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Neonatal jaundice

About

What is covered

This NICE Pathway covers the care of newborn babies (from birth to 28 days) with jaundice.

Updates

Updates to this NICE Pathway

26 October 2016 A recommendation was amended to clarify when intensified phototherapy should be used in relation to time since birth at treatment levels.
10 May 2016 Pathway updated and restructured in line with the partial update to NICE's guideline on jaundice in newborn babies under 28 days. Summarised recommendations replaced with full recommendations.
6 March 2014 Neonatal jaundice (NICE quality standard 57) added.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on diagnosing and treating jaundice in newborn babies under 28 days in an interactive flowchart

What is covered

This NICE Pathway covers the care of newborn babies (from birth to 28 days) with jaundice.

Updates

Updates to this NICE Pathway

26 October 2016 A recommendation was amended to clarify when intensified phototherapy should be used in relation to time since birth at treatment levels.
10 May 2016 Pathway updated and restructured in line with the partial update to NICE's guideline on jaundice in newborn babies under 28 days. Summarised recommendations replaced with full recommendations.
6 March 2014 Neonatal jaundice (NICE quality standard 57) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Jaundice in newborn babies under 28 days (2010 updated 2016) NICE guideline CG98
Jaundice in newborn babies under 28 days (2014) NICE quality standard 57

Quality standards

Jaundice in newborn babies under 28 days

These quality statements are taken from the jaundice in newborn babies under 28 days quality standard. The quality standard defines clinical best practice for jaundice in newborn babies under 28 days and should be read in full.

Quality statements

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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Implementation

NICE has produced resources to help implement its guidance on:

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Consensus-based bilirubin thresholds for management of babies 38 weeks or more gestational age with hyperbilirubinaemia
Age (hours)
Bilirubin measurement (micromol/litre)
0
>100
>100
6
> 125
> 150
12
> 150
> 200
18
> 175
> 250
24
> 200
> 300
30
> 212
> 350
36
> 225
> 400
42
> 237
> 450
48
> 250
> 450
54
> 262
> 450
60
> 275
> 450
66
> 287
> 450
72
> 300
> 450
78
> 312
> 450
84
> 325
> 450
90
> 337
> 450
96+
> 350
> 450
Action
Start phototherapy
Perform an exchange transfusion unless the bilirubin level falls below threshold while the treatment is being prepared
Measure and record the serum bilirubin level urgently (within 2 hours).
Phototherapy that is given with an increased level of irradiance with an appropriate spectrum. Phototherapy can be intensified by adding another light source or increasing the irradiance of the initial light source used.
Phototherapy given using an artificial light sources with an appropriate spectrum and irradiance. This can be delivered using light-emitting diode, fibreoptic or fluorescent lamps, tubes or bulbs.

Glossary

direct antiglobulin test – also known as the direct Coombs' test – used to detect antibodies or complement proteins that are bound to the surface of red blood cells
end-tidal carbon monoxide
intravenous immunoglobulin

Paths in this pathway

Pathway created: May 2011 Last updated: July 2020

© NICE 2020. All rights reserved. Subject to Notice of rights.

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