Nottingham Neonatal Service Clinical Guidelines

Transcription

1 Title: Detection and Management of Jaundice in Newborn Infants Version: 6 (Reviewed by Anjum Deorukhkar: no changes made) Ratification September 2015 Date: Review Date: September 2016 Approval: Author: Job Title: Consultation: Guideline Contact: Distribution: Target audience: Patients to whom this applies: Key Words: Risk Managed: Evidence used: Nottingham Neonatal Service Clinical Guideline Meeting Version 5: Jane Gill; Anjum Deorukhkar; Helen Budge Speciality Trainee; Consultant Neonatologist; Reader in Neonatology Nottingham Neonatal Service Staff and Clinical Guideline Committee Dr Anjum Deorukhkar, Consultant Neonatologist co/ Stephanie Tyrrell, Nottingham Neonatal Service stephanie.tyrrell@nuh.nhs.uk Nottingham Neonatal Service, Neonatal Intensive Care Units, Postnatal Wards of the Nottingham University Hospitals NHS Trust Staff of the Nottingham Neonatal Service, Delivery Suites and Postnatal Wards Patients of the Nottingham Neonatal Service and newborn infants on the Postnatal Wards and Labour Suites of the Nottingham University Hospitals NHS Trust who fit the inclusion criteria of the guideline Neonatal jaundice Prevention of Bilirubin Encephalopathy The contemporary evidence base has been used to develop this guideline. References to studies utilised in the preparation of this guideline are given at its end. Clinical guidelines are guidelines only. The interpretation and application of clinical guidelines remain the responsibility of the individual clinician. If in doubt, contact a senior colleague. Caution is advised when using guidelines after the review date. This guideline has been registered with the Nottingham University Hospitals NHS Trust. 1. Introduction Jaundice is common in the newborn baby particularly in the preterm population (affecting 60% of babies overall and 80% of preterm babies). For most babies, jaundice is non-pathological but it is important to identify those babies with jaundice who require investigation and treatment. Even when no cause is found and physiological jaundice is presumed, bilirubin can occasionally rise to potentially dangerous levels and require intervention. This guideline aims to provide a framework for the management of neonatal jaundice, for babies on the neonatal unit, delivery suite and the postnatal wards. It is based on the NICE guidance for the Management of Newborn Jaundice published May Parent/ Carer Information Parents or carers should be offered information about neonatal jaundice. This information should be first provided by verbal discussion and this should be backed up by written information. This is provided in the hospital information leaflet entitled Newborn Jaundice- Parent Information leaflet (Appendix 6). This leaflet will be updated/ formatted inline with trust policy. 1.2 Babies more likely to develop significant hyperbilirubinaemia The NICE guideline 1 identifies patient groups who have been identified to be a greater risk of developing significant hyperbilirubinaemia. These are babies: - with a gestational age <38 weeks 1

2 - with a previous sibling with neonatal jaundice requiring phototherapy - whose mothers intend to breast feed exclusively - with visible jaundice in the first 24 hours of life Refer to Investigation Pathway (Appendix 3) to aid identification of those at risk. 2. Measurement of Jaundice In a Caucasian baby, jaundice becomes visible at a bilirubin level of approximately 85 mol/l. In dark skinned babies this is less obvious and there should be a lower threshold of measurement of serum bilirubin levels in these babies. Visual inspection for the level of jaundice is unreliable and inadequate and, therefore, it is recommended that: Bilirubin should always be measured if a baby looks visibly jaundiced Bilirubin can be measured by transcutaneous bilirubinometer, heel prick or venous sampling (a 0.4ml Lithium Heparin sample sent to clinical chemistry). However, if a transcutaneous bilirubinometer is available, this may only be used for babies >35weeks and of postnatal age of >24 hours and if a reading of over 250 mol/l is obtained a serum bilirubin must be measured by the laboratory. Phototherapy lights should be switched off or removed before blood sampling for bilirubin measurement. Total serum bilirubin should be used. The conjugated fraction should not be subtracted from the total valve. 3. Summary of Management 2

3 4. Identification / Diagnosis / Initial Management 4.1 Jaundice appearing within the first 24 hours Jaundice appearing within the first 24 hours usually indicates haemolysis and requires investigation as these babies are at greatest risk from bilirubin toxicity due to a rapidly rising bilirubin which, if left untreated, can progress quickly to bilirubin encephalopathy (kernicterus). Therefore, when jaundice appears in the first 24 hours after birth: Each baby requires an individualised management plan according to the gestational age, underlying pathology and the rate of rise of bilirubin A total serum bilirubin should be taken within 2 hours of the jaundice first being noted Phototherapy should be commenced and the bilirubin measured 4-6 hourly until the rise is known to be controlled (See also Section 5) Each case should be discussed with the Duty Consultant Neonatologist Exchange transfusion is usually indicated if the baby is anaemic or the bilirubin rising by >8.5micromol/l per hour (See Nottingham Neonatal Service Guideline D18) Differential diagnosis of jaundice appearing within the first 24 hrs Investigations Rhesus haemolytic disease ABO incompatibility Congenital spherocytosis Congenital elliptocytosis Intrauterine infection (e.g. CMV) Glucose-6-phosphate dehydrogenase deficiency Bacterial sepsis Total serum bilirubin FBC and haemolysis screen Baby blood group and Coomb s test Maternal blood group Consider: Septic screen Intrauterine infection screen G6PD screen 4.2 Antenatally detected presumed haemolytic disease e.g. Rhesus disease/ antibody incompatibility Babies who are known to be haemolysing antenatally Should have an antenatal alert completed Immunoglobulin may be ordered for these babies prior to delivery on a named patient basis where indicated. The dose of immunoglobulin is 500mg/kg. This needs approval from the trust immunoglobulin committee. Should have cord blood taken at delivery for the following: - Blood group - Haemoglobin - Direct Coomb s test (DCT) Should have a baseline bilirubin measured as soon as possible after birth and this should be repeated in 4-6 hours to assess the rate of rise. Phototherapy should be commenced as soon as possible after birth (see Section 5) 3

4 Where indicated immunoglobulin should be administered as soon as possible AFTER discussion with the Duty Consultant Neonatologist for babies with Rhesus disease or ABO incompatibility. Immunoglobulin should be considered particularly if the rate of rise exceeds 8.5micromol/hr and/or the initial bilirubin measurements are above the phototherapy line for the baby s age and gestation. If an exchange transfusion is anticipated: Nottingham Neonatal Service Guideline for Exchange Transfusion (D18) should be used and refer to exchange pathway (Appendix 4). Blood should be made ready for the time of birth or blood ordered from transfusion as expediently and early as possible as blood may take approximately 4h to arrive from the local blood transfusion centre in Sheffield. The transfusion technician must be informed that the blood is required for a double volume exchange transfusion. Appropriate catheters (e.g. UVC, UAC, peripheral arterial line) must be inserted. An from exchange transfusion set is available on the Neonatal Intensive Care Unit. Refer to Exchange transfusion pathway Appendix Jaundice appearing after the first 24 hours Jaundice appearing after the first 24 hours is most commonly due to physiological jaundice. However, this is a diagnosis of exclusion and other pathological causes should be considered. The level of jaundice should be measured that this may be done with a transcutaneous bilirubinometer and compared to the correct gestation specific chart (see Section 5 and Appendices). Importantly, If the baby requires phototherapy or is unwell, investigations must be undertaken A baby who develops jaundice de novo after the 5 th day must have investigations and bilirubin levels monitored as this usually indicates infection or inborn error of metabolism (e.g. galactosaemia) Differential Diagnosis Minimum investigations Infection Bruising / cephalhaematoma Polycythaemia Haemolysis Galactosaemia Metabolic disease FBC and haemolysis screen Total serum bilirubin Baby blood group and Coombs test In the unwell baby, consider: Septic screen Intrauterine infection screen Metabolic screen G6PD screen Galactosaemia screen 5. Management of the jaundiced baby The Phototherapy Pathway 1 is given in Appendix Phototherapy Phototherapy is commenced in order to prevent an exchange transfusion becoming necessary. Conventional blue light phototherapy should be used. LED phototherapy can be used if available. Fibre-optic phototherapy may be used for babies<37 weeks gestation. Thresholds have been agreed at which the attendant health professionals should consider whether phototherapy or exchange transfusion is necessary. These vary by gestational age and the age of the baby and are given in Appendix 1 and. 4

5 For jaundiced babies on the postnatal ward > 38weeks, the threshold table in Appendix 1 and the appropriate graph in should be used and should be filed in the patient s record. For babies < 38 weeks the threshold table in Appendix 1 should NOT be used. Instead the appropriate individual chart in should be selected, based on the baby s gestation, and bilirubin concentrations plotted on it. This should be filed in the patient s record. Babies whose bilirubin concentrations exceed that at which phototherapy is advised (Appendix 1 and 5) for their age and gestation should be placed under phototherapy (See Section 5.2). The Neonatal SHO should be informed and additional investigations performed (See Table 4.3). Babies whose bilirubin concentrations exceed that at which exchange transfusion is advised (Appendix 1 and 5) for their age and gestation should be remain under phototherapy (See Section 5.2) and the Neonatal Registrar informed immediately. The total serum bilirubin measurement should be repeated 6-12 hours after commencing phototherapy. 5.2 Management of babies receiving phototherapy Babies receiving phototherapy should be nursed naked in an incubator or cot with lid, a minimum of 40cms from the light. In addition: - Phototherapy equipment should be checked for safety, that bulbs do not need changing and that the Perspex shield is in place - The baby s temperature should be measured and recorded at least 4 hourly, more frequently if unstable - The baby should be turned regularly to maximise exposed area - The baby s nappy should be as small as possible to maximise exposure while still protecting the gonad s from any potential risk of damage to DNA - The baby s eyes should be shielded using Posey eye shields or a protective orange Perspex shield to avoid retinal damage - If eye shields are used, these should not be applied too tightly to avoid constriction to scalp and excessive pressure over eyes and they should be removed regularly and the baby s eyes inspected for signs of infection - Application of topical creams or lotions should be avoided as there is a risk of burns and blistering - Particular attention should be paid to careful cleaning and drying of the skin, especially if the stools are loose - Consider not nursing babies on a white sheet because of reflective glare. - Parents should be informed of the need for phototherapy and normal parental contact encouraged for routine care. The baby may not always have to receive continuous phototherapy and the phototherapy unit can be removed/switched off during cares and feeds (for up to 30 mins in every 3hour period is acceptable while on single phototherapy). However, if the baby is requiring multiple phototherapy this should not be interrupted. See Phototherapy Pathway (Appendix 2). - The baby should be assessed regularly for signs of dehydration using urine output or frequency of wet nappies. Any concerns should be discussed with the Neonatal SHO. 5

6 5.3 Guidelines for ceasing phototherapy Bilirubin should be measured at least every 6-12hours whilst phototherapy continues. It should be monitored more frequently when the rate of rise is rapid. Phototherapy may be safely discontinued when the bilirubin is 50mol/l below the threshold Repeat bilirubin measurement is necessary hours after ceasing phototherapy to check for rebound jaundice. This must be undertaken with a total serum blood sample, not a transcutaneous value. 6. Follow up of DCT positive babies and babies who have required an exchange transfusion Babies who have been shown to have a haemolytic process with a positive direct coombs test (DCT) causing jaundice requiring treatment need follow up Discuss follow up arrangements for these babies with the Neonatal Registrar prior to discharge Folic Acid 250g/kg/day should be prescribed and should continue until 6 months because of ongoing high red blood cell turnover Blood transfusion should be considered if haemoglobin is less than 7g/dl and the reticulocyte count low All babies who have required an exchange transfusion require a hearing assessment and a neonatal follow-up appointment Babies who have received in-utero transfusion - are often Rhesus negative at birth due to Rh-ve transfused blood - may have mild jaundice only, but should still be monitored carefully - may have marrow suppression secondary to repeated transfusion - often develop late anaemia and require folic acid supplements/transfusion until marrow production recommences (may be up to 3 months) Iron therapy should be avoided in these children as they will already have received extra iron during transfusions 7. Prolonged Neonatal Jaundice Prolonged neonatal jaundice - is defined as jaundice persisting beyond 2 weeks in a term baby 3 weeks in a preterm baby (<37wks at birth) - requires investigation, even if the baby is breast-fed Conjugated jaundice requires investigation at any time (>25micromol/litre). The management of prolonged jaundice is described in Nottingham Neonatal Service Guideline D17. 6

7 Appendix 1 7

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9 Appendix 3 9

10 Appendix 4 10

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25 Appendix 6 25

26 Audit Points prevention of bilirubin encephalopathy prevention of hyperbilirubinaemia associated sensorineural hearing loss use and duration of phototherapy on NNU and postnatal wards avoidance of the requirement for exchange transfusion References 1. Neonatal Jaundice - NICE clinical guideline 98. Issued May Rennie JM, Seghal A, De A et al. Range of UK practice regarding thresholds for phototherapy and exchange transfusion in neonatal hyperbilirubinaemia. Archives of Disease in Childhood Fetal and Neonatal Edition 2009; 94: F323-F Kuzniewicz MW, Escobar GJ, Wi S et al. Risk factors for severe hyperbilirubinemia among infants with borderline bilirubin levels: a nested case-control study. Journal of Pediatrics 2008; 153:(2) Keren R, Bhutani VK, Luan X et al. Identifying newborns at risk of significant hyperbilirubinaemia: a comparison of two recommended approaches. Archives of Disease in Childhood 2005; 90:(4) Maisels MJ, DeRidder J.M., and Kring EA. Routine transcutaneous bilirubin measurements combined with clinical risk factors improve the prediction of subsequent hyperbilirubinemia. Journal of Perinatology 2009; 29: American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation.pediatrics. Pediatrics 2004; 114:(1) Briscoe L, Clark S, and Yoxall CW. Can transcutaneous bilirubinometry reduce the need for blood tests in jaundiced full term babies? Archives of Disease in Childhood Fetal and Neonatal Edition 2002; 86:(3)F190-F Ip S, Chung M, Kulig J. et al. An evidence-based review of important issues concerning neonatal hyperbilirubinemia. Pediatrics. 2004;113 (6) 9. Soorani-Lunsing I, Woltil HA, Hadders-Algra M. Are Moderate Degrees of Hyperbilirubinaemia in Healthy Term Infants Really Safe for the Brain? Pediatric Research 2001; 50(6):