Neonatal Jaundice Pathway

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

http://www.seattlechildrens.org/terms-of-use#medical

http://bilitool.org/

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


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

http://www.seattlechildrens.org/terms-of-use#medical

http://child/policies_procedures/clinical_services/incubator_isolette_use.asp

Return to ED Management Return to Inpatient Management


Return to ED Management

Return to Inpatient Management

Go to Pathophysiology Pg 2













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


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








• 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






Executive Summary


To Exec Summary Pg2


Executive Summary

View Answers

Self-Assessment


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

Completion qualifies you for 1 hour of Category II CME credit. If you are taking this self-assessment as a

part of required departmental training at Seattle Children’s Hospital, you MUST logon to Learning Center.

http://learningcenter/TPOnline/TPOnline.dll/Home

Answer Key


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


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


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


contact: [email protected]


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


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


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

Documents

Neonatal Jaundice Pathway