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Implications for practice: NICE neonatal jaundice guideline
Journal of Neonatal Nursing (2011) 17, 20e21
www.elsevier.com/jneo
CLINICAL PRACTICE
Implications for practice: NICE neonatal jaundice guideline Alison Johns Available online 25 November 2010
Key priorities for implementation Information As neonatal nurses, we have been good at explaining treatment and equipment to parents. We may not have been quite as efficient at providing written information for them to digest later, but have now been provided with an ease to understand leaflet from NICE (download from www.nice.org) if your Trust do not already have their own. This leaflet empowers parents and carers to actively seek help if they are concerned that their baby is showing signs of jaundice. What needs to be added is the pathway to be followed, which will vary from Trust to trust, but needs to be clear so that no jaundiced baby is missed. More explicit information will be required by parents of babies who have jaundice due to ABO incompatibility, G6PD or are close to or above the exchange transfusion line. A good explanation, supported by a more complex leaflet, will give them the additional knowledge they require.
Care for all babies Being aware of infants who are at higher risk of hyperbilirubinaemia is good practice, this will be most apparent on Labour Ward and in the postnatal area, for serum bilirubin (SBR) or E-mail address: [email protected]. 1355-1841/$ - see front matter doi:10.1016/j.jnn.2010.11.003
transcutaneous bilirubin measurement (TcB) depending on age & gestation (TcB only if >35 weeks, >24 h). Make parents aware (preferably antenatally!) that if their previous baby required treatment ie prolonged phototherapy or exchange transfusion, that this is very likely to recur in this pregnancy. The evidence definitely shows that a decision to solely breast feed is a risk factor for hyperbilirubinaemia, however, this gives us excellent opportunities to support breast feeding in order to maximise milk production. Good antenatal preparation and honest expectations will empower women so that their baby has the best chance to be fully breast fed, and therefore be less at risk of hyperbilirubinaemia. These higher risk babies need to be assessed at 48 h for jaundice whether they are in hospital or already at home, which will put a further strain on community services.
How to measure the bilirubin level As previously mentioned, transcutaneous bilibubin measurements may be used for all jaundiced babies who are over 24 h of age, and above 35 weeks gestation. Once the TcB is 250 mmol/L, SBR should be performed. As jaundice in the first 24 h of life is abnormal, and may indicate sepsis, ABO incompatability or Rhesus iso immunization, it must be measured as SBR, along with Group & DAT and any other appropriate investigations eg septic screen.
A. Johns
21
How to manage hyperbilirubinaemia Don’t forget that the guideline has been aimed at “well” babies, as sick babies may well require intervention at lower thresholds of bilirubin. Using the graph for the appropriate gestation, plot carefully, commence phototherapy using conventional overhead phototherapy for babies >38 weeks (babies <37 weeks may manage using fibreoptic phototherapy) and repeat SBR in 4e6 h depending on circumstances. It is no longer appropriate to use TcB whilst babies are receiving phototherapy. Parents will need increased support, with frequent updates on their baby’s condition. Where possible, these babies should not be separated from their mothers, and will need extra feeding support to maximise time under phototherapy, and ensure adequate hydration. Babies may need weighing daily. Encourage parents to watch for wet nappies, and to discuss the colour of their baby’s stools. Educate them so that the baby receives the maximum coverage by keeping the nappy to a minimum. Parents are often concerned about their baby’s eyes remaining covered, so it may be necessary to use an orange shield rather than phototherapy goggles, and it will also be necessary to monitor temperature. Our
responsibility includes using the equipment according to manufacturer’s guidelines, and ensuring that it is maintained properly. Once the bilirubin levels start to fall, SBR may be taken at less frequent intervals ie 6e8 hourly, or occasionally even 12 hourly intervals. Any rise will need further intervention, and may need admission to the neonatal unit for multiple phototherapies, IV fluids or even preparation for exchange transfusion. Once SBR is at least 50 mmol/L below the treatment line, phototherapy can be stopped (unless there is a complicating factor such as ABO incompatability). A rebound SBR should be measured at 12e18 h, so the baby could be discharged and brought back for review, depending on local service availability.
Care of babies with prolonged jaundice Term babies should be reviewed at 14 days, and preterm babies at 21 days, if they still show signs of visible jaundice. A pathway should already be in place so that these babies can be referred in from the community. A conjugated bilirubin of >25 mmol/L needs referral to a tertiary centre for urgent investigation.
Available online at www.sciencedirect.com
www.elsevier.com/jneo
CLINICAL PRACTICE
Implications for practice: NICE neonatal jaundice guideline Alison Johns Available online 25 November 2010
Key priorities for implementation Information As neonatal nurses, we have been good at explaining treatment and equipment to parents. We may not have been quite as efficient at providing written information for them to digest later, but have now been provided with an ease to understand leaflet from NICE (download from www.nice.org) if your Trust do not already have their own. This leaflet empowers parents and carers to actively seek help if they are concerned that their baby is showing signs of jaundice. What needs to be added is the pathway to be followed, which will vary from Trust to trust, but needs to be clear so that no jaundiced baby is missed. More explicit information will be required by parents of babies who have jaundice due to ABO incompatibility, G6PD or are close to or above the exchange transfusion line. A good explanation, supported by a more complex leaflet, will give them the additional knowledge they require.
Care for all babies Being aware of infants who are at higher risk of hyperbilirubinaemia is good practice, this will be most apparent on Labour Ward and in the postnatal area, for serum bilirubin (SBR) or E-mail address: [email protected]. 1355-1841/$ - see front matter doi:10.1016/j.jnn.2010.11.003
transcutaneous bilirubin measurement (TcB) depending on age & gestation (TcB only if >35 weeks, >24 h). Make parents aware (preferably antenatally!) that if their previous baby required treatment ie prolonged phototherapy or exchange transfusion, that this is very likely to recur in this pregnancy. The evidence definitely shows that a decision to solely breast feed is a risk factor for hyperbilirubinaemia, however, this gives us excellent opportunities to support breast feeding in order to maximise milk production. Good antenatal preparation and honest expectations will empower women so that their baby has the best chance to be fully breast fed, and therefore be less at risk of hyperbilirubinaemia. These higher risk babies need to be assessed at 48 h for jaundice whether they are in hospital or already at home, which will put a further strain on community services.
How to measure the bilirubin level As previously mentioned, transcutaneous bilibubin measurements may be used for all jaundiced babies who are over 24 h of age, and above 35 weeks gestation. Once the TcB is 250 mmol/L, SBR should be performed. As jaundice in the first 24 h of life is abnormal, and may indicate sepsis, ABO incompatability or Rhesus iso immunization, it must be measured as SBR, along with Group & DAT and any other appropriate investigations eg septic screen.
A. Johns
21
How to manage hyperbilirubinaemia Don’t forget that the guideline has been aimed at “well” babies, as sick babies may well require intervention at lower thresholds of bilirubin. Using the graph for the appropriate gestation, plot carefully, commence phototherapy using conventional overhead phototherapy for babies >38 weeks (babies <37 weeks may manage using fibreoptic phototherapy) and repeat SBR in 4e6 h depending on circumstances. It is no longer appropriate to use TcB whilst babies are receiving phototherapy. Parents will need increased support, with frequent updates on their baby’s condition. Where possible, these babies should not be separated from their mothers, and will need extra feeding support to maximise time under phototherapy, and ensure adequate hydration. Babies may need weighing daily. Encourage parents to watch for wet nappies, and to discuss the colour of their baby’s stools. Educate them so that the baby receives the maximum coverage by keeping the nappy to a minimum. Parents are often concerned about their baby’s eyes remaining covered, so it may be necessary to use an orange shield rather than phototherapy goggles, and it will also be necessary to monitor temperature. Our
responsibility includes using the equipment according to manufacturer’s guidelines, and ensuring that it is maintained properly. Once the bilirubin levels start to fall, SBR may be taken at less frequent intervals ie 6e8 hourly, or occasionally even 12 hourly intervals. Any rise will need further intervention, and may need admission to the neonatal unit for multiple phototherapies, IV fluids or even preparation for exchange transfusion. Once SBR is at least 50 mmol/L below the treatment line, phototherapy can be stopped (unless there is a complicating factor such as ABO incompatability). A rebound SBR should be measured at 12e18 h, so the baby could be discharged and brought back for review, depending on local service availability.
Care of babies with prolonged jaundice Term babies should be reviewed at 14 days, and preterm babies at 21 days, if they still show signs of visible jaundice. A pathway should already be in place so that these babies can be referred in from the community. A conjugated bilirubin of >25 mmol/L needs referral to a tertiary centre for urgent investigation.
Available online at www.sciencedirect.com