NEONATAL HYPERBILIRUBINEMIA CLINICAL GUIDELINES

Register No: 09094

Status: Public

Developed in response to: Intrapartum NICE Guidelines

RCOG guideline

Contributes to CQC Outcome 9, 12

Consulted With Post/Committee/Group Date

Anita Rao/Alison Cuthbertson Clinical Director for Women’s and Children’s Directorate October 2017
Miss Joshi Consultant for Obstetrics and Gynaecology
Dr Agrawal Deputy Clinical Director/Consultant Paediatrician
Alison Cuthbertson Head of Midwifery
Paula Hollis Lead Midwife Acute Inpatient Services
Chris Berner Lead Midwife Clinical Governance
Toni Laing Lead Nurse for Neonatal Unit
Sarah Moon Specialist Midwife for Guideline and Audit
Sharon Kippen Senior Midwife Postnatal Ward
Emma Towler/Nicola Waterson Practice Development Nurses
Deborah Lepley Senior Librarian, Warner Library
Professionally Approved By
Dr. Hassan Consultant Lead for Risk Management October 2017
Anita Rao Clinical Director, Obstetric and Gynaecology October 2017

Version Number 5.0

Issuing Directorate Women’s and Children’s
Ratified By DRAG Chairmans Action
nd
Ratified On 22 November 2017
Trust Executive Sign Off Date December 2017/January 2018
th
Implementation Date 11 December 2017
Next Review Date November 2020
Author/Contact for Information Dr Hassan, Consultant Paediatrician
Policy to be followed by Midwives, Obstetricians, Paediatricians and Neonatal nurses
Distribution Method Intranet & Website
Related Trust Policies 04071 Standard Infection Prevention
(to be read in conjunction with) 04072 Hand Hygiene
04225 Examination of the Newborn
06036 Guideline for Maternity Record Keeping including Documentation in
Handheld Records
09062 Mandatory training policy for maternity services incorporating training
needs analysis
Exchange transfusion.
Document Review History:

Review No Reviewed by Active Date

1.0 Julie Bishop October 2005
2.0 Sharon Pilgrim October 2009
3.0 Sharon Pilgrim January 2011
3.1 Sharon Pilgrim – clarification to point 6.3 October 2012
4.0 Sharon Pilgrim March 2014
5.0 Dr Hassan, Consultant Paediatrician 11 December 2017

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INDEX

1. Purpose

2. Equality and Diversity

3. Introduction

4. Incidence and Risk factors

5. Types of Jaundice

6. Investigations and Observations

7. Phototherapy

8. Feeding and hydration

9. Exchange Transfusion

10. Other Management Strategies

11. Prolonged Neonatal Jaundice

12. Bilirubin Encephalopathy

13. Infection Prevention

14. Staff and Training

15. Professional Midwifery Advocates

16. Audit and Monitoring

17. Communication

18. References

19. Appendices

A. Appendix A - Threshold tables-------------------------------------------Page 11-19

B. Appendix B – Investigation pathway---------------------------------- Page 20
C. Appendix C - Phototherapy Pathway--------------------------------- Page 21
D. Appendix D - Exchange transfusion Pathway---------------------- Page 22
E. Appendix E – Prolonged jaundice Screen--------------------------- Page 23

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1.0 Purpose

1.1 To ensure that infants with hyperbilirubinaemia are identified and correctly treated.
1.2 To provide management strategies for all types and levels of hyperbilirubinaemia
1.3 Aims to help detect or prevent very high levels of bilirubin, which can be harmful if not
treated.

2.0 Equality and Diversity

2.1 Mid Essex Hospital Services NHS Trust is committed to the provision of a service that is
fair, accessible and meets the needs of all individuals.

3.0 Introduction

3.1 All babies develop elevated serum bilirubin (SBR) levels to a greater or lesser degree in
the first week of life. This is due to an increased production (accelerated red blood cell
breakdown), a decreased removal (transient liver enzyme insufficiency) and an increased
reabsorption (enterohepatic circulation).

3.2 However, when a baby does become jaundiced, a common dilemma is deciding at what
SBR level to intervene. The decision is influenced by whether the baby is term or
preterm, well or sick, and the presence or absence of blood factors predisposing to
hyperbilirubinaemia.

4.0 Risk factors

4.1 Virtually all babies have a transient rise in SBR, but only about 50% are visibly jaundiced.
Babies of Asian background having a higher incidence.

4.2 It is clinically useful to classify jaundice according to the age of the baby when he/she
becomes visibly jaundiced.

4.3 Factors likely to make physiological jaundice worse in a given baby include:

• Prematurity • Delayed passage of meconium

• Bruising • Breast feeding
• Cephalhaematoma • Certain ethnic groups
• Polycythemia

5.0 Types of Jaundice

5.1 Early (days 1-2), always pathological and usually due to the following:
• Haemolysis
o Rhesus isoimmunisation
o ABO and other blood group
incompatibilities
o Rarer causes of Haemolysis
o Red cell membrane defects
o Red cell enzyme defects

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 • Sepsis

• Hepatitis

5.2 Normal (days 3-10), very common occurrence and can be subdivided into the following:

• Physiological - Uncomplicated
• Physiological - Complicated

5.3 Late (days 14+), this jaundice can occur due to the following:

• Breast milk - common occurrence

• Conjugated jaundice - uncommon occurrence
• Inherited deficiency of glucuronyl transferase enzymes - very rare occurrence

6.0 Investigations and Observations

(Refer to Appendix B)

6.1 Detailed history is recorded in the postnatal/neonatal health care records highlighting the
following points:

• Maternal blood group and antibody status

• Baby’s blood group and direct antibody test (DAT) if available
• Feeding history
• Colour of stools/urine
• Neonatal vitamin K administration
• Onset of neonatal jaundice
• Antenatal history
• Any risks for antenatally acquired infections
• Family history (any history of splenectomies or severe jaundice)

6.2 Jaundice starts on the head, and extends towards the feet as the level rises

6.3 Transcutaneous bilirubinometry (Biligun) can be used as an immediate screening test on

infants above 35 weeks gestation who appear jaundiced after 24 hours of age.

6.4 Investigations to be undertaken if the Biligun shows a value of SBR within 50 μmol/L of
the threshold for the relevant phototherapy threshold for the particular baby.

6.5 Any baby having jaundice at less than 24 hours of age should be investigated promptly.

6.6 The following investigations should be performed:

• Blood Group & DAT

• Full blood count (FBC) & Blood Film
• Reticulocytes Count
• Liver function test (LFT) with split serum bilirubin
• Urea and electrolytes
• Investigations for sepsis in unwell babies if clinically indicated

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6.7 If in any doubt with regards to the Biligun value, the laboratory values for serum Bilirubin
should be taken.

6.8 Treatment with phototherapy should be initiated while the results of the lab are awaited if
the screening bilirubin value from the Biligun is near or above the threshold level for
phototherapy.

7.0 Phototherapy
(Refer to Appendix A, B and C)

7.1 Use serum bilirubin measurement & the treatment thresholds in the threshold table and
treatment threshold graphs when considering the use of phototherapy.

7.2 Do not use phototherapy in babies whose bilirubin does not exceed the phototherapy
threshold levels in the threshold table and treatment threshold graphs

7.3 In babies with a gestational age of 38 weeks or more whose bilirubin is in the consider
phototherapy category in the threshold table, repeat the bilirubin measurement in 6 hours
regardless of whether or not phototherapy has subsequently started.

7.4 In babies with a gestational age of 38 weeks or more whose bilirubin is in the repeat
bilirubin measurement category in the threshold table, repeat the bilirubin measurement
in 6 - 12 hours.

7.5 Place the baby in the supine position

7.6 Give baby eye protection and routine eye care

7.7 Ensure treatment is applied to the maximum area of skin

7.8 Monitor the baby’s temperature and ensure the baby is kept in a thermoneutral
environment.

7.9 Monitor hydration by daily weighing of the baby and assessing wet nappies.

7.10 Support parents and carers and encourage them to interact with the baby.

7.11 Do not use white curtains routinely with phototherapy

7.12 During phototherapy:

• Repeat serum bilirubin measurement 4–6 hours after initiating phototherapy

• Repeat serum bilirubin measurement every 6–12 hours when the serum bilirubin level
is stable or falling.

7.13 Once the infant has reached 14 days of age the threshold chart used for plotting the
bilirubin results should be adjusted for the current gestational age.

7.14 Stopping phototherapy

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 • Stop phototherapy once serum bilirubin has fallen to a level at least 50 micromol/litre
(5 small boxes) below the phototherapy threshold (see threshold table and treatment
threshold graphs.
• Check for rebound of significant hyperbilirubinaemia with a repeat serum bilirubin
measurement 12–18 hours after stopping phototherapy.

8.0 Feeding and Hydration

8.1 During conventional phototherapy

• Encourage short breaks of up to 30minutes for breast feeding nappy changing and
cuddles
• Continue lactation/feeding support
• Do not give additional fluids

8.2 During multiple phototherapy

• Do not interrupt phototherapy for feeding. Administer intravenous fluids or enteral
feeds
• Continue lactation support so that breast feeding can start again when treatment
stops

9.0 Exchange transfusion

(Refer to Appendix C)

9.1 Use a double-volume exchange transfusion to treat babies:

• Whose serum bilirubin level indicates its necessity (see threshold table and treatment
threshold graphs despite intensive phototherapy. Blood should be ordered as the
level is approached as it may take some time to arrange.

• With clinical features and signs of acute bilirubin encephalopathy.

• If a baby is admitted with a serum Bilirubin above the exchange line, intensive
phototherapy should be commenced and blood ordered for transfusion, the level
should then be repeated every 2 to 3 hours and exchange performed if the level
remains above the exchange level after 6 hours.

• If there is a known history of significant Rhesus isoimmunisation (indicated by high or

rising maternal antibody levels) and the baby has not received in utero blood
transfusion send cord blood sample for Hb and Bilirubin. Consider transfusion if the
Hb is <10g/dl or cord blood serum bilirubin is >80 micromol/l

• Blood collected after exchange transfusion has no value when investigating rarer
causes of hyperbilirubinaemia, therefore blood for these tests should be done before
the exchange transfusion takes place.

9.2 During exchange transfusion do not:

• Stop continuous multiple phototherapy

• Perform a single-volume exchange
• Use albumin priming
• Routinely administer intravenous calcium.

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9.3 Following exchange transfusion:

• Maintain continuous multiple phototherapy

• Measure serum bilirubin level within 2 hours and manage according to threshold table
and treatment thresholds graphs

10.0 Other Management Strategies

10.1 Term and pre-term babies with significant hyperbilirubinaemia in the first 28 days of life
with bilirubin rising greater than 10 micromol/litre per hour or babies with co-morbid
illnesses such as infections have been shown to have fewer exchange transfusions if
treated with a combination of IVIG (500mg/kg over 4 hours) alongside phototherapy than
those treated with phototherapy alone.

10.2 Indications are as follows:

DAT positive who has predicted severe disease based on antenatal investigation
Rising serum total bilirubin at exchange level

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

10.4 All neonates who receive IVIG need follow-up and will need FBC, Reticulocyte count and
blood film after 2 weeks.

11.0 Prolonged Neonatal Jaundice

(Refer to Appendix E)

11.1 Prolonged jaundice is defined as jaundice lasting more than 14 days in a term baby or 21
days in a preterm baby.

11.2 Full examination including inspection of the colour of urine & stools.

11.3 Investigations: Full Blood Count, Reticulocytes count, blood film, blood group & DAT,
TFT, split bilirubin (Total & conjugated) and LFT.

11.4 Ensure that routine metabolic screening (including screening for congenital
hypothyroidism) has been performed i.e. check with parents that neonatal dried blood
spot screening has been performed (Day 5- 8 of life)

11.5 Consult expert advice for babies with a conjugated bilirubin level greater than 25
umol/litre.

12.0 Bilirubin Encephalopathy

12.1 Unconjugated bilirubin is toxic to brain cells; the mildest form of bilirubin toxicity is
sensorineural hearing loss. Severe jaundice requiring exchange transfusion (criterion
was bilirubin > 340 micromol/litre) and early onset of jaundice (within 24 hours) are
statistically significant risk factors for hearing loss.

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12.2 Risk factors for bilirubin encephalopathy are as follows:
• Lower gestation
• Hypoxia
• Asphyxia
• Acidosis
• Infection
• Hypothermia
• Decreased albumin binding (low levels or drug interference i.e. ceftriaxone)

12.3 Signs of acute bilirubin encephalopathy are as follows:

• Early signs: Lethargy, Hypotonia, Poor feeding

• Unstable temperature
• Arching of head neck and back (opisthotonia)
• Spasticity
• Seizures

12.4 Severe bilirubin toxicity causes Kernicterus which is characterised by death of brain cells
and yellow staining of the grey matter specially the basal ganglia. In the acute stage this
presents as encephalopathy and is associated with late sequelae of athtoid cerebral
palsy

12.5 Babies are at increased risk of developing Kernicterus if they have any of the following:
• A serum bilirubin level greater than 340 micromol/litre in babies with a gestational
age of 37 weeks or more
• A rapidly rising bilirubin level of greater than 8.5 micromol/litre per hour
• Clinical features of acute bilirubin encephalopathy.
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13.0 Infection Prevention

13.1 All staff should follow Trust guidelines on infection control by ensuring that they
effectively ‘decontaminate their hands’ before and after undertaking any patient contact.

14.0 Staff and Training

14.1 All medical, midwifery and nursing staff involved in the care of infants at risk of
hyperbilirubinemia will be trained to identify the symptoms of hyperbilirubinaemia and its
treatment. This will be recorded as part of their appraisal.

14.2 All staff will be aware of the correct equipment to use and the correct way to perform heel
pricks to obtain capillary blood, and be competent at using the transcutaneous
bilirubinometer

14.3 All midwifery and obstetric staff must attend yearly mandatory training which includes
skills and drills training.

14.4 All midwifery and obstetric staff are to ensure that their knowledge and skills are up-to
date in order to complete their portfolio for appraisal.

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15.0 Professional Midwifery Advocates

15.1 Professional Midwifery Advocates provide a mechanism of support and guidance to

women and midwives. Professional Midwifery Advocates are experienced practising
midwives who have undertaken further education in order to supervise midwifery
services and to advise and support midwives and women in their care choices.

16.0 Audit and Monitoring

16.1 Audit of compliance with this guideline will be considered on an annual audit basis in
accordance with the Clinical Audit Strategy and Policy (register number 08076), the
Corporate Clinical Audit and Quality Improvement Project Plan and the Maternity annual
audit work plan; to encompass national and local audit and clinical governance
identifying key harm themes. The Women’s and Children’s Clinical Audit Group will
identify a lead for the audit.

16.2 The findings of the audit will be reported to and approved by the Multi-disciplinary Risk
Management Group (MRMG) and an action plan with named leads and timescales will be
developed to address any identified deficiencies. Performance against the action plan will
be monitored by this group at subsequent meetings.

16.3 The audit report will be reported to the monthly Directorate Governance
Meeting (DGM) and significant concerns relating to compliance will be entered on the
local Risk Assurance Framework.

16.4 Key findings and learning points from the audit will be submitted to the Patient Safety
Group within the integrated learning report.

16.5 Key findings and learning points will be disseminated to relevant staff.

17.0 Guideline Management

17.1 As an integral part of the knowledge, skills framework, staff are appraised annually to
ensure competency in computer skills and the ability to access the current approved
guidelines via the Trust’s intranet site.

17.2 Quarterly memos are sent to line managers to disseminate to their staff the most
currently approved guidelines available via the intranet and clinical guideline folders,
located in each designated clinical area.

17.3 Guideline monitors have been nominated to each clinical area to ensure a system
whereby obsolete guidelines are archived and newly approved guidelines are now
downloaded from the intranet and filed appropriately in the guideline folders. ‘Spot
checks’ are performed on all clinical guidelines quarterly.

17.4 Quarterly Clinical Practices group meetings are held to discuss ‘guidelines’. During this
meeting the practice development midwife can highlight any areas for future training
needs that will be met using methods such as ‘workshops’ or to be included in future
‘skills and drills’ mandatory training sessions.

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18.0 Communication

18.1 A quarterly ‘maternity newsletter’ is issued to all staff with embedded icons to highlight
key changes in clinical practice to include a list of newly approved guidelines for staff to
acknowledge and familiarise themselves with and practice accordingly. Midwives that are
on maternity leave or ‘bank’ staff have letters sent to their home address to update them
on current clinical changes.

18.2 Approved guidelines are published monthly in the Trust’s Staff Focus that is sent via
email to all staff.

18.3 Approved guidelines will be disseminated to appropriate staff quarterly via email.

18.4 Regular memos are posted on the guideline and audit notice boards in each clinical area
to notify staff of the latest revised guidelines and how to access guidelines via the intranet
or clinical guideline folders.

19.0 References

National Institute for Health & Care Excellence (NICE), CG 98. Jaundice in newborn
babies under 28 days. May 2010, Last updated October 2016.

American Academy of Pediatrics (2004) Management of hyperbilirubinaemia in the

newborn infant 35 or more week’s gestation. Pediatrics vol114 pp 297 – 316.

Manning D, Todd P, Maxwell M, Platt MJ (2007) Prospective study of severe

hyperbilirubinaemia in the newborn in the UK and Ireland. Arch. Dis. Child. Fetal
Neonatal ed. Vol92 F342 – 346.

Morris BH et al (2008) Aggressive vs. Conservative phototherapy for infants with

extremely low birth weight. N England J Med vol 359 pp1885

Watchko JF, Maisels MJ, (2003) Jaundice in low birth weight infants: pathobiology and
outcome. Arch. Dis. Child. Fetal neonatal ed. 88 F455 – 458.

Watchko JF, Maisels MJ, (2003) Treatment of Jaundice in low birth weight infants. Arch.
Dis. Child. Fetal neonatal ed. 88 F459 – 463.

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 Treatment threshold graph for babies with neonatal jaundice
Baby's name Date of birth

Hospital number Time of birth Direct Antiglobulin Test

Click below and choose gestation

Shade for phototherapy Baby's blood group Mother's blood group 31 weeks gestation

Multiple
Single

550

500
Total serum bilirubin (micromol/litre)

450

400

350 Exchange transfusion

300

250
Phototherapy

200

150

100

50

0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14
5ays from birth 11
Appendix A
 Treatment threshold graph for babies with neonatal jaundice
Baby's name Date of birth

Hospital number Time of birth Direct Antiglobulin Test

Click below and choose gestation

Shade for phototherapy Baby's blood group Mother's blood group 32 weeks gestation

Multiple
Single

550

500
Total serum bilirubin (micromol/litre)

450

400

350 Exchange transfusion

300

250 Phototherapy

200

150

100

50

0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14
5ays from birth 12
 Treatment threshold graph for babies with neonatal jaundice
Baby's name Date of birth

Hospital number Time of birth Direct Antiglobulin Test

Click below and choose gestation

Shade for phototherapy Baby's blood group Mother's blood group 33 weeks gestation

Multiple
Single

550

500
Total serum bilirubin (micromol/litre)

450

400

Exchange transfusion
350

300

Phototherapy
250

200

150

100

50

0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14
5ays from birth 13
 Treatment threshold graph for babies with neonatal jaundice
Baby's name Date of birth

Hospital number Time of birth Direct Antiglobulin Test

Click below and choose gestation

Shade for phototherapy Baby's blood group Mother's blood group 34 weeks gestation

Multiple
Single

550

500
Total serum bilirubin (micromol/litre)

450

400
Exchange transfusion
350

300
Phototherapy
250

200

150

100

50

0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14
5ays from birth 14
 Treatment threshold graph for babies with neonatal jaundice
Baby's name Date of birth

Hospital number Time of birth Direct Antiglobulin Test

Click below and choose gestation

Shade for phototherapy Baby's blood group Mother's blood group 35 weeks gestation

Multiple
Single

550

500
Total serum bilirubin (micromol/litre)

450

400
Exchange transfusion

350

300
Phototherapy
250

200

150

100

50

0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14
5ays from birth 15
 Treatment threshold graph for babies with neonatal jaundice
Baby's name Date of birth

Hospital number Time of birth Direct Antiglobulin Test

Click below and choose gestation

Shade for phototherapy Baby's blood group Mother's blood group 36 weeks gestation

Multiple
Single

550

500
Total serum bilirubin (micromol/litre)

450

400 Exchange transfusion

350

300
Phototherapy

250

200

150

100

50

0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14
5ays from birth 16
 Treatment threshold graph for babies with neonatal jaundice
Baby's name Date of birth

Hospital number Time of birth Direct Antiglobulin Test

Click below and choose gestation

Shade for phototherapy Baby's blood group Mother's blood group 37 weeks gestation

Multiple
Single

550

500
Total serum bilirubin (micromol/litre)

450

400 Exchange transfusion

350

300 Phototherapy

250

200

150

100

50

0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14
5ays from birth 17
 Treatment threshold graph for babies with neonatal jaundice
Baby's name Date of birth

Hospital number Time of birth Direct Antiglobulin Test

Click below and choose gestation

Shade for phototherapy Baby's blood group Mother's blood group >=38 weeks gestation

Multiple
Single

550

500
Exchange transfusion
Total serum bilirubin (micromol/litre)

450

400
Phototherapy
350

300

250

200

150

100

50

0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14
5ays from birth 18
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 Appendix E

Prolonged Jaundice Screen

Blood

Full blood count and film

Blood group and DAT
Conjugated and Unconjugated bilirubin
Thyroid function free T4 and TSH
Liver function tests

Prolonged Conjugated Jaundice Profile

Blood

Full blood count and film

Clotting studies APTT and PT
Liver function
Gamma GT and ALT
Plasma amino acids
Alpha 1 antitrypsin level
Conjugated and Unconjugated bilirubin
Thyroid function free T4 and TSH
Galactose-1-uridyl transferase.
Toxoplasma serology

Urine

MC&S
Reducing substances
Amino acids
Organic acids
CMV DEAFF virology

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