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Neonatal jaundice overview

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Neonatal jaundice HAI

About

What is covered

This pathway covers neonatal jaundice, one of the most common conditions needing medical attention in newborn babies. It also includes the quality standard on specialist neonatal care.
Jaundice refers to yellow colouration of the skin and the sclerae and is caused by a raised level of bilirubin in the circulation, a condition known as hyperbilirubinaemia.
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 of age. In most babies early jaundice is harmless. However a few babies will develop very high levels of bilirubin, which can be harmful if not treated.
Clinical recognition and assessment of jaundice can be difficult, particularly in babies with dark skin tones. Once jaundice is recognised, there is uncertainty about when to treat, and there is widespread variation in the use of phototherapy and exchange transfusion. This pathway provides guidance on the recognition, assessment and treatment of neonatal jaundice in babies from birth to 28 days.

Updates

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on jaundice in newborn babies.
NICE has also written information for patients and the public explaining its quality standards on the following topics:

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Updates to this pathway

9 May 2014 Minor maintenance updates
6 March 2014 Neonatal jaundice (NICE quality standard 57) added
25 January 2013 Minor maintenance updates
25 October 2011 Minor maintenance updates

Short Text

Neonatal jaundice

What is covered

This pathway covers neonatal jaundice, one of the most common conditions needing medical attention in newborn babies. It also includes the quality standard on specialist neonatal care.
Jaundice refers to yellow colouration of the skin and the sclerae and is caused by a raised level of bilirubin in the circulation, a condition known as hyperbilirubinaemia.
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 of age. In most babies early jaundice is harmless. However a few babies will develop very high levels of bilirubin, which can be harmful if not treated.
Clinical recognition and assessment of jaundice can be difficult, particularly in babies with dark skin tones. Once jaundice is recognised, there is uncertainty about when to treat, and there is widespread variation in the use of phototherapy and exchange transfusion. This pathway provides guidance on the recognition, assessment and treatment of neonatal jaundice in babies from birth to 28 days.

Sources

The NICE guidance that was used to create the pathway.
Neonatal jaundice. NICE clinical guideline 98 (2010)

Quality standards

Neonatal jaundice quality standard

These quality statements are taken from the neonatal jaundice quality standard. The quality standard defines clinical best practice in neonatal jaundice and should be read in full.

Quality statements

Care pathways and guidelines

This quality statement is taken from the specialist neonatal care quality standard. The quality standard defines clinical best practice in specialist neonatal care and should be read in full.

Quality statement

In-utero and postnatal transfers for neonatal special, high-dependency, intensive and surgical care follow perinatal network guidelines and care pathways that are integrated with other maternity and newborn network guidelines and pathways.

Quality measure

Structure
(a) Evidence of perinatal network guidelines and care pathways for in-utero and postnatal transfers for neonatal special, high-dependency, intensive and surgical care.
(b) Evidence that perinatal network guidelines and care pathways for in-utero and postnatal transfers for neonatal special, high-dependency, intensive and surgical care, are integrated with other maternity and newborn network guidelines and pathways.
(c) Evidence of network arrangements to ensure that when a baby is admitted to specialist neonatal care, the mother and any multiple birth siblings can be accommodated in the same hospital during their respective admissions.
Process
(a) Proportion of babies born at less than 28 weeks of gestation who receive intensive care in a neonatal intensive care unit (NICU) within the network.
Numerator: the number of babies receiving intensive care in a NICU within the network.
Denominator: the number of babies born at less than 28 weeks of gestation within the network.
(b) Proportion of babies with antenatally diagnosed fetal malformations requiring early surgery who are delivered at a designated network surgical centre.
Numerator: the number of babies delivered at a designated network surgical centre.
Denominator: the number of babies born within the network with antenatally diagnosed fetal malformations requiring early surgery.
(c) Proportion of babies who are transferred back to their local neonatal unit within 24 hours of request for repatriation.
Numerator: the number of babies transferred within 24 hours of repatriation request.
Denominator: the number of babies transferred back to their local neonatal unit.
(d) Proportion of babies who require neonatal surgery who receive it at a designated network surgical centre.
Numerator: the number of babies undergoing surgery at a designated network surgical centre.
Denominator: the number of babies born within the network who require neonatal surgery.
(e) For singleton births: proportion of mothers who still require inpatient care when their baby is transferred to specialist neonatal care, who are transferred to the same hospital as their baby.
Numerator: the number of mothers transferred to the same hospital as their baby.
Denominator: the number of mothers who still require inpatient care when their baby is transferred to specialist neonatal care.
(f) For multiple births: proportion of babies transferred to specialist neonatal care whose mother and/or multiple birth siblings are transferred to the same hospital if still requiring inpatient care.
Numerator: the number of babies whose mother and/or multiple birth siblings are transferred to the same hospital.
Denominator: the number of babies from multiple births transferred to specialist neonatal care whose mother and/or multiple birth siblings still require inpatient care.

Description of what the quality statement means for each audience

Service providers ensure perinatal network guidelines and care pathways for transfers for neonatal special, high-dependency, intensive and surgical care are implemented and integrated with other maternity and neonatal guidelines and pathways. Ensure regular monitoring of operation and effectiveness.
Healthcare professionals ensure perinatal network guidelines and care pathways are followed when transferring babies for neonatal special, high-dependency, intensive and surgical care, and invoke a report or alert mechanism where this is not possible.
Commissioners and networks ensure all eligible patients within their health economy are covered by perinatal network guidelines and care pathways for transfer for special, high-dependency, intensive and surgical care.
Parents of babies transferred to neonatal special, high-dependency, intensive or surgical care can expect the transfer to be in line with network guidelines and care pathways. These guidelines and care pathways describe specific procedures about safely transferring babies to other hospitals.

Definitions

The Department of Health toolkit (2009) defines a network as ‘linked groups of health professionals and organisations from primary, secondary and tertiary care, working in a coordinated manner, unconstrained by existing professional and health board boundaries, to ensure equitable provision of high-quality, clinically effective services.'
Guidance on the content of guidelines and pathways can be found within the Department of Health toolkit (2009) under Principles 4 and 7.

Data source

Structure
Local and network data collection.
Process
Local and network data collection.

Annual needs assessments

This quality statement is taken from the specialist neonatal care quality standard. The quality standard defines clinical best practice in specialist neonatal care and should be read in full.

Quality statement

Networks, commissioners and providers of specialist neonatal care undertake an annual needs assessment and ensure each network has adequate capacity.

Quality measure

Structure
Evidence of an annual needs assessment including production of an annual report covering, as a minimum, specialist neonatal activity for the network's population, monitoring of quality metrics and how concerns are being addressed.
Process
(a) Proportion of mothers whose babies required specialist neonatal care and who were booked to deliver in the network who received all their perinatal care within the network area (standard 95% as per Department of Health toolkit [2009]).
Numerator: the number of mothers receiving all their perinatal care within the network area.
Denominator: the number of mothers whose babies required specialist neonatal care and who were booked to deliver in the network area.
(b) Proportion of babies who receive specialist neonatal care in the network who are from outside the network area.
Numerator: the number of babies from outside the network area.
Denominator: the number of babies receiving specialist neonatal care in the network.
(c) Bed occupancy for each level of care (standard 80% as specified in the Department of Health toolkit [2009]).

Description of what the quality statement means for each audience

Service providers cooperate with networks and commissioners to carry out an annual specialist neonatal care needs assessment. If service provision levels are found to be inadequate, they ensure action is taken in conjunction with commissioners.
Healthcare professionals assist with specialist neonatal care needs assessments by providing accurate and validated data.
Commissioners and networks ensure that, in conjunction with service providers, an annual specialist neonatal care needs assessment is undertaken. In addition, they clearly define expected levels of service provision.
Parents of babies receiving specialist neonatal care can expect that the needs of their baby will be met by services provided in their area.

Definitions

Quality metrics are defined further in the Department of Health toolkit (2009) section 5.

Data source

Structure
Local and network data collection.
Process
(a): Local and network data collection.
(b): The Royal College of Paediatrics and Child Health National Neonatal Audit Programme collects data on whether all babies who access neonatal services are treated following their own neonatal network clinical pathway.
(c): Local and network data collection.

Skilled and multidisciplinary staff

This quality statement is taken from the specialist neonatal care quality standard. The quality standard defines clinical best practice in specialist neonatal care and should be read in full.

Quality statement

Specialist neonatal services have a sufficient, skilled and competent multidisciplinary workforce.

Quality measure

Structure
(a) Evidence of local arrangements to ensure specialist neonatal staff are compliant with competency levels as described by the Department of Health toolkit (2009).
(b) Evidence of local arrangements to provide a multidisciplinary service, trained and competent in the care of neonates, that has access to:
  • specialist neonatal or paediatric dietitians
  • specialist neonatal occupational therapists
  • specialist neonatal physiotherapists
  • specialist neonatal speech and language therapists
  • specialist neonatal pharmacists.
Process
Proportion of completed specialist neonatal care shifts with the correct nursing and medical staffing levels as specified in the Department of Health toolkit (2009).
Numerator: the number of shifts with the correct nursing and medical staffing levels as specified in the Department of Health toolkit (2009).
Denominator: the number of completed specialist neonatal care shifts.

Description of what the quality statement means for each audience

Service providers ensure specialist neonatal services are staffed in accordance with the Department of Health toolkit (2009), and that training and competencies are regularly reviewed.
Healthcare professionals ensure they are skilled and competent for their roles and responsibilities by accessing appropriate training.
Commissioners ensure that specialist neonatal services assess and monitor the staffing levels, composition and competency of their workforce. In addition, they ensure that appropriate education programmes are commissioned.
Parents of babies receiving specialist neonatal care can expect care to be given by an appropriate number of fully trained healthcare professionals.

Definitions

Definition of a skilled and competent workforce can be found in Department of Health toolkit (2009) Principle 2.
The process measure 'proportion of completed shifts with the correct nursing and medical staffing levels' was considered by the Topic Expert Group (TEG) as an appropriate measure of staffing. It is noted that this is not a mandatory data collection requirement and that collection of this data is at the discretion of local units.

Data source

Structure
Local data collection.
Process
Local data collection.

Neonatal transfer services

This quality statement is taken from the specialist neonatal care quality standard. The quality standard defines clinical best practice in specialist neonatal care and should be read in full.

Quality statement

Neonatal transfer services provide babies with safe and efficient transfers to and from specialist neonatal care.

Quality measure

Structure
Evidence of network arrangements to provide a 24-hour, 7 days a week neonatal transport service with a single telephone contact.
Process
(a) Proportion of transfer teams responding to time-critical emergencies that depart from the transport base within 1 hour from the start of the referring call.
Numerator: the number of transfer teams departing from the transport base within 1 hour from the start of the referring call.
Denominator: the number of emergency transfer requests deemed time-critical.
(b) Proportion of newborn babies who receive specialist neonatal care who have an admission temperature of less than 36°C.
Numerator: the number of newborn babies with an admission temperature of less than 36°C.
Denominator: the number of newborn babies receiving specialist neonatal care.

Description of what the quality statement means for each audience

Service providers ensure a safe and efficient service for babies transferred to and from specialist neonatal care.
Healthcare professionals ensure babies receive a safe and efficient transfer to and from specialist neonatal care.
Commissioners and networks ensure transfer services are contracted and monitored to provide appropriate levels of service provision.
Parents of babies who need to be transferred to or from specialist neonatal services can expect this to be done safely and efficiently.

Definitions

The Department of Health toolkit (2009) states 'a transfer service is concerned with organising and implementing the transfer of babies and/or mothers from within a defined geographical area (network). It encompasses both users and providers, and transfers may be ex-utero or in-utero.'
Further description of a high quality transfer service can be found in Principle 4 of the Department of Health toolkit (2009).

Data source

Structure
Network data collection.
Process
(a) and (b): Network data collection.

Encouraging parental involvement in care

This quality statement is taken from the specialist neonatal care quality standard. The quality standard defines clinical best practice in specialist neonatal care and should be read in full.

Quality statement

Parents of babies receiving specialist neonatal care are encouraged and supported to be involved in planning and providing care for their baby, and regular communication with clinical staff occurs throughout the care pathway.

Quality measure

Structure
(a) Evidence of local arrangements to involve parents in decision-making processes.
(b) Evidence of local audit demonstrating active involvement of parents in providing care for their baby.
(c) Evidence of regular surveys on parent experience.
(d) Evidence of local arrangements to provide bereavement services.
(e) Evidence of local arrangements to provide palliative care.
Process
Parents' experience is monitored through satisfaction surveys and the evidence used to inform learning and change for improvement.

Description of what the quality statement means for each audience

Service providers ensure a policy is in place to maintain accurate records of communication with parents of babies receiving specialist neonatal care and that parents are involved in planning and providing care. Ensure plans are in place to seek regular parental views and experience.
Healthcare professionals communicate regularly with parents of babies receiving specialist neonatal care and ensure parents are involved in decision-making and their baby's care.
Commissioners ensure services use parental feedback on involvement in decision-making and planning and provision of care to inform service improvement of specialist neonatal care.
Parents of babies receiving specialist neonatal care can expect to be encouraged and supported to be actively involved in planning and providing care, joint decision-making and to be in regular contact with their healthcare team.

Definitions

Support provided will depend on the parents’ needs and may include physical, psychological or social support.

Data source

Structure
(a), (b), (d) and (e): Local data collection.
(c): The Royal College of Paediatrics and Child Health National Neonatal Audit Programme denominator survey Question 8: In the last 12 months has the unit carried out a parent satisfaction survey?
Process
A Picker Institute parent survey, developed in conjunction with Bliss, is in development and will contain questions specifically aimed at assessing parent involvement in care and decision-making.

Breastfeeding

This quality statement is taken from the specialist neonatal care quality standard. The quality standard defines clinical best practice in specialist neonatal care and should be read in full.

Quality statement

Mothers of babies receiving specialist neonatal care are supported to start and continue breastfeeding, including being supported to express milk.

Quality measure

Structure
Evidence of a written local policy on breastfeeding and expressing milk for babies receiving specialist neonatal care.
Outcomes
(a) Proportion of babies born at less than 33 weeks of gestation who receive specialist neonatal care who are breastfed when discharged from hospital.
Numerator: the number of babies breastfed when discharged from hospital.
Denominator: the number of babies born at less than 33 weeks of gestation receiving specialist neonatal care and discharged from hospital.
(b) Proportion of babies born at less than 33 weeks of gestation who remain in hospital and still receive their mother's breast milk at 6 weeks.
Numerator: the number of babies receiving their mother's breast milk at 6 weeks.
Denominator: the number of babies born at less than 33 weeks of gestation, receiving specialist neonatal care and remaining in hospital at 6 weeks.

Description of what the quality statement means for each audience

Service providers ensure implementation of a local policy on breastfeeding and expressing milk for babies in specialist neonatal care.
Healthcare professionals ensure all mothers of babies receiving specialist neonatal care are supported to start and continue breastfeeding, including support to express milk.
Commissioners ensure services audit their compliance against agreed standards on supporting mothers to start and continue breastfeeding, including support to express milk.
Mothers of babies receiving specialist neonatal care can expect to be offered support to start and continue to breastfeed, including support to express milk.

Data source

Structure
Local data collection.
Outcomes
(a): The Royal College of Paediatrics and Child Health National Neonatal Audit Programme produce figures on feeding status at discharge for babies born at less than 33 weeks of gestation.
(b): Local data collection.

Coordinated transition to community care

This quality statement is taken from the specialist neonatal care quality standard. The quality standard defines clinical best practice in specialist neonatal care and should be read in full.

Quality statement

Babies receiving specialist neonatal care have their health and social care plans coordinated to help ensure a safe and effective transition from hospital to community care.

Quality measure

Structure
(a) Evidence of provision of a neonatal outreach service.
(b) Evidence of multiagency discharge planning with input from community neonatal outreach services.
Process
Proportion of babies discharged from specialist neonatal care who receive an outreach service follow-up.
Numerator: the number of babies receiving outreach service follow-up.
Denominator: the number of babies discharged from specialist neonatal care requiring an outreach service follow-up.

Description of what the quality statement means for each audience

Service providers ensure that agreements are in place for coordinating the care plans of babies receiving specialist neonatal care between relevant agencies.
Health and social care professionals ensure the care plans of babies receiving specialist neonatal care are coordinated with all relevant agencies.
Commissioners and networks ensure services are commissioned according to agreed levels of care across the specialist neonatal care pathway to enable safe and effective transition from hospital to community care.
Parents of babies discharged from specialist neonatal care can expect to receive support from health or social care professionals working in the community if their baby requires it. They can also expect that their baby's care plan will be coordinated between relevant teams to help ensure a safe and effective transition from hospital to home.

Data source

Structure
(a) and (b): Local and network data collection.
Process
Local and network data collection.

Data, audit and research

This quality statement is taken from the specialist neonatal care quality standard. The quality standard defines clinical best practice in specialist neonatal care and should be read in full.

Quality statement

Providers of specialist neonatal services maintain accurate and complete data, and actively participate in national clinical audits and applicable research programmes.

Quality measure

Structure
(a) Evidence of a documented data validation process to ensure data completeness and accuracy.
(b) Evidence of participation in national clinical audits and benchmarking.
(c) Evidence of participation in applicable research studies.
Process
(a) Complete and accurate data collected for the National Neonatal Audit Programme.
(b) Complete and accurate data collected for the British Association of Perinatal Medicine (BAPM) dataset.
(c) Proportion of babies receiving specialist neonatal care whose parents are invited to participate in applicable research studies.
Numerator: the number of babies whose parents are invited to participate in applicable research studies.
Denominator: the number of babies receiving specialist neonatal care.

Description of what the quality statement means for each audience

Service providers ensure accuracy and completeness of specialist neonatal data collection systems and participate in national clinical audits and applicable research programmes.
Healthcare professionals ensure accurate record keeping and data collection.
Commissioners ensure service providers participate in agreed national clinical audits and applicable research programmes.
Parents of babies receiving specialist neonatal care can expect complete and accurate information to be kept about their baby's care and for it to be used to improve care. They can also expect to be invited to participate in applicable research programmes.

Data source

Structure
(a): Local and network data collection.
Process
(a): The Royal College of Paediatrics and Child Health National Neonatal Audit Programme provides quarterly data completeness and accuracy reports to participating sites.
(b): Data completeness and accuracy figures of BAPM dataset submissions.
(c): Local and network data collection.

Health outcomes

This quality statement is taken from the specialist neonatal care quality standard. The quality standard defines clinical best practice in specialist neonatal care and should be read in full.

Quality statement

Babies receiving specialist neonatal care have their health outcomes monitored.

Quality measure

Structure
Evidence of processes to enable collection of health outcome data within the network for babies who receive specialist neonatal care.
Process
(a) Proportion of babies born at less than 30 weeks of gestation who received specialist neonatal care who have a 2-year outcome form completed.
Numerator: the number of babies with a completed 2-year outcome form.
Denominator: the number of babies born at less than 30 weeks of gestation receiving specialist neonatal care.
(b) Proportion of babies born at 30 weeks of gestation or more who received specialist neonatal care who have a 2-year outcome form completed.
Numerator: the number of babies with a completed 2-year outcome form.
Denominator: the number of babies born at 30 weeks of gestation or more receiving specialist neonatal care.
(c) Proportion of babies born at less than 32 weeks of gestation and/or with a birth weight less than 1501 g who receive specialist neonatal care and undergo retinopathy screening prior to discharge from hospital.
Numerator: the number of babies undergoing retinopathy screening prior to discharge from hospital.
Denominator: the number of babies born at less than 32 weeks of gestation and/or with a birth weight less than 1501 g, receiving specialist neonatal care and discharged from hospital.
(d) Proportion of babies born at less than 32 weeks of gestation and/or with a birth weight less than 1501 g who receive specialist neonatal care who require laser surgery.
Numerator: the number of babies requiring laser surgery.
Denominator: the number of babies born at less than 32 weeks of gestation and/or with a birth weight less than 1501 g receiving specialist neonatal care.
e) Proportion of babies who received specialist neonatal care who have had a culture-positive infection of blood or cerebrospinal fluid prior to discharge from hospital.
Numerator: the number of babies who have had a culture-positive infection of blood or cerebrospinal fluid prior to discharge from hospital.
Denominator: the number of babies receiving specialist neonatal care.
f) Proportion of babies who have had neonatal encephalopathy.
Numerator and denominator under development for the National Neonatal Audit Programme.
Outcomes
(a) Proportion of babies born at less than 30 weeks of gestation who receive specialist neonatal care who have no functional impairment at 2 years when corrected for gestational age.
Numerator: the number of babies with no functional impairment at 2 years when corrected for gestational age.
Denominator: the number of babies born at less than 30 weeks of gestation receiving specialist neonatal care.
(b) Proportion of babies born at 30 weeks of gestation or more who receive specialist neonatal care who have no functional impairment at 2 years when corrected for gestational age.
Numerator: the number of babies with no functional impairment at 2 years when corrected for gestational age.
Denominator: the number of babies born at 30 weeks of gestation or more receiving specialist neonatal care.
(c) 2-year survival rates within and compared with other networks.

Description of what the quality statement means for each audience

Service providers ensure the health outcomes of all babies receiving specialist neonatal care are monitored.
Healthcare professionals ensure accurate and complete baseline data collection through pregnancy, childbirth and the perinatal period.
Commissioners and networks ensure specialist neonatal care health outcomes are monitored and used to inform service improvement.
Parents of babies receiving specialist neonatal care can expect their baby's health will continue to be assessed after discharge from hospital.

Data source

Structure
The Royal College of Paediatrics and Child Health National Neonatal Audit Programme collects data on whether health outcomes are collected.
Process
(a) and (b): The Royal College of Paediatrics and Child Health National Neonatal Audit Programme collects data on whether 2-year outcomes are collected.
(c): The Royal College of Paediatrics and Child Health National Neonatal Audit Programme collects data on retinopathy screening prior to discharge from hospital for babies born at less than 32 weeks of gestation and/or with a birth weight less than 1501 g.
(d): Local and network data collection.
(e): The Royal College of Paediatrics and Child Health National Neonatal Audit Programme will collect data on babies who have had a culture-positive infection of blood or cerebrospinal fluid prior to discharge.
(f): The Royal College of Paediatrics and Child Health National Neonatal Audit Programme will collect data on neonatal encephalopathy.
Outcomes
(a), (b) and (c): Network data collection.

Information for parents or carers

This quality statement is taken from the neonatal jaundice quality standard. The quality standard defines clinical best practice in neonatal jaundice care and should be read in full.

Quality statement

Parents or carers of newborn babies have a discussion with healthcare professionals and are given written information about neonatal jaundice within 24 hours of the birth, including what to look for and who to contact if they are concerned.

Rationale

Early identification of neonatal jaundice is essential to ensure that babies receive appropriate treatment for either underlying disease or for hyperbilirubinaemia caused by physiological jaundice in order to prevent complications and achieve the best clinical outcomes. Advising parents or carers about what to look for and when to contact a healthcare professional will help to ensure rapid access to treatment if needed. This is particularly important in the context of early discharge from maternity units. Giving parents or carers information about neonatal jaundice will also reassure them that it is common, usually transient and harmless, and that normal feeding and normal care of the baby can usually continue (including extra support with breastfeeding). This will reduce their anxiety if their baby does develop jaundice and needs investigations or treatment. Parents or carers of newborn babies receive a large amount of information, which is why a discussion, in addition to written information, is important.

Quality measures

Structure
a) Evidence of local availability of written information about neonatal jaundice for parents or carers of newborn babies.
Data source: Local data collection.
b) Evidence of local arrangements to ensure telephone access to a relevant healthcare professional for parents or carers who are concerned about neonatal jaundice.
Data source: Local data collection.
Process
Proportion of newborn babies whose parents or carers have a discussion with healthcare professionals and receive written information about neonatal jaundice within 24 hours of the birth, including what to look for and who to contact if they are concerned.
Numerator – the number of babies in the denominator whose parents or carers have a discussion with healthcare professionals and receive written information about neonatal jaundice within 24 hours of the birth, including what to look for and who to contact if they are concerned.
Denominator – the number of newborn babies.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure the availability of written information about neonatal jaundice (including what to look for and who parents or carers can contact if they are concerned) and that healthcare professionals understand and act on the need to discuss this with parents or carers of newborn babies.
Healthcare professionals ensure that they discuss neonatal jaundice with parents or carers of newborn babies and give them written information within 24 hours of the birth, including what to look for and who to contact if they are concerned.
Commissioners ensure that they commission services in which written information on neonatal jaundice is available and there is telephone access to relevant healthcare professionals for parents or carers who are concerned about jaundice.

What the quality statement means for patients and carers

Parents or carers of newborn babies have a discussion with healthcare professionals and are given written information about jaundice within 24 hours of the baby being born. This includes information about how to check whether the baby might have jaundice, as well as who to contact if they are concerned.

Source guidance

  • Neonatal jaundice (NICE clinical guideline 98), recommendation 1.1.1 (key priority for implementation)
  • Postnatal care (NICE clinical guideline 37), recommendation 1.4.16

Definitions of terms used in this quality statement

Information about neonatal jaundice
Information about neonatal jaundice should be tailored to the needs and expressed concerns of parents or carers of newborn babies. The information should be provided through discussion backed up by written information. Care should be taken to avoid causing unnecessary anxiety to parents or carers. The combination of discussion and written information should cover:
  • factors that influence the development of significant hyperbilirubinaemia
  • how to check the baby for jaundice (signs and symptoms to look for):
    • the naked baby in bright and preferably natural light
    • note that examination of the sclerae, gums and blanched skin is useful across all skin tones
  • who to contact if they suspect jaundice, jaundice is getting worse, or their baby is passing pale chalky stools or dark urine
  • the importance of recognising jaundice in the first 24 hours and of seeking urgent medical advice
  • the fact that neonatal jaundice is common, and reassurance that it is usually transient and harmless
  • reassurance that support will be provided to continue with normal feeding (including extra advice and support with breastfeeding) and normal care of the baby.
[Adapted from Postnatal care (NICE clinical guideline 37) recommendation 1.4.16, Neonatal jaundice (NICE clinical guideline 98) recommendations 1.1.1 (key priority for implementation) and 1.2.5, and Postnatal care (NICE quality standard 37) statement 3]
A neonatal jaundice parent information factsheet and information for the public about neonatal jaundice are available from NICE.

Equality and diversity considerations

Information about neonatal jaundice should be accessible to parents or carers with additional needs such as physical, sensory or learning disabilities, and to parents or carers who do not speak or read English. Parents or carers of babies with neonatal jaundice in any setting should have access to an interpreter or advocate if needed.
Extra support with visual checks for jaundice in babies and checking nappies for pale stools or dark urine should be provided to parents or carers with sight impairments.
It may be difficult to recognise jaundice in some babies with dark skin tones. The instructions about how to check the baby for jaundice are written to be useful across all skin tones: examination of the sclerae, gums and blanched skin in bright (preferably natural) light.

Measurement of bilirubin level in babies more than 24 hours old

This quality statement is taken from the neonatal jaundice quality standard. The quality standard defines clinical best practice in neonatal jaundice care and should be read in full.

Quality statement

Babies with suspected jaundice who are more than 24 hours old have their bilirubin level measured within 6 hours of a healthcare professional suspecting jaundice or a parent or carer reporting possible jaundice.

Rationale

Visual inspection is used to recognise jaundice but is not very good for assessing the clinical severity of the jaundice. Although bilirubin should not be measured routinely in babies who are not visibly jaundiced, measuring bilirubin levels in babies with suspected or obvious visible jaundice assesses the degree of jaundice and determines whether the baby needs further investigations or treatment. Measuring the bilirubin level as soon as possible (within 6 hours) in babies with suspected jaundice will ensure that those with rapidly rising bilirubin levels are identified promptly for treatment. Bilirubin can be measured by taking a blood sample (serum bilirubin) or, within defined circumstances (see Definitions below), using a transcutaneous bilirubinometer (followed by a blood test if needed). Transcutaneous bilirubinometers, although not as accurate as measuring serum bilirubin, are more accurate than visual inspection alone, are non-invasive, can be used in the community and provide instant results.

Quality measures

Structure
Evidence of local protocols and adequate access to bilirubin measurement, to ensure that babies with suspected jaundice who are more than 24 hours old have their bilirubin level measured within 6 hours of a healthcare professional suspecting jaundice or a parent or carer reporting possible jaundice.
Data source: Local data collection.
Process
a) Proportion of babies with suspected jaundice who are more than 24 hours old who have their bilirubin level measured.
Numerator – the number of babies in the denominator having their bilirubin level measured.
Denominator – the number of babies with suspected jaundice who are more than 24 hours old.
Data source: Local data collection.
b) Proportion of babies with suspected jaundice who are more than 24 hours old who have their bilirubin level measured within 6 hours of a healthcare professional suspecting jaundice or a parent or carer reporting possible jaundice.
Numerator – the number of babies in the denominator having their bilirubin level measured within 6 hours of a healthcare professional suspecting jaundice or a parent or carer reporting possible jaundice.
Denominator – the number of babies with suspected jaundice who are more than 24 hours old who have had their bilirubin measured.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure adequate access to bilirubin measurement and have local education and protocols in place that enable healthcare professionals to measure, within 6 hours, bilirubin levels in babies with suspected jaundice who are more than 24 hours old.
Healthcare professionals ensure that they measure, within 6 hours, bilirubin levels in babies with suspected jaundice who are more than 24 hours old.
Commissioners ensure that they commission services with adequate access to bilirubin measurement that enable healthcare professionals to measure, within 6 hours, bilirubin levels in babies with suspected jaundice who are more than 24 hours old.

What the quality statement means for patients and carers

Babies with suspected jaundice who are more than 24 hours old have their bilirubin level measured within 6 hours of the possible jaundice being noted (bilirubin is the substance that causes the yellow colour seen in jaundice). This may be done by a healthcare professional at the baby’s home, but it may need to be done at a hospital.

Source guidance

  • Neonatal jaundice (NICE clinical guideline 98), recommendations 1.2.14 and 1.2.15 (key priority for implementation).

Definitions of terms used in this quality statement

Measurement of bilirubin level
When measuring the bilirubin level in babies more than 24 hours old:
  • use a transcutaneous bilirubinometer in babies with a gestational age of 35 weeks or more (always use serum bilirubin measurement to determine the bilirubin level in babies less than 35 weeks’ gestational age)
  • if a transcutaneous bilirubinometer is not available, measure the serum bilirubin
  • if a transcutaneous bilirubinometer measurement indicates a bilirubin level greater than 250 micromol/litre check the result by measuring the serum bilirubin
  • always use serum bilirubin measurement for babies at or above the relevant treatment thresholds for their postnatal age, and for all subsequent measurements
  • do not use an icterometer.
[Adapted from Neonatal jaundice (NICE clinical guideline 98) recommendation 1.2.15]
Within 6 hours
The 6-hour timeframe begins when a healthcare professional suspects jaundice or when a parent or carer reports possible jaundice.
[Expert opinion]
Transcutaneous bilirubinometer
A device that uses reflected light to measure the yellow colour (bilirubin level) in the skin.

Equality and diversity considerations

Some parents or carers may find it difficult to access postnatal care for their baby after discharge from hospital; for example, they may be unable to afford to travel to their local clinic or hospital. This quality statement focuses on the period after the initial 24 hours after birth (and so in many cases after discharge from hospital). It promotes equitable access to postnatal care by making reference to the use (where clinically indicated) of transcutaneous bilirubinometers, which can be used in the community.

Management of hyperbilirubinaemia: treatment thresholds

This quality statement is taken from the neonatal jaundice quality standard. The quality standard defines clinical best practice in neonatal jaundice care and should be read in full.

Quality statement

Babies with hyperbilirubinaemia are started on treatment in accordance with standardised threshold tables or charts.

Rationale

Once jaundice in babies is recognised, it is important to know when and how to treat it. Phototherapy is an effective treatment for significant hyperbilirubinaemia and can reduce the need for exchange transfusion (a procedure involving a complete changeover of blood), which is necessary only in the most severe cases. The consistent use of treatment thresholds, alongside NICE guidance, will help to ensure a balance between the thresholds being low enough to prevent complications (such as kernicterus) but not so low that phototherapy is used unnecessarily.

Quality measures

Structure
Evidence of local arrangements to ensure the use of standardised treatment threshold tables or charts when starting treatment for babies with hyperbilirubinaemia.
Data source: Local data collection.
Process
Proportion of babies identified with hyperbilirubinaemia who are started on treatment in accordance with standardised threshold tables or charts.
Numerator – the number of babies in the denominator who are started on treatment in accordance with standardised threshold tables or charts.
Denominator – the number of babies identified with hyperbilirubinaemia.
Data source: Local data collection.
Outcome
Incidence of kernicterus.
Data source: Local data collection. The ICD-10 code for Kernicterus is P57. Data available via Hospital episode statistics (HES) online or the Neonatal Critical Care Minimum Data Set.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers ensure that healthcare professionals have access to, and are competent to use, standardised threshold tables or charts when deciding whether to start (or not start) treatment for babies with hyperbilirubinaemia.
Healthcare professionals ensure that they use standardised threshold tables or charts when deciding whether to start (or not start) treatment for babies with hyperbilirubinaemia.
Commissioners ensure that they commission services in which healthcare professionals have access to, and are competent to use, standardised threshold tables or charts when deciding whether to start (or not start) treatment for babies with hyperbilirubinaemia.

What the quality statement means for patients and carers

Babies with high levels of bilirubin receive treatment according to tables or charts that tell the healthcare team whether to start (or not start) treatment. The information used when making decisions about when to start treatment includes how high the baby’s bilirubin level is, the age of the baby when the bilirubin was measured, and the baby’s maturity at the time of birth (that is, how many weeks of pregnancy they were born after).

Source guidance

  • Neonatal jaundice (NICE clinical guideline 98), recommendations 1.3.4 (key priority for implementation) and 1.2.13.

Definitions of terms used in this quality statement

Standardised threshold tables or charts
These are tables or charts that help healthcare professionals to implement treatment thresholds for phototherapy and exchange transfusion in accordance with NICE clinical guideline 98. These include treatment threshold graphs published on the NICE website. All tables or charts should take into account serum bilirubin level, gestational age and postnatal age.

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Successful effective interventions library details

Implementation

Commissioning

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.

Education and learning

NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.

Service improvement and audit

These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.

Pathway information

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on jaundice in newborn babies.
NICE has also written information for patients and the public explaining its quality standards on the following topics:

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Updates to this pathway

9 May 2014 Minor maintenance updates
6 March 2014 Neonatal jaundice (NICE quality standard 57) added
25 January 2013 Minor maintenance updates
25 October 2011 Minor maintenance updates

Supporting information

How to measure the bilirubin level

When measuring the bilirubin level:
  • use a transcutaneous bilirubinometer in babies with a gestational age of 35 weeks or more and postnatal age of more than 24 hours
  • if a transcutaneous bilirubinometer is not available, measure the serum bilirubin
  • if a transcutaneous bilirubinometer measurement indicates a bilirubin level greater than 250 micromol/litre check the result by measuring the serum bilirubin
  • always use serum bilirubin measurement to determine the bilirubin level in babies:
    • with jaundice in the first 24 hours of life
    • less than 35 weeks gestational age
  • always use serum bilirubin measurement for babies at or above the relevant treatment thresholds for their postnatal age, and for all subsequent measurements
  • do not use an icterometer.
Do not measure bilirubin levels routinely in babies who are not visibly jaundiced.
Do not rely on visual inspection alone to estimate the bilirubin level in a baby with jaundice.

Glossary

Phototherapy given using a single light source (not fibreoptic) that is positioned above the baby
Also known as the direct Coombs' test; this test is used to detect antibodies or complement proteins that are bound to the surface of red blood cells
Phototherapy given using a single light source that comprises a light generator, a fibreoptic cable through which the light is carried and a flexible light pad, on which the baby is placed or that is wrapped around the baby
Phototherapy that is given using more than one light source simultaneously; for example two or more conventional units, or a combination of conventional and fibreoptic units
Less than 37 weeks gestational age
Jaundice lasting more than 14 days in term babies and more than 21 days in preterm babies
An elevation of the serum bilirubin to a level requiring treatment
37 weeks or more gestational age
Jaundice detected by visual inspection

Paths in this pathway

Pathway created: May 2011 Last updated: May 2014

© NICE 2014

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