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Guia Nice Ictericia (BT - 17.1)
Guia Nice Ictericia (BT - 17.1)
Neonatal jaundice
Developed by the National Collaborating Centre for Womens and Childrens Health
NICE clinical guidelines are recommendations about the treatment and care of
people with specific diseases and conditions in the NHS in England and
Wales.
This guidance represents the view of NICE, which was arrived at after careful
consideration of the evidence available. Healthcare professionals are
expected to take it fully into account when exercising their clinical judgement.
However, the guidance does not override the individual responsibility of
healthcare professionals to make decisions appropriate to the circumstances
of the individual patient, in consultation with the patient and/or guardian or
carer, and informed by the summary of product characteristics of any drugs
they are considering.
Implementation of this guidance is the responsibility of local commissioners
and/or providers. Commissioners and providers are reminded that it is their
responsibility to implement the guidance, in their local context, in light of their
duties to avoid unlawful discrimination and to have regard to promoting
equality of opportunity. Nothing in this guidance should be interpreted in a way
that would be inconsistent with compliance with those duties.
National Institute for Health and Clinical Excellence
MidCity Place
71 High Holborn
London WC1V 6NA
www.nice.org.uk
National Institute for Health and Clinical Excellence, 2010. All rights reserved. This material
may be freely reproduced for educational and not-for-profit purposes. No reproduction by or
for commercial organisations, or for commercial purposes, is allowed without the express
written permission of NICE.
Contents
Introduction ...................................................................................................... 3
Patient-centred care......................................................................................... 5
Key priorities for implementation ...................................................................... 7
Guidance ....................................................................................................... 10
1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8
1.9
Exchange transfusion........................................................................... 22
1.10
Implementation ........................................................................................ 24
Research recommendations.................................................................... 25
Introduction
Jaundice is one of the most common conditions needing medical attention in
newborn babies. Jaundice refers to the yellow colouration of the skin and the
sclerae (whites of the eyes) caused by the accumulation of bilirubin in the skin
and mucous membranes. Jaundice is caused by a raised level of bilirubin in
the body, a condition known as hyperbilirubinaemia.
Approximately 60% of term and 80% of preterm babies develop jaundice in
the first week of life, and about 10% of breastfed babies are still jaundiced at
1 month. For most babies, jaundice is not an indication of an underlying
disease, and this early jaundice (termed physiological jaundice) is generally
harmless.
Breastfed babies are more likely than bottle-fed babies to develop
physiological jaundice within the first week of life. Prolonged jaundice that is,
jaundice persisting beyond the first 14 days is also seen more commonly in
these babies. Prolonged jaundice is generally harmless, but can be an
indication of serious liver disease.
Jaundice has many possible causes, including blood group incompatibility
(most commonly Rhesus or ABO incompatibility), other causes of haemolysis
(breaking down of red blood cells), sepsis (infection), liver disease, bruising
and metabolic disorders. Deficiency of a particular enzyme, glucose-6phosphate-dehydrogenase, can cause severe neonatal jaundice. Glucose-6phosphate-dehydrogenase deficiency is more common in certain ethnic
groups and runs in families.
Bilirubin travels in the blood in two ways; some is bound to albumin (a protein)
and is called conjugated or direct bilirubin whereas the remainder is free, not
bound, and is called unconjugated or indirect bilirubin. The terms direct and
indirect refer to the way the laboratory tests measure the different forms.
Some tests measure total bilirubin and do not distinguish between the two
forms.
In young babies, unconjugated bilirubin can penetrate the membrane that lies
between the brain and the blood (the bloodbrain barrier). Unconjugated
bilirubin is potentially toxic to neural tissue (brain and spinal cord). Entry of
unconjugated bilirubin into the brain can cause both short-term and long-term
neurological dysfunction (bilirubin encephalopathy). The term kernicterus is
used to denote the clinical features of acute or chronic bilirubin
encephalopathy, as well as the yellow staining in the brain associated with the
former. The risk of kernicterus is increased in babies with extremely high
bilirubin levels. Kernicterus is also known to occur at lower levels of bilirubin in
term babies who have risk factors, and in preterm babies.
Clinical recognition and assessment of jaundice can be difficult. This is
particularly so in babies with darker skin tones. Once jaundice is recognised,
there is uncertainty about when to treat, and there is widespread variation in
the use of phototherapy and exchange transfusion. There is a need for more
uniform, evidence-based practice and for consensus-based practice where
such evidence is lacking. This guideline provides guidance regarding the
recognition, assessment and treatment of neonatal jaundice. The advice is
based on evidence where this is available and on consensus-based practice
where it is not.
The guideline will assume that prescribers will use a drugs summary of
product characteristics to inform decisions made with individual patients.
Patient-centred care
This guideline offers best practice advice on the care of babies with neonatal
jaundice.
Treatment and care should take into account parents preferences. Parents of
babies with neonatal jaundice should have the opportunity to make informed
decisions about their babies care and treatment, in partnership with their
healthcare professionals. If parents do not have the capacity to make
decisions, healthcare professionals should follow the Department of Healths
advice on consent (available from www.dh.gov.uk/consent) and the code of
practice that accompanies the Mental Capacity Act (summary available from
www.publicguardian.gov.uk/). In Wales, healthcare professionals should
follow advice on consent from the Welsh Assembly Government (available
from www.wales.nhs.uk/consent).
Healthcare professionals should follow the guidelines in Seeking consent:
working with children (available from www.dh.gov.uk/consent).
Good communication between healthcare professionals and parents is
essential. It should be supported by evidence-based written information
tailored to the parents needs. Treatment and care, and the information
parents are given about it, should be culturally appropriate. It should also be
accessible to people with additional needs such as physical, sensory or
learning disabilities, and to people who do not speak or read English.
Families and carers should also be given the information and support they
need.
examination of the sclerae, gums and blanched skin is useful across all
skin tones.
Additional care
Ensure babies with factors associated with an increased likelihood of
developing significant hyperbilirubinaemia receive an additional visual
inspection by a healthcare professional during the first 48 hours of life.
Measuring bilirubin in all babies with jaundice
Do not rely on visual inspection alone to estimate the bilirubin level in a
baby with jaundice.
How to measure the bilirubin level
When measuring the bilirubin level:
use a transcutaneous bilirubinometer in babies with a gestational age of
35 weeks or more and postnatal age of more than 24 hours
if a transcutaneous bilirubinometer is not available, measure the serum
bilirubin
if a transcutaneous bilirubinometer measurement indicates a bilirubin
level greater than 250 micromol/litre check the result by measuring the
serum bilirubin
always use serum bilirubin measurement to determine the bilirubin level
in babies with jaundice in the first 24 hours of life
always use serum bilirubin measurement to determine the bilirubin level
in babies less than 35 weeks gestational age
always use serum bilirubin measurement for babies at or above the
relevant treatment threshold for their postnatal age, and for all
subsequent measurements
do not use an icterometer.
How to manage hyperbilirubinaemia
Use the bilirubin level to determine the management of hyperbilirubinaemia
in all babies (see threshold table1 and treatment threshold graphs2).
1
2
Guidance
The following guidance is based on the best available evidence. The full
guideline (www.nice.org.uk/guidance/CG98/Guidance) gives details of the
methods and the evidence used to develop the guidance.
Threshold table. Consensus-based bilirubin thresholds for management
of babies 38 weeks or more gestational age with hyperbilirubinaemia
Age
Bilirubin measurement (micromol/litre)
(hours)
0
6
12
18
24
30
36
42
48
54
60
66
72
78
84
90
96+
> 100
> 100
> 100
> 100
> 112
> 125
> 137
> 150
> 162
> 175
> 187
> 200
> 112
> 125
> 137
> 150
> 162
> 175
> 187
> 200
> 212
> 225
> 237
> 250
> 262
> 275
> 287
> 300
> 100
> 125
> 150
> 175
> 200
> 212
> 225
> 237
> 250
> 262
> 275
> 287
> 300
> 312
> 325
> 337
> 350
> 100
> 150
> 200
> 250
> 300
> 350
> 400
> 450
> 450
> 450
> 450
> 450
> 450
> 450
> 450
> 450
> 450
Consider
phototherapy
and repeat
bilirubin
measurement
in 6 hours
Start
phototherapy
Action
Repeat
bilirubin
measurement
in
612 hours
Perform an
exchange
transfusion
unless the
bilirubin
level falls
below
threshold
while the
treatment
is being
prepared
10
1.1
1.1.1
1.2
1.2.1
1.2.2
Refer to Routine postnatal care of women and their babies (NICE clinical guideline 37) for
information on breastfeeding support.
11
1.2.3
In all babies:
check whether there are factors associated with an increased
likelihood of developing significant hyperbilirubinaemia soon
after birth
examine the baby for jaundice at every opportunity especially in
the first 72 hours.
1.2.4
1.2.5
1.2.6
1.2.7
1.2.8
Additional care
1.2.9
12
Urgent additional care for babies with visible jaundice in the first
24 hours
1.2.10
1.2.11
Continue to measure the serum bilirubin level every 6 hours for all
babies with suspected or obvious jaundice in the first 24 hours of
life until the level is both:
below the treatment threshold
stable and/or falling.
1.2.12
1.2.13
4
5
13
1.3
1.3.2
1.3.3
14
1.3.5
1.3.6
1.4
Starting phototherapy
1.4.1
1.4.2
1.4.3
1.4.4
During phototherapy
1.4.5
During phototherapy:
repeat serum bilirubin measurement 46 hours after initiating
phototherapy
repeat serum bilirubin measurement every 612 hours when the
serum bilirubin level is stable or falling.
15
Stopping phototherapy
1.4.6
1.4.7
1.4.10
8
9
16
1.4.13
10
11
17
During phototherapy:
place the baby in a supine position unless other clinical
conditions prevent this
ensure treatment is applied to the maximum area of skin
monitor the babys temperature and ensure the baby is kept in
an environment that will minimise energy expenditure
(thermoneutral environment)
monitor hydration by daily weighing of the baby and assessing
wet nappies
support parents and carers and encourage them to interact with
the baby.
1.4.16
Give the baby eye protection and routine eye care during
phototherapy.
18
1.4.17
1.4.19
Phototherapy equipment
1.4.20
1.4.21
1.4.22
19
1.5
1.5.1
1.6
1.6.1
1.6.2
12
13
20
1.7
1.7.1
1.7.2
1.8
Intravenous immunoglobulin
1.8.1
1.8.2
21
1.9
Exchange transfusion
1.9.1
1.9.2
1.9.3
1.9.4
14
15
22
1.10
Other therapies
1.10.1
23
NICE guidelines are developed in accordance with a scope that defines what
the guideline will and will not cover. The scope of this guideline is available
from www.nice.org.uk/guidance/CG98 click on How this guidance was
produced.
This guideline covers all babies with jaundice from birth up to 28 days of age.
Special attention was given to the recognition and management of neonatal
jaundice in babies with dark skin tones.
It does not cover babies with jaundice that lasts beyond the first 28 days of
life, babies with jaundice that requires surgical treatment to correct the
underlying cause and babies with conjugated hyperbilirubinaemia.
How this guideline was developed
NICE commissioned the National Collaborating Centre for Womens and
Childrens Health to develop this guideline. The Centre established a guideline
development group (see appendix A), which reviewed the evidence and
developed the recommendations. An independent guideline review panel
oversaw the development of the guideline (see appendix B).
There is more information about how NICE clinical guidelines are developed
on the NICE website (www.nice.org.uk/HowWeWork). A booklet, How NICE
clinical guidelines are developed: an overview for stakeholders, the public and
the NHS (fourth edition, published 2009), is available from NICE publications
(phone 0845 003 7783 or email publications@nice.org.uk and quote reference
N1739).
Implementation
NICE has developed tools to help organisations implement this guidance (see
www.nice.org.uk/guidance/CG98).
24
Research recommendations
4.1
What are the factors that underlie the association between breastfeeding and
jaundice?
Why this is important
Breastfeeding has been shown to be a factor in significant
hyperbilirubinaemia. The reasons for this association have not yet been fully
elucidated.
This question should be answered by studying infants in the first 28 days of
life receiving different feeding types (breast milk, formula feeds or mixed
feeds). Infants who do not develop significant hyperbilirubinaemia should be
compared with infants with significant hyperbilirubinaemia. The outcomes
chosen should include maternal factors, neonatal factors and blood analyses.
4.2
What is the comparative effectiveness and cost-effectiveness of universal predischarge transcutaneous bilirubin screening alone or combined with a risk
assessment in reducing jaundice-related neonatal morbidity and hospital
readmission?
Why this is important
There is good evidence that a risk assessment that combines the result of a
timed transcutaneous bilirubin level with risk factors for significant
hyperbilirubinaemia is effective at preventing later significant
hyperbilirubinaemia.
This question should be answered by studying the effects of timed predischarge transcutaneous bilirubin levels and timed pre-discharge
25
4.3
Transcutaneous bilirubinometers
What is the comparative accuracy of the Minolta JM-103 and the BiliChek
when compared to serum bilirubin levels in all babies?
Why this is important
The accuracy of transcutaneous bilirubinometers (Minolta JM-103 and
BiliChek) has been adequately demonstrated in term babies below treatment
levels (bilirubin less than 250 micromol/litre). New research is needed to
evaluate the accuracy of different transcutaneous bilirubinometers in
comparison to serum bilirubin levels in all babies.
This question should be answered by comparing bilirubin levels taken using
different transcutaneous bilirubinometers with bilirubin levels assessed using
serum (blood) tests. The study population should comprise babies in the first
28 days of life, with subgroups including preterm babies, babies with dark skin
tones, babies with high levels of bilirubin and babies after phototherapy. The
outcomes chosen should include diagnostic accuracy (sensitivity, specificity,
positive predictive value, negative predictive value), parental anxiety, staff and
parental satisfaction with test and cost effectiveness.
4.4
26
4.5
National registries
27
5.1
Full guideline
The full guideline, Neonatal jaundice contains details of the methods and
evidence used to develop the guideline. It is published by the National
Collaborating Centre for Womens and Childrens Health, and is available from
www.ncc-wch.org.uk and our website
(www.nice.org.uk/guidance/CG98/FullGuidance).
5.2
5.3
28
Published
Diabetes in pregnancy: management of diabetes and its complications from
pre-conception to the postnatal period. NICE clinical guideline 63 (2008).
Available from www.nice.org.uk/guidance/CG63
Antenatal care: routine care for the healthy pregnant woman. NICE clinical
guideline 62 (2008). Available from www.nice.org.uk/guidance/CG62
Intrapartum care: care of healthy women and their babies during childbirth.
NICE clinical guideline 55 (2007). Available from
www.nice.org.uk/guidance/CG55
Routine postnatal care of women and their babies. NICE clinical guideline
37 (2006). Available from www.nice.org.uk/guidance/CG37
29
30
31
Kevin Ives
Consultant Neonatologist, John Radcliffe Hospital, Oxford
Paul Jacklin
Health Economist, National Collaborating Centre for Womens and Childrens
Health
Maria Jenkins
Parent member
Alison Johns
Transitional Care Sister, University College London Hospitals NHS
Foundation Trust
Juliet Kenny (from Jan 10)
Project Manager, National Collaborating Centre for Womens and Childrens
Health
Rajesh Khanna (until Apr 09)
Senior Research Fellow, National Collaborating Centre for Womens and
Childrens Health
Rosalind Lai
Information Scientist, National Collaborating Centre for Womens and
Childrens Health
Donal Manning
Consultant Paediatrician, Wirral University Teaching Hospital NHS Foundation
Trust
Hugh McGuire
Research Fellow, National Collaborating Centre for Womens and Childrens
Health
Stephen Murphy (from Sep 09)
Clinical Co-director, National Collaborating Centre for Womens and
Childrens Health
32
33
Caroline Keir (until January 2010), Sue Latchem (from January 2010)
Guideline Commissioning Manager
Nick Staples (until January 2010), Elaine Clydesdale (from January 2010)
Guidelines Coordinator
Judith Thornton
Technical lead
Acknowledgements
The NCC-WCH and the Guideline Development Group (GDG) would like to
thank Dr Giles Kendall MBBS, BSc(hons), MRCPCH PhD, Academic Clinical
Lecturer Neonatal Medicine, University College London/University College
London Hospital NHS Foundation Trust and TJ Cole, Professor of Medical
Statistics, MRC Centre of Epidemiology for Child Health, UCL Institute of
Child Health for allowing the GDG to adapt their Excel spreadsheet in
developing the treatment threshold graphs included in this guideline.
34
35
36
37
Bilirubin thresholds for phototherapy and exchange transfusion in babies with hyperbilirubinaemia
38
Bilirubin thresholds for phototherapy and exchange transfusion in babies with hyperbilirubinaemia
39
Bilirubin thresholds for phototherapy and exchange transfusion in babies with hyperbilirubinaemia
40
Bilirubin thresholds for phototherapy and exchange transfusion in babies with hyperbilirubinaemia
41
Bilirubin thresholds for phototherapy and exchange transfusion in babies with hyperbilirubinaemia
42
Bilirubin thresholds for phototherapy and exchange transfusion in babies with hyperbilirubinaemia
43
Bilirubin thresholds for phototherapy and exchange transfusion in babies with hyperbilirubinaemia
44
Bilirubin thresholds for phototherapy and exchange transfusion in babies with hyperbilirubinaemia
45
Bilirubin thresholds for phototherapy and exchange transfusion in babies with hyperbilirubinaemia
46
Bilirubin thresholds for phototherapy and exchange transfusion in babies with hyperbilirubinaemia
47
Bilirubin thresholds for phototherapy and exchange transfusion in babies with hyperbilirubinaemia
48
Bilirubin thresholds for phototherapy and exchange transfusion in babies with hyperbilirubinaemia
49
Bilirubin thresholds for phototherapy and exchange transfusion in babies with hyperbilirubinaemia
50
Bilirubin thresholds for phototherapy and exchange transfusion in babies with hyperbilirubinaemia
51
Bilirubin thresholds for phototherapy and exchange transfusion in babies with hyperbilirubinaemia
52
Bilirubin thresholds for phototherapy and exchange transfusion in babies with hyperbilirubinaemia
53