NICE asks NHS to follow new advice for neonatal jaundice
NHS healthcare professionals who look after newborn babies are being called on to adopt different ways of assessing and treating cases of jaundice, one of the most common conditions needing medical attention in newborn babies. Although generally harmless, some cases of severe jaundice can result in a serious neurological condition called kernicterus which is associated with long term problems such as cerebral palsy, hearing loss and visual and dental problems. In other cases, jaundice, particularly prolonged jaundice, may indicate serious underlying liver disease which requires urgent specialist care.
A new guideline published today (19 May) by the National Institute for Health and Care Excellence (NICE), recommends alterations to current NHS practice to recognise and treat neonatal jaundice effectively and avoid problems like kernicterus. NICE has also published a range of practical tools to help facilitate these recommended changes, available at www.nice.org.uk.
Dr Fergus Macbeth, Director of the Centre for Clinical Practice at NICE, said: “The majority of babies will develop jaundice in their first week of life and it will be generally harmless in most cases. Although the condition does have the potential to become serious, it can usually be easily treated with timely and appropriate medical care. This guideline will ensure that happens. It does recommend some changes to current medical practice but only when it is shown to be in the best interests of the baby.”
Jaundice is caused by high levels of bilirubin in the blood, a compound created by the breakdown of red blood cells (a normal bodily process). Around 80% of premature babies and 60% of babies born at full term develop jaundice in their first week of life[i]. Despite this, clinical recognition of the severity of the jaundice can be difficult, especially in babies with darker skin tones, and uncertainty currently exists about when and how to treat it. This new guideline aims to address this by helping midwives, health visitors and paediatricians, amongst others, recognise and treat neonatal jaundice to prevent problems like kernicterus.
Dr Janet Rennie, Chair of the Guideline Development Group (GDG) and Consultant Neonatologist at University College Hospital London, said:“This new guideline should have a significant impact on the diagnosis and treatment of neonatal jaundice, by proposing changes to current practice. These include not relying on visual inspection alone to estimate bilirubin levels, with specific advice on when to start, stop, or increase light treatment (phototherapy) and when to consider exchange transfusion (a complete swap of the baby's blood). These recommendations should ensure that babies who have factors associated with an increased likelihood of developing significant jaundice are identified earlier so they receive prompt effective and appropriate treatment, directed at preventing permanent damage.”
Key recommendations include:
- Examining all babies for jaundice at every opportunity especially in the first 72 hours and identifying those more likely to develop jaundice that will require treatment. However, do not rely on visual inspection alone to estimate the bilirubin level of a baby with jaundice.
- Measuring and recording the serum bilirubin level within 2 hours for all babies in the first 24 hours of life with suspected or obvious jaundice. Continue to measure serum bilirubin every 6 hours for all babies with suspected or obvious jaundice in the first 24 hours of life until certain criteria are met (as set out in the guideline).
- Using a transcutaneous bilirubinometer (TBM) to measure the bilirubin level of babies with a gestational age of 35 weeks or more and a postnatal age of more than 24 hours who are thought to look jaundiced. If a TBM is not available, or if it indicates a bilirubin level greater than 250 micromol/litre, check the result by measuring the baby's serum bilirubin.
- Always use serum bilirubin measurement to determine the bilirubin level in babies with jaundice in the first 24 hours of life and in babies less than 35 weeks gestational age. Serum bilirubin measurement should also be used to determine how more serious neonatal jaundice should be treated.
- Using phototherapy (light therapy) to treat jaundice above a certain threshold, stepping up to multiple phototherapy or double volume exchange transfusion (a type of blood transfusion) to treat babies with serious jaundice. Guidance is provided for judging the threshold for treatment, according to the baby's gestational and postnatal age.
- Use intravenous immunoglobulin (IVIG) alongside continuous multiple phototherapy in certain cases (as set out in the guideline).
- Offering parents or carers information about neonatal jaundice that is tailored to their needs and addresses any concerns they may have.
Tools developed by NICE to help the NHS implement this guideline include innovative practical approaches, such as interactive treatment graphs that can be used by healthcare professionals caring for jaundiced babies. There is currently widespread variation in the treatment of neonatal jaundice and these graphs will help ensure that all babies with jaundice get the right treatment. The treatment threshold graphs are available on the NICE website. Information leaflets for parents, patients and carers, and costing templates and audit tools for managers and commissioners are also available online.
Yvonne Benjamin, Community Midwife for University Hospitals Leicester NHS Trust and part of the GDG, said: “This represents a real step forward in the care of newborn babies with jaundice. In the past, it's not always been clear when treatment should begin, especially as jaundice can be difficult to spot in some babies. Midwives, health visitors, neonatologists and paediatricians now have some definite guidance and tools to help them detect and treat the condition in the most effective manner.”
Farrah Pradhan, whose son developed jaundice soon after he was born, also helped develop this guideline: “Being premature, my son was more likely to develop jaundice than other babies, although I didn't know that at the time. Thankfully, his treatment was straightforward; he was given phototherapy and made a full recovery, but I know some newborns aren't that fortunate.
“Midwives and doctors already do a great job caring for sick babies and I hope this guideline helps them even more. I'm especially pleased with the leaflet for parents and carers that's been developed. It'll give parents the facts about jaundice, how to check for it themselves and what to do if they think their baby might have jaundice. Hopefully it'll save them some of the inevitable worry if their baby needs medical help.”
This guideline has been jointly developed with the National Collaborating Centre for Women and Children's Health. For more information, or to download the guideline or tools, please visit the NICE website.
This page was last updated: 19 May 2010