NEONATAL HYPERBILIRUBINEMIA IN < 35 WEEKS

Neonatal NEONATAL HYPERBILIRUBINEMIA IN < 35 WEEKS Approved by: Gail Cameron Senior Director, Operations Maternal, Neonatal & Child Health Programs D...
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Neonatal

NEONATAL HYPERBILIRUBINEMIA IN < 35 WEEKS Approved by: Gail Cameron Senior Director, Operations Maternal, Neonatal & Child Health Programs Dr. Paul Byrne Medical Director, Neonatology

Policy & Procedures Manual Policy Group Integument Date Effective September, 2015 Next Review September, 2018

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 Statement

• • • • • •

All infants 32 weeks to less than 35 weeks gestation will have TcB (Transcutaneous 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.

Hyperbilirubinemia in Less Than 35 Weeks

Assessment

Date Approved September, 2015

Policy Group Integument

Page 2 of 8

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.

Hyperbilirubinemia in Less Than 35 Weeks

Treatment

Date Approved September, 2015

Policy Group Integument

Page 3 of 8

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

Hyperbilirubinemia in Less Than 35 Weeks

References

Date Approved September, 2015

Policy Group Integument

Page 4 of 8

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.

Date Approved September, 2015

Hyperbilirubinemia in Less Than 35 Weeks

NEONATAL JAUNDICE – Investigation Pathway Offer parents/carers information about neonatal jaundice

Policy Group Integument

Page 5 of 8

Care for babies < 35 weeks gestation

Examine for jaundice every 6 hours during the first week.

Check for signs of acute bilirubin encephalopathy - hypertonia, arching, retrocollis, opisthotonus, fever, high pitched cry.

Does the baby have suspected or obvious jaundice in the first 24 hours?

Yes

Go to exchange transfusion pathway

Measure and record serum bilirubin level within 2 hours.

No Ensure adequate support is offered to all women who intend to breastfeed exclusively

Does the baby have visible jaundice at greater than 24 hours age?

No Treatment threshold graphs are available at www.nicu.org.uk/guidance/ CGSB

Yes

Measure serum bilirubin at 24 – 48 hrs of age

Measure and record serum bilirubin level within 6 hours

Manage hyperbilirubinaemia Interpret results using treatment threshold graphs according to gestational age at birth and age in hours

Monitor bilirubin levels

Bilirubin levels may be screened with TcB before phototherapy or 48 hrs after phototherapy has been stopped. TcB levels are confirmed with a TSB before treatment is started.

Treat using phototherapy

Treat using exchange transfusion

Go to phototherapy pathway

Go to exchange transfusion pathway

Continue to measure the serum bilirubin level every 6 hours until the level is both: -below the treatment threshold - Stable and/or falling Perform a medical review as soon as possible and within 6 hours to exclude pathological causes of jaundice

Date Approved September, 2015

Hyperbilirubinemia in Less Than 35 Weeks

Phototherapy pathway Offer information to parents and carers about phototherapy

Policy Group Integument

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 indicated after 72 hours?

No

Perform formal assessment: • Clinical examination • Serum bilirubin • Blood packed cell volume • Blood group of mother and baby • DAT Consider: • Full blood count and examination of blood film • Blood glucose-6phophate • Microbiological cultures of blood, urine and cerebrospinal fluild

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Yes

Start single phototherapy • Using clinical judgement encourage short breaks for breastfeeding, diaper changes and cuddles • Continue lactation/feeding support • Do not give additional fluids or feeds routinely • Monitor hydration by daily weights and assessment of urine output

Check serum bilirubin level: • 24 hrs after starting phototherapy

Start continuous intensive phototherapy • Do not interrupt for feeding • Continue administration of intravenous / enteral feeds • Continue lactation / feeding support • Monitor hydration by daily weights and assessment of urine output

Check serum bilirubin level: • 6 hours after starting phototherapy • Every day if bilirubin level is stable or falling

Is serum bilirubin level stable or falling? Is serum bilirubin level stable or falling? Yes Yes

Is serum bilirubin level at least 50 micromol/litre below threshold for phototherapy?

No

Is serum bilirubin level 50 micromol/litre belwo threshold for exchange transfusion? Yes

Yes Stop phototherapy Check serum bilirubin for rebound after 24 hours

No

No

No Go to ‘Manage hyperbilirubinaemia’ box in ‘Investiation pathway’

Step down to single phototherapy

Go to ‘Manage hyperbilirubinaemia’ box in “Investigation pathway’

Continue continuous intensive phototherapy and check serum bilirubin level Q 12 hours

Date Approved September, 2015

Hyperbilirubinemia in Less Than 35 Weeks

Policy Group Integument

Page 7 of 8

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

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 threshold for exchange transfusion

Baby has: • 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’

Hyperbilirubinemia in Less Than 35 Weeks

Date Approved September, 2015

Policy Group Integument

Page 8 of 8

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

_________________________

____________________ DATE

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

Original Signed

September, 2015

_________________________

____________________ DATE

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

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