Management of Neonatal Jaundice GL382

Transcription

1 Management of Neonatal Jaundice GL382 Approval and Authorisation Approved by Job Title Date Paediatric Clinical Governance Chair of Paediatric Clinical Governance Nov 2014 Change History Version Date Author Reason 1.0 July 2011 P DeHalpert Update inline with NICE guidelines 1.1 Nov 2014 P DeHalpert Hyperlink to NICE guideline corrected

2 BACKGROUND Jaundice refers to the yellow colour of skin and sclera caused by a raised level of bilirubin in the circulation. This is known as hyperbilirubinaemia. Approximately 60% of term and 80% of preterm babies develop jaundice in the first week of life. In most babies jaundice is harmless; however a few will develop very high levels of billirubin, which can be harmful if not treated. Clinical recognition and assessment if jaundice can be difficult, particularly in babies with dark skin tones. THIS GUIDELINE IS DIRECTLY TAKEN FROM THE NICE CLINICAL GUIDANCE CG98 NEONATAL JAUNDICE. Identification of those at risk The following are risk factors for developing significant jaundice: Gestational age under 38 weeks A previous sibling with neonatal jaundice requiring phototherapy Mother s intention to breast feed exclusively Visible Jaundice at 24 hours of age Those with significant bruising at birth Those with known antibodies

3 Checking for Jaundice All babies should have visual inspections for jaundice within the first 72hours of life. Babies who are identified as being at increased risk (see risk factors above) should have a specific visual check within the first 48hrs. Babies should be examined in bright, natural light. Visual inspection alone CANNOT be relied upon to estimate bilirubin level. Any baby who is clinically jaundiced MUST have a bilirubin level measured. Bilirubin Measurement Billirubin levels can be measured in the serum. Billirubin levels should be measured in the serum in any baby who has level Jaundice within the first 24 hours of life Who is under 35 weeks gestation Where there is no available transcutaneous monitor of bilirubin Who have a transcutaneous monitor reading of greater than 250 Is currently undergoing treatment for neonatal jaundice Billirubin levels can be monitored / estimated using a transcutaneous monitor in those That are over 35 weeks gestational age Become jaundice beyond the first 24 hour of life. Use of Billirubinometer

4 Billirubininometers use transcutaneous light to estimate the serum billirubin level. Billirubin levels can be monitored / estimated using a transcutaneous monitor in those; that are over 35 weeks gestational age that become jaundice beyond the first 24 hours of life. When the billirubinometer indicates a billirubin level of greater than 250 micromols/litre serum estimation is indicated, Interpretation of the bilirubin level The serum billirubin level will determine the management of hyperbilirubinaemia. Age in hours and gestational age are significant variables. A graph for the baby s specific gestational age must be printed off and placed in the patient s notes from the link below. The Charts for 34 weeks and up are included at the end of this document. The bilirubin level can then be plotted against the baby s age in hours. Below the phototherapy line Phototherapy is not indicated. A plan must be made in regards to further clinical review and/or measurement. This should be documented in the medical notes for the child and explained to the parents. Between the phototherapy line and the exchange transfusion line (see section below on phototherapy)

5 Phototherapy is indicated (see below.) Repeat serum measurement is indicated within 4-6 hours. The decision to start phototherapy should be documented in the patient s medical notes, this should be explained to the parents verbally and a parental information leaflet supplied. (Leaflet C) Further investigations in regards to potential cause should be given Above the exchange transfusion line Preparations should be made for exchange transfusion, and phototherapy should be commenced urgently in the interim. The baby needs admission to the neonatal intensive care unit. The Neonatal Registrar should be contacted urgently via bleep 138. Please see guideline on exchange transfusion. THRESHOLD CHART SHOULD BE USED FOR GUIDANCE ONLY IN BABIES GREATER THAN 38 WEEKS GESTATION 6. Phototherapy

6 What is phototherapy? Light of a certain wavelength makes it easier for bilirubin to be removed from the body. Phototherapy is a non-invasive procedure. There are different types of phototherapy. Most types of phototherapy involve placing the baby under a special light Before commencing phototherapy The majority of babies with elevated serum bilirubin do not have an underlying disease. However consideration must be given to the minority of babies presenting with jaundice who do. For example babies who have haemolysis (secondary to G6PD or antibodies) have rapidly rising serum billirubin levels, and identification of such patients early may enable us to avoid further intervention, may have implications for future pregnancies or other family members. Prior to commencing phototherapy the following should be undertaken: Full clinical Examination Serum Billirubin Level ( Split and Total Conjugated > 25 discuss with senior ) Packed Cell Volume Blood Group ( Mother and Baby ) DAT (Coombs test ), Full Blood Count and Blood Film Consider the need for the following: G6PD ( take into account ethnic origin and discuss with consultant) Septic Screen ( Including LP, Urine and Blood Culture; if infection is suspected)

7 Further investigations and treatment should be discussed with the parents. The Parents should be supplied with Patient Leaflet C What type of phototherapy is indicated? Single phototherapy treatment for term babies Conventional single blue light phototherapy is indicated for treatment of significant hyperbilirubinaemia in babies greater than 37 weeks gestational age. Unless: There is a rapidly rising serum bilirubin (greater than 8.5 micromol/litre per hour) The serum bilirubin is within 50 micromol/litre below the threshold for which exchange transfusion is indicated after 72 hours. If either of the above apply see continuous multiple phototherapy treatment below Single phototherapy treatment for preterm babies Use either fibre optic phototherapy or conventional blue light phototherapy, (or in Buscot LED phototherapy unit on the giraffe incubator) as treatment for significant hyperbilirubinaemia in babies less than 37 weeks Unless: There is a rapidly rising serum bilirubin (greater than 8.5 micromol/litre per hour) The serum bilirubin is within 50 micromol/litre below the threshold for which exchange transfusion is indicated after 72 hours. If either of the above apply see continuous multiple phototherapy treatment

8 below Continuous multiple phototherapy treatment for term and preterm babies Initiate continuous multiple phototherapy to treat all babies if any of the following apply: There is a rapidly rising serum bilirubin ( greater than 8.5 micromol/litre per hour) The serum bilirubin is within 50 micromol/litre below the threshold for which exchange transfusion is indicated after 72 hours The bilirubin level fails to respond to single phototherapy (that is, the level of serum bilirubin continues to rise, or does not fall, within 6 hours of starting single phototherapy) The baby will require admission to Buscot Neonatal Unit. Please discuss with the neonatal registrar on call. Monitoring of the serum bilirubin level during phototherapy Once phototherapy is commenced the serum billirubin level should be rechecked within 4-6 hours. If the serum bilirubin level is the same or rising, consider any underlying causes and consider escalation of treatment, and determine an appropriate time for rechecking the bilirubin level after escalation of treatment (this should not be more than 4 hours) If the serum bilirubin level is falling, then no escalation of treatment is required. The Level can be rechecked within 6-12 hours, depending on the rate of fall. Feeding during phototherapy

9 Single Conventional Phototherapy Breastfeeding should continue to be supported. The baby can receive breaks of up to 30 minutes at a time for feeding. Continuous multiple Phototherapy The baby may require admission to the neonatal unit. Phototherapy should not be switched off for feeding. The baby will require NG feeding or IV fluids. Observation during phototherapy The baby should have observation of their temperature, activity, work of breathing, heart rate and respiratory rate at least four hourly during phototherapy. Stopping Phototherapy Phototherapy should be discontinued once the bilirubin level is beyond 100 micromols/litre of the treatment line. Rebound does not need to be checked for unless there is clinical concern of jaundice on visible inspection. Further Points Do not use the albumin/bilirubin ratio when making decisions about the management of hyperbilirubinaemia. Do not subtract conjugated bilirubin from total serum bilirubin when making decisions about the management of hyperbilirubinaemia Do not use white curtains routinely with phototherapy as they may impair observation of the baby

10 Intravenous immunoglobulin o Use intravenous immunoglobulin (IVIG) (500 mg/kg over 4 hours) as an adjunct to continuous multiple phototherapy in cases of Rhesus haemolytic disease or ABO haemolytic disease when the serum bilirubin continues to rise by more than 8.5 micromol/litre per hour. o Offer parents or carers information on IVIG including: Why IVIG is being considered Why IVIG may be needed to treat significant hyperbilirubinaemia The possible adverse effects of IVIG When it will be possible for parents or carers to see and hold the baby. Do not use any of the following to treat hyperbilirubinaemia: Agar, albumin, barbiturates, charcoal, cholestyramine, clofibrate, D- penicillamine, glycerine, manna, metalloporphyrins, riboflavin, traditional Chinese medicine, acupuncture, homeopathy. Key Messages 1. If a baby appears jaundice in natural light, then the level needs to be checked within 4-6 hours, visual inspection for the level of jaundice is inadequate for all babies. 2. Babies of weeks gestation will require phototherapy at lower levels than previously advised locally 3. A care plan in regards to avoiding jaundice and its complications needs to be made on labour ward prior to transfer to the ward or discharge. Babies at increased risk of jaundice as described above, must be reviewed by a healthcare professional in this regard within 48 hours. All babies should be reviewed for jaundice at every opportunity within the first 72 hours of birth. 4. Bilirubinometers can only be used in those >24 hours of life and greater than 35 weeks gestation. These are currently not available at RBH, but a business case has been made to address this. 5. Serum billirubin levels need to be measured when required in accordance with this guidance. To facilitate the implementation of this

11 guideline the current practice of only spinning billirubin levels for the postnatal wards at two specific times of the day, 6 hours apart will have to be changed. 6. Communication with parents is a high priority. Verbal communication should be supported with patient information leaflets.

12

13

14

15

16

17

18