neonatal jaundice pathway
DESCRIPTION
All about neonatal jaundiceTRANSCRIPT
Inclusion CriteriaPreviously healthy
Age ≤ 14 days
Born at ≥ 35 wks gestational age
Exclusion CriteriaDirect hyperbilirubinemia
Meets NICU Direct Admit Criteria
TSB > 5mg/dL above exchange
transfusion threshold
Signs of acute bilirubin
encephalopathy
Suspected sepsis or
ill-appearing
PHASE I (E.D.)
Executive Summary Explanation of Evidence RatingsTest Your Knowledge Summary of Version Changes
Admit on phototherapy
Initial Assessment
Clinical History / Physical Exam
Blood Glucose
Total Serum Bilirubin (TSB) with conjugated fraction
Initiate ED Hyperbilirubinemia (Neonatal) Orders
Start phototherapy while awaiting results if clinically indicated
Determine exchange transfusion threshold using AAP nomogram
Determine phototherapy threshold using BiliTool™ or AAP nomogram
Web Link to BiliTool™
Risk for Kernicterus
ED ManagementGive effective phototherapy
Encourage feeding. The infant should not be removed from bili lights
for > 20 mins in any 3 hour period. Use bottle if needed.
DO NOT interrupt phototherapy for patients nearing exchange
transfusion threshold or with rapidly rising TSB
Use maternal EBM for supplemental feeds, when available
Give 20 mL/kg NS bolus then maintenance IV fluids for patients that
meet NICU consult criteria
Consider additional labs
Inpatient
Admission NICU
(Off Pathway)
!Supplemental
IV Fluids NOT
routinely indicated
Admit to NICU Meets discharge criteria
TSB rising or
meeting NICU
admission criteria
TSB stable or
falling and otherwise
clinically well
Automatic NICU Admission Criteria
Signs of acute bilirubin encephalopathy TSB > 5 mg/dL above exchange transfusion thresholdInclude NICU attending on calls for patients that meet NICU direct admit criteria.
Evaluate for Discharge
TSB below phototherapy threshold
Follow-up appointment arranged for next
day
Feeding adequatelyNo concern for significant hemolysis
Evaluate for NICU Consult Criteria
TSB within 2mg/dL of exchange transfusion thresholdAge < 24 hours
High suspicion for or lab evidence of
hemolysis (e.g. DAT positive)
Evaluate for Inpatient Admission
TSB above phototherapy threshold but
not within 2mg/dL of exchange
transfusion threshold (e.g. at 72 hours of
age, exchange transfusion threshold 24
and TSB 21)
Neonatal Jaundice for Infants ≥ 35 Weeks Gestational Age v.2
For questions concerning this pathway,
contact:[email protected]© 2012, Seattle Children’s Hospital, all rights reserved, Medical Disclaimer
Last Updated: 05/31/2012
Valid until: 05/31/2015
Discharge
Pathophysiology
BiliTool™
AAP nomogram
Orders
AAP nomogram
additional labs
DO NOT interrupt phototherapy
Encourage feeding
Feeding adequately
NICU Admission Criteria NICU Consult Criteria
BiliTool™
Discharge
acute bilirubin encephalopathy
hemolysis
effective phototherapy
PHASE II (INPATIENT)
Neonatal Jaundice for Infants ≥ 35 Weeks Gestational Age v.2
Subsequent LabsTSB every 4 hours until TSB falling
G6PD (for unexplained hemolysis)
No
Inpatient Management
Initiate Hyperbilirubinemia (Neonatal) Admit Orders
If direct admit, obtain baseline total serum bilirubin (TSB)
Continue effective phototherapy until TSB at least 3 mg/dL below phototherapy threshold
Encourage feeding. The infant should not be removed from bili lights for > 20 mins in any 3
hour period. Use bottle if needed.
If patient unable to maintain normal temperature in an open crib, place in isolette per
Isolette Use Policy & Procedure
Consider additional labs for patients meeting NICU consult criteria
Run maintenance IV fluids for patients within 2 mg/dL of exchange transfusion threshold or
with rapidly rising TSB. Stop IVF once TSB has fallen to at least 2 mg/dL below exchange
transfusion threshold and feeding well (e.g. at 72 hours of age, exchange transfusion threshold
24 and TSB less than 22)
!Supplemental
IV Fluids NOT
routinely indicated
TSB within 2 mg/dL of exchange transfusion threshold,
age <72 hours, or known/suspected hemolysis?
Subsequent LabsTSB approximately 12 hours after starting
phototherapy (or with routine AM labs)
Subsequent checks as clinically indicated
Yes No
!Rebound TSB
NOT routinely
indicated prior to
discharge
Yes
Meets Discharge CriteriaPatient off phototherapy and otherwise well
Follow-up appointment arranged for next day
No concern for significant ongoing hemolysis
Inclusion CriteriaPreviously healthy
Age ≤ 14 days
Born at ≥ 35 wks gestational age
Exclusion CriteriaDirect hyperbilirubinemia
Meets NICU Direct Admit Criteria
TSB > 5mg/dL above exchange
transfusion threshold
Signs of acute bilirubin
encephalopathy
Suspected sepsis or ill-appearing
For questions concerning this pathway,
contact:[email protected]© 2012, Seattle Children’s Hospital, all rights reserved, Medical Disclaimer
Last Updated: 05/31/2012
Valid until: 05/31/2015
Discharge
effective phototherapy
Isolette Use Policy & Procedure
NICU consult criteriaadditional labs
Encourage feeding
TSB at least 3 mg/dL below phototherapy threshold
exchange transfusion threshold
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Go to Pathophysiology Pg 2
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Go to Pathophysiology Pg 3
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Go to Pathophysiology Pg 4
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These levels are
approximations
representing a
consensus based
on limited
evidence.
[LOE: E (AAP
2004)]
Guidelines for Initiation of Phototherapy In Hospitalized Infants of 35 or More Weeks’ Gestation
AAP. Pediatrics 2004;114(1):297-316©2004 by American Academy of Pediatrics
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These levels are
approximations
representing a
consensus based
largely on the goal of
keeping TSB levels
below those at which
kernicterus has been
reported.
[LOE: E (AAP 2004)]
Guidelines for Exchange Transfusion In Infants 35 or More Weeks’ Gestation
AAP. Pediatrics 2004;114(1):297-316©2004 by American Academy of Pediatrics
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• Encourage feeding. The infant should not be removed from bili lights for
> 20 mins in any 3 hour period. Use bottle while remaining under bili
lights if needed
• Use maternal expressed breast milk for supplemental feeds, when
available
• Lactation consultation if mom desires to breast feed
Rationale:
Formula feeds and breastfeeding are equally effective at reducing serum
bilirubin during phototherapy.
[LOE: moderate quality (NICE 2010)]
Feeding
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Executive Summary
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To Exec Summary Pg2
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Executive Summary
View Answers
Self-Assessment
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1. Which of the following patients would not be eligible for the neonatal jaundice pathway?a. 5 day old term infant with a total serum bilirubin of 22.4, direct of 1.5b. 3 day old ex-36 week SGA infant with a total serum bilirubin of 19.2, direct of 0.3c. 6 day old lethargic ex-39 week infant with delayed capillary refill and total serum bilirubin of
21.1, direct of 0.1d. 60 hour old ex-37 week infant with a total serum bilirubin of 21.9, Coombs+
2. A 5 day old ex-39 week infant had TSB of 21.7 at PCP earlier today. Weight loss is ~11% from birth. Infant is otherwise well. Mom’s milk has just come in. In the ED, in addition to a TSB, initial laboratory screening would include:a. Complete blood countb. Direct antibody test (DAT)c. Blood glucose leveld. Electrolytese. All of the above
3. In the same patient (5 day old ex-39 week infant, TSB of 21.7 from PCP, ~11% weight loss from birth, otherwise well, mom’s milk just come in), what would be appropriate to do in the ED while awaiting initial laboratory results?a. Keep the baby NPOb. Administer a 20 mL/kg normal saline IV bolusc. Consult the NICUd. Start phototherapy
4. True or False: Supplemental IV fluids are routinely indicated in the treatment of neonatal hyperbilirubinemia?
5. A 96 hour old ex-38 week infant presents to the ED with a total serum bilirubin of 21.9. He is otherwise well. What is the most appropriate next step?a. Keep the baby NPOb. Start phototherapy and admit to the floorc. Give a 20 mL/kg normal saline IV bolusd. Consult the NICU
6. A 48 hour old ex-37 week infant presents to the ED with a total serum bilirubin of 19.1. All of the following would be appropriate except:a. Bottle feed ad libb. Continue breast feeding up to 20 minutes every 2-3 hoursc. Give a 20 mL/kg normal saline IV bolusd. Consult the NICUe. Start phototherapy
7. You are initiating phototherapy for a patient and measure irradiance of 23 µW/cm2/nm. You should:a. Adjust the overhead light until the radiometer reading is less than 20 µW/cm2/nmb. Adjust the overhead light until the radiometer reading is at least 30 µW/cm2/nmc. Adjust the overhead light until the radiometer reading is at least 50 µW/cm2/nmd. Nothinge. Remove the infant's diaper to expose more surface area then recheck the radiometer reading
8. How often should total serum bilirubin be checked?a. Every 12 hours until dischargeb. Every 4 hours until it is falling if age less than 96 hoursc. Every 4 hours until it is falling if TSB is within 2 mg/dL of exchange transfusion thresholdd. a & c onlye. a, b & c
9. A 4 day old ex-38 week infant born at home presents to the ED looking "yellow" for the last few days. He is now refusing to latch with arching and extreme fussiness. Which next step is associated with the best outcome?a. Give a normal saline IV bolus as soon as possible in the EDb. Obtain a total serum bilirubin immediately in the EDc. Start phototherapyd. Admit immediately to the NICU for rapid exchange transfusion
10. You have treated a now 6 day old ex-term infant with 16 hours of phototherapy for breastfeeding jaundice. TSB declined from peak of 21.2 to now 14.8. What is the best next step?a. Stop phototherapy and check a TSB in 8 hoursb. Stop phototherapy and check a TSB in 12 hoursc. Continue phototherapy and check TSB q12 hours until < 12 mg/dLd. Discharge home on home phototherapye. Discharge homef. Discharge home with PCP follow up in 2-3 days
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Answer Key
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1. Answer: c.
Infants with systemic illness (e.g. sepsis) should be excluded from the pathway.
2. Answer: c.
Breastfeeding jaundice; NICU consult criteria not met. Labs minimized to TSB and blood glucose.
3. Answer: d.
Not close to exchange & TSB not rapidly rising. Outside TSB met threshold to initiate phototherapy.
4. Answer: false.
Routine use of supplemental IV fluids is not indicated.
5. Answer: b.
TSB is above phototherapy threshold, but not within 2 mg/dL of exchange.
6. Answer: b.
Do not interrupt phototherapy when near exchange level.
7. Answer: b.
The minimum recommended dose is 30 µW/cm2/nm.
8. Answer: c.
Frequent checks are indicated when near exchange.
9. Answer: d.
Infants with signs of acute bilirubin encephalopathy should be admitted directly to NICU.
10. Answer: e.
Rebound TSB not routinely necessary prior to discharge, F/U appt next day.
Evidence Ratings
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To Bibliography
We used the GRADE method of rating evidence quality. Evidence is first assessed as to
whether it is from randomized trial, or observational studies. The rating is then adjusted in the following manner:
Quality ratings are downgraded if studies:• Have serious limitations
• Have inconsistent results• If evidence does not directly address clinical questions• If estimates are imprecise OR
• If it is felt that there is substantial publication bias
Quality ratings can be upgraded if it is felt that:• The effect size is large• If studies are designed in a way that confounding would likely underreport the magnitude
of the effect OR• If a dose-response gradient is evident
Quality of Evidence: High quality
Moderate quality
Low quality
Very low quality
Expert Opinion (E)
Reference: Guyatt G et al. J Clin Epi 2011: 383-394
Summary of Version Changes
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Version 1 (5/31/2012): Go live
Version 2 (4/2/2013): Added recommendation for ED to notify NICU attending if patient meets
NICU admission criteria; established recommendations for removal from phototherapy for
feeding.
Medical Disclaimer
Last Updated: xx/xx/xxxx
Valid until: xx/xx/xxxx
For questions concerning this pathway,
contact: [email protected]
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Medicine is an ever-changing science. As new research and clinical experience
broaden our knowledge, changes in treatment and drug therapy are required.
The authors have checked with sources believed to be reliable in their efforts to
provide information that is complete and generally in accord with the standards
accepted at the time of publication.
However, in view of the possibility of human error or changes in medical sciences,
neither the authors nor Seattle Children’s Healthcare System nor any other party
who has been involved in the preparation or publication of this work warrants that
the information contained herein is in every respect accurate or complete, and
they are not responsible for any errors or omissions or for the results obtained
from the use of such information.
Readers should confirm the information contained herein with other sources and
are encouraged to consult with their health care provider before making any
health care decision.
Bibliography
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To Bibliography
52 records identified through database searching
0 additional records identified through other sources
48 records after duplicates removed
48 records screened 21 records excluded
27 full-text articles assessed for eligibility22 full-text articles excluded, 16 did not answer clinical question 6 did not meet quality threshold
6 studies included in pathway
Identification
Screening
Elgibility
Included
Flow diagram adapted from Moher D et al. BMJ 2009;339:bmj.b2535
Maisels MJ, Kring E. Bilirubin rebound following intensive phototherapy. Arch Pediatr Adolesc Med. 2002;156(7):669–
672
Maisels MJ, Kring EA. Length of stay, jaundice, and hospital readmission. Pediatrics. 1998;101:995-998
Murray NA, Roberts IA. Haemolytic disease of the newborn. Arch Dis Child Fetal Neonatal Ed. Mar 2007;92(2):F83-8
National Institute for Health and Clinical Excellence. Neonatal jaundice. (Clinical guideline 98.) 2010.
www.nice.org.uk/CG98
Newman TB, et al. Frequency of neonatal bilirubin testing and hyperbilirubinemia in a large health maintenance
organization. Pediatrics. 1999;104:1198-1203
Spencer J. Common problems of breastfeeding and weaning. UpToDate. March 2012. http://uptodate.com
Tan KL. The nature of the dose-response relationship of phototherapy for neonatal hyperbilirubinemia. J Pediatr.
1977;90(3):448-452
Tan KL. The pattern of bilirubin response to phototherapy for neonatal hyperbilirubinemia. Pediatr Res. 1982;16(8):670-
674
Wagle S, Rosenkrantz T (ed.). Hemolytic Disease of Newborn. Medscape Reference. May 2011.
http://emedicine.medscape.com
Bibliography
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American Academy of Pediatrics, Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia in the
newborn infant 35 or more weeks gestation. Pediatrics. 2004;114(1):297-316
American Academy of Pediatrics, Subcommittee on Hyperbilirubinemia. Phototherapy to prevent severe neonatal
hyperbilirubinemia in the newborn infant 35 or more weeks gestation. Pediatrics. 2011;128(4):e1046-e1052
Atkinson LR, et al. Phototherapy use in jaundiced newborns in a large managed care organization: do clinicians
adhere to the guideline? Pediatrics .2003;111:e555
Barak M, et al. When should phototherapy be stopped? A pilot study comparing two targets of serum bilirubin
concentration. Acta Paediatrica. 2009; 98:(2)277-281
Bhutani VK, et al. A systems approach for neonatal hyperbilirubinemia in term and near-term newborns. J Obstet
Gynecol Neonatal Nurs. 2006;35:444-455
Chavez GF, et al. Epidemiology of Rh hemolytic disease of the newborn in the United States. JAMA. Jun 26
1991;265(24):3270-4
Eggert LD, et al. The effect of instituting a prehospital-discharge newborn bilirubin screening program in an 18-
hospital health system. Pediatrics. 2006;117:e855-e862
Harris M, et al. Developmental follow-up of breastfed term and near-term infants with marked hyperbilirubinemia.
Pediatrics. 2001;107:1075-1080
Kaplan M, et al. Post-phototherapy neonatal bilirubin rebound: a potential cause of significant hyperbilirubinaemia.
Archives of Disease in Childhood. 2006; 91:(1)31-34