Neonatal Jaundice for Infants 35 Weeks Gestational Age v.

2
Executive Summary Inclusion Criteria
Previously healthy Age 14 days Born at 35 wks gestational age

Test Your Knowledge

Explanation of Evidence Ratings

Summary of Version Changes Pathophysiology Risk for Kernicterus

PHASE I (E.D.)
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 BiliTool

Exclusion Criteria
Direct hyperbilirubinemia Meets NICU Direct Admit Criteria TSB > 5mg/dL above exchange transfusion threshold Signs of acute bilirubin encephalopathy Suspected sepsis or ill-appearing

!
Supplemental IV Fluids NOT routinely indicated

Automatic NICU Admission Criteria

Signs of acute bilirubin encephalopathy TSB > 5 mg/dL above exchange transfusion threshold Include NICU attending on calls for patients that meet NICU direct admit criteria.
Admit to NICU

Evaluate for Discharge

TSB below phototherapy threshold Follow-up appointment arranged for next day Feeding adequately No concern for significant hemolysis
Meets discharge criteria

Evaluate for NICU Consult Criteria

TSB within 2mg/dL of exchange transfusion threshold Age < 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)
Admit on phototherapy

NICU (Off Pathway)

Discharge

Inpatient Admission

ED Management
Give effective phototherapy feeding. The infant should not be removed from bili lights Encourage feeding 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
For questions concerning this pathway, contact:NeonatalJaundice@seattlechildrens.org
2012, Seattle Childrens Hospital, all rights reserved, Medical Disclaimer

TSB rising or meeting NICU admission criteria

TSB stable or falling and otherwise clinically well

Last Updated: 05/31/2012 Valid until: 05/31/2015

Neonatal Jaundice for Infants 35 Weeks Gestational Age v.2

PHASE II (INPATIENT)

Inclusion Criteria
Previously healthy Age 14 days Born at 35 wks gestational age

Exclusion Criteria

!
Supplemental IV Fluids NOT routinely indicated

Direct hyperbilirubinemia Meets NICU Direct Admit Criteria TSB > 5mg/dL above exchange transfusion threshold Signs of acute bilirubin encephalopathy Suspected sepsis or ill-appearing

!
Rebound TSB NOT routinely indicated prior to discharge

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 feeding The infant should not be removed from bili lights for > 20 mins in any 3 Encourage feeding. hour period. Use bottle if needed. If patient unable to maintain normal temperature in an open crib, place in isolette per Isolette Isolette Use Use Policy Policy & & Procedure 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)

TSB within 2 mg/dL of exchange transfusion threshold, age <72 hours, or known/suspected hemolysis?
Yes No

No

Subsequent Labs
TSB every 4 hours until TSB falling G6PD (for unexplained hemolysis)

Subsequent Labs
TSB approximately 12 hours after starting phototherapy (or with routine AM labs) Subsequent checks as clinically indicated

Meets Discharge Criteria

Patient off phototherapy and otherwise well Follow-up appointment arranged for next day No concern for significant ongoing hemolysis
Yes

Discharge

For questions concerning this pathway, contact:NeonatalJaundice@seattlechildrens.org

2012, Seattle Childrens Hospital, all rights reserved, Medical Disclaimer

Last Updated: 05/31/2012 Valid until: 05/31/2015

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Guidelines for Initiation of Phototherapy

In Hospitalized Infants of 35 or More Weeks Gestation
These levels are approximations representing a consensus based on limited evidence. [LOE: E (AAP 2004)]

AAP. Pediatrics 2004;114(1):297-316

2004 by American Academy of Pediatrics

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Guidelines for Exchange Transfusion

In Infants 35 or More Weeks Gestation
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)]

AAP. Pediatrics 2004;114(1):297-316

2004 by American Academy of Pediatrics

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Feeding
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)]

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Executive Summary

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Executive Summary

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Self-Assessment
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 Childrens Hospital, you MUST logon to Learning Center. 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 1.5 b. 3 day old ex-36 week SGA infant with a total serum bilirubin of 19.2, direct of 0.3 c. 6 day old lethargic ex-39 week infant with delayed capillary refill and total serum bilirubin of 21.1, direct of 0.1 d. 60 hour old ex-37 week infant with a total serum bilirubin of 21.9, Coombs+ 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. Moms milk has just come in. In the ED, in addition to a TSB, initial laboratory screening would include: a. Complete blood count b. Direct antibody test (DAT) c. Blood glucose level d. Electrolytes e. All of the above In the same patient (5 day old ex-39 week infant, TSB of 21.7 from PCP, ~11% weight loss from birth, otherwise well, moms milk just come in), what would be appropriate to do in the ED while awaiting initial laboratory results? a. Keep the baby NPO b. Administer a 20 mL/kg normal saline IV bolus c. Consult the NICU d. Start phototherapy True or False: Supplemental IV fluids are routinely indicated in the treatment of neonatal hyperbilirubinemia? 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 NPO b. Start phototherapy and admit to the floor c. Give a 20 mL/kg normal saline IV bolus d. Consult the NICU 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 lib b. Continue breast feeding up to 20 minutes every 2-3 hours c. Give a 20 mL/kg normal saline IV bolus d. Consult the NICU e. Start phototherapy You are initiating phototherapy for a patient and measure irradiance of 23 W/cm2/nm. You should: a. Adjust the overhead light until the radiometer reading is less than 20 W/cm2/nm b. Adjust the overhead light until the radiometer reading is at least 30 W/cm2/nm c. Adjust the overhead light until the radiometer reading is at least 50 W/cm2/nm d. Nothing e. Remove the infant's diaper to expose more surface area then recheck the radiometer reading How often should total serum bilirubin be checked? a. Every 12 hours until discharge b. Every 4 hours until it is falling if age less than 96 hours c. Every 4 hours until it is falling if TSB is within 2 mg/dL of exchange transfusion threshold d. a & c only e. a, b & c 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 ED b. Obtain a total serum bilirubin immediately in the ED c. Start phototherapy d. Admit immediately to the NICU for rapid exchange transfusion 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 hours b. Stop phototherapy and check a TSB in 12 hours c. Continue phototherapy and check TSB q12 hours until < 12 mg/dL d. Discharge home on home phototherapy e. Discharge home f. Discharge home with PCP follow up in 2-3 days

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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 W/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.

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Evidence Ratings
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

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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.

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Medical Disclaimer
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 Childrens 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.
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For questions concerning this pathway, contact: xxxx@seattlechildrens.org

Last Updated: xx/xx/xxxx Valid until: xx/xx/xxxx

Bibliography

Identification
52 records identified through database searching 0 additional records identified through other sources

Screening
48 records after duplicates removed

48 records screened

21 records excluded

Elgibility
27 full-text articles assessed for eligibility 22 full-text articles excluded, 16 did not answer clinical question 6 did not meet quality threshold

Included
6 studies included in pathway Flow diagram adapted from Moher D et al. BMJ 2009;339:bmj.b2535
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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 18hospital 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
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):670674 Wagle S, Rosenkrantz T (ed.). Hemolytic Disease of Newborn. Medscape Reference. May 2011. http://emedicine.medscape.com

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