Neonatal Jaundice for Infants 35 Weeks Gestational Age v.

2
Executive Summary

Test Your Knowledge

Inclusion Criteria
Previously healthy
Age 14 days
Born at 35 wks gestational age

Exclusion Criteria
Direct hyperbilirubinemia
Meets NICU Direct Admit Criteria
TSB > 5mg/dL above exchange
transfusion threshold
Signs of acute bilirubin
encephalopathy
Suspected sepsis or
ill-appearing

Automatic NICU Admission Criteria

Signs of acute bilirubin encephalopathy
TSB > 5 mg/dL above exchange
transfusion threshold
Include NICU attending on calls for
patients that meet NICU direct admit
criteria.
Admit to NICU

NICU
(Off Pathway)

Explanation of Evidence Ratings

Summary of Version Changes

PHASE I (E.D.)

Pathophysiology

Initial Assessment

Risk for Kernicterus

Clinical History / Physical Exam

Blood Glucose
Total Serum Bilirubin (TSB) with conjugated fraction
Initiate ED Hyperbilirubinemia (Neonatal) Orders
Start phototherapy while awaiting results if clinically indicated
Determine exchange transfusion threshold using AAP nomogram
Determine phototherapy threshold using BiliTool or AAP nomogram
Web Link to BiliTool
BiliTool

Evaluate for Discharge

Evaluate for NICU Consult Criteria

TSB below phototherapy threshold

Follow-up appointment arranged for next
day
Feeding adequately
No concern for significant hemolysis

TSB within 2mg/dL of exchange

transfusion threshold
Age < 24 hours
High suspicion for or lab evidence of
hemolysis (e.g. DAT positive)

!
Supplemental
IV Fluids NOT
routinely indicated

Evaluate for Inpatient Admission

TSB above phototherapy threshold but
not within 2mg/dL of exchange
transfusion threshold (e.g. at 72 hours of
age, exchange transfusion threshold 24
and TSB 21)

Meets discharge criteria

Admit on phototherapy

Discharge

Inpatient
Admission

ED Management

TSB rising or
meeting NICU
admission criteria

Give effective phototherapy

feeding. The infant should not be removed from bili lights
Encourage feeding
for > 20 mins in any 3 hour period. Use bottle if needed.
DO NOT interrupt phototherapy for patients nearing exchange
transfusion threshold or with rapidly rising TSB
Use maternal EBM for supplemental feeds, when available
Give 20 mL/kg NS bolus then maintenance IV fluids for patients that
meet NICU consult criteria
Consider additional labs
For questions concerning this pathway,
contact:NeonatalJaundice@seattlechildrens.org
2012, Seattle Childrens Hospital, all rights reserved, Medical Disclaimer

TSB stable or
falling and otherwise
clinically well

Last Updated: 05/31/2012

Valid until: 05/31/2015

Neonatal Jaundice for Infants 35 Weeks Gestational Age v.2

PHASE II (INPATIENT)

Inclusion Criteria
Previously healthy
Age 14 days
Born at 35 wks gestational age

Exclusion Criteria

Direct hyperbilirubinemia
Meets NICU Direct Admit Criteria
TSB > 5mg/dL above exchange
transfusion threshold
Signs of acute bilirubin
encephalopathy
Suspected sepsis or ill-appearing

Supplemental
IV Fluids NOT
routinely indicated

!
Rebound TSB
NOT routinely
indicated prior to
discharge

Inpatient Management
Initiate Hyperbilirubinemia (Neonatal) Admit Orders
If direct admit, obtain baseline total serum bilirubin (TSB)
Continue effective phototherapy until TSB at least 3 mg/dL below phototherapy threshold
feeding The infant should not be removed from bili lights for > 20 mins in any 3
Encourage feeding.
hour period. Use bottle if needed.
If patient unable to maintain normal temperature in an open crib, place in isolette per
Isolette
Isolette Use
Use Policy
Policy &
& Procedure
Procedure
Consider additional labs for patients meeting NICU consult criteria
Run maintenance IV fluids for patients within 2 mg/dL of exchange transfusion threshold or
with rapidly rising TSB. Stop IVF once TSB has fallen to at least 2 mg/dL below exchange
transfusion threshold and feeding well (e.g. at 72 hours of age, exchange transfusion threshold
24 and TSB less than 22)

TSB within 2 mg/dL of exchange transfusion threshold,

age <72 hours, or known/suspected hemolysis?

No

No

Yes

Subsequent Labs

Subsequent Labs

TSB approximately 12 hours after starting

phototherapy (or with routine AM labs)
Subsequent checks as clinically indicated

TSB every 4 hours until TSB falling

G6PD (for unexplained hemolysis)

Meets Discharge Criteria

Patient off phototherapy and otherwise well
Follow-up appointment arranged for next day
No concern for significant ongoing hemolysis
Yes

Discharge

For questions concerning this pathway,

contact:NeonatalJaundice@seattlechildrens.org
2012, Seattle Childrens Hospital, all rights reserved, Medical Disclaimer

Last Updated: 05/31/2012

Valid until: 05/31/2015

Return to ED Management

Return to Inpatient Management

Return to ED Management

Return to Inpatient Management

Go to Pathophysiology Pg 2
Return to ED Management
Return to Inpatient Management

Go to Pathophysiology Pg 3

Return to ED Management

Return to Inpatient Management

Go to Pathophysiology Pg 4
Return to ED Management

Return to Inpatient Management

Return to ED Management

Return to Inpatient Management

Return to ED Management
Return to Inpatient Management

Return to ED Management

Return to Inpatient Management

Return to ED Management

Return to Inpatient Management

Return to ED Management

Return to Inpatient Management

Guidelines for Initiation of Phototherapy

In Hospitalized Infants of 35 or More Weeks Gestation
These levels are
approximations
representing a
consensus based
on limited
evidence.
[LOE: E (AAP
2004)]

AAP. Pediatrics 2004;114(1):297-316

2004 by American Academy of Pediatrics

Return to ED Management

Return to Inpatient Management

Guidelines for Exchange Transfusion

In Infants 35 or More Weeks Gestation
These levels are
approximations
representing a
consensus based
largely on the goal of
keeping TSB levels
below those at which
kernicterus has been
reported.
[LOE: E (AAP 2004)]

AAP. Pediatrics 2004;114(1):297-316

2004 by American Academy of Pediatrics

Return to ED Management

Return to Inpatient Management

Return to ED Management

Return to Inpatient Management

Return to ED Management

Return to Inpatient Management

Return to ED Management

Return to Inpatient Management

Return to ED Management

Return to Inpatient Management

Return to ED Management

Return to Inpatient Management

Return to ED Management

Return to Inpatient Management

Feeding
Encourage feeding. The infant should not be removed from bili lights for
> 20 mins in any 3 hour period. Use bottle while remaining under bili
lights if needed
Use maternal expressed breast milk for supplemental feeds, when
available
Lactation consultation if mom desires to breast feed

Rationale:
Formula feeds and breastfeeding are equally effective at reducing serum
bilirubin during phototherapy.
[LOE: moderate quality (NICE 2010)]

Return to ED Management

Return to Inpatient Management

Return to ED Management

Return to Inpatient Management

Return to ED Management

Return to Inpatient Management

Return to ED Management

Return to Inpatient Management

Return to ED Management

Return to Inpatient Management

Return to ED Management

Return to Inpatient Management

Executive Summary

To Exec Summary Pg2

Return to ED Management

Return to Inpatient Management

Executive Summary

Return to ED Management

Return to Inpatient Management

Self-Assessment
Completion qualifies you for 1 hour of Category II CME credit. If you are taking this self-assessment as a
part of required departmental training at Seattle Childrens Hospital, you MUST logon to Learning Center.
1.

Which of the following patients would not be eligible for the neonatal jaundice pathway?
a. 5 day old term infant with a total serum bilirubin of 22.4, direct of 1.5
b. 3 day old ex-36 week SGA infant with a total serum bilirubin of 19.2, direct of 0.3
c. 6 day old lethargic ex-39 week infant with delayed capillary refill and total serum bilirubin of
21.1, direct of 0.1
d. 60 hour old ex-37 week infant with a total serum bilirubin of 21.9, Coombs+

2.

A 5 day old ex-39 week infant had TSB of 21.7 at PCP earlier today. Weight loss is ~11% from birth.
Infant is otherwise well. Moms milk has just come in. In the ED, in addition to a TSB, initial
laboratory screening would include:
a. Complete blood count
b. Direct antibody test (DAT)
c. Blood glucose level
d. Electrolytes
e. All of the above

3.

In the same patient (5 day old ex-39 week infant, TSB of 21.7 from PCP, ~11% weight loss from
birth, otherwise well, moms milk just come in), what would be appropriate to do in the ED while
awaiting initial laboratory results?
a. Keep the baby NPO
b. Administer a 20 mL/kg normal saline IV bolus
c. Consult the NICU
d. Start phototherapy

4.

True or False: Supplemental IV fluids are routinely indicated in the treatment of neonatal
hyperbilirubinemia?

5.

A 96 hour old ex-38 week infant presents to the ED with a total serum bilirubin of 21.9. He is
otherwise well. What is the most appropriate next step?
a. Keep the baby NPO
b. Start phototherapy and admit to the floor
c. Give a 20 mL/kg normal saline IV bolus
d. Consult the NICU

6.

A 48 hour old ex-37 week infant presents to the ED with a total serum bilirubin of 19.1. All of the
following would be appropriate except:
a. Bottle feed ad lib
b. Continue breast feeding up to 20 minutes every 2-3 hours
c. Give a 20 mL/kg normal saline IV bolus
d. Consult the NICU
e. Start phototherapy

7.

You are initiating phototherapy for a patient and measure irradiance of 23 W/cm2/nm. You
should:
a. Adjust the overhead light until the radiometer reading is less than 20 W/cm2/nm
b. Adjust the overhead light until the radiometer reading is at least 30 W/cm2/nm
c. Adjust the overhead light until the radiometer reading is at least 50 W/cm2/nm
d. Nothing
e. Remove the infant's diaper to expose more surface area then recheck the radiometer reading

8.

How often should total serum bilirubin be checked?

a. Every 12 hours until discharge
b. Every 4 hours until it is falling if age less than 96 hours
c. Every 4 hours until it is falling if TSB is within 2 mg/dL of exchange transfusion threshold
d. a & c only
e. a, b & c

9.

A 4 day old ex-38 week infant born at home presents to the ED looking "yellow" for the last few
days. He is now refusing to latch with arching and extreme fussiness. Which next step is
associated with the best outcome?
a. Give a normal saline IV bolus as soon as possible in the ED
b. Obtain a total serum bilirubin immediately in the ED
c. Start phototherapy
d. Admit immediately to the NICU for rapid exchange transfusion

10.

You have treated a now 6 day old ex-term infant with 16 hours of phototherapy for breastfeeding
jaundice. TSB declined from peak of 21.2 to now 14.8. What is the best next step?
a. Stop phototherapy and check a TSB in 8 hours
b. Stop phototherapy and check a TSB in 12 hours
c. Continue phototherapy and check TSB q12 hours until < 12 mg/dL
d. Discharge home on home phototherapy
e. Discharge home
f. Discharge home with PCP follow up in 2-3 days

View Answers

Return to ED Management

Return to Inpatient Management

Answer Key
1.

Answer: c.
Infants with systemic illness (e.g. sepsis) should be excluded from the pathway.

2.

Answer: c.
Breastfeeding jaundice; NICU consult criteria not met. Labs minimized to TSB and blood glucose.

3.

Answer: d.
Not close to exchange & TSB not rapidly rising. Outside TSB met threshold to initiate phototherapy.

4.

Answer: false.
Routine use of supplemental IV fluids is not indicated.

5.

Answer: b.
TSB is above phototherapy threshold, but not within 2 mg/dL of exchange.

6.

Answer: b.
Do not interrupt phototherapy when near exchange level.

7.

Answer: b.
The minimum recommended dose is 30 W/cm2/nm.

8.

Answer: c.
Frequent checks are indicated when near exchange.

9.

Answer: d.
Infants with signs of acute bilirubin encephalopathy should be admitted directly to NICU.

10.

Answer: e.
Rebound TSB not routinely necessary prior to discharge, F/U appt next day.

Return to ED Management

Return to Inpatient Management

Evidence Ratings
We used the GRADE method of rating evidence quality. Evidence is first assessed as to
whether it is from randomized trial, or observational studies. The rating is then adjusted in
the following manner:
Quality ratings are downgraded if studies:
Have serious limitations
Have inconsistent results
If evidence does not directly address clinical questions
If estimates are imprecise OR
If it is felt that there is substantial publication bias
Quality ratings can be upgraded if it is felt that:
The effect size is large
If studies are designed in a way that confounding would likely underreport the magnitude
of the effect OR
If a dose-response gradient is evident
Quality of Evidence:
High quality
Moderate quality
Low quality
Very low quality
Expert Opinion (E)
Reference: Guyatt G et al. J Clin Epi 2011: 383-394

To Bibliography

Return to ED Management

Return to Inpatient Management

Summary of Version Changes

Version 1 (5/31/2012): Go live
Version 2 (4/2/2013): Added recommendation for ED to notify NICU attending if patient meets
NICU admission criteria; established recommendations for removal from phototherapy for
feeding.

Return to ED Management

Return to Inpatient Management

Medical Disclaimer
Medicine is an ever-changing science. As new research and clinical experience
broaden our knowledge, changes in treatment and drug therapy are required.
The authors have checked with sources believed to be reliable in their efforts to
provide information that is complete and generally in accord with the standards
accepted at the time of publication.
However, in view of the possibility of human error or changes in medical sciences,
neither the authors nor Seattle Childrens Healthcare System nor any other party
who has been involved in the preparation or publication of this work warrants that
the information contained herein is in every respect accurate or complete, and
they are not responsible for any errors or omissions or for the results obtained
from the use of such information.
Readers should confirm the information contained herein with other sources and
are encouraged to consult with their health care provider before making any
health care decision.
Return to ED Management

Return to Inpatient Management

For questions concerning this pathway,

contact: xxxx@seattlechildrens.org

Last Updated: xx/xx/xxxx

Valid until: xx/xx/xxxx

Bibliography

Identification
52 records identified through
database searching

0 additional records identified

through other sources

Screening
48 records after duplicates removed

48 records screened

21 records excluded

27 full-text articles assessed for eligibility

22 full-text articles excluded,

16 did not answer clinical question
6 did not meet quality threshold

Elgibility

Included
6 studies included in pathway
Flow diagram adapted from Moher D et al. BMJ 2009;339:bmj.b2535
To Bibliography
Return to ED Management

Return to Inpatient Management

Bibliography
American Academy of Pediatrics, Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia in the
newborn infant 35 or more weeks gestation. Pediatrics. 2004;114(1):297-316
American Academy of Pediatrics, Subcommittee on Hyperbilirubinemia. Phototherapy to prevent severe neonatal
hyperbilirubinemia in the newborn infant 35 or more weeks gestation. Pediatrics. 2011;128(4):e1046-e1052
Atkinson LR, et al. Phototherapy use in jaundiced newborns in a large managed care organization: do clinicians
adhere to the guideline? Pediatrics .2003;111:e555
Barak M, et al. When should phototherapy be stopped? A pilot study comparing two targets of serum bilirubin
concentration. Acta Paediatrica. 2009; 98:(2)277-281
Bhutani VK, et al. A systems approach for neonatal hyperbilirubinemia in term and near-term newborns. J Obstet
Gynecol Neonatal Nurs. 2006;35:444-455
Chavez GF, et al. Epidemiology of Rh hemolytic disease of the newborn in the United States. JAMA. Jun 26
1991;265(24):3270-4
Eggert LD, et al. The effect of instituting a prehospital-discharge newborn bilirubin screening program in an 18hospital health system. Pediatrics. 2006;117:e855-e862
Harris M, et al. Developmental follow-up of breastfed term and near-term infants with marked hyperbilirubinemia.
Pediatrics. 2001;107:1075-1080

Kaplan M, et al. Post-phototherapy neonatal bilirubin rebound: a potential cause of significant hyperbilirubinaemia.
Archives of Disease in Childhood. 2006; 91:(1)31-34
Maisels MJ, Kring E. Bilirubin rebound following intensive phototherapy. Arch Pediatr Adolesc Med. 2002;156(7):669
672
Maisels MJ, Kring EA. Length of stay, jaundice, and hospital readmission. Pediatrics. 1998;101:995-998
Murray NA, Roberts IA. Haemolytic disease of the newborn. Arch Dis Child Fetal Neonatal Ed. Mar 2007;92(2):F83-8
National Institute for Health and Clinical Excellence. Neonatal jaundice. (Clinical guideline 98.) 2010.
www.nice.org.uk/CG98
Newman TB, et al. Frequency of neonatal bilirubin testing and hyperbilirubinemia in a large health maintenance
organization. Pediatrics. 1999;104:1198-1203
Spencer J. Common problems of breastfeeding and weaning. UpToDate. March 2012. http://uptodate.com
Tan KL. The nature of the dose-response relationship of phototherapy for neonatal hyperbilirubinemia. J Pediatr.
1977;90(3):448-452
Tan KL. The pattern of bilirubin response to phototherapy for neonatal hyperbilirubinemia. Pediatr Res. 1982;16(8):670674
Wagle S, Rosenkrantz T (ed.). Hemolytic Disease of Newborn. Medscape Reference. May 2011.
http://emedicine.medscape.com

Return to ED Management

Return to Inpatient Management