Jaundice in the Newborn
Canberra Hospital & Health Services
Clinical Procedure
Jaundice in the Newborn
|Contents |
Contents 1
Purpose 2
Alerts 2
Scope 2
Section 1 – Assessment and screening of infants at risk of jaundice 2
Section 2 – Measurement of hyperbilirubinaemia 4
Section 3 – Guide for Direct Coombs Test (DCT) positive infants 5
Section 4 – Phototherapy treatment 6
Section 5 – Management of Jaundiced Infants in the Community 7
Implementation 8
Related Policies, Procedures, Guidelines and Legislation 9
References 9
Definition of Terms 9
Search Terms 10
Attachments 10
Attachment A - Initial Management Flowchart 11
Attachment B: Screening for hyperbilirubinaemia in term infants using transcutaneous bilirubinometer (TcB): 12
Attachment C: Treatment threshold for DCT negative, Well Term Infants 13
Attachment D: Treatment threshold for DCT positive or premature infants 14
Attachment E: Phototherapy Pathway: SBR in Phototherapy Range 15
(For haemolytic jaundice use phototherapy Attachment C and for well term infants without haemolysis use Attachment D) 15
Attachment F: Kramer’s Rule 16
|Purpose |
This purpose of this clinical procedure is to assist Canberra Hospital Health Services (CHHS) staff with recognising and treating infants with jaundice.
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|Alerts |
• To avoid the possibility of burns, do not use lotions or creams on the baby’s skin.
• Phototherapy lights need to be turned off during blood collection for a Serum Bilirubin (SBR).
• Do not use a Transcutaneous Bilirubinometer (TcB) for infants who are receiving phototherapy via conventional phototherapy lights as the forehead is exposed to the therapeutic light and will result in inaccurate measurement of bilirubin level.
• Use Transcutaneous Bilirubinometer only in term infants ≥37 weeks gestation, who are otherwise well, with a postnatal age of more than 24 hours and not DCT +ve.
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|Scope |
This document applies to the following medical staff working within their scope of practice:
• Medical Officers (MO)
• Nurses and Midwives
• Student midwives and medical students under supervision
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|Section 1 – Assessment and screening of infants at risk of jaundice |
Using the Assessment and screening of infants at risk of jaundice (Attachment A)
Risk Factors include:
• Maternal red cell antibodies (Rhesus or other)
• Infants with a positive Direct Coombs Test (DCT)
• Infants with accumulation of extra vascular blood (cephalhaematoma, bruising)
• Prematurity
• Unwell infants (sepsis/viral infections/metabolic disease)
• Elevated haemoglobin and haematocrit / plethoric
• Dehydration, bowel obstruction including delayed passage of meconium
• Family history of previous sibling with haemolytic disease of the newborn, sickle cell anaemia, G6PD deficiency
• Family history of predisposition to haemolysis e.g., sickle cell anaemia, G6PD deficiency
Medical Officer Evaluation and Consultation:
Every baby with jaundice in the following situations requires referral to a neonatal medical officer for evaluation of jaundice before 24 hours of age:
• Infants with symptoms and/or signs of illness.
• If the conjugated bilirubin is greater than 10% of the total bilirubin level.
In a term baby, the following applies:
• When SBR >200 micromol/L on the second day of life.
• When SBR >250 micromol/L and when jaundice is of late onset (7-10 days of life or later) or is prolonged.
• When SBR >200 micromol/L after 7-10 days of life.
Screening:
In the following cases, infant’s blood for Group and DCT should be taken from cord blood within 2 hours of birth, and results checked and written into the notes as soon as possible. Depending on the results treatment may be required:
• RhD negative mothers.
• Blood group O mothers
• Antibody positive mothers.
• Women with known isoimmunisation or known antibody production.
• Visible jaundice at birth
• Preterm 4 micromol/L/hour should be considered rapid) to decide the timing of repeating the measurement of SBR. In all cases, a careful review of risk factors of jaundice as applicable in an individual case is mandatory to see if an earlier assessment may be indicated. If 2 successive levels show a decline (without intervening phototherapy), then the testing may be reduced/ceased.
See Attachment C-Guideline for SBR Levels and Phototherapy for when to commence phototherapy.
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|Section 3 – Guide for Direct Coombs Test (DCT) positive infants |
This applies to neonates with a positive DCT . Assess the infant clinically for jaundice, anaemia and hepatosplenomegaly and collect blood for SBR, FBC and reticulocytes at 6-12 hours of age. The strength of the DCT result does not reflect the need for phototherapy.
If the SBR value meets treatment threshold, start the infant on a single overhead phototherapy light (not Biliblanket); this includes infants in the postnatal ward. However, in the first 24 hours if the SBR value is >50 micromol/L above the treatment threshold or in the first 24 hours, discuss the result with a senior clinician and consider admission to NICU for double overhead light phototherapy. See Section 4 and Attachment D below how to commence Phototherapy treatment. For those infants who have not required treatment there is no specific follow up unless clinically indicated.
Routine follow up of all infants with DCT +ve result who have received phototherapy for haemolytic jaundice:
• Postnatal follow up at 6 weeks of age with FBC and reticulocyte count – this is done through the postnatal follow-up calendar with NICU registrar contacting parents with the results.
• Parents are to be advised to seek medical advice if baby remains visibly jaundiced > 2 weeks (>3 weeks if premature), has dark urine or pale stools.
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|Section 4 – Phototherapy treatment |
Equipment:
• Alcohol Based Hand Rub (ABHR)
• Phototherapy light(s) or Biliblanket/fibreoptic blanket
• Eye protection.
• Perspex cot cover/shield if not in isolette.
• Tape measure
• Thermometer
• Oxygen Saturation monitor-NICU/Special Care Nursery (SCN) only
Commencing Phototherapy via Fluorescent Lights:
1. Discuss with the parents the reasons why their baby needs phototherapy and develop a care plan for the baby:
1. Describe how phototherapy will help their baby.
2. 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.
3. Implement the medically prescribed feeding plan and ensure adequate hydration.
2. Collect equipment.
3. Attend hand hygiene before touching the baby by either hand washing or using ABHR.
4. Remove the baby’s clothes and leave nappy in situ.
5. Provide eye protection using phototherapy goggles for the baby according to baby’s size and weight.
6. Attach saturation probe to baby if admitted to the NICU/SCN.
7. Position the baby on back into a warmed cot under a perspex shield or in an isolette.
8. Place overhead phototherapy at a distance of 25-30cms from the baby and 5cms above the top of the incubator or according to the manufacturer recommendations.
9. Perform baseline observations and document:
• Temperature
• Apex beat
• Respiration rate
• Skin colour
• Hydration status, and
• Baby’s behaviour.
10. Phototherapy lights can interfere with thermoregulation - monitor the baby’s temperature hourly for 4 hours and reassess when commencing phototherapy and adjust incubator temperature as required to avoid overheating.
11. Take temperature before feeds.
12. Attend cares including eye and skin care four to six hourly.
13. Continue lactation support unless otherwise ordered by M.O.
14. Record the baby’s wellbeing and monitor feeding and output.
15. Document any changes to the skin.
16. Perform a daily SBR unless otherwise indicated.
17. Record “phototherapy commenced” on phototherapy sticker in clinical notes and on care plan if on postnatal, antenatal, NICU and SCN.
Biliblanket Phototherapy System:
1. Cover the biliblanket with disposable cover.
2. 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.
3. Blankets may be worn over/around the fibre-optic blanket.
4. Eye protection should be worn at all times when undergoing treatment. Phototherapy goggles should be removed when baby is out for breast feeding if not having treatment during this time.
5. Appropriate eye care needs be attended if required.
Fibre-optic light sources (Spotlights):
1. Fibre-optic light sources (Spotlights) with Intensive Care Isolettes are to be used as per manufacturer’s instructions.
2. For nursing care follow as per phototherapy via Fluorescents lights section above.
3. Document all nursing observations and results of all investigations in progress notes.
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|Section 5 – Management of Jaundiced Infants in the Community |
Assessment
The Maternal and Child Health (MACH) nurse will consider and document variances related to both the mother and the infant when making the following assessment.
Infant Physical Assessment:
• Jaundice is assessed in natural light by blanching the baby’s skin with a finger and observing the underlying skin colour
• Level of vigour
• Hydration status
• Weight
• Extent of jaundice colour on the infant’s body using Kramer’s Rule (Attachment F).
• Note: Kramer’s rule is a guide to clinical examination only. It will be less helpful in non-caucasian babies. If in doubt to the extent of jaundice then an SBR level should be preformed.
Infant History:
• Risk factors as per Section 1 of this document Assessment and screening of infants at risk of jaundice
• Volume and colour of urine and stools
• Behaviour
• Feeding history.
Maternal Assessment/History:
• Health
• Birthing
• Breasts/lactation assessment
• Psychosocial.
Intervention
A jaundiced infant must be referred for further medical assessment if any of the following is evident:
• Jaundice is persistent (evident for 2 weeks or more)
• Jaundice is in Zone 3 (Kramer’s rule Attachment F)
• Indicators of dehydration
• Indicators of a poor feeding effort or pattern
• The infant is lethargic
• The infant has a fever
• The infant has pale chalky stools/dark urine.
Ongoing management
• Address any feeding issues. Ensure infant is receiving adequate hydration from breast or bottle. Consider increasing frequency of feed and the medical indication for complementing breastfed infants with EBM or formula.
• Document (as per variance pathway) nature and duration of concern regarding jaundice, assessment and plan.
• Ensure parents or carers know to follow up if concerns persist or if condition worsens.
• Provide information regarding jaundice to parents.
Referral Process
• Where referral is indicated the nurse/midwife will refer the client urgently to their GP, Paediatrician or the Emergency Dept at CHHS or Calvary.
• Document in the clinical records and follow up according to agreed plan.
• Alert the Clinical Nurse consultant (CNC) if concerns are identified.
• If the woman is still on Midcall or under the care of CatCH or CMP she could be referred back to CHHS Department of Neonatology.
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|Implementation |
• This Clinical Procedure will be communicated to staff working in the NICU/SCN during orientation for new staff.
• Those staff undertaking the New Graduate Program, the Transition Program or the Graduate Diploma in NICU/SCN Nursing will be informed of its existence during lectures relating to the topic.
• An all staff email will be sent to all relevant areas.
• Midwives will be informed of the procedure and receive education during orientation.
• Community Child Health Nurses will be informed of this procedure during orientation.
• Education of all CHHS staff to access the Clinical Policy and Guidelines via the Intranet.
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|Related Policies, Procedures, Guidelines and Legislation |
Procedures
• CHHS Patient Identification and Procedure Matching, CHHS15/052
• CHHS Blood Collection using Heel Lance Device SOP, CHHS12/087
• CHHS Venepuncture Blood Collection SOP, CHHS13/074
• CHHS Healthcare Associated Infections Procedure, CHHS 15/072
Guidelines
• CHHS Cord Blood Collection for Blood Group, Direct Coomb’s test (DCT) and Blood Gas Sampling guideline, CHHS16/095
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|References |
• Fundamentals of Phototherapy for Neonatal Jaundice Stokowski, L. (2006) Advances in Neonatal Care 6 (6) 303-312.
• National Institute for Health and Clinical Excellence (2011) “Neonatal Jaundice” retrieved on the 25/01/2012 from
• Assessing Jaundice Risk–Without the Trauma- Drȁger JM-105
• Fusion Healthcare Bilisoft Biliblanket
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|Definition of Terms |
Midcall – Hospital Based Community Midwifery
Anti-D Immunoglobulin – Immunoglobulin given to Rh negative blood group mothers as per policy
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|Search Terms |
Neonatal Intensive Care, Maternity, Infant, Jaundice, Phototherapy, Biliblanket, Hyperbilirubinaemia
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|Attachments |
Attachment A - Initial Management Flowchart
Attachment B - Screening for hyperbilirubinaemia in term infants using transcutaneous bilirubinometer (TcB)
Attachment C - Treatment threshold for DCT negative, Well Term Infants
Attachment D - Treatment threshold for DCT positive or premature infants
Attachment E - Phototherapy Pathway: SBR in Phototherapy Range
(For well term infants with –ve DCT use chart C and +ve DCT use phototherapy chart D)
Attachment F Kramer’s Rule
Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Service 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 Health Directorate assumes no responsibility whatsoever.
|Date Amended |Section Amended |Approved By |
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Attachment A - Initial Management Flowchart
[pic]
Attachment B: Screening for hyperbilirubinaemia in term infants using transcutaneous bilirubinometer (TcB):
|Signs of jaundice 24 hours of age |→ |Do SBR |
|+ | | |
|Risk factors (maternal antibodies/history of G6PD) | | |
|Signs of jaundice 24-48 hours of age |→ |If TcB > 140 micromol/L |
| | |Do SBR |
|Well infant/no risk factors | | |
|Signs of jaundice >48hours of age |→ |If TcB > 200 micromol/L |
| | |Do SBR |
|Well infant/no risk factors | | |
|Phototherapy via a Biliblanket |→ |If SBR level falling do daily SBR as per guidelines |
|Well infant/no risk factors | |Monitor jaundice using TcB |
Attachment C: Treatment threshold for DCT negative, Well Term Infants
[pic]
Attachment D: Treatment threshold for DCT positive or premature infants
[pic]
Attachment E: Phototherapy Pathway: SBR in Phototherapy Range
(For haemolytic jaundice use phototherapy Attachment C and for well term infants without haemolysis use Attachment D)
[pic]
Attachment F: Kramer’s Rule
Kramers rule is a guide to clinical examination only. It will be less reliable in non-caucasion babies. If in doubt to the extent of jaundice then an SBR level should be preformed.
Rather than estimating the level of jaundice by simply observing the baby's skin colour, one can utilise the cephalocaudal progression of jaundice. Kramer drew attention to the observation that jaundice starts on the head, and extends towards the feet as the level rises. This is useful in deciding whether or not a baby needs to have the SBR measured. Kramer divided the infant into 5 zones, the SBR range associated with progression to the zones is as follows:
| Zone |1 |2 |3 |4 |5 |
|SBR (micromol/L) |100 |150 |200 |250 |>250 |
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