Detection and treatment of neonatal jaundice

On May 19, the UK's National Institute for Health and Clinical Excellence (NICE) published a new guideline for assessment and treatment of neonatal jaundice. The guideline, which was developed by the National Collaborating Centre for Women's and Children's Health, recommends substantial changes to current practice throughout the National Health Service for babies from birth to 28 days of age, including preterm babies. For the first time nationally, practical step-by-step guidance is provided for parents, midwives, health visitors, general practitioners, and paediatricians on the detection of jaundice in newborn babies, the prediction of those likely to develop adverse consequences, and treatment options.About 60% of term babies, and 80% of preterm babies, develop jaundice in their first week of life. 10% of breastfed babies are still jaundiced at 1 month of age. Rapid differentiation between the majority of babies with jaundice who have no underlying disease (physiological jaundice) and those with pathological causes is important to detect the underlying disease and to prevent adverse sequelae such as bilirubin encephalopathy and kernicterus.The NICE guideline urges health professionals not to rely on visual inspection alone to estimate the bilirubin concentration in a newborn baby with jaundice. Clinical examination can detect jaundice, but not the bilirubin level itself. The other main recommendations, based on detailed appraisal and systematic synthesis of the available evidence, include visually examining all babies for jaundice at every opportunity, especially in the first 72 h. Because most babies are now discharged from hospital 1–2 days after birth in the UK, and some are born at home, it is particularly important that parents and community midwives are alert to the possibility of jaundice. Separate information is provided for parents and carers, suggesting that they examine their baby carefully, looking for yellowing of the whites of the eyes and gums, as well as of the skin, and checking for dark urine and pale stools. If jaundice is suspected or obvious to parents or health professionals, the bilirubin concentration should be measured. A transcutaneous bilirubinometer (rather than a blood test) can be used in babies who are more than 35 weeks of gestation and more than 24 h old. However, any baby who is thought to be jaundiced in the first 24 h of life or who is less than 35 weeks' requires an urgent blood test. Transcutaneous bilirubinometers cannot be relied upon at concentrations of bilirubin higher than 250 μmol/L, and if such a reading is obtained the serum bilirubin should be measured. The guideline identifies babies most at risk of developing significant hyperbilirubinaemia as those less than 38 weeks' gestational age, those who have a sibling who had neonatal jaundice that required phototherapy, those who are exclusively breastfed, or those who have visible jaundice in the first 24 h of life. These babies should receive an additional visual inspection by a health-care professional within the first 48 h of life.Currently, there is wide variation in the UK, especially for preterm babies, in the bilirubin threshold chosen to initiate phototherapy. The NICE guideline clearly outlines the management of babies with hyperbilirubinaemia according to gestational and postnatal ages, with thresholds given for phototherapy, multiple phototherapy, intravenous immunoglobulin, or exchange transfusion. Separate treatment threshold graphs are included in the guideline for babies from 23 weeks' to 38 or more weeks' gestational age, along with advice on care of the baby during treatment.Gaps in the available evidence are identified by the members of the guideline development group who recommend priority areas for research. The factors that underlie the association between breastfeeding and jaundice is one area in which studies are needed. Whether or not universal transcutaneous bilirubin screening with or without a risk assessment for hyperbilirubinaemia is effective in reducing morbidity and readmission is unknown, and more research on the accuracy of transcutaneous bilirubinometers compared with serum bilirubin measurement is needed. Whether phototherapy can be interrupted, and for how long, without adversely affecting clinical outcomes needs further study, and national registries of cases of significant hyperbilirubinaemia and kernicterus should be initiated.Implementing this guideline for neonatal jaundice will cost, NICE estimates, about £12 500 for a population of 100 000, but could prevent some, if not all, of the current seven new cases of kernicterus that occur in the UK every year. In the USA, hospital admissions with kernicterus declined after the introduction of the American Academy of Pediatrics' hyperbilirubinaemia clinical practice guideline in 1994. Adoption of the NICE guideline on neonatal jaundice should go a long way towards making kernicterus a diagnosis of the past in the UK. On May 19, the UK's National Institute for Health and Clinical Excellence (NICE) published a new guideline for assessment and treatment of neonatal jaundice. The guideline, which was developed by the National Collaborating Centre for Women's and Children's Health, recommends substantial changes to current practice throughout the National Health Service for babies from birth to 28 days of age, including preterm babies. For the first time nationally, practical step-by-step guidance is provided for parents, midwives, health visitors, general practitioners, and paediatricians on the detection of jaundice in newborn babies, the prediction of those likely to develop adverse consequences, and treatment options. About 60% of term babies, and 80% of preterm babies, develop jaundice in their first week of life. 10% of breastfed babies are still jaundiced at 1 month of age. Rapid differentiation between the majority of babies with jaundice who have no underlying disease (physiological jaundice) and those with pathological causes is important to detect the underlying disease and to prevent adverse sequelae such as bilirubin encephalopathy and kernicterus. The NICE guideline urges health professionals not to rely on visual inspection alone to estimate the bilirubin concentration in a newborn baby with jaundice. Clinical examination can detect jaundice, but not the bilirubin level itself. The other main recommendations, based on detailed appraisal and systematic synthesis of the available evidence, include visually examining all babies for jaundice at every opportunity, especially in the first 72 h. Because most babies are now discharged from hospital 1–2 days after birth in the UK, and some are born at home, it is particularly important that parents and community midwives are alert to the possibility of jaundice. Separate information is provided for parents and carers, suggesting that they examine their baby carefully, looking for yellowing of the whites of the eyes and gums, as well as of the skin, and checking for dark urine and pale stools. If jaundice is suspected or obvious to parents or health professionals, the bilirubin concentration should be measured. A transcutaneous bilirubinometer (rather than a blood test) can be used in babies who are more than 35 weeks of gestation and more than 24 h old. However, any baby who is thought to be jaundiced in the first 24 h of life or who is less than 35 weeks' requires an urgent blood test. Transcutaneous bilirubinometers cannot be relied upon at concentrations of bilirubin higher than 250 μmol/L, and if such a reading is obtained the serum bilirubin should be measured. The guideline identifies babies most at risk of developing significant hyperbilirubinaemia as those less than 38 weeks' gestational age, those who have a sibling who had neonatal jaundice that required phototherapy, those who are exclusively breastfed, or those who have visible jaundice in the first 24 h of life. These babies should receive an additional visual inspection by a health-care professional within the first 48 h of life. Currently, there is wide variation in the UK, especially for preterm babies, in the bilirubin threshold chosen to initiate phototherapy. The NICE guideline clearly outlines the management of babies with hyperbilirubinaemia according to gestational and postnatal ages, with thresholds given for phototherapy, multiple phototherapy, intravenous immunoglobulin, or exchange transfusion. Separate treatment threshold graphs are included in the guideline for babies from 23 weeks' to 38 or more weeks' gestational age, along with advice on care of the baby during treatment. Gaps in the available evidence are identified by the members of the guideline development group who recommend priority areas for research. The factors that underlie the association between breastfeeding and jaundice is one area in which studies are needed. Whether or not universal transcutaneous bilirubin screening with or without a risk assessment for hyperbilirubinaemia is effective in reducing morbidity and readmission is unknown, and more research on the accuracy of transcutaneous bilirubinometers compared with serum bilirubin measurement is needed. Whether phototherapy can be interrupted, and for how long, without adversely affecting clinical outcomes needs further study, and national registries of cases of significant hyperbilirubinaemia and kernicterus should be initiated. Implementing this guideline for neonatal jaundice will cost, NICE estimates, about £12 500 for a population of 100 000, but could prevent some, if not all, of the current seven new cases of kernicterus that occur in the UK every year. In the USA, hospital admissions with kernicterus declined after the introduction of the American Academy of Pediatrics' hyperbilirubinaemia clinical practice guideline in 1994. Adoption of the NICE guideline on neonatal jaundice should go a long way towards making kernicterus a diagnosis of the past in the UK.