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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

20 April 2021 Postnatal care (NICE quality standard 37) added.
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

20 April 2021 Postnatal care (NICE quality standard 37) added.
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
Postnatal care (2013, updated 2021) NICE quality standard 37

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

Continuity of care

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

Quality statement

This statement has been removed. For full details, see update information in the NICE quality standard.

Maternal health – potentially serious conditions

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

Quality statement

Women are advised, at the first postnatal midwife contact, of the symptoms and signs of potentially serious conditions that require them to seek medical advice without delay.

Rationale

Women are at an increased risk of experiencing serious health events in the immediate hours, days and weeks following the birth, some of which could lead to maternal death or severe morbidity. Providing women with information about the symptoms and signs that may indicate a serious physical illness or mental health condition may prompt them to seek medical advice without delay and avoid unnecessary deaths and severe morbidity.

Quality measures

Structure
Evidence of local arrangements to ensure that women are advised, at the first postnatal midwife contact, of the symptoms and signs of potentially serious conditions that require them to seek medical advice without delay.
Data source: Local data collection.
Process
The proportion of women who are advised, at the first postnatal midwife contact, of the symptoms and signs of potentially serious conditions that require them to seek medical advice without delay.
Numerator – the number in the denominator who are advised, at the first postnatal midwife contact, of the symptoms and signs of potentially serious conditions that require them to seek medical advice without delay.
Denominator – the number of women who have given birth.
Data source: Local data collection.
Outcome
a) Incidence of potentially avoidable maternal morbidity and mortality.
Data source: Local data collection. The Healthcare Quality Improvement Partnership’s Maternal, Newborn and Infant Clinical Outcome Review Programme (undertaken by MBRRACE-UK) reports on rates of maternal death and severe maternal morbidity.
b) Women who have given birth feel informed about symptoms and signs of potentially serious postnatal conditions.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers ensure that systems are in place for women to be advised, at the first postnatal midwife contact, of the symptoms and signs of potentially serious conditions that require them to seek medical advice without delay.
Midwives advise women, at the first postnatal contact, of the symptoms and signs of potentially serious conditions that require them to seek medical advice without delay.
Commissioners ensure that they commission services that advise women, at the first postnatal midwife contact, of the symptoms and signs of potentially serious conditions that require them to seek medical advice without delay.
Women are given advice by their midwife at their first postnatal contact about the symptoms and signs of potentially serious conditions that should prompt them to seek medical advice without delay.

Source guidance

Definitions of terms used in this quality statement

First postnatal midwife contact
The first postnatal midwife contact should take place within 36 hours after transfer of care from the place of birth or after a home birth. [NICE’s guideline on postnatal care, recommendation 1.1.14]
Symptoms and signs of potentially serious conditions
The following symptoms and signs are suggestive of potentially serious physical conditions in the woman:
  • sudden or very heavy vaginal bleeding, or persistent or increased vaginal bleeding, which could indicate retained placental tissue or endometritis
  • abdominal, pelvic or perineal pain, fever, shivering, or vaginal discharge with an unpleasant smell, which could indicate infection
  • leg swelling and tenderness, or shortness of breath, which could indicate venous thromboembolism
  • chest pain, which could indicate venous thromboembolism or cardiac problems
  • persistent or severe headache, which could indicate hypertension, pre-eclampsia, postdural-puncture headache, migraine, intracranial pathology or infection
  • worsening reddening and swelling of breasts persisting for more than 24 hours despite self-management, which could indicate mastitis
  • symptoms or signs of potentially serious conditions that do not respond to treatment.
[NICE’s guideline on postnatal care, recommendation 1.2.4]
The following symptoms and signs are suggestive of potentially serious mental health conditions in the woman:
  • severe depression, such as feeling extreme unnecessary worry, being unable to concentrate due to distraction from depressive feelings
  • severe anxiety, such as uncontrollable feeling of panic, being unable to cope or becoming obsessive
  • the desire to hurt others or yourself, including thoughts about taking your own life
  • confused and disturbed thoughts, which could include other people telling you that you are imagining things (hallucinations and delusions).

Equality and diversity considerations

Communication and information-giving between women (and their families) and members of the maternity team is a key aspect of this statement. Relevant adjustments will need to be in place for anyone who has communication difficulties, and for those who do not speak or read English. Written and verbal information should be appropriate for the woman’s level of literacy, culture and language.

Infant health – serious illness

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

Quality statement

Women or main carers of babies are advised, within 24 hours of the birth, of the symptoms and signs of serious illness in the baby that require them to contact emergency services.

Rationale

Babies may experience serious health conditions in the immediate hours, days and weeks following the birth, which can lead to severe illness or in rare cases, death. Providing the mother or main carer with verbal and written information about the symptoms and signs that might indicate their baby has a serious health problem may result in them contacting emergency services more promptly. This information should be provided within 24 hours of the birth.

Quality measures

Structure
Evidence of local arrangements to ensure that women or main carers of babies are advised, within 24 hours of the birth, of the symptoms and signs of serious illness in the baby that require them to contact emergency services.
Data source: Local data collection.
Process
The proportion of women or main carers of babies who are advised, within 24 hours of the birth, of the symptoms and signs of serious illness in the baby that require them to contact emergency services.
Numerator – the number in the denominator who are advised, within 24 hours of the birth, of the symptoms and signs of serious illness in the baby that require them to contact emergency services.
Denominator – the number of mothers or main carers of babies.
Data source: Local data collection.
Outcome
a) Incidence of potentially avoidable infant morbidity and mortality.
Data source: Local data collection. The NHS Digital Maternity Services Data Set collects data on neonatal deaths. The Healthcare Quality Improvement Partnership’s perinatal mortality surveillance report (MBRRACE-UK) reports on rates of perinatal death.
b) Women and main carers feel informed about symptoms and signs of serious illness in the baby.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers ensure that systems are in place for women or main carers of babies to be advised, within 24 hours of the birth, of the symptoms and signs of serious illness in the baby that require them to contact emergency services.
Healthcare practitioners advise women or main carers of babies, within 24 hours of the birth, of the symptoms and signs of serious illness in the baby that require them to contact emergency services.
Commissioners ensure that they commission services that advise women or main carers of babies, within 24 hours of the birth, of the symptoms and signs of serious illness in the baby that require them to contact emergency services.
Women or the main carer of the baby are given advice within 24 hours of the birth about symptoms and signs of serious illness in the baby, for which they need to contact emergency services.

Source guidance

Definitions of terms used in this quality statement

Symptoms and signs of serious illness in the baby
The following symptoms and signs are suggestive of serious illness in a baby:
  • appearing pale, ashen, mottled or blue (cyanosis)
  • unresponsive or unrousable
  • having a weak, abnormally high-pitched or continuous cry
  • abnormal breathing pattern, such as:
    • grunting respirations
    • increased respiratory rate (over 60 breaths/minute)
    • chest indrawing
  • temperature of 38°C or over or under 36°C
  • non-blanching rash
  • bulging fontanelle
  • neck stiffness
  • seizures
  • focal neurological signs
  • diarrhoea associated with dehydration
  • frequent forceful (projectile) vomiting
  • bilious vomiting (green or yellow-green vomit).
  • within the first 24 hours after the birth:
    • has not passed urine
    • has not passed faeces (meconium)
    • develops a yellow skin colour (jaundice).
[NICE’s guideline on postnatal care, recommendations 1.3.2 and 1.4.9, NICE’s guideline on jaundice in newborn babies under 28 days, recommendation 1.1.1 and expert opinion]
Main carers of babies
For the majority of babies, the main carer will be the mother. For some babies, the main carer could be a close relative, for example, the baby’s father or grandparent, or for looked-after babies, this could be a foster parent. [Expert opinion]

Equality and diversity considerations

Communication and information-giving between women or main carers of babies (and their families) and members of the maternity team is a key aspect of this statement. Relevant adjustments will need to be in place for anyone who has communication difficulties, and for those who do not speak or read English.

Infant health – bed sharing

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

Quality statement

Women, their partner or main carers of babies have discussions with their healthcare professional about safer bed-sharing practices.

Rationale

There are risk factors associated with sudden unexpected death in infancy when bed sharing. Discussing safer bed-sharing practices and the circumstances in which bed sharing with a baby is strongly advised against with women, their partner or main carers of babies will support them to establish safer infant sleeping habits.

Quality measures

Structure
Evidence of local arrangements to ensure that women, their partner or main carers of babies have discussions with their healthcare professional about safer bed-sharing practices.
Data source: Local data collection.
Process
Proportion of postnatal contacts in which women, their partner or main carers of babies have discussions with their healthcare professional about safer bed-sharing practices.
Numerator – the number in the denominator in which women, their partner or main carers of babies have discussions with their healthcare professional about safer bed-sharing practices.
Denominator – the number of postnatal contacts.
Data source: Local data collection.
Outcome
a) Incidence of sudden infant death syndrome (SIDS).
b) Women, their partner and main carers of babies know about safer bed-sharing practices.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers ensure that information about safer bed-sharing practices is available, and that healthcare professionals are trained to discuss safer bed-sharing practices with women, their partner or main carers of babies.
Healthcare practitioners ensure that they understand and can explain safer bed-sharing practices, and that they have discussions about this with women, their partner or the main carers of babies.
Commissioners ensure that they commission services that provide information about safer bed-sharing practices, and that train healthcare professionals to discuss this with women, their partner or main carers of babies.
Women, their partner or main carers of babies have discussions about safer bed-sharing practices with their healthcare professional. This should include how to keep their baby safe if they share a bed with their baby and when they should not share a bed with their baby.

Source guidance

Postnatal care. NICE guideline NG194 (2021), recommendations 1.3.13 and 1.3.14

Definitions of terms used in this quality statement

Main carers of babies
For the majority of babies, the main carer will be the mother. For some babies, the main carer could be a close relative, for example, the baby’s father or grandparent, or for looked-after babies, this could be a foster parent. [Expert opinion]
Safer bed-sharing practices
Discussions about bed sharing should include:
  • safer practices for bed sharing, including:
    • making sure the baby sleeps on a firm, flat mattress, lying face up (rather than face down or on their side)
    • not sleeping on a sofa or chair with the baby
    • not having pillows or duvets near the baby
    • not having other children or pets in the bed when sharing a bed with a baby
  • advice not to share a bed with their baby if their baby was low birth weight or if either parent:
    • has had 2 or more units of alcohol
    • smokes
    • has taken medicine that causes drowsiness
    • has used recreational drugs.
[NICE’s guideline on postnatal care, recommendations 1.3.13 and 1.3.14]

Equality and diversity considerations

Communication and information-giving between women, their partners or main carers of babies (and their families), and members of the maternity team are key aspects of this statement. Relevant adjustments should be in place for people with communication difficulties, and those who do not speak or read English. Verbal and written information should be appropriate for the person’s level of literacy, culture, language and family circumstances. Bed sharing can be intentional or a necessity, but all women, their partners or main carers of babies should be given information in a format they can understand, irrespective of their culture.

Breastfeeding

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

Quality statement

Women receive breastfeeding support from a service that uses an evaluated, structured programme.

Rationale

Breastfeeding contributes to the health of both the mother and child in the short and longer term. Women should be made aware of these benefits and those who choose to breastfeed should be supported by a service that is evidence-based and delivers an externally audited, structured programme. Delivery of breastfeeding support should be coordinated across the different sectors.

Quality measures

Structure
Evidence of local arrangements for breastfeeding support to be provided through a service that uses an evaluated, structured programme.
Data source: Local data collection.
Process
a) Proportion of women who receive breastfeeding support through a service that uses an evaluated, structured programme.
Numerator – the number in the denominator who receive breastfeeding support through a service that uses an evaluated, structured programme.
Denominator – the number of women who breastfeed (exclusively or partially).
Data source: Local data collection.
b) Proportion of women who wanted to continue breastfeeding but stopped before they had planned to.
Numerator – the number in the denominator who wanted to continue breastfeeding but stopped before they had planned to.
Denominator – the number of women who breastfed (exclusively or partially).
Data source: Local data collection.
Outcome
a) Rates of breastfeeding initiation.
Data source: The NHS Digital Maternity Services Data Set reports percentage of babies receiving breast milk as first feed.
b) Rates of exclusive or partial breastfeeding on discharge from hospital and at 6 to 8 weeks after the birth.
c) Women’s satisfaction with breastfeeding support.
Data source: The Care Quality Commission maternity services survey collects information about women’s experiences of maternity care and this includes a section on infant feeding.

What the quality statement means for different audiences

Service providers ensure that women receive breastfeeding support through a service that uses an evaluated, structured programme.
Healthcare practitioners ensure that women receive breastfeeding support through an integrated service that uses an evaluated, structured programme.
Commissioners ensure that they commission a service that delivers breastfeeding support through an evaluated, structured programme.
Women receive breastfeeding support through a service that uses an evaluated, structured programme.

Source guidance

Maternal and child nutrition. NICE guideline PH11 (2008, updated 2014), recommendations 1 and 7

Definitions of terms used in this quality statement

Structured programme
All maternity care providers (whether working in hospital or in primary care) should implement an externally evaluated, structured programme that encourages breastfeeding, using the UNICEF Baby Friendly Initiative as a minimum standard. If providers implement a locally developed programme, this should be evidence-based, structured, and undergo external evaluation. The structured programme should be delivered and coordinated across all providers, including hospital, primary, community and children’s centre settings. Breastfeeding outcomes should be monitored across all services. [Adapted from NICE’s guideline on maternal and child nutrition, recommendation 7]
Breastfeeding support
All people involved in delivering breastfeeding support should receive the approriate training and undergo assessment of competencies for their role. This includes employed staff and volunteer workers in all sectors, for example, hospitals, community settings, children’s centres and peer supporter services.

Equality and diversity considerations

Breastfeeding support should be culturally appropriate and accessible to people with additional needs, such as physical, sensory or learning disabilities, and to people who do not speak or read English. Women should have access to an interpreter or advocate if needed. Special consideration will be needed if the mother and baby have been separated for any reason, for example, if the baby has been admitted to neonatal care or the baby has been taken into care.

Formula feeding

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

Quality statement

Information about bottle feeding is discussed with women or main carers of formula-fed babies.

Rationale

Babies who are fully or partially formula-fed can develop infections and illnesses if their formula milk is not prepared safely. In a small number of babies these cause serious harm and are life threatening and require the baby to be admitted to hospital. The mother or main carer of the baby needs consistent, evidence-based advice about how to sterilise feeding equipment and safely prepare formula milk.

Quality measures

Structure
Evidence of local arrangements to ensure that information about bottle feeding is discussed with women or main carers of formula-fed babies.
Data source: Local data collection.
Process
The proportion of women or main carers of formula-fed babies who have information about bottle feeding discussed with them.
Numerator – the number in the denominator who have information about bottle feeding discussed with them.
Denominator – the number of women or main carers of formula-fed babies.
Data source: Local data collection.
Outcome
a) Rates of hospital admissions for formula feeding-related conditions.
Data source: Local data collection.
b) Women’s and main carers’ knowledge of how to sterilise feeding equipment and safely prepare formula milk.
Data source: Local data collection, for example, use of patient surveys.
c) Women’s and main carers’ satisfaction with feeding support.
Data source: The Care Quality Commission maternity services survey collects information about women’s experiences of maternity care and this includes a section on infant feeding.

What the quality statement means for different audiences

Service providers ensure that information about bottle feeding is discussed with women or main carers of formula-fed babies.
Healthcare practitioners discuss information about bottle feeding with women or main carers of formula-fed babies.
Commissioners ensure that they commission services in which information about bottle feeding is discussed with women or main carers of formula-fed babies.
Women or main carers of formula-fed babies have the opportunity to discuss information about bottle feeding.

Source guidance

Postnatal care. NICE guideline NG194 (2021), recommendations 1.5.18 and 1.5.19

Definitions of terms used in this quality statement

Formula-fed baby
This statement relates to mothers and main carers who totally or partially formula feed their baby, and breastfeeding mothers who plan to formula feed their baby. [Expert opinion]
Information about bottle feeding
The woman or main carer of the baby should have a one-to-one discussion about safe formula feeding and face-to face support supplemented with written, digital or telephone information.
Face-to-face formula feeding support should include:
  • advice about responsive bottle feeding and help to recognise feeding cues
  • offering to observe a feed
  • positions for holding a baby for bottle feeding and the dangers of ‘prop’ feeding
  • advice about how to pace bottle feeding and how to recognise signs that a baby has had enough milk (because it is possible to overfeed a formula-fed baby), and advice about other ways than feeding that can comfort and soothe the baby
  • how to bond with the baby when bottle feeding, through skin-to-skin contact, eye contact and the potential benefit of minimising the number of people regularly feeding the baby.
[NICE’s guideline on postnatal care, recommendations 1.5.18 and 1.5.19]
Main carers of babies
For the majority of babies, the main carer will be the mother. For some babies, the main carer could be a close relative, for example, the baby’s father or grandparent, or for looked-after babies, this could be a foster parent. [Expert opinion]

Equality and diversity considerations

Communication and information-giving between women or main carers of babies (and their families), and members of the maternity team is a key aspect of this statement. Relevant adjustments will need to be in place for anyone who has communication difficulties, and for those who do not speak or read English. Verbal and written information should be appropriate in terms of women’s (and their families) level of literacy, culture, language and family circumstances.

Infant health – physical examination

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

Quality statement

Babies have a complete 6- to 8-week physical examination.

Rationale

The purpose of the examination is to identify babies more likely to have conditions that would benefit from further investigation and management. This includes an overall physical examination as well as screening for eye problems, congenital heart defects, developmental dysplasia of the hip and undescended testicles. Most babies will be healthy, but the small number of babies who do have serious problems will benefit from prompt identification. Early treatment can improve the health of the baby and prevent or reduce disability.

Quality measures

Structure
a) Evidence of local arrangements to ensure that parents or main carers of babies are offered an appointment for the baby to attend for a 6- to 8-week physical examination.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that a system is in place to monitor the competency of practitioners undertaking a 6- to 8-week physical examination.
Data source: Local data collection.
Process
Proportion of babies who had a 6- to 8-week physical examination.
Numerator – the number in the denominator who had a 6- to 8-week physical examination.
Denominator – the number of babies aged 8 weeks.
Data source: Local data collection could include data collected for the Public Health England newborn and infant physical examination (NIPE) screening programme.
Outcomes
a) Incidence of physical abnormalities in babies.
Data source: Local data collection.
b) Health outcomes associated with early intervention for babies with physical abnormalities.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers ensure that babies are offered a complete 6- to 8-week physical examination.
Healthcare practitioners ensure that they perform a complete 6- to 8-week physical examination of babies and that they maintain the necessary competencies for this role.
Commissioners ensure that they commission services that offer a complete 6- to 8-week physical examination for babies, which is carried out in a timely manner and by a competent practitioner.
The mother or main carer of the baby is given the opportunity for their baby to have a complete 6- to 8-week physical examination, which is carried out in a timely manner and by a competent practitioner.

Source guidance

Postnatal care. NICE guideline NG194 (2021), recommendations 1.3.3, 1.3.4 and 1.3.5

Definitions of terms used in this quality statement

6- to 8-week physical examination
The 6- to 8-week physical examination should include:
  • checking the baby’s:
    • appearance, including colour, breathing, behaviour, activity and posture
    • head (including fontanelles), face, nose, mouth (including palate), ears, neck and general symmetry of head and facial features
    • eyes: opacities, red reflex and colour of sclera
    • neck and clavicles, limbs, hands, feet and digits; assess proportions and symmetry
    • heart: position, heart rate, rhythm and sounds, murmurs and femoral pulse volume
    • lungs: respiratory effort, rate and lung sounds
    • abdomen: assess shape and palpate to identify any organomegaly; check condition of umbilical cord
    • genitalia and anus: completeness and patency and undescended testes in boys
    • spine: inspect and palpate bony structures and check integrity of the skin
    • skin: colour and texture as well as any birthmarks or rashes
    • central nervous system: tone, behaviour, movements and posture; check newborn reflexes only if concerned
    • hips: symmetry of the limbs, Barlow and Ortolani's manoeuvres
    • cry: assess sound
    • social smiling and visual fixing and following
  • measuring the baby’s weight and head circumference and plotting the results on a growth chart.
[NICE’s guideline on postnatal care, recommendations 1.3.3, 1.3.4 and 1.3.5]

Maternal health – weight management

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

Quality statement

Women with a body mass index (BMI) of 30 kg/m2 or more at the 6- to 8-week postnatal check are offered a referral for advice on healthy eating and physical activity.

Rationale

The woman’s eating habits and physical activity levels could influence the health behaviour of the wider family, including children who are developing habits that may remain with them for life. Supporting the woman in the postnatal period to change her eating habits and physical activity levels may improve her health, her infant’s health and the health of the wider family. It may also improve the outcomes of future pregnancies.
Women who are obese during pregnancy face increased risks of complications that include gestational diabetes, miscarriage, pre-eclampsia, thromboembolism and maternal death. Risks for the infant include fetal death, stillbirth, shoulder dystocia, and macrosomia. Infants of obese women face health risks in childhood including diabetes and obesity in later life.

Quality measures

Structure
a) Evidence of local arrangements to ensure that women have their BMI assessed and recorded at the 6- to 8-week postnatal check.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that women with a BMI of 30 kg/m2 or more at the 6- to 8-week postnatal check are offered a referral for advice on healthy eating and physical activity.
Data source: Local data collection.
c) Evidence of local arrangements to ensure that the local workforce has appropriate numbers of staff trained to deliver healthy eating and physical activity services to postnatal women.
Data source: Local data collection.
Process
a) The proportion of women who have their BMI recorded at the 6- to 8-week postnatal check.
Numerator – the number in the denominator who have their BMI recorded.
Denominator – the number of women who attend a 6- to 8-week postnatal check.
Data source: Local data collection.
b) The proportion of women with a BMI of 30 kg/m2 or more at the 6- to 8-week postnatal check who are offered a referral for advice on healthy eating and physical activity.
Numerator – the number in the denominator who are offered a referral for advice on healthy eating and physical activity.
Denominator – the number of women with a BMI of 30 kg/m2 or more who attend a 6- to 8-week postnatal check.
Data source: Local data collection.
c) The proportion of women with a BMI of 30 kg/m2 or more at the 6- to 8-week postnatal check who accept a referral for advice on healthy eating and physical activity.
Numerator – the number in the denominator who accept a referral for advice on healthy eating and physical activity.
Denominator – the number of women with a BMI of 30 kg/m2 or more who attend a 6- to 8-week postnatal check.
Data source: Local data collection.
Outcome
Women feel able to make informed decisions about healthy eating, physical activity and weight management for themselves and their family.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers ensure that systems are in place for women with a BMI of 30 kg/m2 or more at the 6- to 8-week postnatal check to be offered a referral for advice on healthy eating and physical activity.
Healthcare practitioners offer women with a BMI of 30 kg/m2 or more at the 6- to 8-week postnatal check a referral for advice on healthy eating and physical activity.
Commissioners ensure that they commission services that offer women with a BMI of 30 kg/m2 or more at the 6- to 8-week postnatal check a referral for advice on healthy eating and physical activity.
Women who have a body mass index of 30 kg/m2 or more at the 6- to 8-week postnatal check are offered a referral for advice on healthy eating and physical activity.

Source guidance

Definitions of terms used in this quality statement

Structured programme
Women should be offered a referral to an individual or group-based service that uses a structured programme. Services should deliver a structured programme that:
  • addresses the reasons why women may find it difficult to lose weight, particularly after pregnancy
  • is tailored to the needs of an individual or group
  • combines advice on healthy eating and physical exercise (advising them to take a brisk walk or other moderate exercise for at least 30 minutes on at least 5 days of the week)
  • identifies and addresses individual barriers to change
  • provides ongoing support over a sufficient period of time to allow for sustained lifestyle changes.
Services should be delivered by an appropriately trained person. This is someone who can demonstrate expertise and competencies in healthy eating and/or physical activity, including weight management for women in the postnatal period. This may include midwives, health visitors, obstetricians, dietitians, GPs, nurses, midwifery assistants, support workers and those working in weight management programmes (commercial or voluntary).
Women who choose not to accept a referral should be given information about where they can get support on healthy eating and physical activity in future.
[Adapted with expert group consensus from NICE’s guideline on weight management before, during and after pregnancy, recommendations 3 and 4, and NICE’s guideline on maternal and child nutrition, recommendation 6]

Equality and diversity considerations

Women should be able to access services that are appropriate to their cultural and religious beliefs, and that make relevant adjustments for anyone who has communication difficulties, and for those who do not speak or read English.

Emotional wellbeing and bonding with the baby

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

Quality statement

Women have an assessment of their emotional wellbeing, including bonding with their baby, at each postnatal contact.

Rationale

The baby’s relationship with the mother has a significant impact on the baby’s social and emotional development. In turn, the woman's ability to provide a nurturing relationship is partly dependent on her own emotional wellbeing. Regular assessment of the woman’s emotional wellbeing, including bonding with her baby, may lead to earlier detection of problems.

Quality measures

Structure
Evidence of local arrangements that women have an assessment of their emotional wellbeing, including bonding with their baby, at each postnatal contact.
Data source: Local data collection.
Process
Proportion of postnatal contacts that include an assessment of the woman’s emotional wellbeing, including bonding with their baby.
Numerator – the number in the denominator that include an assessment of the woman’s emotional wellbeing, including bonding with their baby.
Denominator – the number of postnatal contacts.
Data source: Local data collection.
Outcome
a) Incidence of postnatal mental health problems.
Data source: Local data collection.
b) Incidence of baby-to-mother emotional attachment problems.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers ensure that systems are in place so that women have an assessment of their emotional wellbeing, including bonding with their baby, at each postnatal contact.
Healthcare practitioners ensure that they assess women’s emotional wellbeing, including bonding with their baby, at each postnatal contact.
Commissioners ensure that they commission services that have local agreements to ensure women have an assessment of their emotional wellbeing, including bonding with their baby, at each postnatal contact.
Women have an assessment of their emotional wellbeing, including bonding with their baby, at each postnatal contact.

Source guidance

Postnatal care. NICE guideline NG194 (2021), recommendations 1.2.2, 1.3.15 and 1.3.17

Definitions of terms used in this quality statement

Postnatal contacts
Women and their babies should receive the number of postnatal contacts that are appropriate to their care needs. A postnatal contact is a scheduled postnatal appointment that may occur in the woman or baby’s home or another setting such as a GP practice, children’s centre or this could be a hospital setting where women and/or the baby requires extended inpatient care. [Expert opinion]
Emotional wellbeing
Being happy and confident and not anxious or depressed. [NICE’s guideline on social and emotional wellbeing: early years, glossary]
Bonding
Bonding is the positive emotional and psychological connection that the parent develops with the baby [NICE’s guideline on postnatal care, terms used in this guideline section]

Equality and diversity considerations

Communication between women (and their families) and members of the maternity team is a key aspect of this statement. Relevant adjustments will need to be in place for anyone who has communication difficulties, and for those who do not speak or read English.

Maternal health – mental wellbeing

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

Quality statement

This statement has been removed. In 2016, NICE published a separate quality standard on antenatal and postnatal mental health, which focuses on this area of care in more detail. For more details, see update information in the NICE quality standard.

Parent–baby attachment

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

Quality statement

This statement has been removed. For full details, see update information in the NICE quality standard.

Information for parents or carers

This quality statement is 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 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 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 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 different audiences

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.
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

Jaundice in newborn babies under 28 days. NICE guideline CG98 (2010, updated 2016), recommendation 1.1.1

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):
    • check 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 NICE’s guideline on jaundice in newborn babies, recommendations 1.1.1 and 1.2.5]

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 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 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 the definitions section), 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 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 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 different audiences

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.
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

Jaundice in newborn babies under 28 days. NICE guideline CG98 (2010, updated 2016), recommendations 1.2.14 and 1.2.16

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 NICE’s guideline on jaundice in newborn babies, recommendation 1.2.15, 1.2.16 and 1.2.17]
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 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 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 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 NHS Digital’s Hospital Episode Statistics or the NHS Digital’s Neonatal Critical Care Minimum Data Set.

What the quality statement means for different audiences

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.
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

Jaundice in newborn babies under 28 days. NICE guideline CG98 (2010, updated 2016), recommendations 1.3.4 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’s guideline on jaundice in newborn babies. These include treatment threshold graphs for NICE’s guideline on jaundice in newborn babies. All tables or charts should take into account serum bilirubin level, gestational age and postnatal age.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

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: April 2021

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