Healthcare professionals, neonatal units, hospital, and health service
Statement of standard
All newborn infants are assessed for neonatal jaundice with the aim of implementing effective prevention of severe hyperbilirubinaemia.
Rationale
Hyperbilirubinaemia is common in newborn infants. Physiological jaundice appears after the first 24 hours of life and usually resolves spontaneously within the first week. However, neonatal hyperbilirubinaemia may also become more severe and require treatment to prevent or treat bilirubin encephalopathy and risk of later cerebral palsy and hearing deficiencies. Monitoring of bilirubin levels in all newborn infants, and awareness of risk factors, are vital for adequate management. Risk factors for severe neonatal hyperbilirubinaemia include: prematurity, haemolytic disorders, early jaundice (<24 hours), bruising and haematoma after delivery, infections, excessive weight loss, family history of jaundice – including conditions such as spherocytosis, conjugation disorders, and haemoglobinopathies, for example sickle cell anaemia and glucose-6-phosphate dehydrogenase deficiency (G6PD),which are more prevalent in Mediterranean, African and Asian populations. (1–3)
Phototherapy is effective in reducing bilirubin concentrations. Initiation of phototherapy should take into account the gestational age, postnatal age and risk factors. Phototherapy usually may be implemented without separating mother and infant. Severe hyperbilirubinaemia may be treated effectively by blood exchange transfusion and the use of gammaglobulin may reduce the need for exchange transfusion in the presence of ongoing haemolysis. (4,5)
In most European countries, national professional societies and health services have developed comprehensive guidelines and charts for the management of hyperbilirubinaemia in their populations, which should be followed. (6–12) It is also critical to monitor for prolonged jaundice (greater than 14 days) in newborn infants and investigation should detect the presence of conjugated hyperbilirubinaemia in such infants. (4,13,14)
Benefits
Short-term benefits
Reduced occurrence of severe neonatal jaundice (4,15,16)
Reduced length of hospital/NICU stay (5)
Early detection of cholestasis (17)
Long-term benefits
Reduced neurological complications (16)
Reduced occurrence of hearing loss (16)
Reduced hospital readmission (17)
Components of the standard
Component
Grading of evidence
Indicator of meeting the standard
For parents and family
Parents are informed by healthcare professionals about identification, prevention, and management of hyperbilirubinaemia. (2,14,15)
A (Moderate quality) B (High quality)
Patient information sheet1
Parents are informed by healthcare professionals about the role of breastfeeding and adequate nutrition in the prevention of hyperbilirubinaemia. (4) (see Nutrition, see Care procedures)
A (High quality) B (High quality)
Patient information sheet1
For healthcare professionals
A unit guideline on hyperbilirubinaemia including management after discharge is adhered to by all healthcare professionals.
B (High quality)
Guideline
Transcutaneous bilirubinometers is used to screen newborn infants for hyperbilirubinaemia. (3,18–23)
A (High quality)
Guideline
Training in the management of hyperbilirubinaemia is attended by all healthcare professionals. (4,16)
A (High quality) B (High quality)
Training documentation
For neonatal unit
A unit guideline on hyperbilirubinaemia including management after discharge is available and regularly updated.
B (High quality)
Guideline
For hospital
Training in the management of hyperbilirubinaemia is ensured.
B (High quality)
Training documentation
Equipment for the diagnosis and management of hyperbilirubinaemia, including transcutaneous bilirubinometers, is provided.
B (High quality)
Audit report2
For health service
A national guideline on management of hyperbilirubinaemia including management after discharge is available and regularly updated.
B (High quality)
Guideline
Systems for the identification of prolonged jaundice are available and audited. (4)
A (High quality)
Audit report2, guideline
1The indicator “patient information sheet” is an example for written, detailed information, in which digital solutions are included, such as web-based systems, apps, brochures, information leaflets, and booklets.
2The indicator “audit report” can also be defined as a benchmarking report.
Where to go
Further development
Grading of evidence
For parents and family
N/A
For healthcare professionals
N/A
For neonatal unit
N/A
For hospital
N/A
For health service
Support research in new therapeutic modalities, cost effectiveness, and improvement in technology. (24)
A (Moderate quality)
Getting started
Initial steps
For parents and family
Parents are verbally informed by healthcare professionals about identification, prevention, and management of hyperbilirubinaemia.
For healthcare professionals
Attend training in the management of hyperbilirubinaemia.
For neonatal unit
Use published guidelines regarding management of hyperbilirubinaemia including management after discharge. (17)
Develop and implement a unit guideline on hyperbilirubinaemia including management after discharge.
Develop information material about identification, prevention, and management of hyperbilirubinaemia for parents.
For hospital
Support healthcare professionals to participate in training in the management of hyperbilirubinaemia.
Provide equipment for non-invasive measurement of bilirubin.
For health service
Develop and implement a national guideline on hyperbilirubinaemia including management after discharge.
Lauer BJ, Spector ND. Hyperbilirubinemia in the Newborn. Pediatr Rev. 2011 Aug 1;32(8):341–9.
Bromiker R, Bin-Nun A, Schimmel MS, Hammerman C, Kaplan M. Neonatal hyperbilirubinemia in the low-intermediate-risk category on the bilirubin nomogram. Pediatrics. 2012 Sep;130(3):e470-475.
Burgos AE, Flaherman VJ, Newman TB. Screening and follow-up for neonatal hyperbilirubinemia: a review. Clin Pediatr (Phila). 2012 Jan;51(1):7–16.
American Academy of atrics. Practice Parameter: Management of Hyperbilirubinemia in the Healthy Term Newborn. Pediatrics. 1994 Oct 1;94(4):558–65.
Romagnoli C, Dani C, Pratesi S, Raimondi F, Capasso L, Zecca E. PER IL TRATTAMENTO DELL’IPERBILIRUBINEMIA NEONATALE.
National Institute for Health and Care Excellence (NICE). Jaundice in newborn babies under 28 days. 2016 Oct [cited 2018 Feb 28]; Available from: https://www.nice.org.uk/guidance/cg98
Nederlandse Vereniging voor Kindergeneeskunde. Richtlijn preventie, diagnostiek en behandeling van hyperbilirubinemie bij de pasgeborene, geboren na een zwangerschapsduur van meer dan 35 weken [Internet]. 2008. Available from: https://www.nvk.nl/Portals/0/richtlijnen/hyperbili/richtlijnhyperbili.pdf
Gesellschaft für Neonatologie und Pädiatrische Intensivmedin (GNPI), Deutsche Gesellschaft für Kinder- und Jugendmedizin (DGKJ), Deutsche Gesellschaft für Perinatalmedizin (DGPM), Deutsche Gesellschaft für Gynäkologie und Geburtshilfe (DGGG). S2k-Leitlinie 024/007: Hyperbilirubinämie des Neugeborenen – Diagnostik und Therapie. AWMF. 2015 Aug.
Arlettaz R, Blumberg A, Buetti H, Mieth D, Roth-Kleiner M. Abklärung und Behandlung von ikterischen Neugeborenen ab 35 0/7 Schwangerschaftswochen. Paediatrica. 2006;17:26–9.
Norman M, Bruun CF, Karlsson H akan, Sarman I, Engberg S, Ewald U. Neonatal Hyperbilirubinemi. 2016.
Fawaz R, Baumann U, Ekong U, Fischler B, Hadzic N, Mack CL, et al. Guideline for the Evaluation of Cholestatic Jaundice in Infants: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr. 2017 Jan;64(1):154–68.
Weiss EM, Zimmerman SS. A Tale of Two Hospitals: The Evolution of Phototherapy Treatment for Neonatal Jaundice. Pediatrics. 2013 Jun 1;131(6):1032–4.
Kramer LI. Advancement of Dermal Icterus in the Jaundiced Newborn. Am J Dis Child. 1969 Sep 1;118(3):454–8.
Barrington KJ, Sankaran K, Canadian Paediatric Society, Fetus and Newborn Committee. Guidelines for detection, management and prevention of hyperbilirubinemia in term and late preterm newborn infants. Paediatr Child Health. 2018 Feb;12(Suppl B):1B–12B.
Maisels MJ. Managing the jaundiced newborn: a persistent challenge. CMAJ Can Med Assoc J J Assoc Medicale Can. 2015 Mar 17;187(5):335–43.
Bhutani VK, Committee on Fetus and Newborn, American Academy of Pediatrics. Phototherapy to prevent severe neonatal hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics. 2011 Oct;128(4):e1046-1052.
De Luca D, Jackson GL, Tridente A, Carnielli VP, Engle WD. Transcutaneous bilirubin nomograms: a systematic review of population differences and analysis of bilirubin kinetics. Arch Pediatr Adolesc Med. 2009 Nov;163(11):1054–9.
Maisels MJ. Noninvasive measurements of bilirubin. Pediatrics. 2012 Apr;129(4):779–81.
O’Connor MC, Lease MA, Whalen BL. How to use: transcutaneous bilirubinometry. Arch Dis Child – Educ Pract. 2013 Aug 1;98(4):154–9.
Mantagou L, Fouzas S, Skylogianni E, Giannakopoulos I, Karatza A, Varvarigou A. Trends of transcutaneous bilirubin in neonates who develop significant hyperbilirubinemia. Pediatrics. 2012 Oct;130(4):e898-904.
Wickremasinghe AC, Karon BS, Cook WJ. Accuracy of neonatal transcutaneous bilirubin measurement in the outpatient setting. Clin Pediatr (Phila). 2011 Dec;50(12):1144–9.
