Neonatal jaundiceImplementing NICE guidance

2010

NICE clinical guideline 98

What this presentation coversKey definitions

Background

Scope

Key priorities for implementation

Costs and savings

Discussion

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Term – 37 weeks or more gestational ageNear-term – 35 to 36 weeks gestational agePreterm – less than 37 weeks gestational age

Kernicterus – clinical features of acute or chronic bilirubin encephalopathy, including cerebral palsy, hearing loss and visual problems

Prolonged jaundice – jaundice lasting more than 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

Visible jaundice – jaundice detected by visual inspection

Key definitions

Background

• Approximately 60% of term and 80% of preterm babies develop jaundice in the first week of life.

• For most babies, this early jaundice is harmless.

• Babies with very high bilirubin levels are at risk of developing kernicterus. Kernicterus is also known to occur at lower levels of bilirubin in term babies who have risk factors, and in preterm babies.

Scope

Recognition, assessment and treatment of neonatal jaundice for all babies with jaundice from birth up to 28 days of age.

Special attention has been given to the recognition and management of neonatal jaundice in babies with dark skin tones.

Key priorities for implementation

• Information for parents and carers

• Care for all babies

• Additional care for babies at risk

• How to measure bilirubin in all babies with jaundice

• How to manage hyperbilirubinaemia

• Care of babies with prolonged jaundice

Factors that influence the development of significant hyperbilirubinaemia  

How to check the baby and 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 usually transient and harmless

Reassurance that breastfeeding can usually continue.

 

Information for parents and carers

Examine all babies for jaundice at every opportunity especially in the first 72 hours.

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.

Care for all babies

Ensure babies with factors associated with an increasedlikelihood of developing significant hyperbilirubinaemia:

• receive an additional visual examination by a healthcare professional during the first 48 hours of life

Additional care for babies at risk

Do not rely on visual inspection alone to estimate the

bilirubin level in a baby with jaundice.

Measuring bilirubin in all babies with jaundice

• Use a transcutaneous bilirubinometer (TCB) in babies with a gestational age of 35 weeks or more and postnatal age of more than 24 hours. 

• If a TCB is not available, measure the serum bilirubin.

• If a TCB measurement indicates a bilirubin level greater than 250 micromol/litre check the result by measuring the serum bilirubin.

• Do not use an icterometer.

How to measure the bilirubin level - 1

Always use serum bilirubin measurement :

• to determine the bilirubin level in babies with jaundice in the first 24 hours of life

• to determine the bilirubin level in babies less than 35 weeks gestational age 

• for babies at or above the relevant treatment threshold for their postnatal age, and for all subsequent measurements 

How to measure the bilirubin level - 2

Use the bilirubin level to determine the management

of hyperbilirubinaemia in all babies.

Refer to the guideline for the:• threshold table• treatment threshold graphs • investigation pathway • phototherapy and exchange transfusion pathways

How to manage hyperbilirubinaemia

Follow expert advice about care for babies with a

conjugated bilirubin level greater than 25 micromol/litre

because this may indicate serious liver disease.

Care of babies with prolonged jaundice

Costs and savings

Significant annually recurring costs per 100,000 population

Testing £2,555

Significant non-recurrent costs per 100,000 population

Purchase of TCBs £10,200

Estimated savings

Per case of kernicterus avoided £5.5 million

Reduced use of exchange transfusion Unquantified

Discussion• Where does our current practice differ from the

recommendations made by NICE about the recognition and assessment of neonatal jaundice?

• When and how often do we currently measure serum bilirubin? What changes do we need to make to enable us to measure serum bilirubin as outlined in the NICE guideline?

• How does our current practice compare to the treatment thresholds recommended by NICE?

Find out more

Visit www.nice.org.uk/CG98 for:

•the guideline •the quick reference guide•‘Understanding NICE guidance’•costing report and template•audit support•a parent information factsheet•treatment threshold graphs