Jaundice in newborn babies under 28 days

Jaundice in newborn babies under 28 days

RECOGNITION AND ASSESSMENT

Risk factors for hyperbilirubinaemia

 <38 weeks’ gestation
 Previous sibling required treatment for jaundice
 Mother intends to exclusively breastfeed
 Visible jaundice in baby aged <24 hr

Risk factors for kernicterus

 High bilirubin level (>340 micromol/L in term baby)
 Rapidly rising bilirubin level (>8.5 micromol/L/hr)
 Clinical features of bilirubin encephalopathy

Symptoms and signs of Jaundice in newborn 

 When looking for jaundice (visual inspection):
 check naked baby in bright and preferably natural light
 examine the sclerae and gums, and press lightly on skin to check for signs of jaundice in ‘blanched’ skin

Assess Jaundice in newborn 

 Pallor (haemolysis)
 Poor feeding, drowsiness (neurotoxicity)
 Hepatosplenomegaly (blood-group incompatibility or cytomegalovirus)
 Splenomegaly (spherocytosis)

Causes of Jaundice in newborn 

 Physiological
 Prematurity
 Increased bilirubin load:
 blood group incompatibility (Rhesus or ABO)
 G6PD deficiency and other red cell enzyme deficiencies
 congenital spherocytosis
 cephalhaematoma, bruising
 Rarely infection (e.g. UTI, congenital infection)
 Metabolic disorder

Persistent jaundice after aged 14 days

 Breast milk jaundice
 Hypothyroidism
 Liver disease (e.g. extra hepatic biliary atresia and neonatal hepatitis)
 Alpha-1-antitrypsin deficiency
 Galactosaemia
 TPN-induced cholestasis

Investigations of Jaundice in newborn 

Assessment of jaundice

 Babies aged <72 hr, at every opportunity (risk factors and visual inspection)
 Babies with suspected or obvious jaundice, measure and record bilirubin level urgently
 <24 hr: within 2 hr
 ≥24 hr: within 6 hr
 If serum bilirubin >100 micromol/L in first 24 hr
 repeat measurement in 6–12 hr
 interpret result in accordance with baby’s age and gestation – see Table
 urgent medical review as soon as possible (and within 6 hr)
 Interpret bilirubin result in accordance with baby’s gestational and postnatal age according to Table

Jaundice requiring treatment

 Total bilirubin
 Baby’s blood group and direct Coombs’ test (interpret result taking into account strength of reaction and whether mother received prophylactic anti-D immunoglobulin during pregnancy)
 Mother’s blood group and antibody status (should be available from maternal healthcare record)

 PCV

Plus (if clinically indicated)

 Full infection screen (in an ill baby)
 G6PD level and activity (if indicated by ethnic origin: Mediterranean, Middle Eastern, South East Asian)
 FBC and film

Persistent jaundice >14 days term baby; >21 days preterm baby (see Liver dysfunction guideline)

 Total and conjugated bilirubin
 Examine stool colour
 FBC
 Baby’s blood group and direct Coombs’ test (interpret result taking into account strength of reaction and whether mother received prophylactic anti-D immunoglobulin during pregnancy)
 Ensure routine metabolic screening performed (including screening for hypothyroidism)
 Urine culture

Baby with conjugated bilirubin >25 micromol/L, refer urgently to a specialist centre

2nd line investigations (not in NICE guideline)

 Liver function tests (ALT, AST, albumin, GGT)
 Coagulation profile
 G6PD screen in African, Asian or Mediterranean babies
 Thyroid function tests: ask for ‘FT4 priority and then TSH’
 Congenital infection screen
 Urine for CMV PCR, toxoplasma ISAGA-IgM and throat swab for HSV culture/PCR
 Metabolic investigations e.g:
 blood galactose-1-phosphate
 urine for reducing substances
 alpha-1-antitrypsin

TREATMENT <7 DAYS

Babies ≥38 weeks’ gestation

 Use conventional blue light phototherapy (not fibre optic) as treatment of choice
 Use continuous multiple phototherapy for babies who:
 fail to respond to conventional phototherapy (bilirubin does not fall within 6 hr of starting treatment)
 have a rapid rise in bilirubin (>8.5 micromol/L/hr)
 have a bilirubin level at which exchange transfusion is indicated

Babies <38 weeks’ gestation

 Use fibre optic or conventional blue light as 1st line treatment
 based on gestational age and postnatal age, use Threshold graphs
(http://www.nice.org.uk/guidance/CG98 under ‘Tools and resources’ then ‛CG98 Neonatal Jaundice: treatment threshold graphs’) to determine threshold for phototherapy
 Indications for multiple phototherapy as term babies

Management during phototherapy

 Offer parents information on procedure (www.nice.org.uk/guidance/cg98/resources/jaundice-in-newborn-babies-318006690757)

 Unless other clinical conditions prevent, place baby in supine position
 Ensure treatment applied to maximum area of skin
 Monitor baby’s temperature
 Use eye protection and give routine eye care
 Provided bilirubin not significantly elevated, encourage breaks of up to 30 min for breastfeeding, nappy change and cuddles
 Do not give additional fluids routinely
 During multiple phototherapy:
 do not interrupt for feeds
 monitor hydration by weighing baby daily and assessing wet nappies

Monitoring during phototherapy

 Repeat serum bilirubin 4–6 hr after starting treatment
 Repeat serum bilirubin 6–12 hrly when bilirubin stable or falling
 Stop phototherapy once serum bilirubin has fallen to at least 50 micromol/L below threshold
 Check for rebound jaundice with repeat serum bilirubin 12–18 hr after stopping phototherapy

DISCHARGE AND FOLLOW-UP

 GP follow-up with routine examination at 6–8 weeks

 If exchange transfusion necessary or considered, request developmental follow-up and hearing test
 In babies with more than weakly positive Coombs’ test who require phototherapy:
 check haemoglobin at aged 2 and 4 weeks due to risk of continuing haemolysis
 give folic acid 1 mg daily


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Jaundice in newborn babies under 28 days

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