Jaundice neonatal

Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline. 

Read the full PCH Emergency Department disclaimer.

Aim

To guide staff with the assessment and management of neonatal jaundice.

Background

  • A sick neonate with jaundice is septic.
  • Conjugated hyperbilirubinaemia needs urgent discussion with a gastroenterologist.
  • Breast milk jaundice is a diagnosis of exclusion.

Risk factors

  • Jaundice in first 48 hours
  • ABO / Rhesus incompatibility
  • Significant weight loss with breast feeding
  • Delayed meconium passage
  • Ethnicity - East Asian descent
  • Visible jaundice before hospital discharge
  • Exclusive breast feeding
  • Male gender
  • Excessive birth trauma
  • Family history of haemolytic disease

Key points

  • Up to 60% of term and 80% preterm neonates will become clinically jaundiced in the first week of life.
  • Usually, the total serum bilirubin (TSB) rises during day 3-5 of life, and begins to decline from then, and usually resolves within 10-14 days.
  • Most well newborns with jaundice have physiological jaundice with unconjugated bilirubin and usually do not require specific treatment.
  • Kernicterus was rarely seen in decades following the introduction of phototherapy and exchange transfusion; however, recent reports suggest it is re-emerging. This has been partly attributed to earlier hospital discharge (within 48 hours of birth) before the natural peak of bilirubin in the neonate, as well as a result of relaxation of the treatment criteria.

Assessment

Pathological jaundice

 

  • Jaundice occurs in the first 48 hours of life
  • Associated anaemia and hepatomegaly
  • Rapid rising total serum bilirubin (> 85 micromol/L per day)
  • ↑ conjugated bilirubin level > 20% total serum bilirubin – cholestasis (e.g. biliary atresia)
  • Prolonged jaundice > 14 days

History

Clinical history should include:
  • birth history, gestational age, birth weight
  • timing of jaundice; when jaundice started, is it worse now?
  • feeding habit, volume of intake, exclusive breastfeeding, vomiting
  • urine output and colour (dark urine)
  • stooling – delayed passage of meconium or light coloured stool
  • change of behaviour – lethargy, cries becoming shrill, arching of the body
  • history of temperature instability.

Examination

  • Assessment of jaundice is best done in natural light.
  • Jaundice usually follows a cephalocaudal progression.
  • Pallor, petechiae, cephalohaematoma, excessive bruising, hepatoslenomegaly.
  • Hydration and weight status.
  • Plethora (polycythaemia).

Investigations

Initial

  • Transcutaneous bilirubinometry (if available)
  • Bilirubin conjugated and unconjugated
  • LFT
  • FBC (add reticulocyte count if anaemic)
  • Urine culture
  • + / - TFT (check if infant has had normal neonatal screening)
  • G-6PD
  • Urine for reducing substances
  • Direct Coombs if not already done

Management

Guidelines for phototherapy in hospitalised Infants of greater than 35 weeks gestation.

Guidelines for phototherapy in hospitalised infants of 35 or more weeks gestation

 

 

Initial management

Emergency management and disposition of neonates with jaundice

  • Sick babies need a septic screen, antibiotics and admission
  • Full term, well appearing and afebrile neonates without significant risk factors and bilirubin level less than the level indicated in the graph can be discharged with GP follow-up in 1-2 days for repeat SBR
  • Admit for phototherapy if bilirubin level is over the line as per the graph

Breast milk jaundice

  • Breast milk jaundice is common. Breast feeding should continue to be encouraged. It may last 3-12 weeks
  • Outline the risks and benefits of continuation of breastfeeding with close monitoring, supplementation with formula or brief substitution of breastfeeding with formula + continue to express breast milk to maintain breast milk secretion

 

 

Further management

Management - Prolonged unconjugated jaundice (> 14 days for term and > 21 days for preterm)

Check for adequate fluid intake – dehydration, fewer wet nappies, weight loss > 10% of birth weight, then:

 

  • Bilirubin – conjugated and unconjugated
  • FBC, LFT, TFT, urine culture, Direct Coombs test if not yet done
  • Red blood cell enzyme assays for G6PD
  • If unwell - consider septic screen, TORCH screen and metabolic screen.

Management - Conjugated hyperbilirubinaemia

  • Cholestatsis e.g. biliary atresia, choledochal cyst, alpha anti-trypsin deficiency 
  • Consider: LFT, FBC, TFT, urine culture, CRP, abdo US
  • Discuss with gastroenterologist early.

Bibliography

  1. NETS WA accessed at http://netswa.net.au
  2. Maisels MJ, McDonagh AF.Phototherapy for neonatal jaundice.N Engl J Med. 2008 Feb 28;358(9):920-8. Review. PubMed PMID: 18305267
  3. Management of hyperbilirubinaemia in the Newborn 35 or more weeks gestation, Pediatrics 114:297-316, July 2004
  4. Chou S-C et al. Managemnt of hyperbilirubinaemia in newborns: measuring performance by using a benchmarking model. Pediatrics 2003; 112(6):1264-73
  5. Johnson, L, Bhutani VK, Brown AK. System-based approach to management of neonatal jaundice and prevention of kernicterus. J Pediatrics 2002;140(4):396-403
  6. Bhutani VK, Johnson LH, Maisels MJ, et al. Kernicterus: epidemiological strageies for its prevention through systems based approaches. J Perinatal 2004;24:650-62
  7. Hamilton P, Schwartz, Beth E, Haberman RM. Hyperbilirubinaemia. Paediatric Emergency Care, 2001;27(9):884-9
  8. Colletti JE, Kathari S, Jackson D, Kagore K, Berringer K. An emergency Medicine Approach to neonatal hyperbilirubinaemia. Emerg Med Clin N AM 2007;25:1117-1135

Endorsed by:  Director, Emergency Department   Date:  Mar 2018


 Review date:   Jun 2020


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