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Practice Guidelines

Neonatal jaundice: summary of NICE guidance

BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c2409 (Published 19 May 2010) Cite this as: BMJ 2010;340:c2409
  1. Janet Rennie, consultant and senior lecturer in neonatal medicine1,
  2. Shona Burman-Roy, senior research fellow2,
  3. M Stephen Murphy, clinical co-director for children’s health2
  1. 1Elizabeth Garrett Anderson Institute for Women’s Health, University College London NHS Foundation Trust London, London NW1 2BU
  2. 2National Collaborating Centre for Women’s and Children’s Health, King’s Court, London W1T 2QA
  1. Correspondence to: J Rennie janet.rennie{at}uclh.nhs.uk

    Neonatal jaundice is one of the most common conditions needing medical attention in newborn babies. About 60% of term and 80% of preterm babies develop jaundice in the first week of life, and about 10% of breast fed babies are still jaundiced at age 1 month.1 Neonatal jaundice is generally harmless, but high concentrations of unconjugated bilirubin may occasionally cause kernicterus (permanent brain damage). This is a rare condition (about seven new cases each year in the United Kingdom2) and sequelae include choreoathetoid cerebral palsy, deafness, and upgaze palsy. Jaundice can also be a sign of serious liver disease, such as biliary atresia, the prognosis for which is better if it is treated before age 6 weeks.3 Early recognition of jaundice is vital for treatment of any underlying condition and for the appropriate use of phototherapy, which can safely control bilirubin concentrations in most cases.

    This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on how to diagnose and treat jaundice in newborns up to 28 days old.4

    Recommendations

    NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets.

    Information for parents and carers

    Offer parents or carers information about neonatal jaundice that is tailored to their needs and expressed concerns, taking care to avoid causing unnecessary anxiety; discuss verbally and back up the discussions with written information. [Based on low quality qualitative studies and on the experience and opinion of the Guideline Development Group (GDG)]

    The information might include the following:

    • The fact that neonatal jaundice is common, and reassurance that it is usually transient and harmless

    • Risk factors for significant hyperbilirubinaemia (a rise in the serum bilirubin concentration to a level requiring treatment)

    • How to check the baby for jaundice

    • What to do if they suspect jaundice

    • The importance of recognising jaundice in the first 24 hours and of seeking urgent medical advice

    • The importance of checking the baby’s nappies for dark urine or pale, chalky stools

    • Reassurance that breast feeding can usually continue.

    Care for all babies

    • Check if babies have the following risk factors for developing significant hyperbilirubinaemia:

      • -Visible jaundice in the first 24 hours of life

      • -A gestational age of <38 weeks

      • -A previous sibling who had neonatal jaundice needing phototherapy, and/or

      • -A mother who intends to breast feed exclusively.

    [Based on moderate quality comparative observational and cross sectional studies]

    • Ensure babies with risk factors for significant hyperbilirubinaemia receive an additional visual inspection by a healthcare professional during the first 48 hours of life. [Based on moderate quality diagnostic studies]

    • Examine all babies for jaundice at every opportunity, especially in the first 72 hours. [Based on moderate quality diagnostic studies]

    • When inspecting for jaundice:

      • -Check the naked baby in bright and preferably natural light

      • -Examine the sclerae, gums, and blanched skin, in babies of all skin tones.

    [Based on moderate quality diagnostic studies]

    Babies with jaundice

    Measure bilirubin concentrations in all babies with jaundice—do not rely on visual inspection alone to estimate the bilirubin concentration. [Based on moderate quality diagnostic studies]

    When measuring the bilirubin concentration:

    • Use a transcutaneous bilirubinometer (a non-invasive device applied to the baby’s forehead to measure bilirubin concentrations) in babies with a gestational age of 35 weeks or more and postnatal age of more than 24 hours

    • If a transcutaneous bilirubinometer is not available, measure the serum bilirubin

    • If a transcutaneous bilirubinometer measurement indicates a bilirubin concentration >250 μmol/l, check the result by measuring the serum bilirubin concentration

    • Always use a serum bilirubin measurement to determine the bilirubin concentration in (a) babies with jaundice in the first 24 hours of life; (b) preterm babies less than 35 weeks’ gestational age; and (c) babies receiving phototherapy

    • Do not use an icterometer (a non-invasive device allowing comparison of skin colour to a reference strip).

    [Based on moderate and low quality diagnostic studies]

    Management of hyperbilirubinaemia

    Use bilirubin concentration to determine management (see figure and the treatment threshold graphs in the NICE guidance4). [Based on the experience and opinion of the GDG]

    Figure1

    Consensus based bilirubin thresholds for the management of babies of 38 weeks or more gestational age with hyperbilirubinaemia

    During phototherapy

    • Using clinical judgment, encourage short breaks for breast feeding, nappy changing, and cuddles unless bilirubin concentrations are approaching the exchange threshold or are rising by more than 8.5 μmol/l per hour.

    • Continue lactation and feeding support.

    • Do not routinely give additional fluids or feeds.

    Maternal expressed milk is the additional feed of choice if available and when additional feeds are indicated.

    Prolonged jaundice

    Prolonged jaundice is jaundice that lasts more than 14 days in term babies and more than 21 days in preterm babies. In babies with prolonged jaundice:

    • Look for pale, chalky stools and/or dark urine that stains the nappy

    • Measure the conjugated bilirubin (as raised concentrations may indicate liver disease)

    • Do a full blood count

    • Determine the blood group of the mother and the baby and do a direct antigen test (in the baby); interpret the result and likelihood of Rh disease or other haemolytic disease, taking account of the strength of reaction and whether mother received prophylactic anti-D immunoglobulin during pregnancy

    • Arrange a urine culture

    • Ensure that routine metabolic screening (including screening for congenital hypothyroidism) has been done.

    Follow expert advice for babies with a conjugated bilirubin concentration of >25 μmol/l because this level may indicate serious liver disease. [Based on low quality observational and case series studies and on the experience and opinion of the GDG]

    Overcoming barriers

    The guideline recommends that babies at risk of hyperbilirubinaemia be further assessed within 48 hours. As most healthy term babies are at home by this stage, this requirement for a home visit is also an opportunity to deliver breastfeeding support and other advice.

    More widespread use of transcutaneous bilirubinometry, recommended as a first line test in assessing jaundice, has implications for community workers and commissioners or purchasers. A health economic review in the guideline’s development showed that investment in these devices would be cost effective if only one or two cases of kernicterus a year were averted by their use.4

    Calculation of the bilirubin concentration according to the baby’s postnatal age in hours can be difficult to do quickly. A guideline implementation tool (“the biliwheel”) designed to help perform this calculation and to determine when to refer babies is currently undergoing validation.5

    The use of phototherapy currently varies widely.6 The guideline’s treatment threshold graphs provide guidance on starting phototherapy and on considering exchange transfusion, with advice on when to measure the serum bilirubin concentration and on continuation and cessation of phototherapy.

    Further information on the guidance

    Background

    About 650 000 babies are born in England and Wales each year, of whom at least 300 000 will develop visible jaundice.1 Most babies never develop a serum bilirubin concentration >300 μmol/l and the jaundice clears before 2 weeks of age.7 Reports vary, but probably one in every 650-1000 babies develops a serum bilirubin concentration >427 μmol/l and about one in 10 000 has a concentration of more than 500 μmol/l.2 8 Kernicterus occurs in about one in 17 babies with a serum bilirubin concentration >340 μmol/l and perhaps one in seven with a concentration more than 500 μmol/l.9

    Phototherapy is a highly effective treatment for hyperbilirubinaemia, enabling a rapid conversion of bilirubin to a water soluble form, which can be excreted from the body. The only alternative treatment is a double volume exchange transfusion of blood, an intensive care procedure which carries risks, including a small risk of death. Phototherapy is safe but is used at different thresholds.6 and does require readmission to hospital, which can jeopardise breast feeding at a critical time. A nationally agreed guideline will allow future audit of practice, via national registries of cases of kernicterus, extreme hyperbilirubinaemia, and exchange transfusions.

    What’s new?

    This guidance allows for changes to service development to assess bilirubin readily in the community and specifies treatment thresholds for term and preterm babies.

    The guidance builds on existing NICE guidance for postnatal care10 and can be used alongside the newborn and infant physical examination (NIPE) screening programme (http://newbornphysical.screening.nhs.uk/).

    Intravenous immunoglobulin is recommended for babies with Rh disease or other haemolytic disease whose bilirubin concentrations are rising by more than 8.5 μmol/l per hour.

    Methods

    The guidance was developed by the National Collaborating Centre for Women’s and Children’s Health in accordance with NICE guideline development methods (see www.nice.org.uk/aboutnice/howwework/developingniceclinicalguidelines/developing_nice_clinical_guidelines.jsp). The collaborating centre established a guideline development group consisting of healthcare professionals and patient and carer representatives, with experts in guideline methodology from the collaborating centre. The guideline development group identified and appraised clinical evidence and evaluated cost effectiveness of interventions where possible. Stakeholder organisations were invited to comment on a draft of the guideline, which was subsequently revised to take account of comments received.

    NICE has produced four different versions of the guideline: a full version containing all the evidence and the recommendations; a quick reference guide; a version known as the “NICE guideline” that lists the recommendations; and a version for patients and the public. All these versions are available from the NICE website (www.nice.org.uk/CG98). Future updates of the guidance will be produced as part of the NICE guideline development programme.

    Key areas for future research
    • What factors underlie the association between breast feeding and jaundice?

    • Universal pre-discharge screening with transcutaneous bilirubinometry versus the same screening plus a risk assessment: how effective and cost effective is each in reducing jaundice related neonatal morbidity and hospital readmission?

    • How accurately do the measurements obtained with the Minolta JM-103 and the BiliChek transcutaneous bilirubinometers match the serum bilirubin concentrations in all babies, including those with high concentrations?

    • How frequently and for how long can conventional phototherapy be interrupted without adversely affecting clinical outcomes?

    Notes

    Cite this as: BMJ 2010;340:c2409

    Footnotes

    • doi:10.1136/bmj.c2383
    • This is one of a series of BMJ summaries of new guidelines based on the best available evidence; they highlight important recommendations for clinical practice, especially where uncertainty or controversy exists.

    • The members of the guideline development group are Christiana Aride (general practitioner, Tynemouth Medical Practice), Jeffrey Barron (former member of the group; consultant chemical pathologist, St Helier Hospital), Yvonne Benjamin (community midwife, University Hospitals Leicester NHS Trust), Sally Cottrell (former member of the group; consultant midwife, University of the West of England), Karen Ford (senior lecturer, De Montfort University), Kevin Ives (consultant neonatologist, John Radcliffe Hospital), Maria Jenkins (parent representative), Alison Johns (transitional care sister, University College London NHS Foundation Trust), Donal Manning (consultant paediatrician, Wirral University Teaching Hospital NHS Foundation Trust), Farrah Pradhan (parent representative), Janet Rennie (chair of group; consultant and senior lecturer in neonatal medicine, Elizabeth Garrett Anderson Institute for Women’s Health, University College London NHS Foundation Trust), and Debra Teasdale (head of health, wellbeing and the family, Canterbury Christ Church University); and the following (who work for the National Collaborating Centre for Women’s and Children’s Health (NCC-WCH)): Wahab Bello (office administrator), Shona Burman-Roy (senior research fellow), Katherine Cullen (health economist), Hannah-Rose Douglas (health economist), Paul Jacklin (health economist), Juliet Kenny (project manager), Rosalind Lai (information scientist), Hugh McGuire (research fellow), Edmund Peston (document supply coordinator), and M Stephen Murphy (clinical co-director, children’s health); and former colleagues at NCC-WCH: Jay Bannerjee (clinical co-director), Martin Whittle (clinical co-director), Itrat Iqbal (health economist), Rajesh Khanna (senior research fellow), Carolina Ortega (work programme co-ordinator), Debbie Pledge (senior information scientist), Anuradha Sekhri (freelance systematic reviewer), and Kristina Pedersen (project manager).

    • Contributors: JR, SB-R, and MSM wrote the initial draft of the article using material produced collectively by the entire Guideline Development Group. They also contributed to its revision and the final draft, having received feedback from every member of the group. JR is the guarantor.

    • Funding: The National Collaborating Centre for Women’s and Children’s Health was commissioned and funded by the National Institute for Health and Clinical Excellence to write this summary.

    • Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: (1) No support for the submitted work except from their employer; (2) JR has received payment from the Legal Aid Board and the National Health Service Litigation Authority for providing independent expert medico legal reports for civil proceedings in cases of kernicterus. This work is undertaken outside of NHS time. All other authors have had no relationships with companies that might have an interest in the submitted work; (3) No spouses, partners, or children with financial relationships that may be relevant to the submitted work; and (4) No non-financial interests that may be relevant to the submitted work.

    • Provenance and peer review: Commissioned; not externally peer reviewed

    References

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