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Jaundice - Management of neonatal jaundice

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Overview

Jaundice (SBR >50 μmol /L) is one of the most common physical signs observed during the neonatal period. Approximately 50-60% of newborn infants will become jaundiced during the first week of life.

For many newborn infants the jaundice may be regarded as a manifestation of their ongoing adaptation to the extra uterine environment.
Although most jaundice is mild and physiological in origin, it cannot safely be automatically assumed to be either.

If the unconjugated bilirubin level gets too high, exceeding the albumin binding capacity, it can become neurotoxic presenting as bilirubin encephalopathy or kernicterus. High levels affect the basal ganglia and the auditory nerve causing permanent injury. Because of this rare complication it is important to identify babies at risk and manage them appropriately.

Jaundice may be a sign of pathology and demands evaluation and rational management. Atypical presentation of jaundice (early onset, rapid rise in SBR, prolonged jaundice, and/or late onset jaundice) is likely to reflect pathology. Furthermore, it is important to appreciate that an infant's symptoms may be attributed to its jaundice when in fact they are due to other pathology.

Indications for paediatric referral

Jaundice requires paediatric evaluation in the following situations and whenever there is a possibility that hyperbilirubinaemia may indicate or cause pathology.

  • Maternal red cell antibody
    Clinically present before 24hrs of age.
    Whenever other symptoms and/or signs of illness are present. 
  • When SBR >200 μmol/L on the second day of life.
    When SBR >250 μmol/L
    When jaundice is of late onset (7-10 days or later) or is prolonged with SBR >200 μmol/L after 7-10 days of life.

Assessment

The evaluation of the jaundiced newborn infant must include a thorough history and physical examination, with particular emphasis on the state of hydration and consideration of the possibility of an acute haemolytic process and/or infection. Does the baby have a risk factor such as significant bruising, cephalohaematoma or subgaleal haemorrhage? Is there a previous sibling with ABO incompatibility?

The following approach to the evaluation of neonatal jaundice is recommended:-

  1. Review maternal blood group and antibodies.
  2. Request infant's blood group and Coomb's test if mother's blood group is O.
  3. Check SBR (note that a direct SBR very rarely indicated within the first 5 days of life).
  4. Haemoglobin, WBC and differential, and reticulocytes if suspicion/evidence of haemolysis.
  5. Urine for microscopy and a culture only if clinical suspicion of a urinary tract infection.
  6. If galactosaemia is suspected, then discuss an urgent serum assay through the National Testing Laboratory. Urine samples for reducing substances are not reliable nor specific.
  7. Is there a family history of G6PD?

Other investigations may be necessary depending upon the specific clinical situation. The significance of any SBR estimation depends upon the maturity and postnatal age of the infant, the clinical status of the infant (hypoxaemia, acidaemia, hypoalbuminaemia, and/or hypothermia) and the aetiology of the jaundice. Serial SBR estimations are an essential component of the continuing assessment and management of the jaundiced newborn infant. 

Management

It is important to maintain normal hydration and enteral nutrition of the jaundiced newborn infant. This may be achieved by the encouragement of breastfeeding, the provision of additional oral fluids or may require the intravenous administration of fluid. There is no evidence to support the administration of excessive quantities of fluid and most infants will not need extra fluids.

Phototherapy

Phototherapy causes photodegradation of bilirubin in the infant's skin. This form of physical therapy has been shown to be an efficient method of lowering the SBR and is usually effective.

Complications of phototherapy are generally mild and include increased insensible water losses, loose green stools, skin rashes, overheating and/or chilling.

An inadequate quantum of phototherapy (<4 mcw/nm/cm2) is ineffective. Recommended range for phototherapy is 5-10 mcw/nm/cm2. Increasing phototherapy above 9-10 mcw/nm/cm2 is unlikely to provide any additional benefit.

Infants receiving phototherapy should be under paediatric supervision.

Phototherapy treatment thresholds

There is no high level evidence for the threshold for treatment of jaundice. Treatment charts are based on a consensus of expert opinion for safe treatment. At ADHB we use the NICE Guidelines.

Treatment Guidelines for Term Infants without Haemolysis

Term infants without haemolysis
Treatment Guidelines for Preterm Infants or Infants with Haemolysis
Preterm with haemolysis

For babies in the NICU, to enable you to assess the threshold for initiating treatment in a patient, the bilirubin level should be entered into the patient database and a graph generated. (NB The graph generated is based on the NICE recommendations and will take gestation, birth weight and risk factors into account (https://www.nice.org.uk/guidance/cg98/evidence/full-guideline-pdf-245411821)

Phototherapy can usually be ceased when the total bilirubin level is >50 micromol/L below the treatment threshold. However, the presence of additional risk factors such as haemolysis should be considered.

Administration of Immunoglobulin

(see Immunoglobulin guideline for details)

  • Used when an infant has Isoimmune Haemolytic Jaundice.
  • Used when an infant is nearing the need for Exchange Transfusion, while equipment is being set up for an exchange transfusion or if the bilirubin is rising significantly despite maximal phototherapy.

Exchange Transfusion

An exchange transfusion is indicated for any infant in whom the degree of hyperbilirubinaemia cannot be adequately controlled by phototherapy alone.

Discuss the indications for exchange transfusion with the appropriate specialist. Note that infants with jaundice due to a haemolytic disorder usually benefit from phototherapy but may also require an exchange transfusion.

With appropriate management, exchange transfusion should rarely be required.

Management of Jaundice on the Postnatal Ward

Management is dictated both by the bilirubin level, the underlying condition and gestational age. For example, a significant haemolytic condition may indicate earlier or longer treatment.

Treatment may consist of both ensuring adequate hydration, and encouraging photo-degradation of unconjugated bilirubin in the skin by the provision of phototherapy. This may prevent serum bilirubin levels rising to levels where exchange transfusion would be necessary. Phototherapy is very effective at preventing the need for an exchange transfusion. 

Phototherapy on the postnatal ward allows the mother and baby to stay together and can be safely managed as long as the infant is well and the bilirubin level not excessive or requiring intensive treatment.

There is no high level evidence for the threshold for treatment of jaundice. Treatment charts are based on a consensus of expert opinion for safe treatment. At ADHB we use the NICE Guidelines. Graphs can be printed from within the guideline which can be found here (https://www.nice.org.uk/guidance/cg98/chapter/Recommendations#measuring-and-monitoring-bilirubin-thresholds-before-and-during-phototherapy)

As a rough guide, the bilirubin threshold above which phototherapy should be considered:

Day of Life 35-37 weeks > 38 weeks
1 110 200
2 180 250
3 260 300
4   350

Phototherapy on the postnatal ward

  1. If advised by the Paediatrician the baby is to have phototherapy, discuss phototherapy with the mother and develop a care plan for her baby. 
  2. Educate the mother regarding phototherapy cares and keep her up to date with the baby's progress. 
  3. Implement the feeding plan and ensure adequate hydration. 
  4. Ensure that the room is warm. 
  5. Follow the Newborn Services Phototherapy guideline
  6. Record baby's temperature and respirations before feeds
  7. Document SBR results. Ensure that there is medical follow-up regarding the SBR results and/or management plan. A threshold graph can be printed from the NICE Guidelines

Note: No creams or lotions are to be applied to the baby's skin during phototherapy.

Stopping phototherapy

Babies born before 37 weeks and those with haemolysis are at risk of clinically significant rebound following ceasation of phototherapy and should be monitored for this. Infants who have had fetal iso-immunisation may require extended monitoring as they are at risk of developing late anaemia. Unless there is an identified pathology, discharge need not be delayed to observe the baby for rebound but a follow up should be arranged for a bilirubin level to be checked within 24 hours by their LMC or if appropriate referred to newborn homecare.

On discharge parents should be advised to contact a healthcare professional if baby's jaundice is worsening, jaundice persists beyond 14 days or their baby is passing pale stools.

Atypical Jaundice - late onset and prolonged

See Starship Clinical Guideline on Investigation of Prolonged jaundice.

Prolonged jaundice is defined as:

  • >14 days in term infants
  • >21 days in preterm infants

Persisting jaundice is more common in breastfed infants than artificially-fed infants. At least 9% of breastfed infants are still jaundiced at 28 days of age.1 Jaundiced breast-fed infants who are well are unlikely to have serious disease.2 However, a diagnosis of breast milk jaundice is a diagnosis of exclusion, after investigation as below.

In artificially-fed infants, prolonged jaundice should be aggressively investigated.

Jaundice which has not previously been apparent and then appears after day 7 should be investigated carefully.

Assessment

  • Physical examination, including evaluation of growth and feeding since birth
  • Examination of stool colour and enquiry about urine colour
  • Total bilirubin AND conjugated (direct) fraction
  • Full blood count and blood film to evaluate for haemolytic anaemia and possible infection.
  • Thyroid function tests (TSH and T4)
    The newborn screening test in NZ screens for congenital hypothyroidism and evaluates only TSH. This test is less reliable in preterm infants, and does not screen for hypopituitary hypothyroidism.
  • Urine sample for microscopy and culture. Be aware that a bag urine may yield ambiguous results which may require further (potentially invasive or unnecessary) investigation.
  • Glucose-6-phosphate dehydrogenase screen (in selected infants).
  • Check that the Newborn Screening Test has been done.

Notes:

  • Liver function tests are not indicated unless there is a conjugated hyperbilirubinaemia. LFTs are often abnormal in the newborn period in breastfed infants with no pathological cause for jaundice.
  • A Coomb's test is not required if the baby is not anaemic, did not have early jaundice, and does not have evidence of haemolysis on the FBC.

Management if baby is well and investigations are normal

  • The phototherapy charts are not validated in infants of this age. Bilirubin levels which are above treatment levels at 4 days may not require phototherapy at 14 days.
  • If approaching treatment levels, recheck the bilirubin within 1-2 days to ensure that it is decreasing. Otherwise repeat weekly or less often as indicated by clinical examination. If persistent, recheck the conjugated fraction
  • Parents may need reassurance that the jaundice itself is not harmful. They should be asked to contact their GP or LMC if they have concerns about their baby's growth or health.
  • Although temporary cessation of breastfeeding may reduce or eliminate prolonged jaundice associated with breast milk, we do not currently recommend this.

Management if any investigations are abnormal

The baby may have a pathological cause for jaundice and urgent further assessment is indicated.

References

  1. Crofts DJ, Michel VJ-M, Rigby AS, Tanner MS, Hall DMB, Bonham JR. Assessment of stool colour in community management of prolonged jaundice in infancy. Acta Paediatr 1999;88:969-74.
  2. Hannam S, McDonnell M, Rennie JM. Investigation of prolonged neonatal jaundice. Acta Paediatr 2000;89(6):694-7.
  3. Neonatal Jaundice. NICE Clinical Guideline 2008. National Institute for Health and Clinical Excellence, 2010.
  4. Management of Hyperbilirubinaemia in the Newborn Infant 35 or More Weeks of gestation. AAP Guideline. Paediatrics 2004;114;297

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Document Control

  • Date last published: 09 July 2018
  • Document type: Clinical Guideline
  • Services responsible: Neonatology
  • Owner: Newborn Services Clinical Practice Committee
  • Editor: Sarah Bellhouse
  • Review frequency: 2 years