Pediatric ED Triage Protocol: Neonatal Jaundice

Date Issued: 8/14/19 Author(s): K. Clausen, J. Cochrane, K. Lubke, S. Maciolek, J. Panice, R. Patel, C. Spanierman, D. Zarlengo Version Date: 8/14/19 Originating Department: Advocate Children’s Hospital

This information is meant as a guideline only and not a substitute for physician order or clinical judgement.

Inclusion Criteria: • Age < 14 days • Previously healthy • Born at ≥ 35 weeks gestation • Presentation or report of elevated bilirubin or jaundice

Exclusion Criteria: • Presents with hypo/hyperthermia (temperature < 36◦ C or ≥ 38◦ C) per rectal temperature • Ill appearing or suspected sepsis • Direct hyperbilirubinemia • Hyperbilirubinemia at < 24 hours of life

Does patient meet protocol criteria?

YES

1. Assign ESI Level 2 2. Apply heel warms upon arrival 3. Room immediately & notify physician/APC of patient arrival

• Order and obtain STAT Bilirubin Panel: Total & Direct, heel stick preferred

• Consider bedside blood glucose if concern for poor feeding GOAL = 15 minutes from triage

TIME

0 mins

15

mins

30 mins

Initiate Intensive Phototherapy • Remove clothing except diaper, place eye covers • Bili-blanket + overhead light • Initiate temperature monitoring à

GOAL = 30 minutes from triage

Temperature Monitoring • Correlate rectal baseline temp

with an axillary temp • Obtain axillary temp every 15

mins x 1 hour then every 2 hrs • If patient unable to maintain

normal temp (< 36◦ C or ≥ 38◦ C), confirm by obtaining rectal temp and inform physician immediately

Promote Oral Feeding (breastmilk or formula) • If breastfeeding, limit feed to less than 20 mins in duration. Remove

overhead light. Maintain bili-blanket, eye cover, and swaddle. • Continue intensive phototherapy if bottle fed. • Monitor I & O – record time breastfeeding, weigh diapers.

If known TSB level is nearing exchange transfusion threshold, DO NOT interrupt intensive phototherapy.

NO OFF Pathway

Link to

ED/Inpatient Management

Guidelines

Link to References

Inpatient General Pediatric Protocol: Neonatal Jaundice

Date Issued: 8/14/19 Author(s): K. Clausen, J. Cochrane, K. Lubke, S. Maciolek, J. Panice, R. Patel, C. Spanierman, D. Zarlengo Version Date: 8/14/19 Originating Department: Advocate Children’s Hospital

This information is meant as a guideline only and not a substitute for physician order or clinical judgement.

Inclusion Criteria: • Age < 14 days • Previously healthy • Born at ≥ 35 weeks gestation • Presentation or report of elevated bilirubin or jaundice

Exclusion Criteria: • Presents with hypo/hyperthermia (temperature < 36◦ C or ≥ 38◦ C) per rectal temperature • Ill appearing or suspected sepsis • Direct hyperbilirubinemia • Hyperbilirubinemia at < 24 hours of life

Does patient meet protocol criteria?

YES

1. Set up room – open crib or cribette, Bili-blanket + overhead light 2. Notify physician/APC of patient arrival 3. Apply heel warmers upon arrival

• Order and obtain STAT Bilirubin Panel: Total & Direct, heel stick preferred

• Consider bedside blood glucose if concern for poor feeding GOAL = 15 to 30 minutes from patient arrival

TIME

0 mins

15 mins

30 mins

Initiate Intensive Phototherapy • Remove clothing except diaper, place eye covers • Bili-blanket + overhead light • Initiate temperature monitoring à

GOAL = 30 minutes from patient arrival

Promote Oral Feeding (breastmilk or formula) • If breastfeeding, limit feed to less than 20 mins in duration. Remove

overhead light. Maintain bili-blanket, eye cover, and swaddle. • Continue intensive phototherapy if bottle fed. • Monitor I & O – record time breastfeeding, weigh diapers.

If known TSB level is nearing exchange transfusion threshold, DO NOT interrupt intensive phototherapy.

NO OFF Pathway

Link to References

Temperature Monitoring • Correlate rectal baseline temp

with an axillary temp • Obtain axillary temp every 15

mins x 1 hour then every 2 hrs • If patient unable to maintain

normal temp (< 36◦ C or ≥ 38◦ C), confirm by obtaining rectal temp and inform physician immediately

Link to

ED/Inpatient Management

Guidelines

Neonatal Jaundice Pathway: ED/Inpatient Management Guidelines

Date Issued: 8/14/19 Author(s): K. Clausen, J. Cochrane, K. Lubke, S. Maciolek, J. Panice, R. Patel, C. Spanierman, D. Zarlengo Version Date: 8/14/19 Originating Department: Advocate Children’s Hospital

This information is meant as a guideline only and not a substitute for physician order or clinical judgement.

Inclusion Criteria: • Age < 14 days • Previously healthy • Born at ≥ 35 weeks gestation • Presentation or report of

elevated bilirubin or jaundice

Exclusion Criteria: • Presents with

hypo/hyperthermia (< 36◦ C and ≥ 38◦ C) per rectal temperature

• Ill appearing or suspected sepsis

• Direct hyperbilirubinemia • Hyperbilirubinemia at < 24

hours of life

• Continue Intensive Phototherapy: Bili-blanket + spot light • Temperature monitoring † • Promote oral feeding every 2-3 hr. If breastfeeding, do not remove from phototherapy for more than 20min every 3h.

o Remove overhead light and maintain bili-blanket, eye cover, and swaddle

Neurotoxicity Risk Factors Isoimmune hemolytic disease-ABO or Rh incompatibility + evidence of hemolysis (+Coombs, elevated retic)

• Asphyxia • Significant lethargy • Temperature instability • Sepsis • Acidosis • Albumin <3.0g/dL

IV not routinely indicated

‡If patient was born at facility can be obtained from newborn admission

Follow Inpatient Management Guidelines Discharge Admit ICU

(Off Pathway)

† Temperature Monitoring • Correlate rectal baseline temp

with an axillary temp • Obtain axillary temp every 15

mins x 1 hour then every 2 hrs • If patient unable to maintain

normal temp, off pathway

Care is continued from Inpatient General Pediatric Protocol and Pediatric ED Triage Protocol

Initial Assessment • History including:

a. Gestational age at birth b. Time of birth/Age in hours of life c. Weight and % change from birth weight d. Adequacy of intake e. Mom’s blood type

• Consider further labs‡: a. ABO b. Rh c. Coombs

• Utilize BiliTool for phototherapy and transfusion exchange threshold

Evaluate for Discharge: • TSB below phototherapy threshold • Feeding adequately (q 2-3h) • Weight loss not greater than 10%

from BW • Follow up appointment scheduled

per BiliTool recommendation • No concern for hemolysis

Inpatient Floor Admission Criteria: • TSB at or above

phototherapy threshold • If within 2 mg/dL of

exchange transfusion threshold, NICU consult required

ICU Admission Criteria: • TSB above exchange

transfusion threshold • Signs of acute bilirubin

encephalopathy

NICU Consult Criteria: • TSB within 2 mg/dL

of exchange transfusion level

Neonatal Jaundice Pathway: ED/Inpatient Management Guidelines

Date Issued: 8/14/19 Author(s): K. Clausen, J. Cochrane, K. Lubke, S. Maciolek, J. Panice, R. Patel, C. Spanierman, D. Zarlengo Version Date: 8/14/19 Originating Department: Advocate Children’s Hospital

Inpatient Management Guidelines • Encourage feeding q2-3h- If breastfeeding do not remove from

phototherapy for more than 20min every 3h • Continue Intensive Phototherapy: Bili-blanket + overhead light • Consider lactation consultation

Bilirubin not improving as expected, consider:

• CBC • Retic • G6PD level (if appropriate

ethnic group) • Assessment for sepsis

TSB within 2 mg/dL of exchange transfusion threshold

TSB within 2-4 mg/dL of exchange transfusion threshold

TSB > 4 mg/dL below exchange transfusion threshold or down trending

IV not routinely indicated

Evaluate for Discharge: • TSB below phototherapy threshold • Feeding adequately (q2-3h) • Follow up appointment scheduled

per Bili tool recommendation • Rebound TSB not routinely indicated

Recheck total bilirubin in 4 hours Recheck total bilirubin in 6 hours

Recheck total bilirubin in 8-12 hours or with routine AM labs

Link to References

Neonatal Jaundice

Date Issued: 8/14/19 Author(s): K. Clausen, J. Cochrane, K. Lubke, S. Maciolek, J. Panice, R. Patel, C. Spanierman, D. Zarlengo Version Date: 8/14/19 Originating Department: Advocate Children’s Hospital

References Adekunle-Ojo, A. O., Smitherman, H. F., Parker, R., Ma, L., & Caviness, A. C. (2010). Managing

well-appearing neonates with hyperbilirubinemia in the emergency department observation unit. Pediatric Emergency Care, 26(5), 343-348.

American Academy of Pediatrics, Subcommittee on Hyperbilirubinemia (2004). Management of

hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics, 114(1) 297-316.

Aydemir, O., Soysaldh, E., Kale, Y., Kavurt, S., Yagmur Bas, A., & Demirel, N. (2014). Body

temperature changes of newborns under fluorescent versus LED phototherapy. Indian J Pediatrics, 81(8), 751-754. doi 10.1007.s12098-013-1209-2

Bhutani, V. K. and the Committee on Fetus and Newborn (2011). Phototherapy to prevent severe

neonatal hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics, 128, e1046-e1052. https://doi.org/10.1542/peds.2011-1494

Donneborg, M. L., Vandborg, P. K., Hansen, B. M., Rodrigo-Domingo, M., & Ebbesen, F. (2018).

Double versus single intensive phototherapy with LEDs in treatment of neonatal hyperbilirubinemia. Journal of Perinatology 38, 154-158.

Flynn, M. E. (2017). A quality improvement project to decrease the serum bilirubin and increase

appropriate phototherapy use by following the AAP guidelines in a well nursery. Pediatric Nursing, 43(3), 143-148.

Ringer, S. A. (2013). Core concepts: Thermoregulation in the newborn, part II: Prevention of the

aberrant body temperature. NeoReivews, 14(6), e221-e226. Romero, H. M., Ringer, C., Leu, M. G., Beardsley, E., Kelly, K., Fesinmeyer, M. D., . . . Migita, D.

(2018). Neonatal jaundice: Improved quality and cost savings after implementation of a standard pathway. Pediatrics 141(3). 1-9. doi: 10.1542/peds.2016-1472

Schwartz, H. P., Haberman, B. E., & Ruddy, R. M. (2011). Hyperbilirubinemia: current guidelines

and emerging therapies. Pediatric Emergency Care, 27(9), 884-889. Wells, C., Ahmed, A., & Musser, A. (2013). Neonatal hyperbilirubinemia: a literature review. The

American Journal of Maternal Child Nursing, 38(6), 377-384. http://dx.doi.org/10.1097/NMC.0b013e3182alfb7a

Wolf, M., Schinasi, D.A., Lavelle, J., Boorstein, N., & Zorc, J. J. (2012). Management of neonates

with hyperbilirubinemia: improving timeliness of care using a clinical pathway. Pediatrics, 130, e1668-e1694. https://doi.org/10.1542/peds.2012-1156