may be done by the neonatologist in the Neonatal Department (paediatric outpatient clinic or review in the ward in individual cases). Subsequently a formal referral to Paediatrician or/and Paediatric Gastroenterologist should be organised.Infants with Conjugated Hyperbilirubinemia should be immediately discussed with/referred to the Paediatric Gastroenterology team.Back to Table of Contents Evaluation The evaluation of this guideline includes:Audit of cases of neonates with jaundice above, or close to, the threshold of exchange transfusion.Audit of the number of TcB measurements that will be used in the postnatal ward before and after this guideline has been approved and implemented. Audit of the number of SBR samples per baby needed before discharge, before and after the implementation of this guideline. Audit of the number of readmissions due to jaundice via Neonatal Morbidity and Mortality Meetings, when the 3 monthly statistical data of the unit are reviewed. Number of Riskman entries related to the management of neonates with jaundice in the postnatal ward, NICU and SCN. Review of Riskman entries related to the management of neonates with jaundice in the postnatal ward, NICU and SCN. Back to Table of ContentsRelated Policies, Procedures, Guidelines and LegislationProceduresPatient Identification and Procedure Matching Blood Collection using Heel Lance Device (Neonates)Venepuncture Blood Specimen CollectionInfection Prevention and Control. Healthcare Associated InfectionsNeonatal Routine Care ProcedureFresh Blood Products Administration. Adults, Paediatrics, Infants and Neonates Patient Identification. Pathology Specimen LabellingGuidelinesCord Blood Collection for Blood Group, Direct Coomb’s test (DCT) and Blood Gas Sampling guidelineBack to Table of ContentsReferencesManagement of Hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. American Academy of Paediatrics. Clinical Practice Guideline. Pediatrics 2004; 114(1); 297-316.NHS National Institute for Health and Clinical Excellence. Neonatal Jaundice: A Clinical Guideline. May 2010 (updated October 2016). in the newborn: what’s new? Yurdakok. Journal of Paediatrics and Neonatal Individualized Medicine 2015; 4 (2); e040255.Jaundice: Newborn to age 2 months. Pan et al. Pediatrics in review 2017; 38, 499-510.Pathogenesis and Management of Indirect Hyperbilirubinemia in Preterm Neonates less than 35 weeks: Moving Toward a Standardized Approach. Pillai A et all. Neoreviews May 2020; 21 (5); e298-e307.An approach to the management of hyperbilirubinemia in the preterm infant less than 35 weeks of gestation. Maisels et al. Journal of Perinatology 2012; 32; 660-664.Visual assessment of jaundice in term and late preterm infants. Keren et all. Arch Dis Child Fetal Neonatal Ed 2009; 94; F317-F322.Double versus single intensive phototherapy with LEDs in treatment of neonatal hyperbilirubinemia. Donneborg M et al. Journal of Perinatology 2018; 38; 154-158.Is visual assessment of jaundice reliable as a screening tool to detect significant neonatal hyperbilirubinemia? Riskin et al. Journal of Paediatrics 2008; 152; 782-787Utility of decision rules for transcutaneous bilirubin measurements. Taylor et al. Pediatrics 2016; 137 (5); e20153032.‘Halving the heel pricks’: evaluation of a neonatal jaundice protocol incorporating the use of a transcutaneous bilirubinometer. Hartshorn et al. Journal of Paediatrics and Child Health 2010; 46; 595-599.Transcutaneous Bilirubinometery versus Serum Bilirubin in Neonatal Jaundice. Mahram et al. Acta Medica Iranica 2015; 53; 12; 764-769.Evaluation of a new transcutaneous bilirubinometers. Maisels et al. Pediatrics 2004; 113; 1628-35.Assessing jaundice in infants of 35-week gestation and greater. Lease et al. Current Opinion in Paediatrics 2010; 22; 352-365.Phototherapy for neonatal jaundice. Maisels et al. N Engl J Med 2008; 358(9);920-928.Prospective Surveillance of Extreme Neonatal Hyperbilirubinemia in Australia. McGillivray et al. Journal of Paediatrics 2016; 168; 82-parison of skin sites for estimating serum total bilirubin in inpatients and outpatients: chest is superior to brow. Poland et al. J Perinatol 2007; 24; 541-543.Immunoglobulin for alloimmune haemolytic disease in neonates. The Cochrane library 2018; Issue 3 (Cochrane review) phototherapy for neonatal jaundice. The Cochrane library 2001 (Cochrane review) diode phototherapy for unconjugated hyperbilirubinemia in neonates. The Cochrane review 2011 Jaundice Risk–Without the Trauma- Dr?ger JM-105 \Fusion Healthcare Bilisoft Biliblanket to Table of ContentsDefinition of Terms ABHR: Alcohol Based Hand Rub DCT: Direct Coombs Test FBC: Full Blood CountGA: Gestational AgeNICE: NHS National Institute for Health and Clinical ExcellenceMid-call: Hospital Based Community MidwiferyMACH: Maternal and Child HealthSBR: Total Serum BilirubinTcB: Transcutaneous Bilirubin Back to Table of ContentsSearch Terms NICU, SCN, Hyperbilirubinemia, Jaundice, Maternity, Infant, Newborn, Neonate, Phototherapy, Biliblanket, Overhead light, Exchange transfusion, bilirubin, SBR, Serum Bilirubin, Serum Bilirubin Result, NeonatologyBack to Table of ContentsAttachmentsAttachment A: How to perform a TcB Attachment B: How to start phototherapy Attachment C: Phototherapy/Exchange transfusion chartsDisclaimer: This document has been developed by Canberra Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Canberra Health Services assumes no responsibility whatsoever.Policy Team ONLY to complete the following:Date AmendedSection AmendedDivisional ApprovalFinal Approval 10/03/2021Complete ReviewBoon Lim, ED, WY&CCHS Policy CommitteeThis document supersedes the following: Document NumberDocument NameCHHS16/175Jaundice in the NewbornAttachment A. How to perform transcutaneous bilirubin measurement (TcB)IndicationsUse the TcB to facilitate the decision of when to perform an SBR in infants ≥35 weeks of gestational age at birth and ≥24 hours since birth. If a TcB is not available in a clinically jaundiced infant perform SBR test. ContraindicationsDo not use the TcB in preterm infants <35 weeks of gestational age at birth Do not use the TcB in infants <24 hours of postnatal age, or in infants older than 14 days.Do not use the TcB for an infant on phototherapyDo not use the TcB to do a rebound jaundice assessment after ceasing phototherapy NoteThe Drager JM-105 requires daily calibrationThe long and short optical paths should read within +/- 1.0 the reference value on the unit coverProcedureClean the tip of the TcB with an alcohol wipe to maintain cleanliness between patients and perform usual hand hygienePosition the TcB on the sternum of the baby between the superior 1/3 and the inferior 2/3 of the sternum avoiding any bruised or discoloured areas of skin.Press the TcB onto the skin until the machine tip flashes, and you are prompted to take a second and then third reading on the display screen:Each TcB requires three readings to be taken and the highest reading used to determine whether a SBR is required (this will be calculated by the TcB and displayed on the screen after the three readings have been performed.)Record the TcB on the jaundice chart and plot it in relation to the newborn’s gestational age and number of hours since birth. Use an “X” to plot the TcB in the chart.Please note that the TcB is not interpreted in the same way as the SBR. If the TcB is:Within 50 micromol/L of the gestation and age specific phototherapy treatment line, OR above the line of phototherapy treatment, OR does not read at all a SBR sample should be taken and sent. If the TcB is above the appropriate treatment line start phototherapy whilst awaiting the SBR result.If the TcB is >50micromol/L below the gestation and age specific phototherapy line, re-assess the baby clinically and perform a new TcB within the next 24 hours.Attachment B: Commencing Phototherapy and Caring for infants under Phototherapy Equipment:Alcohol Based Hand Rub (ABHR)Phototherapy LED-light(s)Biliblanket/fibreoptic blanketEye protectionPerspex cot cover/shield if not in isoletteTape measureThermometerOxygen Saturation monitor (in NICU and Special Care Nursery only)Commencing Phototherapy/Procedure:Explain the need for phototherapy to the newborn’s parents:Describe what phototherapy is and how it will help their baby. Educate the parents regarding phototherapy cares and keep them up to date with the baby’s progress.Give parents ‘Jaundice in the Newborn’ parent information sheet.Provide lactation information and organise support.Implement the medically prescribed feeding plan and ensure adequate hydration.Collect equipment.Attend hand hygiene before touching the baby by either hand washing or using ABHR.Remove the baby’s clothes and leave nappy in situ.Provide eye protection using phototherapy goggles for the baby according to baby’s size and weight.Attach saturation probe to baby if admitted to the NICU/SCN.Position the baby on their back into a warmed cot under a perspex shield or in an isolette.Place overhead phototherapy at a distance of 30 cm (use tape measure) from the baby and 5cms above the top of the incubator or according to the manufacturer recommendations.Record “phototherapy commenced” on phototherapy sticker in clinical notes and on care plan if on postnatal, antenatal, NICU and SCN. Record if the phototherapy commenced is “standard or intensive”.Perform baseline observations and document:Temperature Apex beat Respiration rateSkin colour Hydration statusBaby’s behaviourOxygen saturations If baby is in NICU/SCNPhototherapy lights can interfere with thermoregulation - monitor the baby’s temperature hourly for 4 hours and adjust incubator temperature as required as required to avoid overheating.Take temperature before feeds. Attend cares including eye and skin care four to six hourly.Continue lactation support unless otherwise ordered by the medical team.Monitor and record feeding and output on fluid balance chart.Document any changes to the skin.Perform SBR every 12-24 hours, unless otherwise indicated.Record when the phototherapy is ceased.Biliblanket Phototherapy System:Cover the Biliblanket with a disposable cover.Position the baby on the back directly on the illuminated side of the pad with the tip of the pad at the baby’s shoulder and the cable at the baby’s feet.Blankets may be worn over/around the fibre-optic blanket.Eye protection should be worn at all times when undergoing treatment. Appropriate eye care needs be attended if required.Phototherapy Devices available in the TCH and level of irradiance provided:DeviceIrradiance uW/cm2/nm (Overhead light at 30 cm)Bilisoft LED Phototherapy System (Biliblanket)Large Pad35Small Pad 50NeoBlue LED phototherapy NatusHigh level35BiliLux Drager 20%1840%3360%5080%65100%85Attachment C: Phototherapy and Exchange Transfusion Charts ................
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