The aim and objective of this guideline is the early detection and treatment of newborn or physiological jaundice.
Jaundice is one of the most common conditions needing medical attention in newborn babies. Jaundice refers to yellow colouration of the skin and the sclerae and is caused by a raised level of bilirubin in the circulation, a condition known as hyperbilirubinaemia ( Rationale 1).
Approximately 60 per cent of term and 80 per cent of preterm babies develop jaundice in the first week of life, and about 10 per cent of breastfed babies are still jaundiced at one month of age. In most babies, jaundice is harmless. However, a few babies will develop very high levels of bilirubin, which can be harmful if not treated ( Rationale 2).
This guidance is based on National Institute for Clinical Excellence ( NICE 2010) recommendations on neonatal jaundice.
Conventional phototherapy: Phototherapy given using a single light source (not fibre optic) that is positioned above the baby.
Direct antiglobulin test (DAT): Also known as the direct Coombs' test; this test is used to detect antibodies or complement proteins that are bound to the surface of red blood cells.
Fibre optic phototherapy: Phototherapy given using a single light source that comprises a light generator, a fibre optic cable through which the light is carried and a flexible light pad, on which the baby is placed or that is wrapped around the baby.
Multiple phototherapy: Phototherapy that is given using more than one light source simultaneously; for example, two or more conventional units, or a combination of conventional and fibre optic units.
Preterm: Less than 37 weeks completed gestational age.
Prolonged jaundice: Jaundice lasting more than 14 days in term babies and more than 21 days in preterm babies.
Significant hyperbilirubinaemia: An elevation of the serum bilirubin to a level requiring treatment.
Term: 37 weeks or more gestational age.
Visible jaundice: Jaundice detected by visual inspection.
Management of newborn jaundice
In all babies:
- Examine the baby for jaundice at every opportunity, especially in the first 72 hours ( Rationale 3).
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.
- Clinical recognition and assessment of jaundice can be difficult, particularly in babies with dark skin tones.
- Additional signs and symptoms include lethargy, poor feeding, darkened urine.
Factors associated with an increased likelihood of developing significant hyperbilirubinaemia soon after birth:
- visible jaundice within the first 24 hours of life
- blood group incompatibility
- previous sibling with neonatal jaundice requiring phototherapy
- cephalhaematoma or significant bruising
- weight loss greater than 10 per cent of birthweight; may be associated with ineffective breast-feeding
- gestational age under 38 weeks
- mother’s intention to breastfeed exclusively
- family history of red cell enzyme defects
- infant of a diabetic mother
- clinical signs of sepsis
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 ( NICE 2010).
Key priorities for management
Measuring bilirubin in all babies with jaundice
Do not rely on visual inspection alone to estimate the bilirubin level in a baby with jaundice. Always use serum bilirubin measurement to determine the bilirubin level.
To measure bilirubin in babies with jaundice, send a sample of capillary, venous or arterial blood to biochemistry and request for unconjugated, conjugated and total serum bilirubin levels.
The result of the total bilirubin must be plotted on an appropriate treatment threshold graph ( Rationale 5). These can be found on the forms page of the intranet or as part of the NICE jaundice guideline (available to Great Ormond Street Hospital (GOSH) staff internally on the GOSHweb intranet).
All nursing and medical staff who care for neonates should have completed the 'how to plot a treatment threshold graph' teaching video available on the 'other courses' section of the GOSH GOLD online learning and development website. The video only takes a minute and should also be used as a refresher for staff who have not used the charts for a while.
When selecting a graph ensure you select the appropriate graph for the baby's gestational week at birth to guide treatment for the first 14 days of life ( Rationale 5).
Information for parents
Offer parents or carers information about neonatal jaundice that is tailored to their needs and expressed concerns. GOSH has developed a neonatal jaundice information leaflet to provide parents with information about what they can expect while an inpatient. NICE ( NICE 2010) also produce information booklets to help parents understand the care and treatment for jaundice in newborn babies.
This information includes:
- Factors that influence the development of significant hyperbilirubinaemia
- Encouragement of mothers to breastfeed frequently and to wake the baby for feeds if necessary
- Information on phototherapy including:
- why phototherapy may be needed to treat significant hyperbilirubinaemia
- anticipated duration of treatment
- 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
- impact on breastfeeding and how to minimise this.
Treatment of jaundice
- Treatment of the cause (eg infection)
- Adequate hydration
- If breastfed, the baby should be put to the breast between eight to 12 times per day for several days.
- If supplementation of breastfeeding is required, this should be expressed breast milk or formula not water ( NICE, 2010).
- If oral intake is inadequate give intravenous fluids. There is no evidence to support the administration of additional fluids to jaundiced babies ( NICE, 2010).
Considering the use of phototherapy
Exposure of jaundiced skin to light photo-isomerises the bilirubin molecule into forms that can be excreted directly into the bile, without having to be conjugated ( Rationale 7). Phototherapy should only be used as outlined in the phototherapy pathway ( Appendix 3).
The effectiveness of the phototherapy increases with:
- blue light
- intensity of the light
- the greater amount of skin exposed (babies requiring phototherapy should be nursed in only a nappy and eye protection)
- the distance of the light from the baby (the neoBLUE® lights should positioned 30cm away from the baby, if the baby is in an incubator the distance will be dictated by the top of the incubator.)
Before starting phototherapy
- Use serum bilirubin measurement and the treatment thresholds in the threshold table (for infants >38 weeks) and treatment threshold graphs when considering the use of phototherapy ( Appendix 2).
- 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 six to 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.
- Commencement of phototherapy is not an indication for transfer of the baby to NICU.
- The major drawback with phototherapy is that its effect is slow and is rarely effective with severe haemolytic causes of jaundice ( NICE, 2010).
Phototherapy is should be given via the free standing neoBLUE® lights or the fiber optic blanket see further guidance below. The phototherapy option in the babytherms should not be used.
Three neoBLUE® lights are available from the main equipment store and can be requested via the CARPS system. Lights can also be tracked via the asset tracker system. NICU also have two neoBLUE® lights and one fibre optic blanket which can be shared more widely if hospital wide equipment is in use or unavailable due to service.
Phototherapy treatment is given as follows:
- a neoBLUE® blight; or
- fibre optic blanket (infants <37 weeks gestation only)
- neoBLUE® lights (with the double phototherapy switch on); and/or
- optional addition of a fibre optic blanket (all gestational ages)
Once phototherapy treatment has commenced, the NICE neonatal jaundice pathway must be followed in relation to escalating and reducing/stopping treatment. Any concerns about rising bilirubin levels must be escalated to the consultant in charge of the patient’s care.
Ensure all phototherapy equipment is maintained and used according to the manufacturers' guidelines (Rationale 8).
General care of the baby during phototherapy
Perform a clinical handwash in line with standard precautions (Rationale 9).
- Undress the baby ensuring they are wearing only a nappy and eye protection to maximize surface area exposed to the light;
- Staff must ensure that practices not endorsed by NICE, including the use of cling wrap over babytherms, are not undertaken as they may pose a risk of harm.
- Give the baby eye protection (Rationale 10). Remove eye shields and check eyes regularly
- Ensure the light source is at the correct distance from the baby (follow the manufacturer’s guidance);
- If the baby is nursed in a babytherm the neoBLUE® light will need to be adjusted to prevent it blocking the radian heater (see information sheet attached to lights)
- Ensuring treatment is applied to the maximum area of skin;
- Ensure adequate hydration - this includes providing advice and support to breastfeeding mothers. Extra fluids should not be given routinely. Hydration should be monitored by daily weighing of the baby and assessing fluid balance;
- Do not apply any cream or oil to the exposed area of skin (Rationale 11).
- Monitor the baby’s temperature three hourly and ensure the baby is kept in a thermo-neutral environment (e.g. temperature per axilla 36.8 - 37.2oC).
- Monitor hydration by daily weighing of the baby and assessing wet nappies.
- Place the baby in a supine position unless other clinical conditions prevent this. Change the position of the baby after nursing care (Rationale 12).
- Support parents and carers and encourage them to interact with the baby.
- Observe for potential signs of bilirubin encephalopathy (e.g. lethargy, poor feeding, hypotonia, arching of the head and neck, and seizures).
- Document time of commencement and completion of phototherapy in the neonate’s health care records and on the phototherapy chart (Appendix 1) (Rationale 13).
Potential complications of phototherapy
- skin rash
- 'bronzing' of baby’s skin
- parental anxiety/separation
- water loss
- retinal damage
- See phototherapy pathway.
- When serum bilirubin is 50 micromol/litre below the threshold – stop phototherapy.
- Check serum bilirubin for rebound 12–18 hours post ceasing phototherapy.
Exchange transfusion should be considered if intensive photothrapy fails to control a rapidly rising serum bilirubin in the first 24–48 hours of life or if it does not lead to a reduction of serum bilirubin of >17-34 micromol/litre every four to six hours after the first 48–72 hours of life.
- See exchange transfusion pathway ( Appendix 4).
- Transfer baby to NICU.
- Refer to GOSH PICU guideline for exchange transfusion.
Further issues on treatment and management
Management of hyperbilirubinaemia
When making decisions about the management of hyperbilirubinaemia:
- do not use the albumin/bilirubin ratio
- do not subtract conjugated bilirubin from total serum bilirubin.
Do not use any of the following to treat hyperbilirubinaemia ( NICE 2010):
- traditional Chinese medicine
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 term babies
- a rapidly rising bilirubin level of greater than 8.5 micromol/litre per hour
- clinical features of acute bilirubin encephalopathy.
Care for babies with prolonged jaundice
In preterm and term babies with prolonged jaundice:
- look for pale chalky stools and/or dark urine that stains the nappy
- measure the conjugated bilirubin
- carry out a full blood count, blood group determination, DAT and urine culture
- ensure that routine metabolic screening has been performed.
- follow expert advice about care for babies with a conjugated bilirubin level greater than 25 micromol/litre (NICE 2010)
Rationale 1: High bilirubin levels result from a high haemoglobin level and the short lifespan of the neonatal red cell, ie 40 days in the preterm baby, 60–70 days in the term baby ( Dent 2000), 120 days in the adult ( Juretschke 2005).
Rationale 2: If bilirubin levels rise rapidly above a safe level, and are left untreated, damage to the brain can result. This is known as kernicterus ( Juretschke 2005).
Rationale 3: To determine presence of visual jaundice.
Rationale 4: Visual inspection alone is not accurate.
Rationale 5: Treatment threshold graphs should be used to guide treatment and treatment and exchange threshold varies greatly with gestational age.
Rationale 6: To ensure treatment is provided appropriately allowing for the normal pattern of bilirubin metabolism in the newborn and to ensure prompt diagnosis and investgation of infants jaundiced at <24 hours of age.
Rationale 7: Light from the phototherapy lamp isomerizes the unconjugated bilirubin passing through the skin into a non-toxic form, which can readily be excreted in stool and urine ( Metherall 2003).
Rationale 8: To optimise the effectiveness of the treatment without overheating the neonate.
Rationale 9: To minimise the risk of cross infection.
Rationale 10: There is the potential for photochemical damage to eyes with phototherapy.
Rationale 11: They can cause skin burns during therapy.
Rationale 12: To expose maximum skin area in order to reduce serum bilirubin.
Rationale 13: To maintain an accurate record of treatment.
Dent J (2000) Hematological Problems In Boxwell G. ED. Neonatal Intensive Care. Cambridge, Cambridge University Press
Juretschke LJ (2005) Kernicterus: still a concern. Neonatal Netw 24 (2): 7-19
Metherall J (2003) Phototherapy for neonatal hyperbilirubinaemia: delivering an adequate dose. Journal of Neonatal Nursing 9(6): 182-186
National Institute for Clinical Excellence (NICE) (2010) Neonatal jaundice www.nice.org.uk/guidance/CG98 (last viewed 26/11/2014)
Shaw NM (2003) Assessment and management of hematologic dysfunction Comparative Neonatal Nursing: a physiologic perspective (3rd edition) in: WB Saunders. Philadelphia, Philadelphia
Appendix 1: Threshold graphs for neonatal jaundice
Threshold graphs for neonatal jaundice will help healthcare professionals assess whether babies with jaundice should be given phototherapy or exchange transfusion:
- Click on the ‘Treatment threshold graphs’ to access the graphs.
- The sheet contains a treatment graph for each gestational age. Before printing, use the drop-down menu that is marked in red to choose the graph for the correct gestational age for each baby with jaundice.
- Print off the graph and store it with the baby’s clinical notes.
- Plot the baby’s bilirubin level on the graph each time it is measured, against the baby’s age.
- Each line on the horizontal (X) axis is equal to six hours and each line on the vertical (Y) axis is equal to 10 microl/litre.
- Assess whether the threshold for either phototherapy or exchange transfusion has been reached.
- Shade the ‘single’ or ‘multiple’ cells to show the type of phototherapy that the baby is receiving each day.
- The graph reflects the baby’s actual age and should used until the baby is 14 days old.
- The baby’s ‘corrected’ gestational age should not be taken into consideration and should not move up to the next graph when the baby is seven days old.
Appendix 2: Threshold table (only for use in babies >38 weeks gestation ( NICE 2010)
Appendix 3: Phototherapy pathway (NICE 2010)
Appendix 4: Exchange Transfusion (NICE 2010)