Neonatal

NEONATAL Policy & Procedures

HYPERBILIRUBINEMIA IN Manual
< 35 WEEKS
Policy Group
Integument
Approved by: Date Effective
September, 2015
Gail Cameron
Senior Director, Operations Maternal, Neonatal & Child Health Programs Next Review

Dr. Paul Byrne September, 2018

Medical Director, Neonatology

Dr. Sharif Shaik

Medical Director, Neonatology

Purpose To identify and treat neonates at risk for hyperbilirubinemia and to prevent and reduce the
incidence of neonatal hyperbilirubinemia encephalopathy and kernicterus.

Policy • All infants 32 weeks to less than 35 weeks gestation will have TcB (Transcutaneous
Statement Bilirubin) or SB (serum bilirubin) measured in the first 72 hours of life.
• Infants less than 32 weeks gestation will have SB done before 36 hours of life. This may
be timed with the Newborn Metabolic Screen.
• Infants with visible jaundice in the first 24 hours will have a TcB or SB done within 2
hours.
• TcB levels that suggest treatment is needed, are confirmed with a SB level before
treatment is started.
• Decisions for further screening or treatment will be made based on National Institute for
Health & Clinical Excellence (NICE) treatment threshold guidelines for gestational age.
• Information will be given to parents regarding jaundice, screening for jaundice, and
treatment information as applicable (phototherapy / exchange transfusion).

Applicability This policy applies to Covenant Health employees, members of the medical and midwifery
staff, students, volunteers and other persons acting on behalf of or in conjunction with
Covenant Health (including contracted services providers as necessary).

Assessment 1. All newborns less than 35 weeks will be monitored for the development of
hyperbilirubinemia by physical assessment for the presence of jaundice every 6 hours
for the first week of life. This includes the evaluation of jaundice when the forehead skin
is blanched with digital pressure.

2. Serum Bilirubin Monitoring

a. Infants visibly jaundiced within the first 24 hours of life will have a screening TcB or
SB measured within 2 hours of recognition.
b. All newborns 32 weeks to less than 35 weeks will have their TcB measured every 12
hours between 24 h and 48 h of life.
c. If phototherapy is started within the first 24 hours of life, a follow-up SB will be
ordered 6 hours after treatment is started to detect a rapidly rising bilirubin level.
d. If phototherapy is started after the first 24 hours, a follow-up SB will be ordered 24
hours after treatment is started to determine the effectiveness of the therapy.
e. A SB 24 hours after phototherapy is discontinued is done to detect rebound level.
f. Additional TcB or SB will be ordered by a physician or nurse practitioner.
g. SB at the end of and 6 hours after exchange transfusion.
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Assessment 3. SB results will be plotted on a gestational age specific treatment threshold graph to
determine the risk of progression of severe hyperbilirubinemia and recommendation for
treatment.

4. Infants visibly jaundiced within the first 24 hours of life will have a systemic assessment
including evaluation of maternal & infant blood group, DAT, and CBC with peripheral
smear.

5. If the SB is approaching exchange levels or not responding to phototherapy, check

reticulocyte count and evaluate for G6PD.

6. Do not subtract direct bilirubin level from TSB to determine treatment.

7. Infants with severe or prolonged hyperbilirubinemia should be investigated further,

including measurement of conjugated component of bilirubin.

Refer to NEONATAL JAUNDICE- Investigation Pathway

Treatment Phototherapy
The efficacy of phototherapy depends on the dose of phototherapy administered. The
dose is dependent on the spectrum of light emitted by the unit, spectral irradiance, and
spectral power (average irradiance across the surface area). Efficacy also depends on
cause of jaundice with less power to lower SB if the cause is related to hemolysis or if
cholestasis is present.

Phototherapy will be started at the SB level indicated on the gestational age specific graph
based on the infant’s age in hours.

Refer to NICE phototherapy guidelines for gestational age specific recommendations

http://guidance.nice.org.uk/CG98/treatmentthresholdgraph/xls/English

Continuous intensive phototherapy is recommended when:

SB rising rapidly >8.5 micromol/L/hr
SB fails to respond to single phototherapy
SB within 50 micromol/L of exchange transfusion when less than 72 hours old

Intensive phototherapy provides coverage over as much body surface as possible with light
intensity at least 30µW/cm2 / nm. To maximize phototherapy intensity, the distance
between the light and patient should be minimized subject to manufacturer’s
recommendations for halogen phototherapy. Surface area receiving phototherapy can be
maximized by using a fibre-optic blanket phototherapy unit. More than one spot
phototherapy light may be used if the light area does not cover the anterior surface area of
the patient.

May change to conventional phototherapy use if SB greater than 50 micromol/L less than
threshold for exchange.
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Treatment Discontinuing phototherapy depends on the age at which phototherapy was initiated and
the cause of the hyperbilirubinemia. For infants who are readmitted after their birth
hospitalization with hyperbilirubinemia not related to an identified pathology, phototherapy
may be discontinued when the SB falls below 240µmol/L.

Refer to Phototherapy Pathway

Care during phototherapy

Position supine
Expose the maximum amount of skin. Remove diaper if levels are close to exchange
levels.
Monitor hydration. Fluids may need to be increased.
Provide eye protection and routine eye care while under phototherapy unless infant is
swaddled using fibreoptic phototherapy only with no light exposure to the eyes.
Intensive phototherapy is not interrupted for feeds.
Assess newborn at least every 4 hours for the following:
-Temperature
-Skin integrity / Color
-Muscle Tone
-General behaviour (activity and position)
-Hydration

Intravenous Immune Globulin (IVIG)

IVIG may be indicated for isoimmune haemolytic disease and SB rising >8.5 micromol/L/hr
or if patient SB is within 35-50 micromol/L of exchange level despite intensive
phototherapy. Dose is 0.5 – 1 gram /kg over 2 hours. Dose can be repeated in 12 hours if
needed.

Exchange Transfusions
Decision for an exchange transfusion will be based on the SB level indicated on the
gestational age specific graph based on the infant’s age in hours or if signs of acute
bilirubin encephalopathy are present (hypertonia, arching, retrocollis, opisthotonus, fever,
high pitched cry).
Performed only by trained personnel in neonatal intensive care units with full monitoring
and resuscitation capabilities
Double-volume exchange transfusions are preferred.
Arterial-venous exchange transfusions preferred to venous exchange transfusion
Do not routinely administer calcium during exchange transfusion.
Continue intensive phototherapy during exchange transfusion

Refer to Exchange Transfusion Pathway

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References Evidence Update Advisory Group NICE (2012) Neonatal jaundice: Evidence Update March
2012.A summary of selected new evidence relevant to NICE clinical guideline 98 ‘Neonatal
jaundice’ (2010). National Institute for Clinical Evidence: Manchester U.K.

National Collaborating Centre for Women’s and Children’s Health Commissioned by the
National Institute for Health and Clinical Excellence (May 2010). Neonatal Jaundice. Royal
College of Obstetricians and Gynaecologists: London.
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NEONATAL JAUNDICE – Investigation Pathway Care for babies < 35 weeks gestation

Check for signs of acute bilirubin

Offer parents/carers Go to exchange
encephalopathy
information about transfusion pathway
- hypertonia, arching, retrocollis,
neonatal jaundice Examine for jaundice every 6 hours opisthotonus, fever, high pitched
during the first week. cry.

Does the baby have suspected or Yes Measure and record

obvious jaundice in the first 24 hours?
serum bilirubin level
within 2 hours.
No
Ensure adequate
support is offered to all Does the baby have visible jaundice
women who intend to at greater than 24 hours age?
breastfeed exclusively

No Yes

Treatment threshold graphs Continue to measure the

are available at Measure serum bilirubin at Measure and record serum serum bilirubin level
www.nicu.org.uk/guidance/ 24 – 48 hrs of age bilirubin level within 6 hours every 6 hours until the
CGSB level is both:
-below the treatment
threshold
- Stable and/or falling

Manage hyperbilirubinaemia Perform a medical

Interpret results using treatment threshold graphs according to gestational age at birth and age in hours review as soon as
possible and within 6
hours to exclude
pathological causes of
jaundice
Monitor bilirubin levels Treat using phototherapy Treat using exchange transfusion

Bilirubin levels may be screened with TcB before

Go to phototherapy pathway Go to exchange transfusion pathway
phototherapy or 48 hrs after phototherapy has
been stopped. TcB levels are confirmed with a
TSB before treatment is started.
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Phototherapy pathway Is serum bilirubin level:

• Rising rapidly (more than 8.5 micromol/litre/hour) and /or
• Within 50 micromol/litre below the threshold for which exchange transfusion is
Offer information to parents and
indicated after 72 hours?
carers about phototherapy

No Yes

Start single phototherapy Start continuous intensive phototherapy

• Using clinical judgement encourage • Do not interrupt for feeding
short breaks for breastfeeding, • Continue administration of
diaper changes and cuddles intravenous / enteral feeds
Perform formal assessment: • Continue lactation/feeding support • Continue lactation / feeding support
• Clinical examination • Do not give additional fluids or feeds • Monitor hydration by daily weights
• Serum bilirubin routinely and assessment of urine output
• Blood packed cell • Monitor hydration by daily weights
volume and assessment of urine output
• Blood group of mother
and baby
• DAT
Check serum bilirubin level:
Consider:
• 6 hours after starting phototherapy
• Full blood count and
examination of blood film
Check serum bilirubin level: • Every day if bilirubin level is stable or
• 24 hrs after starting phototherapy falling
• Blood glucose-6-
phophate
• Microbiological cultures
of blood, urine and
cerebrospinal fluild
Is serum bilirubin level stable or falling?
Is serum bilirubin level stable or falling?
Yes
Yes No
Is serum bilirubin level 50
Continue
micromol/litre belwo No continuous
Is serum bilirubin level at least 50 micromol/litre below threshold for exchange
intensive
threshold for phototherapy? transfusion?
phototherapy
and check
Yes No serum bilirubin
Yes No
level Q 12
Step down to Go to ‘Manage hours
Stop phototherapy Go to ‘Manage hyperbilirubinaemia’ hyperbilirubinaemia’ box in
Check serum bilirubin for rebound box in ‘Investiation pathway’ single
phototherapy “Investigation pathway’
after 24 hours
Hyperbilirubinemia in Less Than 35 Weeks
Exchange transfusion pathway
Offer information to parents and
carers about exchange transfusions
and intravenous immunoglobulin
(IVIG) including:
• Why the treatment is being
considered
• Anticipated duration of
treatment
• Possible adverse effects
• When it will be possible for
parents or carers to see and
hold the baby
• The need to admit the baby
to intensive care for an
exchange transfusion (if
needed)
During exchange transfusion, do
not:
• Stop continuous intensive
phototherapy
• Perform a single-volume
exchange
• Use albumin priming
• Routinely administer
intravenous calcium
Date Approved Policy Group Page 7 of 8
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Prepare for exchange transfusion
• Initiate/maintain continuous intensive phototherapy
• Use IVIG(500 mg/kg over 4 hours) for babies with Rhesus or ABO haemolytic
disease if serum bilirubin level rises by more than 8.5 micromol/litre/hour
Serum bilirubin level falls to below Baby has:
threshold for exchange transfusion • Bilirubin level that remains above
threshold for exchange
transfusion
And/or
• Clinical signs of acute bilirubin
encephalopathy
Continue intensive phototherapy and
perform exchange transfusion
Continue intensive phototherapy and
measure bilirubin level within 2 hours of
exchange transfusion and manage
according to threshold table and
treatment threshold graphs
Go to ‘Manage hyperbilirubinaemia’ box in “Investigation pathway’
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Signing
Original Signed
September, 2015
_________________________ ____________________
GAIL CAMERON DATE
SENIOR DIRECTOR, OPERATIONS
MATERNAL, NEONATAL & CHILD HEALTH PROGRAMS
COVENANT HEALTH
GREY NUNS & MISERCORDIA HOSPITALS

Original Signed September, 2015

_________________________ ____________________
DR. PAUL BYRNE DATE
MEDICAL DIRECTOR
NEONATAL PROGRAM
COVENANT HEALTH
GREY NUNS HOSPITAL

Original Signed September, 2015

_________________________ ____________________
DR. SHARIF SHAIK DATE
MEDICAL DIRECTOR
NEONATAL PROGRAM
COVENANT HEALTH
MISERCORDIA HOSPITAL