Neonatal Jaundice Pathway
Neonatal Jaundice Pathway
Neonatal Jaundice Pathway
3
Approval & Citation Explanation of Evidence Ratings Summary of Version Changes
Automatic NICU Admission Criteria Evaluate for Discharge Evaluate for NICU Consult Criteria Evaluate for Inpatient Admission
Signs of acute bilirubin encephalopathy TSB below phototherapy threshold TSB within 2mg/dL of exchange TSB above phototherapy threshold but
TSB > 5 mg/dL above exchange Follow-up appointment arranged for next transfusion threshold not within 2mg/dL of exchange
transfusion threshold Age < 24 hours
Include NICU attending on calls for day transfusion threshold (e.g. at 72 hours of
patients that meet NICU direct admit Feeding adequately High suspicion for or lab evidence of age, exchange transfusion threshold 24
criteria. No concern for significant hemolysis hemolysis (e.g. DAT positive) and TSB 21)
Inpatient
NICU Discharge
Admission
(Off Pathway)
ED Management
Give effective phototherapy
Encourage feeding
feeding. The infant should not be removed from bili lights
for > 20 mins in any 3 hour period. Use bottle if needed.
TSB rising or DO NOT interrupt phototherapy for patients nearing exchange TSB stable or
meeting NICU falling and otherwise
transfusion threshold or with rapidly rising TSB
admission criteria clinically well
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
PHASE II (INPATIENT)
Inclusion Criteria
Previously healthy
Age 14 days
Born at 35 wks gestational age
Exclusion Criteria
! Direct hyperbilirubinemia
!
Rebound TSB
Supplemental Meets NICU Direct Admit Criteria
NOT routinely
IV Fluids NOT TSB > 5mg/dL above exchange
indicated prior to
routinely indicated transfusion threshold
discharge
Signs of acute bilirubin
encephalopathy
Suspected sepsis or ill-appearing
Inpatient Management
Yes No
Subsequent Labs
Subsequent Labs
TSB approximately 12 hours after starting
TSB every 4 hours until TSB falling
phototherapy (or with routine AM labs)
G6PD (for unexplained hemolysis)
Subsequent checks as clinically indicated
Yes
Discharge
Return to ED Management
Return to ED Management
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)]
DESCRIPTION OF CARE TREATMENT OPTION Obtain serum blood Do not routinely obtain
glucose on all patients blood glucose levels on
admitted with neonatal patients unless
jaundice symptomatic
OPERATIONAL FACTORS
Percent adherence to care (goal 80%) Neutral Neutral NEUTRAL
Effects on natural history of the disease over equivalent time Neutral Neutral NEUTRAL
COST (Complications/adverse effects arising from Options A or B)- express as cost per day
ROOM RATE ($ or time to recovery) Neutral Neutral NEUTRAL
A or B, operational A or B, operational
A and B costs are the same A factors may influence B factors may influence
choice choice, PDSA in 1 year
VALUE STATEMENT
Blood glucose should not be ordered routinely for patients with neonatal jaundice, levels should be
obtained only if symptomatic. This recommendation is based on a review of local data, 1 out of 194
FINAL CSW VALUE STATEMENT
blood glucose values was <40mg/dl, this patient was asymptomatic and did not require intravenous
glucose. Estimated yearly cost savings is $1,333.
Return to ED Management
Value Analysis: PIVs and IV Fluids
OPERATIONAL FACTORS
Percent adherence to care (goal 80%) Neutral Neutral NEUTRAL
Effects on natural history of the disease over equivalent time Neutral Neutral NEUTRAL
COST (Complications/adverse effects arising from Options A or B)- express as cost per day
ROOM RATE ($ or time to recovery) Neutral Neutral NEUTRAL
A or B, operational A or B, operational
A and B costs are the same A factors may influence B factors may influence
choice choice, PDSA in 1 year
VALUE STATEMENT
Peripheral IVs and IVFs should only be utilized if the patient meets NICU admission or consult criteria.
FINAL CSW VALUE STATEMENT This option is preferred due to lower cost, increased palatability and decreased risk for harm while
providing safe and appropriate care. Estimated yearly cost savings is $4,633
Return to ED Management
Neonatal Jaundice Approval & Citation
Approved by the CSW Neonatal Jaundice for 5/31/2012 go live
Executive Approval:
Sr. VP, Chief Medical Officer Mark Del Beccaro, MD
Sr. VP, Chief Nursing Officer Madlyn Murrey, BSN, MN
Surgeon-in-Chief Bob Sawin, MD
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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 of Evidence:
High quality
Moderate quality
Low quality
Very low quality
Expert Opinion (E)
To Bibliography
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.
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.
Identification
52 records identified through 0 additional records identified
database searching through other sources
Screening
48 records after duplicates removed
Elgibility
22 full-text articles excluded,
27 full-text articles assessed for eligibility 16 did not answer clinical question
6 did not meet quality threshold
Included
6 studies included in pathway
To Bibliography
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 18-
hospital 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):670-
674
Wagle S, Rosenkrantz T (ed.). Hemolytic Disease of Newborn. Medscape Reference. May 2011.
http://emedicine.medscape.com