Jaundice neonatal

Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.

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Aim

To guide staff with the assessment and management of neonatal jaundice in patients who present to Emergency Department (ED).

Background

Up to 60% of term and 80% of preterm neonates will become clinically jaundiced in the first week of life^{1, 2}
Usually, the total serum bilirubin (TSB) rises during days 3-5 of life, begins to decline from then, and usually resolves within 10-14 days.⁴
Very high bilirubin levels can cause neurological damage, a condition known as kernicterus.
Early recognition of jaundice is vital for treatment of any underlying cause and for appropriate use of phototherapy to control bilirubin levels.²

Key points

Most well newborns with jaundice have physiological jaundice with unconjugated bilirubin and usually do not require specific treatment.^1,2
Kernicterus was rarely seen in the decades following the introduction of phototherapy and exchange transfusion; however, recent reports suggest it is re-emerging. This has been partly attributed to earlier hospital discharge (within 48 hours of birth) before the natural peak of bilirubin in the neonate, as well as a result of relaxation of the treatment criteria.⁴
Assume a sick neonate who presents with jaundice is septic.
Conjugated hyperbilirubinaemia requires urgent discussion with a paediatric gastroenterologist.³
Measure bilirubin concentrations in all babies with jaundice- visual inspection alone is not reliable to estimate the bilirubin concentration.²

Risk factors^1,2

Maternal	Neonatal
Blood group O RhD negative Red cell antibodies Genetic: family history, East Asian, Mediterrean Diabetes Previous baby requiring phototherapy	Feeding - breastfeeding, reducing intake Haematoma, bruising Polycythaemia Haemolysis Bowel obstruction Infection Pre-term, male

Sub optimal intake jaundice or breastfeeding associated jaundice usually appears between 48-72 hours of life, peaks at day 3-5, and is associated with poor intake, poor weight gain and delayed or reduced bowel motions.
Increasing oral intake +/- phototherapy is the treatment.
If there are concerns for a breastfed baby regarding milk supply or poor oral attachment, refer to a lactation consultant for assessment at the Breastfeeding Centre of WA (King Edward Memorial Hospital (KEMH), Community Health breastfeeding support or a private lactation consultant.

Assessment

Red flags for pathological jaundice

Jaundice that occurs in the first 24 hours of life
Associated anaemia and hepatomegaly
Rapidly rising total serum bilirubin (> 85 micromol/L per day)¹
Elevated conjugated bilirubin level > 10% total serum bilirubin, or >20micromol/L – neonatal cholestasis (e.g. biliary atresia)²
Prolonged jaundice > 14 days in term, >21 days in preterm infants.1,2 Notably, 10% of breastfed babies are still jaundiced at 1 month, but breastmilk jaundice remains a diagnosis of exclusion.²

History

Clinical history should include:

Birth history: Instrumental delivery/birth trauma, gestational age, birth weight
Timing of jaundice: Onset and progression of jaundice, <24 hours pathological, >2 weeks prolonged (>3 weeks in preterm)
Feeding: Breast or formula, intake, weight loss, vomiting
Output: Hydration status, dark urine and pale stools (cholestasis), delayed passage of meconium
Behaviour: lethargy, cries becoming shrill, arching of the body (bilirubin encephalopathy)
Family history: ABO/rhesus incompatibility, glucose-6-phosphate-dehydrogenase (G6PD) deficiency, hereditary spherocytosis, prolonged jaundice, thyroid dysfunction
History of temperature instability.

Examination

General tone and neurological examination
Pallor, petechiae, cephalohaematoma, excessive bruising, hepatosplenomegaly.
Hydration and weight status (calculate percentage weight loss).
Plethora due to polycythaemia.

Initial ED investigations

Initial

Transcutaneous biliometry (TcB) (if available) for immediate estimate of bilirubin. Very difficult to assess level of jaundice by eye alone. Refer to Jaundice – Neonatology Guideline
Serum Bilirubin (SBR) conjugated and unconjugated
Blood group and Direct Coombs if not previously done
Full Blood Count (FBC) (add reticulocyte count if anaemic)
Liver Function Tests (LFTs) + albumin
Urine culture
+ / - Thyroid Function Test (TFT) (check if infant has had normal neonatal screening)
+/- Glucose-6-phosphate-dehydrogenase deficiency (G6PD)
+/- Urine for reducing substances

Table 1: Overview of initial investigations and management of neonatal jaundice

Unwell neonate	Well neonate			Conjugated hyperbilirubinaemia
	<24 hours old	2 to 14 days old	>14 days old
Septic screen: FBC, CRP, blood cultures, urine +/- LP SBR (direct and indirect) Consider TORCH and metabolic screen	SBR (direct and indirect) Direct Coombs test (DCT) + blood group FBC + retics DTC + blood group - if not done	TcB (if available) SBR (direct and indirect) FBC + retics DCT + blood group - if not done	SBR (direct and indirect) FBC + retics DCT + blood group if not done LFTs + albumin TFTs Red cell enzynes (G6PD) Urine culture	LFTs and albumin FBC + retucs INR Blood sugar
				Consider sepsis if unwell Further investigations guided by Gastro
Empiric antibiotics and admission	Admission and early consult with neonates Phototherapy if SBR above treatment line	Consider discharge if well and bloods normal. F/up GP in 1 to 2 days Phototherapy if SBR above treatment line	Feeding support/fluid replacement. Consider d/c if well and bloods normal Phototherapy if SBR above treatment line	Early consult with paediatric gastroenterologist

Management - Phototherapy

Plot SBR level on graph below.
Admit for phototherapy if bilirubin level is over the line as per the graph. (Refer to Phototherapy – Neonatal Guidelines).
If significantly above the treatment line consider possibility of requiring exchange transfusion. Plot on exchange graph and consult early with neonatology/intensive care.(Refer to Phototherapy – Neonatal Guidelines).
Phototherapy should be commenced in the Emergency Department if there is a delay in transfer to an inpatient ward

Graph 1: Guidelines for phototherapy in hospitalised Infants of greater than 35 weeks gestation¹¹

Guidelines for phototherapy in hospitalised infants of 35 or more weeks gestation

Breast milk jaundice¹²

Breast milk jaundice is common and is a diagnosis of exclusion.
Breast milk jaundice usually appears between day 5-10, the infant is generally thriving, and no intervention is required.
Breast feeding should continue to be encouraged and supported. Breast milk jaundice may last 3-12 weeks.

Disposition

Unwell babies should have a septic screen, antibiotics and admission +/- phototherapy. Refer to Sepsis Recognition and Management.
Babies requiring phototherapy should be admitted under general paediatrics or neonatology
Babies requiring exchange transfusion should be admitted under neonatology
Conjugated hyperbilirubinaemia requires gastroenterology admission or follow up
Full term, well appearing and afebrile neonates without significant risk factors and bilirubin level less than treatment level indicated in the graph can be discharged with GP follow-up in 1-2 days for review of intake/results check +/- repeat SBR.
Sunlight exposure is not recommended for the management of hyperbilirubinaemia since it is an uncontrolled source of multiple wavelengths of light. Sunburn is a risk and parents should be discouraged from using this approach.

References

Management of hyperbilirubinaemia in the Newborn 35 or more weeks gestation, Pediatrics 114:297-316, July 2004
Neonatal Jaundice: summary of NICE guidance. BMJ 2010;340:c2409 doi: 10.1136/bmj.c2409 (Published 19 May 2010)
McKiernan P. Neonatal Jaundice. Clinics and Research in Hepatology and Gastroenterology, 2012-06-01, Volume 36, Issue 3, Pages 253-256
Managing the jaundiced newborn: a persistent challenge. CMAJ 2015. DOI:10.1503 /cmaj.122117
Maisels MJ, McDonagh AF.Phototherapy for neonatal jaundice.N Engl J Med. 2008 Feb 28;358(9):920-8. Review. PubMed PMID: 18305267
Chou S-C et al. Management of hyperbilirubinaemia in newborns: measuring performance by using a benchmarking model. Pediatrics 2003; 112(6):1264-73
Johnson, L, Bhutani VK, Brown AK. System-based approach to management of neonatal jaundice and prevention of kernicterus. J Pediatrics 2002;140(4):396-403
Bhutani VK, Johnson LH, Maisels MJ, et al. Kernicterus: epidemiological strategies for its prevention through systems based approaches. J Perinatal 2004;24:650-62
Hamilton P, Schwartz, Beth E, Haberman RM. Hyperbilirubinaemia. Paediatric Emergency Care, 2001;27(9):884-9
Colletti JE, Kathari S, Jackson D, Kagore K, Berringer K. An emergency Medicine Approach to neonatal hyperbilirubinaemia. Emerg Med Clin N AM 2007;25:1117-1135
Jaundice Threshold Graphs – CAHS document. Last Modified 28 August 2020. Available from: https://cahs-healthpoint.hdwa.health.wa.gov.au/Neonatology/Documents/CAHS.NEO.Jaundice_ThresholdGraphs.xlsx
International Lactation Consultant Association. Core Curriculum for Lactation Consultant Practice. 3rd Ed. 2012

Endorsed by:	Nurse Co-director, Surgical Services	Date:	Apr 2022
		Review date:	Apr 2024

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