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Guideline Summary
Guideline Title
Neonatal jaundice.
Bibliographic Source(s)
National Collaborating Centre for Women's and Children's Health. Neonatal jaundice. London (UK): National Institute for Health and Clinical Excellence (NICE); 2010 May. 53 p. (Clinical guideline; no. 98). 
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Neonatal jaundice

Guideline Category
Diagnosis
Evaluation
Management
Treatment
Clinical Specialty
Family Practice
Nursing
Obstetrics and Gynecology
Pediatrics
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Health Care Providers
Hospitals
Nurses
Patients
Physician Assistants
Physicians
Public Health Departments
Guideline Objective(s)

To provide guidance on the recognition and assessment of neonatal jaundice, prediction of later significant hyperbilirubinaemia and adverse sequelae, treatment, and information and education for parents/carers of babies with jaundice

Target Population
  • All newborn infants (both term and preterm) from birth to 28 days
  • Special attention will be given to the recognition and management of neonatal jaundice in babies with darker skin.
Interventions and Practices Considered

Diagnosis

  1. Visual/clinical examination
  2. Bilirubin measurement (serum levels, transcutaneous bilirubinometer)
  3. Formal assessment of underlying disease (serum bilirubin, blood packed cell volume, blood group [mother and baby], direct antiglobulin test [DAT] [Coombs' test])
  4. Other haematological and biochemical tests as indicated (full blood count, examination of blood film, blood glucose-6-phosphate dehydrogenase levels, microbiological cultures of blood, urine and/or cerebrospinal fluid, metabolic screening, measurement of conjugated bilirubin)

Management/Treatment

  1. Referral of babies with visible jaundice for urgent medical review
  2. Phototherapy (including care during and monitoring of bilirubin during)
  3. Identification of babies at increased risk of kernicterus
  4. Intravenous immunoglobulin
  5. Exchange transfusion
  6. Education and provision of information to parents or carers
Major Outcomes Considered
  • Serum bilirubin concentrations (change from baseline)
  • Duration of treatment
  • Treatment failure
  • Adverse effects
  • Mortality

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Note from the National Guideline Clearinghouse (NGC): This guideline was developed by the National Collaborating Centre for Women's and Children's Health on behalf of the National Institute for Health and Clinical Excellence (NICE). See the "Availability of Companion Documents" field for the full version of this guidance.

Literature Search Strategy

Initial scoping searches were executed to identify relevant guidelines (local, national, and international) produced by other development groups. The reference lists in these guidelines were checked against subsequent searches to identify missing evidence. Relevant published evidence to inform the guideline development process and answer the clinical questions was identified by systematic search strategies. The questions are presented in Appendix H in the full guideline document.

Systematic searches to answer the clinical questions formulated and agreed by the Guideline Development Group (GDG) were executed using the following databases via the 'Ovid' platform: Medline (1966 onwards), EMBASE (1980 onwards), Cumulative Index to Nursing and Allied Health Literature (1982 onwards), and PsycINFO (1967 onwards). The most recent search conducted for the three Cochrane databases (Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and the Database of Abstracts of Reviews of Effectiveness) was Quarter 2, 2009. Searches to identify economic studies were undertaken using the above databases and the National Health Service Economic Evaluations Database (NHS EED).

Search strategies combined relevant controlled vocabulary and natural language in an effort to balance sensitivity and specificity. Unless advised by the GDG, searches were not date specific. Language restrictions were not applied to searches, although publications in languages other than English were not appraised. Both generic and specially developed methodological search filters were used appropriately.

There was no systematic attempt to search grey literature (conferences, abstracts, theses and unpublished trials). Hand searching of journals not indexed on the databases was not undertaken.

Towards the end of the guideline development process, searches were updated and re-executed, thereby including evidence published and included in the databases up to June 2009. Studies identified after this date could only be included if they were specifically requested during the consultation process. Evidence published after this date has not been included in the guideline. This date should be considered the starting point for searching for new evidence for future updates to this guideline.

Further details of the search strategies, including the methodological filters employed, are presented in Appendix I of the full guideline document.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Levels of Evidence for Intervention Studies

1++ High-quality meta-analyses, systematic reviews of randomised controlled trials (RCTs) or RCTs with a very low risk of bias

1+ Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias

1– Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk of bias

2++ High-quality systematic reviews of case–control or cohort studies; high-quality case–control or cohort studies with a very low risk of confounding, bias or chance and a high probability that the relationship is causal

2+ Well-conducted case–control or cohort studies with a low risk of confounding, bias or chance and a moderate probability that the relationship is causal

2– Case–control or cohort studies with a high risk of confounding, bias, or chance and a significant risk that the relationship is not causal

3 Non-analytical studies (for example, case reports, case series)

4 Expert opinion, formal consensus

Levels of Evidence for Studies of the Accuracy of Diagnostic Tests

Ia - Systematic review (with homogeneity)a of level 1 studiesb

Ib - Level 1 studiesb

II - Level 2 studiesc; systematic reviews of level 2 studies

III - Level 3 studiesd; systematic reviews of level 3 studies

IV - Consensus, expert committee reports or opinions and/or clinical experience without explicit critical appraisal; or based on physiology, bench research or "first principles"

a Homogeneity means there are minor or no variations in the directions and degrees of results between individual studies that are included in the systematic review.

b Level 1 studies are studies that use a blind comparison of the test with a validated reference standard (gold standard) in a sample of patients that reflects the population to whom the test would apply.

c Level 2 studies are studies that have only one of the following:

  • Narrow population (the sample does not reflect the population to whom the test would apply)
  • Use a poor reference standard (defined as that where the "test" is included in the "reference", or where the "testing" affects the "reference")
  • The comparison between the test and reference standard is not blind
  • Case–control studies

d Level 3 studies are studies that have at least two or three of the features listed above.

Methods Used to Analyze the Evidence
Meta-Analysis of Randomized Controlled Trials
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

Note from the National Guideline Clearinghouse (NGC): This guideline was developed by the National Collaborating Centre for Women's and Children's Health on behalf of the National Institute for Health and Clinical Excellence (NICE). See the "Availability of Companion Documents" field for the full version of this guidance.

Appraisal and Synthesis of Clinical Effectiveness Evidence

Evidence relating to clinical effectiveness was reviewed using established guides and classified using the established hierarchical system presented in "Rating Scheme for the Strength of the Evidence" in this summary. This system reflects the susceptibility to bias that is inherent in particular study designs.

The type of clinical question dictates the highest level of evidence that may be sought. In assessing the quality of the evidence, each study receives a quality rating coded as '++', '+' or '−'. For issues of therapy or treatment, the highest possible evidence level (EL) is a well conducted systematic review or meta-analysis of randomised controlled trials (RCTs; EL 1++) or an individual RCT (EL 1+). Studies of poor quality are rated as '−'. Usually, studies rated as '−' should not be used as a basis for making a recommendation, but they can be used to inform recommendations. For issues of prognosis, the highest possible level of evidence is a cohort study (EL 2). A level of evidence was assigned to each study, and to the body of evidence for each question.

For each clinical question, the highest available level of evidence was selected. Where appropriate, for example, if a systematic review, meta-analysis or RCT existed in relation to a question, studies of a weaker design were not considered. Where systematic reviews, meta-analyses, and RCTs did not exist, other appropriate experimental or observational studies were sought. For diagnostic tests, test evaluation studies examining the performance of the test were used if the efficacy (accuracy) of the test was required, but where an evaluation of the effectiveness of the test in the clinical management of patients and the outcome of disease was required, evidence from RCTs or cohort studies was optimal. For studies evaluating the accuracy of a diagnostic test, sensitivity, specificity and positive and negative predictive values (PPVs and NPVs) were calculated or quoted where possible.

Clinical evidence for individual studies was extracted into evidence tables (see Appendix H in the full guideline document) and, where possible, quantitative synthesis (meta-analysis) was carried out. If no meta-analysis was possible, a brief summary of each study was included in the guideline text. If an analysis was carried out, the results may be presented pictorially (i.e., forest plots, summary Receiver Operating Characteristic [ROC] curves) as well as in the text. If no meta-analysis was carried out, the results from each included study are reported in the text and, where appropriate, in summary tables. The body of evidence identified for each clinical question was synthesised qualitatively or quantitatively in clinical evidence statements that accurately reflect the evidence.

Lists of excluded studies for each clinical question are presented in Appendix J of the full guideline document.

Methods Used to Formulate the Recommendations
Expert Consensus
Informal Consensus
Description of Methods Used to Formulate the Recommendations

Note from the National Guideline Clearinghouse (NGC): This guideline was developed by the National Collaborating Centre for Women's and Children's Health on behalf of the National Institute for Health and Clinical Excellence (NICE). See the "Availability of Companion Documents" field for the full version of this guidance.

For each clinical question, recommendations for clinical care were derived using, and linked explicitly to, the evidence that supported them. In the first instance, informal consensus methods were used by the Guideline Development Group (GDG) to agree clinical evidence statements. Statements summarising the GDG's interpretation of the clinical and economic evidence and any extrapolation (including economic modelling) from the evidence used to form recommendations were also prepared. In areas where no substantial evidence was identified, the GDG considered other evidence-based guidelines and consensus statements or used their collective experience to identify good practice. The GDG also identified areas where evidence to answer their clinical questions was lacking and used this information to draft recommendations for future research.

Towards the end of the guideline development process, formal consensus methods were used to consider all the clinical care recommendations that had been drafted previously. Consensus was again used to agree the wording of recommendations. All recommendations for which at least one GDG member indicated any level of disagreement were discussed at a subsequent GDG meeting, and the final wording was agreed following discussion of the relevant issues.

The GDG identified key priorities for implementation which were those recommendations expected to have the biggest impact on patients' care and patients' outcomes in the National Health Service (NHS) as a whole. Each GDG member submitted a paper form indicating their top ten recommendations in order of priority. The GDG members' votes were collated and priority recommendations were obtained by including all recommendations that had been voted for by at least four GDG members in order of popularity.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

The aim of the economic input in this guideline was to inform the Guideline Development group (GDG) of potential economic issues relating to neonatal jaundice, and to ensure that recommendations represented a cost-effective use of scarce resources.

The GDG sought to identify relevant economic evidence for this guideline, but no published evidence was identified that fully answered the guideline questions. Had any such evidence been identified, it would have been assessed using a quality assessment checklist based on good practice in decision-analytic modelling (because no standard system of grading the quality of economic evaluations exists).

Where it is not possible to make recommendations based on published economic evidence, the guideline health economist may undertake de novo economic analysis. Health economic analysis may be required for a clinical question where there are genuine competing alternatives for decision-makers that may have implications for healthcare resources and patient outcomes. Cost-effectiveness analysis can provide clarity as to which alternative is currently the best option for the National Health Service (NHS).

After GDG discussion of the clinical questions it became apparent that economic analysis would not actually influence the recommendations as originally expected, since genuine alternatives to current practice did not practically exist in the NHS. For example, 'no treatment' would not be considered as a serious alternative to phototherapy or exchange transfusion in any modern healthcare system. Therefore, the remaining areas where health economics was thought to be important in guiding recommendations was around testing for hyperbilirubinaemia and the use of the intravenous immunoglobulin (IVIG).

A more detailed description of the health economic methods and results is presented in Appendices C and D of the full guideline document.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

The guideline was validated through two consultations.

  1. The first draft of the guideline (The full guideline, National Institute for Clinical Excellence [NICE] guideline and Quick Reference Guide) were consulted with stakeholders and comments were considered by the Guideline Development Group (GDG).
  2. The final consultation draft of the full guideline, the NICE guideline and the Information for the Public were submitted to stakeholders for final comments.

The final draft was submitted to the Guideline Review Panel for review prior to publication.

Recommendations

Major Recommendations

Note from the National Guideline Clearinghouse (NGC): This guideline was developed by the National Collaborating Centre for Women's and Children's Health on behalf of the National Institute for Health and Clinical Excellence (NICE). See the "Availability of Companion Documents" field for the full version of this guidance.

Threshold Table. Consensus-based Bilirubin Thresholds for Management of Babies 38 weeks or More Gestational Age with Hyperbilirubinaemia

Age
(hours)
Bilirubin Measurement (micromol/litre)
0 > 100 > 100
6 > 100 > 112 > 125 > 150
12 > 100 > 125 > 150 > 200
18 > 100 > 137 > 175 > 250
24 > 100 > 150 > 200 > 300
30 > 112 > 162 > 212 > 350
36 > 125 > 175 > 225 > 400
42 > 137 > 187 > 237 > 450
48 > 150 > 200 > 250 > 450
54 > 162 > 212 > 262 > 450
60 > 175 > 225 > 275 > 450
66 > 187 > 237 > 287 > 450
72 > 200 > 250 > 300 > 450
78 > 262 > 312 > 450
84 > 275 > 325 > 450
90 > 287 > 337 > 450
96+ > 300 > 350 > 450
Action Repeat bilirubin measurement in 6–12 hours Consider phototherapy and repeat bilirubin measurement in 6 hours Start phototherapy Perform an exchange transfusion unless the bilirubin level falls below threshold while the treatment is being prepared

Information for Parents or Carers

Offer parents or carers information about neonatal jaundice that is tailored to their needs and expressed concerns. This information should be provided through verbal discussion backed up by written information. Care should be taken to avoid causing unnecessary anxiety to parents or carers. Information should include:

  • Factors that influence the development of significant hyperbilirubinaemia
  • How to check the baby for jaundice
  • What to do if they suspect jaundice
  • The importance of recognising jaundice in the first 24 hours and of seeking urgent medical advice
  • The importance of checking the baby's nappies for dark urine or pale chalky stools
  • The fact that neonatal jaundice is common, and reassurance that it is usually transient and harmless
  • Reassurance that breastfeeding can usually continue

Care for All Babies

Identify babies as being more likely to develop significant hyperbilirubinaemia if they have any of the following factors:

  • Gestational age under 38 weeks
  • A previous sibling with neonatal jaundice requiring phototherapy
  • Mother's intention to breastfeed exclusively
  • Visible jaundice in the first 24 hours of life

Ensure that adequate support is offered to all women who intend to breastfeed exclusively.*

In all babies:

  • Check whether there are factors associated with an increased likelihood of developing significant hyperbilirubinaemia soon after birth
  • Examine the baby for jaundice at every opportunity especially in the first 72 hours.

Parents, carers and healthcare professionals should all look for jaundice (visual inspection).

When looking for jaundice (visual inspection):

  • Check the naked baby in bright and preferably natural light
  • Examination of the sclerae, gums and blanched skin is useful across all skin tones.

Do not rely on visual inspection alone to estimate the bilirubin level in a baby with jaundice.

Do not measure bilirubin levels routinely in babies who are not visibly jaundiced.

Do not use any of the following to predict significant hyperbilirubinaemia:

  • Umbilical cord blood bilirubin level
  • End-tidal carbon monoxide (ETCOc) measurement
  • Umbilical cord blood direct antiglobulin test (DAT) (Coombs' test)

Additional Care

Ensure babies with factors associated with an increased likelihood of developing significant hyperbilirubinaemia receive an additional visual inspection by a healthcare professional during the first 48 hours of life.

Urgent Additional Care for Babies with Visible Jaundice in the First 24 Hours

Measure and record the serum bilirubin level urgently (within 2 hours) in all babies with suspected or obvious jaundice in the first 24 hours of life.

Continue to measure the serum bilirubin level every 6 hours for all babies with suspected or obvious jaundice in the first 24 hours of life until the level is both:

  • Below the treatment threshold
  • Stable and/or falling

Arrange a referral to ensure that an urgent medical review is conducted (as soon as possible and within 6 hours) for babies with suspected or obvious jaundice in the first 24 hours of life to exclude pathological causes of jaundice.

Interpret bilirubin levels according to the baby's postnatal age in hours and manage hyperbilirubinaemia according to the threshold table** and treatment threshold graphs.***

Care for Babies More Than 24 Hours Old

Measure and record the bilirubin level urgently (within 6 hours) in all babies more than 24 hours old with suspected or obvious jaundice.

How to Measure the Bilirubin Level

When measuring the bilirubin level:

  • Use a transcutaneous bilirubinometer in babies with a gestational age of 35 weeks or more and postnatal age of more than 24 hours
  • If a transcutaneous bilirubinometer is not available, measure the serum bilirubin
  • If a transcutaneous bilirubinometer measurement indicates a bilirubin level greater than 250 micromol/litre check the result by measuring the serum bilirubin
  • Always use serum bilirubin measurement to determine the bilirubin level in babies with jaundice in the first 24 hours of life
  • Always use serum bilirubin measurement to determine the bilirubin level in babies less than 35 weeks gestational age
  • Always use serum bilirubin measurement for babies at or above the relevant treatment thresholds for their postnatal age, and for all subsequent measurements
  • Do not use an icterometer

Management and Treatment of Hyperbilirubinaemia

Information for Parents or Carers on Treatment

Offer parents or carers information about treatment for hyperbilirubinaemia, including:

  • Anticipated duration of treatment
  • Reassurance that breastfeeding, nappy-changing and cuddles can usually continue

Encourage mothers of breastfed babies with jaundice to breastfeed frequently, and to wake the baby for feeds if necessary.

Provide lactation/feeding support to breastfeeding mothers whose baby is visibly jaundiced.

How to Manage Hyperbilirubinaemia

Use the bilirubin level to determine the management of hyperbilirubinaemia in all babies (see threshold table** and treatment threshold graphs***).

Do not use the albumin/bilirubin ratio when making decisions about the management of hyperbilirubinaemia.

Do not subtract conjugated bilirubin from total serum bilirubin when making decisions about the management of hyperbilirubinaemia (see management thresholds in the threshold table** and treatment threshold graphs***).

Measuring and Monitoring Bilirubin Thresholds During Phototherapy

Starting Phototherapy

Use serum bilirubin measurement and the treatment thresholds in the threshold table** and treatment threshold graphs*** when considering the use of phototherapy.

In babies with a gestational age of 38 weeks or more whose bilirubin is in the 'repeat bilirubin measurement' category in the threshold table** repeat the bilirubin measurement in 6–12 hours.

In babies with a gestational age of 38 weeks or more whose bilirubin is in the 'consider phototherapy' category in the threshold table** repeat the bilirubin measurement in 6 hours regardless of whether or not phototherapy has subsequently been started.

Do not use phototherapy in babies whose bilirubin does not exceed the phototherapy threshold levels in the threshold table** and treatment threshold graphs.***

During Phototherapy

During phototherapy:

  • Repeat serum bilirubin measurement 4–6 hours after initiating phototherapy
  • Repeat serum bilirubin measurement every 6–12 hours when the serum bilirubin level is stable or falling

Stopping Phototherapy

Stop phototherapy once serum bilirubin has fallen to a level at least 50 micromol/litre below the phototherapy threshold (see threshold table** and treatment threshold graphs*** in the original guideline document).

Check for rebound of significant hyperbilirubinaemia with a repeat serum bilirubin measurement 12–18 hours after stopping phototherapy. Babies do not necessarily have to remain in hospital for this to be done.

Type of Phototherapy to Use

Do not use sunlight as treatment for hyperbilirubinaemia.

Single Phototherapy Treatment for Term Babies

Use conventional 'blue light' phototherapy as treatment for significant hyperbilirubinaemia in babies with a gestational age of 37 weeks or more unless:

  • The serum bilirubin levels are rising rapidly (more than 8.5 micromol/litre per hour)
  • The serum bilirubin is at a level that is within 50 micromol/litre below the threshold for which exchange transfusion is indicated after 72 hours (see the threshold table** and treatment threshold graphs*** in the original guideline document).

Do not use fibreoptic phototherapy as first-line treatment for hyperbilirubinaemia for babies with a gestational age 37 weeks or more.

Single Phototherapy Treatment in Preterm Babies

Use either fibreoptic phototherapy or conventional 'blue light' phototherapy as treatment for significant hyperbilirubinaemia in babies less than 37 weeks unless:

  • The serum bilirubin levels are rising rapidly (more than 8.5 micromol/litre per hour)
  • The serum bilirubin is at a level that is within 50 micromol/litre below the threshold for which exchange transfusion is indicated after 72 hours (see threshold table** and treatment threshold graphs*** in the original guideline document).

Continuous Multiple Phototherapy Treatment for Term and Preterm Babies

Initiate continuous multiple phototherapy to treat all babies if any of the following apply:

  • The serum bilirubin level is rising rapidly (more than 8.5 micromol/litre per hour)
  • The serum bilirubin is at a level within 50 micromol/litre below the threshold for which exchange transfusion is indicated after 72 hours (see threshold table** and treatment threshold graphs***).
  • The bilirubin level fails to respond to single phototherapy (that is, the level of serum bilirubin continues to rise, or does not fall, within 6 hours of starting single phototherapy).

If the serum bilirubin level falls during continuous multiple phototherapy to a level 50 micromol/litre below the threshold for which exchange transfusion is indicated step down to single phototherapy.

Information for Parents or Carers on Phototherapy

Offer parents or carers verbal and written information on phototherapy including all of the following:

  • Why phototherapy is being considered
  • Why phototherapy may be needed to treat significant hyperbilirubinaemia
  • The possible adverse effects of phototherapy
  • The need for eye protection and routine eye care
  • Reassurance that short breaks for feeding, nappy changing and cuddles will be encouraged
  • What might happen if phototherapy fails
  • Rebound jaundice
  • Potential long-term adverse effects of phototherapy
  • Potential impact on breastfeeding and how to minimise this

General Care of the Baby During Phototherapy

During phototherapy:

  • Place the baby in a supine position unless other clinical conditions prevent this
  • Ensure treatment is applied to the maximum area of skin
  • Monitor the baby's temperature and ensure the baby is kept in an environment that will minimise energy expenditure (thermoneutral environment)
  • Monitor hydration by daily weighing of the baby and assessing wet nappies
  • Support parents and carers and encourage them to interact with the baby

Give the baby eye protection and routine eye care during phototherapy.

Use tinted headboxes as an alternative to eye protection in babies with a gestational age of 37 weeks or more undergoing conventional 'blue light' phototherapy.

Monitoring the Baby During Phototherapy

During conventional 'blue light' phototherapy:

  • Using clinical judgement, encourage short breaks (of up to 30 minutes) for breastfeeding, nappy changing and cuddles
  • Continue lactation/feeding support
  • Do not give additional fluids or feeds routinely

Maternal expressed milk is the additional feed of choice if available, and when additional feeds are indicated.

During multiple phototherapy:

  • Do not interrupt phototherapy for feeding but continue administering intravenous/enteral feeds
  • Continue lactation/feeding support so that breastfeeding can start again when treatment stops

Maternal expressed milk is the additional feed of choice if available, and when additional feeds are indicated.

Phototherapy Equipment

Ensure all phototherapy equipment is maintained and used according to the manufacturers' guidelines.

Use incubators or bassinets according to clinical need and availability.

Do not use white curtains routinely with phototherapy as they may impair observation of the baby.

Factors that Influence the Risk of Kernicterus

Identify babies with hyperbilirubinaemia as being at increased risk of developing kernicterus if they have any of the following:

  • A serum bilirubin level greater than 340 micromol/litre in babies with a gestational age of 37 weeks or more
  • A rapidly rising bilirubin level of greater than 8.5 micromol/litre per hour
  • Clinical features of acute bilirubin encephalopathy

Formal Assessment for Underlying Disease

In addition to a full clinical examination by a suitably trained healthcare professional, carry out all of the following tests in babies with significant hyperbilirubinaemia as part of an assessment for underlying disease (see threshold table** and treatment threshold graphs***):

  • Serum bilirubin (for baseline level to assess response to treatment)
  • Blood packed cell volume
  • Blood group (mother and baby)
  • DAT (Coombs' test). Interpret the result taking account of the strength of reaction, and whether mother received prophylactic anti-D immunoglobulin during pregnancy

When assessing the baby for underlying disease, consider whether the following tests are clinically indicated:

  • Full blood count and examination of blood film
  • Blood glucose-6-phosphate dehydrogenase levels, taking account of ethnic origin
  • Microbiological cultures of blood, urine and/or cerebrospinal fluid (if infection is suspected)

Care of Babies with Prolonged Jaundice

In babies with a gestational age of 37 weeks or more with jaundice lasting more than 14 days, and in babies with a gestational age of less than 37 weeks and jaundice lasting more than 21 days:

  • Look for pale chalky stools and/or dark urine that stains the nappy
  • Measure the conjugated bilirubin
  • Carry out a full blood count
  • Carry out a blood group determination (mother and baby) and DAT (Coombs' test). Interpret the result taking account of the strength of reaction, and whether mother received prophylactic anti-D immunoglobulin during pregnancy.
  • Carry out a urine culture
  • Ensure that routine metabolic screening (including screening for congenital hypothyroidism) has been performed

Follow expert advice about care for babies with a conjugated bilirubin level greater than 25 micromol/litre because this may indicate serious liver disease.

Intravenous Immunoglobulin

Use intravenous immunoglobulin (IVIG) (500 mg/kg over 4 hours) as an adjunct to continuous multiple phototherapy in cases of Rhesus haemolytic disease or ABO haemolytic disease when the serum bilirubin continues to rise by more than 8.5 micromol/litre per hour.

Offer parents or carers information on IVIG including:

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

Exchange Transfusion

Offer parents or carers information on exchange transfusion including:

  • The fact that exchange transfusion requires that the baby be admitted to an intensive care bed
  • Why an exchange transfusion is being considered
  • Why an exchange transfusion may be needed to treat significant hyperbilirubinaemia
  • The possible adverse effects of exchange transfusions
  • When it will be possible for parents or carers to see and hold the baby after the exchange transfusion

Use a double-volume exchange transfusion to treat babies:

  • Whose serum bilirubin level indicates its necessity (see threshold table** and treatment threshold graphs*** in the original guideline document) and/or
  • With clinical features and signs of acute bilirubin encephalopathy

During exchange transfusion do not:

  • Stop continuous multiple phototherapy
  • Perform a single-volume exchange
  • Use albumin priming
  • Routinely administer intravenous calcium

Following exchange transfusion:

  • Maintain continuous multiple phototherapy
  • Measure serum bilirubin level within 2 hours and manage according to the threshold table** and treatment threshold graphs***.

Other Therapies

Do not use any of the following to treat hyperbilirubinaemia:

  • Agar
  • Albumin
  • Barbiturates
  • Charcoal
  • Cholestyramine
  • Clofibrate
  • D-penicillamine
  • Glycerin
  • Manna
  • Metalloporphyrins
  • Riboflavin
  • Traditional Chinese medicine
  • Acupuncture
  • Homeopathy

* Refer to 'Routine postnatal care of women and their babies' (NICE clinical guideline 37) for information on breastfeeding support.

** The threshold table is listed above and on page 10 of the original guideline document.

*** The treatment threshold graphs are in Appendix D of the original guideline document.

Clinical Algorithm(s)

Clinical algorithms on investigation, phototherapy and exchange transfusion for babies with neonatal jaundice are available in the quick reference guide (see "Availability of Companion Documents").

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of evidence supporting the recommendations is not specifically stated.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate assessment and management of babies with jaundice

Potential Harms

Adverse effects of treatment

Qualifying Statements

Qualifying Statements
  • This guidance represents the view of National Institute for Health and Clinical Excellence (NICE), which was arrived at after careful consideration of the evidence available. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. However, the guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, and informed by the summary of product characteristics of any drugs they are considering.
  • Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.
  • While every effort has been made to ensure the accuracy of the information contained within this publication, the publisher can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case the respective user must check current indications and accuracy by consulting other pharmaceutical literature and following the guidelines laid down by the manufacturers of specific products and the relevant authorities in the country in which they are practising.

Implementation of the Guideline

Description of Implementation Strategy

The Healthcare Commission assesses how well National Health Service (NHS) organisations meet core and developmental standards set by the Department of Health in 'Standards for better health' (available from www.dh.gov.uk External Web Site Policy). Implementation of clinical guidelines forms part of the developmental standard D2. Core standard C5 states that NHS organisations should take into account national agreed guidance when planning and delivering care.

The National Institute for Health and Clinical Excellence (NICE) has developed tools to help organisations implement this guidance. These are available on the NICE website http://guidance.nice.org.uk/CG98 External Web Site Policy; see also the "Availability of Companion Documents" field).

Key Priorities for Implementation

Information

Offer parents or carers information about neonatal jaundice that is tailored to their needs and expressed concerns. This information should be provided through verbal discussion backed up by written information. Care should be taken to avoid causing unnecessary anxiety to parents or carers. Information should include:

  • Factors that influence the development of significant hyperbilirubinaemia
  • How to check the baby for jaundice
  • What to do if they suspect jaundice
  • The importance of recognizing jaundice in the first 24 hours and of seeking urgent medical advice
  • The importance of checking the baby's nappies for dark urine or pale chalky stools
  • The fact that neonatal jaundice is common, and reassurance that it is usually transient and harmless
  • Reassurance that breastfeeding can usually continue

Care for All Babies

  • Identify babies as being more likely to develop significant hyperbilirubinaemia if they have any of the following factors:
    • Gestational age under 38 weeks
    • A previous sibling with neonatal jaundice requiring phototherapy
    • Mother's intention to breastfeed exclusively
    • Visible jaundice in the first 24 hours of life
  • In all babies:
    • Check whether there are factors associated with an increased likelihood of developing significant hyperbilirubinaemia soon after birth
    • Examine the baby for jaundice at every opportunity especially in the first 72 hours
  • When looking for jaundice (visual inspection):
    • Check the naked baby in bright and preferably natural light
    • Examination of the sclerae, gums and blanched skin is useful across all skin tones.

Additional Care

Ensure babies with factors associated with an increased likelihood of developing significant hyperbilirubinaemia receive an additional visual inspection by a healthcare professional during the first 48 hours of life.

Measuring Bilirubin in All Babies with Jaundice

Do not rely on visual inspection alone to estimate the bilirubin level in a baby with jaundice.

How to Measure the Bilirubin Level

When measuring the bilirubin level:

  • Use a transcutaneous bilirubinometer in babies with a gestational age of 35 weeks or more and postnatal age of more than 24 hours
  • If a transcutaneous bilirubinometer is not available, measure the serum bilirubin
  • If a transcutaneous bilirubinometer measurement indicates a bilirubin level greater than 250 micromol/litre check the result by measuring the serum bilirubin
  • Always use serum bilirubin measurement to determine the bilirubin level in babies with jaundice in the first 24 hours of life
  • Always use serum bilirubin measurement to determine the bilirubin level in babies less than 35 weeks gestational age
  • Always use serum bilirubin measurement for babies at or above the relevant treatment threshold for their postnatal age, and for all subsequent measurements
  • Do not use an icterometer.

How to Manage Hyperbilirubinaemia

Use the bilirubin level to determine the management of hyperbilirubinaemia in all babies (see threshold table* and treatment threshold graphs**).

Care of Babies with Prolonged Jaundice

Follow expert advice about care for babies with a conjugated bilirubin level greater than 25 micromol/litre because this may indicate serious liver disease.

*The threshold table is on page 10 of the original guideline document.

**The treatment threshold graphs are in Appendix D of the original guideline document.

Implementation Tools
Audit Criteria/Indicators
Clinical Algorithm
Foreign Language Translations
Patient Resources
Quick Reference Guides/Physician Guides
Resources
Slide Presentation
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
National Collaborating Centre for Women's and Children's Health. Neonatal jaundice. London (UK): National Institute for Health and Clinical Excellence (NICE); 2010 May. 53 p. (Clinical guideline; no. 98). 
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2010 May
Guideline Developer(s)
National Collaborating Centre for Women's and Children's Health - National Government Agency [Non-U.S.]
Source(s) of Funding

National Institute for Health and Clinical Excellence (NICE)

Guideline Committee

Guideline Development Group

Composition of Group That Authored the Guideline

Guideline Development Group Members: Janet Rennie, Consultant and Senior Lecturer in Neonatal Medicine, Elizabeth Garrett Anderson Institute for Women's Health, University College London Hospitals NHS Foundation Trust; Christiana Aride, GP, Tynemouth Medical Practice, London; Jay Bannerjee (until Mar 09), Clinical Co-director, National Collaborating Centre for Women's and Children's Health; Yvonne Benjamin, Community Midwife, Leicester Royal Infirmary; Shona Burman-Roy (from Sep 09), Senior Research Fellow, National Collaborating Centre for Women's and Children's Health; Katherine Cullen, Health Economist, National Collaborating Centre for Women's and Children's Health; Hannah-Rose Douglas, Health Economist, National Collaborating Centre for Women’s and Children's Health; Karen Ford, Senior Lecturer, De Montfort University, Leicester; Itrat Iqbal (until Aug 09), Health Economist, National Collaborating Centre for Women's and Children's Health; Kevin Ives, Consultant, Neonatologist, John Radcliffe Hospital, Oxford; Paul Jacklin, Health Economist, National Collaborating Centre for Women's and Children's Health; Maria Jenkins, Parent member; Alison Johns, Transitional Care Sister, University College London Hospitals NHS Foundation Trust; Juliet Kenny (from Jan 10), Project Manager, National Collaborating Centre for Women's and Children's Health; Rajesh Khanna (until Apr 09), Senior Research Fellow, National Collaborating Centre for Women's and Children's Health; Rosalind Lai, Information Scientist, National Collaborating Centre for Women's and Children's Health; Donal Manning, Consultant Paediatrician, Wirral University Teaching Hospital NHS Foundation Trust; Hugh McGuire, Research Fellow, National Collaborating Centre for Women's and Children's Health; Stephen Murphy (from Sep 09), Clinical Co-director, National Collaborating Centre for Women's and Children's Health; Caroline Ortega (until Apr 09), Work Programme Co-ordinator, National Collaborating Centre for Women's and Children's Health; Kristina Pedersen (until Oct 09), Project Manager, National Collaborating Centre for Women’s and Children’s Health; Edmund Peston, Document Supply Coordinator; Debbie Pledge (until Apr 09), Senior Information Scientist, National Collaborating Centre for Women's and Children's Health; Farrah Pradhan, Parent member; Wendy Riches, Executive Director, National Collaborating Centre for Women's and Children's Health; Anuradha Sekhri, Freelance Systematic Reviewer; Debra Teasdale, Head of Department – Health, Wellbeing and the Family, Canterbury Christ Church University; Martin Whittle (until September 09), Clinical Co-director, National Collaborating Centre for Women's and Children's Health

Financial Disclosures/Conflicts of Interest

At each Guideline Development Group (GDG) meeting, all GDG members declared any potential conflict of interests. In accordance with guidance from the National Institute for Health and Clinical Excellence (NICE), all GDG members' interests were recorded on a standard declaration form that covered consultancies, fee-paid work, share-holdings, fellowships, and support from the healthcare industry. The GDG members' declarations of interests are listed in Appendix B of the full version of the original guideline document (see "Availability of Companion Documents").

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) format from the National Institute for Health and Clinical Excellence (NICE) Web site External Web Site Policy.

Availability of Companion Documents

The following are available:

  • Neonatal jaundice. Quick reference guide. London (UK): National Institute for Health and Clinical Excellence; 2010 May. 18 p. (Clinical guideline; no. CG98). Electronic copies: Available in Portable Document Format (PDF) from the National Institute for Health and Clinical Excellence (NICE) Web site External Web Site Policy.
  • Neonatal jaundice. Full guideline. London (UK): National Institute for Health and Clinical Excellence; 2010 May. 525 p. (Clinical guideline; no. CG98). Electronic copies: Available in PDF from the NICE Web site External Web Site Policy.
  • Neonatal jaundice. Costing report. Implementing NICE guidance. London (UK): National Institute for Health and Clinical Excellence; 2010 May. 29 p. (Clinical guideline; no. CG98). Electronic copies: Available in PDF from the NICE Web site External Web Site Policy.
  • Neonatal jaundice. Costing template. Implementing NICE guidance. London (UK): National Institute for Health and Clinical Excellence; 2010 May. (Clinical guideline; no. CG98). Electronic copies: Available from the NICE Web site External Web Site Policy.
  • Neonatal jaundice. Audit support. Implementing NICE guidance. London (UK): National Institute for Health and Clinical Excellence; 2010 May. (Clinical guideline; no. CG98). Electronic copies: Available from the National Institute for NICE Web site External Web Site Policy.
  • Neonatal jaundice. Slide set. Implementing NICE guidance. London (UK): National Institute for Health and Clinical Excellence; 2010 May. 17 p. (Clinical guideline; no. CG98). Electronic copies: Available from the NICE Web site External Web Site Policy.
  • Neonatal jaundice. Baseline assessment tool. Implementing NICE guidance. London (UK): National Institute for Health and Clinical Excellence; 2010 May. 3 p. (Clinical guideline; no. CG98). Electronic copies: Available from the NICE Web site External Web Site Policy.
  • Neonatal jaundice. Treatment threshold graphs. London (UK): National Institute for Health and Clinical Excellence; 2010 May. (Clinical guideline; no. CG98). Electronic copies: Available from the NICE Web site External Web Site Policy.
Patient Resources

The following are available:

  • Neonatal jaundice. Understanding NICE guidance. Information for people who use NHS services. National Institute for Health and Clinical Excellence (NICE), 2010 May. 12 p. (Clinical guideline; no. CG97). Electronic copies: Available from the NICE Web site External Web Site Policy. Also available in Welsh from the NICE Web site External Web Site Policy.
  • Neonatal jaundice. Parent information factsheet. London (UK): National Institute for Health and Clinical Excellence; 2010 May. 2 p. (Clinical guideline; no. CG98). Electronic copies: Available in PDF from the NICE Web site External Web Site Policy.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This summary was completed by ECRI Institute on December 6, 2010.

The National Institute for Health and Clinical Excellence (NICE) has granted the National Guideline Clearinghouse (NGC) permission to include summaries of their clinical guidelines with the intention of disseminating and facilitating the implementation of that guidance. NICE has not yet verified this content to confirm that it accurately reflects that original NICE guidance and therefore no guarantees are given by NICE in this regard. All NICE clinical guidelines are prepared in relation to the National Health Service in England and Wales. NICE has not been involved in the development or adaptation of NICE guidance for use in any other country. The full versions of all NICE guidance can be found at www.nice.org.uk External Web Site Policy.

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This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

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