AL KHAFJI NATIONAL HOSPITAL

Evidence Based Clinical Practice

Guidelines for the Management of
Neonatal Jaundice
A Clinical Practice Guidelines Adopted from CPG Source:
National Institute for Health and Clinical Excellence, 2010 updated 2015
Presented by:
Dr. Enas Refaat
Senior Registrar Pediatrics
Neonatal Intensive Care Unit Head
Neonatal Jaundice

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 Background
Neonatal jaundice is one of the most common conditions needing
medical attention in newborn babies. The purpose of this guideline is to
provide a guide regarding the recognition, early assessment and early
treatment of neonatal jaundice. The goal of careful evaluation of
neonatal jaundice is to avoid pathologic elevations of serum bilirubin
which can result in bilirubin toxicity to the central nervous system
(Medstar Health, 2010).
Approximately 60% of term and 80% of preterm babies develop jaundice
in the first week of life, and about 10% of breastfed babies are still
jaundiced at 1 month.
Jaundice refers to yellowish discoloration of skin and sclera due to
accumulation of bilirubin in the skin and mucous membrane .
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 Why Neonatal Jaundice?
Based on the Pediatric/NICU CPG Subcommittee they selected to work on this
guidelines based on the criteria stipulated below and they prioritized it to come
up with and adopted best practice and guidelines.
RESPIRATORY
CRITERIA PREMATURITY JAUNDICE
DISTRESS
The prevalence of the condition and/or 4 4 5
burden associated with the condition
Existence of underuse, overuse or 3 4 5
misuse of interventions
The likelihood that the guideline will be 4 3 5
effective in influencing practice
The existence of relevant good quality 5 5 5
evidence-based guidelines
SUM 16 16 20

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KNH Hyperbilirubenia Cases
Month Number of Cases Percentage
January 1/5 30%
February 1/6 16.6%
March 0
April 2/4 50%
May 1/5 20%
June 4/6 66.6%
July 2/4 50%
August 5/10 50%

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 Bilirubin
Metabolism

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Jaundice has many possible causes:-
 Physiological jaundice (early, no harm and no underlying disease)
 Prematurity
 Increased bilirubin load:
 blood group incompatibility(most commonly rhesus or ABO incompatibility)
 other causes of hemolysis (breaking down of red blood cells)
 G6PD deficiency(common in certain ethnic groups)
 Congenital spherocytosis
 Cephalohematoma & bruising
 Other causes: sepsis, congenital infection, metabolic disorders, liver
disease.

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Persistent jaundice beyond the first 14 days:
 Prolonged physiological more commonly in breast fed babies usually
harmless(breast milk jaundice)
 Hypothyroidism
 Liver diseases –extra hepatic biliary atresia, neonatal hepatitis
 Alpha 1 antitrypsin deficiency
 Galactosemia
 TPN induced cholestasis

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 Risk Factors for Hyperbilirubinemia
*<38 weeks gestation
*previous sibling required treatment for jaundice
*mother intends to exclusively breast feeding
*visible jaundice in baby <24 hours

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 Risk for Kernicterus

High bilirubin level >20 mg/dl (>340 micromole/l) in

term babies
Rapidly rising >0.5mg/dl (8.5micromol/l) / hour
Clinical features of bilirubin encephalopathy

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Why is Hyperbilirubinemia a Concern?

Although low levels of bilirubin are not usually a

concern, large amounts can circulate to tissues in the
brain and may cause seizures and brain damage. This
is a condition called kernicterus.

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 Objectives in Adapting a CPG for
Hyperbilirubinemia

To look for an evidence based CPG to effectively management neonatal jaundice

in babies from birth up to 28 days of age. And to effectively;
 recognize and perform assessment
 prediction of later significant hyperbilirubinaemia and adverse sequelae
 treatment
 information and education for parents/carers of babies with jaundice

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 National Institute for Health and Clinical Excellence,
(2010). Neonatal jaundice. Retrieved from https://
www.nice.org.uk/guidance/cg132/evidence/full-guid
eline-pdf-184810861

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 KNH INSTITUTIONAL
PROTOCOL BASED ON
THE ADOPTED CPG

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Information for Parents and 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.

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 Care for all Babies
 Identify babies as being more likely to develop significant hyperbilirubinemia (risk factors)
 Ensure that adequate support is offered to all women who intend to breastfeed exclusively
 In all babies:
o Check whether there are factors associated with an increased likelihood of developing significant
hyperbilirubinemia soon after birth
o 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)
o Check the naked baby in bright and preferably natural light
o Examination of the sclera, 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

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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
 If >100 micromole/l (6mg/dl)repeat the serum bilirubin level every 6-12 hours for all babies
with suspected or obvious jaundice in the first 24 hours of life until the level is both
o Below the treatment threshold
o Stable and/or falling.
 Interpret bilirubin levels according to the baby’s postnatal age in hours and manage
hyperbilirubinemia according to the threshold table and treatment threshold graphs

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Baby with conjugated hyperbilirubinemia
>25 micromole/l (1.5mg/dl) refer
urgently to specialist center.

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 Urgent Additional Care for Babies
with Visible Jaundice >24 Hours
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:
o Use a transcutaneous bilirubinometer in babies with a gestational age of 35 weeks or more and postnatal age of
more than 24 hours
o If a transcutaneous bilirubinometer is not available, measure the serum bilirubin
o If a transcutaneous bilirubinometer measurement indicates a bilirubin level greater than 250 micromole/litre (15
mg/dl) check the result by measuring the serum bilirubin
o Always use serum bilirubin measurement to determine the bilirubin level in babies with jaundice in the first 24
hours of life
o Always use serum bilirubin measurement to determine the bilirubin level in babies less than 35 weeks gestational
age
o Always use serum bilirubin measurement for babies at or above the relevant treatment threshold for their postnatal
age, and for all subsequent measurements

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 How to manage hyperbilirubinemia

Start phototherapy:

 Use the bilirubin level to determine the management of hyperbilirubinemia using

treatment threshold graphs

 Do not subtract conjugated bilirubin from total serum bilirubin when making
decisions about the management of hyperbilirubinemia and treatment threshold
graphs

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Provide information to parents
and carers prior to start of any
treatment.
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 Jaundice requiring treatment
 the following tests in babies with significant hyperbilirubinaemia as part of an
assessment for underlying disease (see threshold table and treatment threshold
graphs:
o serum bilirubin (for baseline level to assess response to treatment)
o blood packed cell volume
o blood group (mother and baby)
o Direct 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:
o full blood count and examination of blood film
o blood glucose-6-phosphate dehydrogenase levels, taking account of ethnic origin
o microbiological cultures of blood, urine and/or cerebrospinal fluid (if infection is suspected)

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Care of Babies with Prolonged Jaundice
 In babies with a gestational age of 37 weeks (term)or more with jaundice lasting more than
14 days, and in babies with a gestational age of less than 37 weeks(preterm) with jaundice
lasting more than 21 days:
o look for pale chalky stools
o measure the conjugated bilirubin
o carry out a full blood count
o 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
o carry out a urine culture
o 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 or (>1.4mg/dl) because this may indicate serious liver disease.

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 When to Stop Phototherapy

 Once serum bilirubin has fallen to a level at least 50

micromole/l (3mg/dl) below the phototherapy threshold
 Check rebound of significant hyperbilirubinemia with a repeat
serum bilirubin 12-18 hours after stopping phototherapy
 Babies do not necessarily have to remain in the hospital for this
to be done

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 Intravenous Immunoglobulin
 Use intravenous immunoglobulin (IVIG) (500 mg/kg over
4 hours) as an adjunct to intensive phototherapy in cases
of Rhesus haemolytic disease or ABO hemolytic disease
when the serum bilirubin continues to rise by more than
8.5 micromol/litre (0.5mg/dl) per hour.

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 Exchange Transfusion
 Double blood volume
 During exchange do not:-
 Stop intensified phototherapy
 Perform a single volume exchange
 Use albumin priming
 Routinely administer IV calcium
 After exchange measure serum bilirubin within 2hours &manage

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Indicator and Compliance Supporting the
Effectiveness of Adopted CPG
Month Number of Cases Percentage Remarks
Discharge without
January 1/5 30% complication
Discharge without
February 1/6 16.6% complication

March 0
Discharge without
April 2/4 50% complication
Discharge without
May 1/5 20% complication
Discharge without
June 4/6 66.6% complication

July 2/4 50% Discharge without

complication
Discharge without
August 5/10 50% complication

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 Implementation Strategies
 Orientation to disseminate information
 Multidisciplinary meeting with other health
professionals (nurses, laboratory technicians)
 Competency Assessment
 Continuous Compliance Verification

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 The success of impletion of this CPG will not be
possible without the T.E.A.M approach of the medical
and nursing team.

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