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Neonatal jaundice
About
What is covered
This pathway covers the care of newborn babies (from birth to 28 days) with jaundice.
Updates
Updates to this 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 partial update to CG98 and 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
What is covered
This pathway covers the care of newborn babies (from birth to 28 days) with jaundice.
Updates
Updates to this 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 partial update to CG98 and 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
Neonatal specialist care (2010) NICE quality standard 4
Quality standards
Neonatal specialist care
These quality statements are taken from the neonatal specialist care quality standard. The quality standard defines clinical best practice in neonatal specialist care and should be read in full.
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 in jaundice in newborn babies under 28 days and should be read in full.
Quality statements
Care pathways and guidelines
This quality statement is taken from the neonatal specialist care quality standard. The quality standard defines clinical best practice in neonatal specialist 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.
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 neonatal specialist care quality standard. The quality standard defines clinical best practice in neonatal specialist 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]).
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. Contained within the Royal College of Paediatrics and Child Health National Neonatal Audit Programme.
b) 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 neonatal specialist care quality standard. The quality standard defines clinical best practice in neonatal specialist 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.
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 neonatal specialist care quality standard. The quality standard defines clinical best practice in neonatal specialist 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.
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 neonatal specialist care quality standard. The quality standard defines clinical best practice in neonatal specialist 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.
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) and b) Local data collection. Contained within the Picker Institute Europe's neonatal survey.
c) 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?
d) and e) Local data collection.
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 neonatal specialist care quality standard. The quality standard defines clinical best practice in neonatal specialist 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.
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. Contained within the Picker Institute Europe's neonatal survey.
Outcome
a) Royal College of Paediatrics and Child Health National Neonatal Audit Programme produces figures on feeding status at discharge for babies born at less than 33 weeks of gestation. Also contained within the Picker Institute Europe's neonatal survey.
b) Local data collection.
Coordinated transition to community care
This quality statement is taken from the neonatal specialist care quality standard. The quality standard defines clinical best practice in neonatal specialist 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.
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 neonatal specialist care quality standard. The quality standard defines clinical best practice in neonatal specialist 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 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.
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.
b) Participation in Royal College of Paediatrics and Child Health National Neonatal Audit Programme.
Process
a) 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.
Health outcomes
This quality statement is taken from the neonatal specialist care quality standard. The quality standard defines clinical best practice in neonatal specialist 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.
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
Royal College of Paediatrics and Child Health National Neonatal Audit Programme collects data on whether health outcomes are collected.
Process
a) and b) Royal College of Paediatrics and Child Health National Neonatal Audit Programme collects data on whether 2-year outcomes are collected.
c) 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 or gestation and/or with a birth weight less than 1501 g.
d) Local and network data collection.
e) 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) Royal College of Paediatrics and Child Health National Neonatal Audit Programme will collect data on neonatal encephalopathy.
Outcomes
a) and c) Network data collection.
b) Network data collection. Also contained within the Royal College of Paediatrics and Child Health National Neonatal Audit Programme.
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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Pathway information
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People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
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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: December 2016
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