Management Of NNJ 2015

Management Of NNJ 2015

Neonatal Jaundice (NNJ) or neonatal hyperbilirubinaemia is one of the most common medical conditions in newborn babies. All babies have a transient rise in serum bilirubin but only about 75% are visibly jaundiced. Jaundice is clinically detectable when the serum bilirubin levels are >85 μmol/L (5 mg/dl). 

Hyperbilirubinaemia is either unconjugated or conjugated. Without treatment, high levels of unconjugated bilirubin may lead to acute and chronic bilirubin encephalopathy. This may cause to neurodevelopmental problems including athetoid cerebral palsy, hearing loss and visual impairment.

Risk factors of severe NNJ are:-

1. Prematurity 
2. Low birth weight 
3. Jaundice in the first 24 hours of life 
4. Mother with Blood Group O or Rhesus Negative
5. G6PD deficiency 
6. Rapid rise of total serum bilirubin 
7. Sepsis 
8. Lactation failure 
9. Exclusive breastfeeding 
10. High predischarge bilirubin level 
11. Cephalhaematoma or bruises 
12. Babies of diabetic mothers 
13. amily history of severe NNJ in siblings

Physiological jaundice in babies: 

1. Due to excessive bilirubin production (higher haemoglobin content and shorter red blood cell life span in newborn babies) and poor bilirubin clearance (liver immaturity) 
2. Usually appears two to four days after birth, resolving after one to two weeks (three weeks if preterm) 
3. Not associated with underlying disease and is usually benign

Recommendation 1

• Risk factors for developing severe jaundice in babies need to be identified during the antenatal and postnatal period.
• Health education on neonatal jaundice should be given during antenatal and postnatal visits.

Recommendation 2

• All babies should be visually assessed for jaundice at every opportunity.
• Transcutaneous Bilirubinometer (TcB) should be used if jaundice is detected. If TcB levels exceed 200 µmol/L (12 mg/dL), total serum bilirubin (TSB) should be measured.
• When TcB is not available, TSB should be measured in babies with jaundice.
• TcB should not be used to monitor bilirubin levels in babies on phototherapy

Recommendation 3

• The adequacy of breastfeeding, weight and hydration status of all babies should be assessed during the first week of life.
• Babies with weight loss >7% of birth weight should be referred for further evaluation and closely monitored for jaundice.

Recommendation 4

• Bilirubin-Induced Neurologic Dysfunction score may be used in babies with severe neonatal jaundice to assess the severity and progression of acute bilirubin encephalopathy.

Recommendation 5

In babies with severe hyperbilirubinaemia, early-onset neonatal jaundice (<24 hours) or rapid rise of TSB (>8.5 µmol/L/h or >0.5 mg/dL/h), further laboratory evaluation may be required to ascertain underlying cause and extent of haemolysis.

This may include: 

• G6PD testing (if not screened) 
• Mother’s and baby’s blood groups 
• Full blood count ± peripheral blood picture 
• Reticulocyte count 
• Direct Coombs test
• Septic workup (if infection is suspected)

Recommendation 6

• All babies should be screened for Glucose-6-phosphate dehydrogenase (G6PD) deficiency. The results should be reviewed within 24 hours. 
• G6PD enzyme assays may be considered in babies suspected to have G6PD deficiency but with normal/indeterminate Fluorescent Spot Test

Recommendation 7

• Phototherapy should be commenced when total serum bilirubin reaches the phototherapy threshold for neonatal jaundice*. 
• Irradiance of phototherapy units (non-Light Emitting Diode) should be regularly checked. 
• Overhead phototherapy is preferred to underneath phototherapy. 
• Babies should be placed in the supine position with adequate exposure. 
• Phototherapy should be started at a lower threshold in preterm and low birth weight babies. 
• Light Emitting Diode phototherapy is preferred in preterm babies

Recommendation 8 

• Exchange transfusion (ET) should be considered when total serum bilirubin reaches the threshold levels in neonatal jaundice (NNJ). 
• ET procedure should follow a standardised protocol and supervised by experienced personnel. Babies undergoing ET should be closely monitored. 
• Reconstituted blood products may be used if citrated fresh whole blood is not available for ET in NNJ.

Recommendation 9

• All babies discharged <48 hours after birth should be seen by a healthcare provider in an ambulatory setting or at home within 24 hours of discharge. 
• For babies with severe jaundice admitted for treatment, early followup is needed to detect rebound jaundice after discharge

Recommendation 10

• Breastfeeding, because of its benefits, should be continued in the jaundiced babies. 
• Adequate lactation/breastfeeding support should be provided to all mothers, particularly those with preterm babies. 
• In breastfed babies with jaundice associated with inadequate intake, excessive weight loss or dehydration, supplementation with expressed breast milk or formula may be considered

Recommendation 11

• Predischarge screening should be used to prevent severe neonatal jaundice (NNJ) in late preterm and term babies. 
• Clinical risk factor assessment or/and predischarge bilirubin levels [transcutaneous bilirubin or total serum bilirubin (TSB)] can be used as predischarge screening. 
• Universal predischarge bilirubin screening may be considered for all babies if resources are available. All G6PD deficient babies should be admitted and monitored for NNJ during the first five days of life. A TSB should be done if there is clinical jaundice. 
• Term G6PD deficient babies with birth weights >2500 g may be discharged earlier on day four of life if the TSB is <160 μmol/L (9 mg/dL), and followed-up closely

Recommendation 12

Babies should be referred to secondary/tertiary care when they present with any of the following:-

• Onset of jaundice within 24 hours of life 
• Rapidly rising total serum bilirubin of greater than 6 mg/dL/day (103 µmol/L/day) 
• Clinical jaundice below umbilicus, corresponding to total serum bilirubin of 12 - 15 mg/dL (205 - 257 µmol/L) 
• Clinical jaundice till the soles of the feet (urgent referral for possibility of exchange transfusion) 
• G6PD deficiency (if not previously hospitalised) 
• Clinical symptoms/signs suggestive of sepsis

Recommendation 13 

• Babies with acute bilirubin encephalopathy should have long-term follow-up to monitor for neurodevelopmental sequelae. 
• Term and late preterm babies with TSB >20 mg/dL (342 μmol/L) or exchange transfusions should have Auditory Brainstem Response (ABR) testing done within the first three months of life. If the ABR is abnormal, neurodevelopmental follow-up should be continued.
• Healthy term and late preterm babies with non-haemolytic hyperbilirubinaemia and TSB <25 mg/dL (428 μmol/L) may be followed-up at the primary care level. 
• Preterm babies with jaundice should be followed-up for neurodevelopmental sequelae as per follow-up plans for all preterm babies.

Assessment Components

A. When a baby presents with NNJ, it is important to identify the risk factors severity of hyperbilirubinaemia, to assess the general condition of the baby and to observe signs of bilirubin toxicity. Proper assessment is needed in deciding on subsequent management.

In exclusively breast-fed babies: 

1. Weight loss ≥8% at day two of life and >11% at day three of life predicts subsequent significant hyperbilirubinaemia [OR=1.45 (95% CI 1.06 to 1.97) and OR=2.01 (95% CI 1.16 to 3.46) respectively].37, level III 
2. Weight loss ≥7% is a risk factor for developing severe hyperbilirubinaemia [(TSB >20mg/dL (342 umol/l)] with OR=3.9 (95% CI 1.4 to 10.8).38, level III

B. BIND score BIND score, which was first introduced by Johnson et al. in 1999, quantifies the severity and progression of Acute Bilirubin Encephalopathy (ABE).

C. Blood tests

Indication For Treatment

Potential Resource Implications

To implement the CPG, there must be strong a commitment to:-

• ensure widespread distribution of the CPG to healthcare providers via printed and electronic copies.
• strengthen training (with adequate funding) of healthcare providers by regular seminars or workshops to ensure information is up-todate
• ensure availability of equipment for measuring bilirubin levels and managing NNJ in both health clinics and hospitals
• ensure empowerment of caregivers via education materials improve the current reporting system to include bilirubin
• encephalopathy and other related parameters

It is important to standardise the management of NNJ at all healthcare levels in Malaysia by using an evidence-based CPG. This aims to prevent long-term morbidity and mortality.

Download Management Of Neonatal Jaundice 2015 CPG

Download Management Of Neonatal Jaundice Quick Reference

Source : Malaysia Health Technology Assessment Section (MaHTAS)