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Assessment and Management of Neonatal Jaundice in Term and Near-Term Neonates – Neonatal – Emergency Department/Inpatient

Assessment and Management of Neonatal Jaundice in Term and Near-Term Neonates – Neonatal – Emergency Department/Inpatient - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Neonatology


1
Assessment and Management of
Neonatal Jaundice in Term and Near-
Term Neonates – Neonatal –
Inpatient/Ambulatory
Clinical Practice Guideline
Table of Contents
EXECUTIVE SUMMARY ........................................................................................................... 3
SCOPE ...................................................................................................................................... 4
METHODOLOGY ...................................................................................................................... 5
INTRODUCTION ....................................................................................................................... 7
RECOMMENDATIONS .............................................................................................................. 7
1. Inclusion Criteria .................................................................................................................... 7
2. ED Management of Suspected Hyperbilirubinemia .............................................................. 8
3. Placement .............................................................................................................................. 9
4. Thermoregulation ................................................................................................................ 10
5. Phototherapy ....................................................................................................................... 11
6. Assessment and Management of Hydration ....................................................................... 12
7. Nutrition during Phototherapy ............................................................................................. 13
8. Laboratory Testing .............................................................................................................. 14
9. Criteria for NICU Consultation or Transfer from General Care ........................................... 15
10. Discharge Criteria ................................................................................................................ 15
UW HEALTH IMPLEMENTATION ............................................................................................16
REFERENCES .........................................................................................................................17
APPENDIX A. AAP HYPERBILIRUBINEMIA TREATMENT NOMOGRAMS 3,6 .......................18
APPENDIX B. NORMAL NEONATAL WEIGHT LOSS8 ...........................................................19
APPENDIX C. HYPERBILIRUBINEMIA MANAGEMENT- ED ALGORITHM ...........................20
APPENDIX D. HYPERBILIRUBINEMIA- INPATIENT ALGORITHM ........................................21
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2
CPG Contact for Content:
Name: Dan Sklansky, MD- Pediatrics- Hospitalists
Phone Number: (608) 262-5625
Email Address: djsklansky@pediatrics.wisc.edu
CPG Contact for Changes:
Name: Lindsey Spencer, MS- Center for Clinical Knowledge Management (CCKM)
Phone Number: (608) 890-6403
Email Address: lspencer2@uwheatlh.org
Guideline Author(s): Sarah Webber, Crystal Curry, Jamie Limjoco, Dan Sklansky
Coordinating Team Members:
Sarah Webber, MD- Pediatrics Resident
Jamie Limjoco, MD- Pediatrics- Neonatology
Kelly Bush, MD- Pediatrics- Neonatology
Elizabeth Goetz, MD- Pediatrics- Newborn Nursery
Joshua Ross, MD- Pediatric Emergency Medicine
Laura Bodine, MS, RD, CNSC, CD- Clinical Nutrition
Laura Konkol, CNS- Nursing- Neonatal ICU
Crystal Curry, RN- P5 (General Medicine/Surgery Pediatric)
Windy Smith- P5 (General Medicine/Surgery Pediatric)
Deborah Soetenga, RN- Pediatric Intensive Care
Lori Williams, DNP, RN, RNC-NIC, CCRN, NNP-BC- Nursing- Universal Care
Kevin Straka, MS, MBA – Center for Clinical Knowledge Management (CCKM)
Jennifer Grice, PharmD, BCPS- Center for Clinical Knowledge Management (CCKM)
Review Individuals/Bodies:
Gail Allen, MD- Pediatrics- General
Teresa Darcy, MD- Pathology-General
Committee Approvals/Dates:
AFCH Practice Council (06/10/2015)
Clinical Knowledge Management (CKM) Council (06/25/2015)
Release Date: June 2015
Next Review Date: June 2017
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Executive Summary
Guideline Overview
This clinical practice guideline is an internal creation based upon current evidence,
expert opinion and external tools for management of previously healthy neonates <14
days of age born at or after 35 weeks gestational age, with jaundice. It was developed
to improve safety, consistency of care, and to reflect standards of practice.
Key Practice Recommendations
1. Perform initial assessment including:
a. Blood glucose if concern for poor feeding or lethargy
b. Total bilirubin level with conjugated fraction (AAP Grade D, strong recommendation)
c. IV placement should be limited to infants at high risk for requiring exchange
transfusion or with signs of cardiovascular effects of dehydration. (UW Health
Class IIa, LOE B)
2. Use a radiant warmer and monitor temperature (UW Health Class I, LOE C)
3. Neonates above treatment threshold per the AAP nomogram (see Appendix A)
should be initiated on phototherapy (AAP Grade C, recommendation)
a. Eye protection that fully covers the infant’s eyes is required. (UW Health Class
IIa, LOE C)
b. Infant should be undressed except for smallest size diaper possible to cover
gonadal area. (UW Health Class IIa, LOE C)
c. Phototherapy lights must be turned off while bilirubin levels are being drawn
to avoid falsely low total bilirubin values. (UW Health Class I, LOE C)
d. Discontinue phototherapy when total bilirubin < 13mg/dl (see Section 8) (AAP
Grade C, recommendation)
4. Mild to moderate dehydration may be treated enterally (UW Health Class I LOE B)
5. Limit feeding to 20 minutes every 3 hours to ensure adequate exposure to
phototherapy (UW Health Class I, LOE C)
6. The NICU attending physician should be consulted for any infant still requiring
hospitalization after 48 hours, or sooner if other concerns (i.e., concerning vital
signs). (UW Health Class I, LOE C)
7. Rebound total bilirubin is not routinely required (UW Health Class I, LOE C)
Companion Documents
1. Neonatal Jaundice- Emergency Department Algorithm
2. Neonatal Jaundice- Inpatient General Care Algorithm
Pertinent UW Health Policies & Procedures
1. UWHC Policy 4.20- Neonatal Thermoregulation (Pediatric)
2. UWHC Policy 15.13- Care of the Infant Requiring Phototherapy for the Management
of Hyperbilirubinemia (Jaundice)
3. Policy 13.16P- Basic Care- Inpatient Pediatrics (Birth-18 years of age)
Patient Resources
1. HFFY #7434- Jaundice in Newborns (Hyperbilirubinemia)
2. HFFY #4331- Postpartum Information
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Scope
Disease/Condition(s):
Neonatal Hyperbilirubinemia, Neonatal Jaundice
Clinical Specialty:
Pediatric Hospital Medicine, Neonatology, Pediatric Emergency Medicine, AFCH
Nursing, AFCH Speech Language Therapy, Pediatric Nutrition, Pharmacists, Laboratory
Services
Intended Users:
Any physician, physician assistant, nurse practitioner, or registered nurse caring for
neonates with hyperbilirubinemia.
CPG objective(s):
To provide evidence-based guidelines for health care professionals responsible for the
management of neonates with jaundice and/or hyperbilirubinemia.
Target Population:
All previously healthy neonates <14 days of age born at or after 35 weeks gestational
age, with jaundice receiving care at AFCH in the inpatient, outpatient or emergency
setting.
Interventions and Practices Considered:
1. Published literature on diagnosis and management of neonates with
hyperbilirubinemia.
2. Expert opinion and resources on diagnosis and management of neonates with
hyperbilirubinemia.
Major Outcomes Considered:1,2
1. Number of readmissions for rebound hyperbilirubinemia
2. Parent satisfaction scores
3. Number of patients seen in ED, general care ward, and NICU
4. Transfers from general care ward to NICU
5. Median and Mean Length of Stay
Guideline Metrics:1,2
1. Number of core temperatures recorded <36.5°C
2. Number of blood culture orders
3. Number of patients receiving intravenous fluids
4. Time to initiation of phototherapy from admission to ward
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Methodology
Methods Used to Collect/Select the Evidence:
1. Adaptation of 2012 Seattle Children’s Hospital guideline that uses
a. Systematic review of evidence from 2002-2012
b. Review of prior guidelines
2. Search of electronic database PUBMED for relevant articles using the search
strategy:
a. Search ((neonatal hyperbilirubinemia AND "last 5 years"[PDat] AND
Humans[Mesh] AND English[lang])) NOT case report Filters: Publication date
from 2012/01/01 to 2015/12/31; Humans; English
b. Read all 635 titles to assess for relevance
c. Selected 50 abstracts, leading to 12 new articles reviewed for application to
guideline based on applicability, with evidence level noted.
Methods Used to Assess the Quality and Strength of the Evidence:
Recommendations developed by external organizations, such as the American
Academy of Pediatrics (AAP), maintained the evidence grade assigned within the
original document and were adopted for use at UW Health (see Figures 2 and 3).
Recommendations which were developed internally during the workgroup meetings
were evaluated using a modified Grading of Recommendations, Assessment,
Development and Evaluation (GRADE) scale developed by the American Heart
Association and American College of Cardiology (Figure 1).
Rating Schemes for the Strength of the Evidence/Recommendation:
Figure 1. AAP Evidence Rating Scheme
A Well-designed, randomized, controlled trials or diagnostic studies on relevant populations.
B Randomized, controlled trials or diagnostic studies with minor limitations; overwhelming, consistent evidence from observational studies
C Observational studies (case-control and cohort design)
D Expert opinion, case reports, reasoning from first principles
Figure 2. AAP Recommendation Definitions
Strong
recommendation
The Committee believes that the benefits of the recommended approach clearly
exceed the harms of that approach and that the quality of the supporting
evidence is either excellent or impossible to obtain. Clinicians should follow
these recommendations unless a clear and compelling rationale for an
alternative approach is present.
Recommendation
The Committee believes that the benefits exceed the harms, but the quality of
the evidence on which this recommendation is based is not as strong. Clinicians
should also generally follow these recommendations but should be alert to new
information and sensitive to patient preferences.
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Option
Either the quality of the evidence that exists is suspect or well-performed
studies have shown little clear advantage to one approach over another. Patient
preference should have a substantial role in influencing clinical decision-making
when a policy is described as an option.
No
recommendation
There is a lack of pertinent evidence and the anticipated balance of benefits and
harms is unclear.
Figure 3. ACC/AHA Grading Scheme
Methods Used to Analyze the Evidence & Formulate the
Recommendations: The workgroup conducted a systematics review of the
literature and considered evidence-based guidelines such as the AAP and Seattle
Children’s. Institutional expert opinion and consideration for patient experience/safety
were also valued from key stakeholders among nursing, physician, and quality leaders.
The interdisciplinary workgroup members agreed to adopt recommendations developed
by external organizations and/or arrived at a consensus through discussions of the
literature evidence and expert experiences.
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Introduction
Jaundice occurs in most newborn infants and is usually benign, but is monitored
because therapies exist to prevent the rare outcome of permanent bilirubin
encephalopathy known as kernicterus.
Hyperbilirubinemia is defined as a total bilirubin > 95th percentile for age in hours.
Clinical goals include appropriately identifying and treating children who are at risk from
their degree of hyperbilirubinemia, while minimizing unintended harms including
maternal anxiety, decreased breastfeeding, and unnecessary costs of treatment. These
guidelines apply to the initial evaluation, disposition, and general care inpatient setting
treatment of infants < 14 days old and ≥ 35 weeks gestational age with jaundice and/or
hyperbilirubinemia. Care of children admitted to the NICU is outside of the scope of the
evidence collected for the formation of this guideline. The purpose of this guideline is to
provide a unified, evidence-based approach consistent with national American
Association of Pediatrics standards for the monitoring and treatment of neonatal
hyperbilirubinemia at American Family Children’s Hospital (AFCH).3
Recommendations
This guideline is intended for otherwise well infants < 14 days old and ≥ 35 weeks
gestational age with suspected or confirmed hyperbilirubinemia. It is designed to
provide a framework for the assessment, disposition, and treatment of children at AFCH
in the ED and General Care settings to provide safe, patient centered, and evidence-
based care.
Indirect hyperbilirubinemia may result in acute bilirubin encephalopathy, which
may progress to cause kernicterus, a form of permanent encephalopathy.
Hyperbilirubinemia in the neonate may be treated by increasing enteral intake and
output, applying phototherapy, and/or exchange transfusion depending on
severity and other clinical factors, thus preventing the development of acute and
chronic encephalopathy. 3 (UW Health Class I, LOE C)
1. INCLUSION CRITERIA
Key Recommendations
I. Infants < 14 days old and born ≥ 35 weeks gestational age
II. Concern for jaundice.
III. Previously well appearing and without underlying medical conditions
IV. Infants are excluded if any of the following are present
a. Direct hyperbilirubinemia
b. Suspected sepsis, shock
c. Have moderate to severe acute bilirubin encephalopathy
d. Otherwise ill-appearing
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Acute bilirubin encephalopathy (ABE) describes the acute manifestations of bilirubin
toxicity seen in the first weeks after birth. The early stages are characterized by mild
lethargy, low tone and poor suck. Early stage ABE is reversible and does not result in
kernicterus if treated. (UW Health Class I, LOE C) Early stage ABE plays an important role in
the pathophysiology of the ongoing worsening of hyperbilirubinemia in that it may result
in decreased oral intake by the neonate, preventing bilirubin elimination through the GI
tract. In the intermediate phase, infants can develop stupor, irritability and hypertonia
with a high-pitched cry. This can alternate with drowsiness and hypotonia. The
advanced phase is characterized by pronounced retrocollis-opisthotonos, shrill cry,
anorexia, apnea, fever, deep stupor or coma and seizures.3
2. ED MANAGEMENT OF SUSPECTED HYPERBILIRUBINEMIA
Key Recommendations
I. Perform initial assessment including:
a. Blood glucose if concern for poor feeding or lethargy
b. Total bilirubin level with conjugated fraction (AAP Grade D, strong recommendation)
c. Encourage feeding while waiting for total bilirubin result (AAP Grade C,
recommendation)
d. IV placement should be limited to infants at high risk for requiring exchange
transfusion or with signs of cardiovascular effects of dehydration.4,5 (UW Health
Class IIa, LOE B)
II. NICU Consult Criteria
a. Total bilirubin within 2 mg/dL of exchange transfusion threshold per AAP
nomogram (see Appendix A)
b. Age less than 24 hours
c. History of NICU admission or stay (UW Health Class IIa, LOE C)
III. Consider obtaining additional labs if high risk for hemolysis (UW Health Class I, LOE
C) Risk factors include: family history of G6PD or other hemolytic disorders;
maternal blood type is O; or patient age is less than 24 hours.3
a. Complete blood count (CBC) without differential
b. Blood type and screen if mother is type O or unknown
c. Direct Antibody Test (Direct Coomb’s Test)
d. Reticulocyte Count
Poor enteral intake contributes to the development of hyperbilirubinemia because
bilirubin is excreted in stool. (UW Health Class I, LOE C) Enteral intake should be promoted
via breast feeding or use of expressed breast milk if given supplemental bottle feeds.3
(AAP Grade C, recommendation) If infant has not been feeding well, consider placement of
nasogastric tube for enteral feedings of expressed breast milk or formula. IV placement
for fluid administration is not routinely recommended. IV fluids do not improve bilirubin
elimination or outcomes in otherwise well jaundiced neonates.4 (UW Health Class I, LOE B)
Interpretation of serum bilirubin results for therapy and placement should be performed
using the AAP 2004 guidelines on management of hyperbilirubinemia in the newborn
infant 35 or more weeks gestation in Appendix A. 3 (AAP Grade C, recommendation)
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3. PLACEMENT
Key Recommendations
I. Discharge Home
a. Total bilirubin < phototherapy threshold per AAP nomogram3 (see Appendix A)
b. No signs of rapid total bilirubin rise based on prior labs if available3,6
c. Adequate follow up available and accessible
d. Infant is otherwise well
II. General care ward (Hospitalist team)
a. Total bilirubin ≥ phototherapy threshold per AAP nomogram3 (see Appendix A)
b. Total bilirubin < phototherapy threshold but follow up is uncertain and level is
high enough to warrant check the next day
c. Does not meet direct NICU admission criteria
d. May meet NICU consult criteria, teams agree that general care setting is
appropriate
e. Late pre-term infants (gestational age 35-36 weeks) should have lactation and
speech consults on the general care ward
f. Consider phone consultation with patient’s primary care physician to determine if
appropriate for outpatient management
III. NICU
a. Total bilirubin ≥ 2 mg/dL above exchange transfusion threshold
b. Total bilirubin within 2 mg/dl of exchange transfusion threshold and symptomatic
based on the clinical evaluation and assessment of the medical team
Phototherapy is a well-established treatment for neonatal hyperbilirubinemia that may
be performed in the home or inpatient setting. (UW Health Class I, LOE C) This guideline
presumes that neonates meeting AAP phototherapy criteria (see Section 1- Inclusion
Criteria) are admitted to the general care ward, PICU, or NICU for treatment, however in
some settings home therapy with a phototherapy blanket and close follow-up may be
appropriate. (UW Health Class I, LOE C)
Infants should not be discharged home if medical providers or caregivers have doubts
about the ability to follow up, or the child’s safety at home. All neonates with total
bilirubin ≥ 2 mg/dL above transfusion threshold should receive IV fluids and be directly
admitted to the NICU. (UW Health Class IIa, LOE B)
Infants with total bilirubin near or above phototherapy threshold, but not within 2 mg/dL
of transfusion threshold, should be admitted to the general care ward on the hospitalist
team. (UW Health Class I, LOE C)
A discussion between the NICU and hospitalist team should occur for infants with total
bilirubin +/- 2mg/dL of the transfusion threshold to identify best placement based on the
clinical scenario. Factors to consider during the discussion include gestational age,
appearance, and additional laboratory findings.
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4. THERMOREGULATION
Key Recommendations
I. Warmer use (UW Health Class I, LOE C)
a. Warmers should be obtained for all infants receiving phototherapy
b. Obtain radiant warmer from NICU or PICU before patient arrives
c. Set warmer to servo-control with temperature at 36.5 °C and ensure temperature
sensor is well-secured on the right upper quadrant of the abdomen.
d. If increasing warmer support is required, provider should consult the NICU for
further guidance or possible transfer of care.
II. Temperature monitoring (UW Health Class I, LOE C)
a. Axillary temperature should be checked and compared with skin servo
temperature every 4 hours with vital sign checks.
III. Discontinuation of warmer (UW Health Class I, LOE C)
a. Occurs when phototherapy is discontinued
b. The infant should be swaddled and axillary temperature should be checked
within 60 minutes. If normal, it is appropriate to check subsequent temperatures
with vital sign checks.
Use of a Radiant Warmer
A radiant warmer should be obtained for every patient who meets the inclusion criteria
for this guideline (see Section 1). Exposed infants in an open crib during phototherapy
with low heat-emitting LED lights may require a radiant warmer for support. The radiant
warming should be continued if the patient is unable to maintain a neutral thermal
temperature of at least 36.5 degrees Celsius while under phototherapy lights. (UW Health
Class I, LOE C)
When utilizing a radiant warmer, skin or servo-controlled mode is recommended as the
thermostat responds to changes in the infant’s skin temperature. This ensures a normal
temperature despite environmental fluctuation. Radiant warmers should never be used
in the manual mode due to the risk of hyperthermia. Current radiant warmers are also
equipped with safety alarms to alert staff to dislodged probes.
Infants ≥ 35 weeks gestational age should be able to transition out of the radiant
warmer if properly dressed. If the infant is unable to maintain normal temperature after
placement in a normal environment, other causes of temperature instability should be
considered. (UW Health Class I, LOE C)
Temperature Monitoring
Maintenance of a normal body temperature must be a priority in all infants. A normal
core temperature for infants is estimated to be between 36.5 and 37.5 degrees Celsius,
but there is likely some normal variability in this vital sign. Axillary temperature
measurement should be obtained and compared with skin servo temperature
measurements every 4 hours, with vital sign checks. (UW Health Class I, LOE C)
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5. PHOTOTHERAPY
Key Recommendations
I. Neonates above treatment threshold per the AAP nomogram (see Appendix A)
should be initiated on phototherapy (AAP Grade C, recommendation)
II. Physical arrangement of phototherapy
a. One overhead LED phototherapy light in conjunction with one LED blanket
should be utilized to cover maximal body surface area. (UW Health Class I, LOE A)
b. The overhead light should be placed on high intensity in order to deliver
recommended irradiance. (UW Health Class I, LOE A)
c. The lights should be positioned ≤12 inches from the patient. (UW Health Class I,
LOE A)
d. If using with radiant warmer, position lights so as not to be blocked by heat
source. (UW Health Class I, LOE A)
e. The blanket should be placed directly under the infant. (UW Health Class I, LOE C)
III. Protection from potential harms of phototherapy
a. Eye protection that fully covers the infant’s eyes is required. (UW Health Class IIa,
LOE C)
b. Infant should be undressed except for smallest size diaper possible to cover
gonadal area. (UW Health Class IIa, LOE C)
IV. Phototherapy lights must be turned off while bilirubin levels are being drawn to
avoid falsely low total bilirubin values. (UW Health Class I, LOE C)
V. Discontinue phototherapy when total bilirubin < 13mg/dl (see Section 8)3 (AAP
Grade C, recommendation)
VI. There are not limitations for normal newborn skin care while under the
phototherapy lights.
Phototherapy is a commonly used safe and effective method to reduce the toxicity of
unconjugated bilirubin by facilitating conjugation. Light absorption converts
unconjugated bilirubin into bilirubin photoproducts, decreasing or blunting the rise of
unconjugated bilirubin. (UW Health Class I, LOE A) The visible white light spectrum ranges
from approximately 350-800 nm and bilirubin absorbs light most strongly in the blue
region of the spectrum near 460 nm. The initiation and duration of phototherapy is
defined by a specific range of total bilirubin values based on an infant’s postnatal age
and potential risk for bilirubin neurotoxicity. Continuous phototherapy is more effective
than intermittent.
A wide selection of devices is available for phototherapy including fluorescent blue
lights, halogen white lights, fiberoptic blankets or pads and blue light-emitting diodes
(LEDs) although there is no standardized method of delivery. LEDs deliver high
intensity narrow band light in the 460-490 nm range and are available as both overhead
and underneath devices. LED-based devices emit low levels of heat, making insensible
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fluid loss and overheating less of a concern, and have no UV emission, decreasing risk
of skin damage. Supplemental fluids may be required less frequently with LEDs
compared to traditional incandescent lights, but the need for separate warmers may be
greater. The necessary irradiance can be achieved using a phototherapy light placed at
a distance of 10 to 30 cm from the infant's body in combination with a fiberoptic pad,
LED mattress, or specialized blue lights below the infant. In a recent randomized
controlled trial infants receiving LED phototherapy had the same incidence and
resolution of rash as children receiving traditional phototherapy.7 (UW Health Class I, LOE
B)
Eye masks to prevent retinal damage are used routinely, although there is no evidence
to support this recommendation. Similarly, concerns for the long-term effects of
continuous phototherapy exposure of the reproductive system have been raised but not
substantiated.3
6. ASSESSMENT AND MANAGEMENT OF HYDRATION
Key Recommendations
I. Weight is a poor marker of clinical dehydration in the first week of life
a. It is normal for weight to decrease up to 10-12% 8(UW Health Class I, LOE C)
b. Neonatal weight loss nomogram (see Appendix B) may be used to interpret
additional weight loss that may represent dehydration8
II. Mild to moderate dehydration may be treated enterally4 (UW Health Class I, LOE B)
a. If no cardiovascular effects from dehydration
b. See next section for enteral recommendations
III. Clinically significant dehydration may require IV fluid therapy
a. Consider bolus and/or maintenance IVF if: (UW Health Class IIa, LOE C)
i. Resting heart rate is markedly elevated
ii. Delayed capillary refill
iii. Weak pulses
iv. Minimal urine output in last 24 hours
v. Total bilirubin near transfusion threshold per AAP nomogram (Appendix A)
Evaluating the Patient for Dehydration
Neonates are expected to lose weight over the first 3-5 days of life, thus weight loss to a
normal degree based on population standards is not evidence of dehydration. A recent
large, diverse, population-based study has yielded data on normal amounts of weight
loss by age in term neonates.8 Weight loss beyond the normal amount suggested by the
nomogram in Appendix B can be used to estimate dehydration beyond expected weight
loss for age. Clinical signs of dehydration include the above markers in addition skin
turgor, sunken fontanel, and tacky mucous membranes. These clinical signs have been
studied in infants and children and have not been found to be very effective at predicting
degree of dehydration, compared to the gold standard of weight loss.9 (UW Health Class I,
LOE A) Studies in term neonates are less robust and predictive. Thus, using the degree
of weight loss beyond expected for age may be the best method of determining degree
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of dehydration for neonates who are not showing cardiovascular effects. (UW Health Class
IIa, LOE C)
Administration of IV Fluids
In one study the initial use of IV fluids in neonates who were at high risk of requiring an
exchange transfusion was associated with fewer transfusions required. Thus IV
placement and fluid bolus is recommended for neonates thought to be at high risk for
requiring exchange transfusion.5 (UW Health Class IIa, LOE C) Risk factors for severe
dehydration and for requiring exchange transfusion include: markedly elevated resting
heart rate, delayed capillary refill, weak pulses, minimal urine output in the last 24
hours, and total bilirubin levels near the transfusion threshold (as defined in the AAP
nomogram).
7. NUTRITION DURING PHOTOTHERAPY
Key Recommendations
I. Feeding interventions in family-centered progression
a. Feeding should start with oral cues such as mouth opening, hand-to-mouth
movements, and stretching per AFCH nursing education orientation
b. Goal of providing hydration and nutrition
c. Enteral intake assists with GI tract bilirubin clearance (UW Health Class I, LOE C)
d. Superior to IV hydration for treatment of hyperbilirubinemia
e. Goal of approximately 100kcal/kg/24 hrs. and 150ml/kg/24 hrs. (UW Health Class I,
LOE C)
f. Assessment of enteral hydration efficacy should include clinical impression
based on urine and stool output appropriate for day of life
II. Breast feeding
a. Limit to 20 minutes per every 3 hours to ensure adequate exposure to
phototherapy (UW Health Class I, LOE C)
b. Lactation consult for help with feeding and environment
c. Not recommended if total bilirubin near transfusion threshold (UW Health Class IIa,
LOE C)
d. Use blanket phototherapy while breast feeding away from the phototherapy light
bank
e. Bottle supplementation with expressed breast milk or formula should be used for
clinically determined inadequate breast feeding
III. Bottle feeding (UW Health Class IIa, LOE C)
a. After breast feeding, if possible
b. May use expressed breast milk (EBM)
c. If EBM not available, formula is acceptable
d. May be administered while receiving phototherapy
e. May be useful for increasing enteral bilirubin clearance for neonates too fatigued
to breast feed on admission
IV. Nasogastric feeding (UW Health Class IIa, LOE C)
a. May supplement or replace bottle or breast feeding
b. Use based on inadequate oral intake
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i. As estimated from breast feeding
ii. As known from bottle feeding quantity
c. PO/Gavage technique for allowing oral feeds
d. Nutrition consult should be obtained for nasogastric feeding assistance
Enteral feeds should be encouraged to provide nutrition, hydration, and bilirubin
clearance in the least invasive and most natural manner. Breast feeding is preferable,
noting that the AAP recommends only removing infants from phototherapy for 20
minutes every three hours. (AAP Grade C, recommendation) If enteral feeds are not
tolerated, IV fluids should be initiated for hydration. (UW Health Class I, LOE C)
8. LABORATORY TESTING
Key Recommendations
I. Initial total bilirubin monitoring (UW Health Class I, LOE C)
a. If total bilirubin ≥ 25 mg/dL, repeat in 2-3 hours
b. If total bilirubin 20-25 mg/dL, repeat in 4-6 hours
II. Subsequent total bilirubin monitoring (UW Health Class I, LOE C)
a. Once total bilirubin < 20 mg/dL and falling, repeat every 8-12 hours
III. Discontinuing total bilirubin testing and phototherapy (UW Health Class I, LOE C)
a. Once total bilirubin <13 mg/dL
b. May choose lower target for higher-risk infant based on age or time to anticipated
follow-up based on time of day
IV. Indications for other laboratory testing (UW Health Class I, LOE C)
a. If total bilirubin is not decreasing as expected, or new risk factors are identified,
more extensive laboratory testing based on clinical suspicion of hemolysis and/or
risk factors. These may include:
i. Complete blood count with smear for morphology
ii. Blood type and antibody screen
iii. Reticulocyte count
iv. Direct antibody test
v. Serum albumin10
vi. G6PD screen
vii. Infectious, metabolic studies as clinically indicated
Most neonates treated for hyperbilirubinemia do not require extensive laboratory testing.
If total bilirubin levels decrease as expected and hemolysis or other more severe
conditions are not suspected, monitoring of total bilirubin until below 13 mg/dL is
acceptable. (UW Health Class I, LOE C) Testing can be expanded for children nearing
transfusion threshold, not responding briskly to phototherapy, or with specific risk
factors for hemolysis or impaired hepatic function. Recent research suggests that
bilirubin:albumin ratio is not more predictive of neurologic sequelae than total bilirubin
alone, thus this is not a required investigation and may be obtained at the provider’s
discretion if useful to inform other clinical decisions.10
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
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15
9. CRITERIA FOR NICU CONSULTATION OR TRANSFER FROM
GENERAL CARE
Key Recommendations
I. The NICU attending physician should be consulted in the event of concerning
neonatal vital sign changes (UW Health Class I, LOE C)
a. Infant has episodes of apnea >20 seconds, bradycardia <100 beats per minute, or
frequent oxygen saturation <90%
II. The NICU attending physician should be consulted if any infant still requires
hospitalization after 48 hours, or sooner if other concerns. (UW Health Class I, LOE C)
III. Infants becoming critically ill based on altered mental status, hemodynamic
instability, or respiratory instability should be transferred to the NICU immediately.
(UW Health Class I, LOE C)
10. DISCHARGE CRITERIA
Key Recommendations
I. Rebound total bilirubin is not routinely required (UW Health Class I, LOE C)
a. Rebound total bilirubin off phototherapy for 6-8 hours may be obtained in cases
of hemolysis, prior rapid rate of rise, or slow response to phototherapy at
provider’s discretion
II. Infant must be able to regulate temperature normally
a. Bundled appropriately
b. Out of warmer for at least 4 hours
III. Infant must be feeding normally
a. As estimated by normal breast feeding
b. As measured by bottle feeding
IV. Infant must be otherwise well
V. Infant must have follow up available the next day (AAP Grade C, recommendation)
Rebound Total Bilirubin Measurement
Routine rebound total bilirubin levels are not recommended by the AAP policy
statement, and have not been shown to be effective for preventing readmissions in
recent literature.11 (UW Health Class I, LOE B)
However, in certain clinical scenarios that have not been well studied, rebound total
bilirubin may be helpful in making follow-up timing decisions, and for assessing the
need for ongoing phototherapy, especially with known active hemolysis. (UW Health Class
IIa, LOE C)
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2015CCKM@uwhealth.org

16
Postdischarge Follow-up
Next day follow up with primary care physician is recommended, with option for follow
up total bilirubin. (AAP Grade C, recommendation)
UW Health Implementation
Potential Benefits:
ξ Standardize the care of neonates ≥ 35 weeks of gestational age with
hyperbilirubinemia at AFCH
o Outpatient and ED providers can expect consistent recommendations regarding
workup and placement
o Perform quality improvement measures related to metrics in the guideline
ξ Improve care of neonates and families
o Promote breast feeding during illness
o Minimize disruption of normal newborn care and bonding
o Better communication with families based on teams referencing the same guideline
ξ Limit excessive resource utilization
Potential Harms:
ξ Standard risks involved with hospitalization
ξ Side effects of phototherapy include skin bronzing, evaporative fluid loss
ξ Interference with breast feeding
ξ Skin breakdown if requiring constant phototherapy
ξ Rare blistering in neonates with congenital porphyria
Qualifying Statements
This guideline is not intended to treat or diagnosis infants who are < 35 weeks
gestational age, who have comorbidities, or who are being cared for in the NICU. This
guideline does not replace clinical judgment when treating infants with
hyperbilirubinemia.
Implementation Plan/Tools
1. Guideline will be housed on U-Connect in a dedicated folder for CPGs.
2. Release of the guideline will be advertised in the Clinical Knowledge Management
Corner within the Best Practice newsletter.
3. Links to this guideline will be added into Health Link via the creation of an order set.
Disclaimer
CPGs are described to assist clinicians by providing a framework for the evaluation and
treatment of patients. This Clinical Practice Guideline outlines the preferred approach
for most patients. It is not intended to replace a clinician’s judgment or to establish a
protocol for all patients. It is understood that some patients will not fit the clinical
condition contemplated by a guideline and that a guideline will rarely establish the only
appropriate approach to a problem.
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2015CCKM@uwhealth.org

17
References
1. Tartaglia KM, Campbell J, Shaniuk P, McClead RE. A Quality Project to Improve
Compliance With AAP Guidelines for Inpatient Management of Neonatal
Hyperbilirubinemia. Hospital Pediatrics. 2013;3(3):251-257.
2. Wolff M, Schinasi DA, Lavelle J, Boorstein N, Zorc JJ. Management of neonates with
hyperbilirubinemia: improving timeliness of care using a clinical pathway. Pediatrics.
Dec 2012;130(6):e1688-1694.
3. American Academy of Pediatrics Subcommittee on H. Management of
hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics. Jul
2004;114(1):297-316.
4. Boo NY, Lee HT. Randomized controlled trial of oral versus intravenous fluid
supplementation on serum bilirubin level during phototherapy of term infants with severe
hyperbilirubinaemia. Journal of paediatrics and child health. Apr 2002;38(2):151-155.
5. Mehta S, Kumar P, Narang A. A randomized controlled trial of fluid supplementation in
term neonates with severe hyperbilirubinemia. The Journal of pediatrics. Dec
2005;147(6):781-785.
6. Bhutani VK, Johnson L, Sivieri EM. Predictive ability of a predischarge hour-specific
serum bilirubin for subsequent significant hyperbilirubinemia in healthy term and near-
term newborns. Pediatrics. Jan 1999;103(1):6-14.
7. Surmeli-Onay O, Korkmaz A, Yigit S, Yurdakok M. Phototherapy rash in newborn
infants: does it differ between conventional and light emitting diode phototherapy?
Pediatric dermatology. Sep-Oct 2013;30(5):529-533.
8. Flaherman VJ, Schaefer EW, Kuzniewicz MW, Li SX, Walsh EM, Paul IM. Early weight
loss nomograms for exclusively breastfed newborns. Pediatrics. Jan 2015;135(1):e16-23.
9. Steiner MJ, DeWalt DA, Byerley JS. Is this child dehydrated? Jama. Jun 9
2004;291(22):2746-2754.
10. Iskander I, Gamaleldin R, El Houchi S, et al. Serum bilirubin and bilirubin/albumin ratio
as predictors of bilirubin encephalopathy. Pediatrics. Nov 2014;134(5):e1330-1339.
11. Berkwitt A, Osborn R, Grossman M. The utility of inpatient rebound bilirubin levels in
infants readmitted after birth hospitalization for hyperbilirubinemia. Hosp Pediatr. Feb
2015;5(2):74-78.
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2015CCKM@uwhealth.org

18
Appendix A. AAP Hyperbilirubinemia Treatment Nomograms 3,6
Figure 1. Phototherapy Threshold Nomogram
Figure 2. Exchange Transfusion Threshold Nomogram
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2015CCKM@uwhealth.org

19
Appendix B. Normal Neonatal Weight Loss8
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2015CCKM@uwhealth.org

Neonatal Jaundice for Infants > 35 Weeks Gestational Age
EMERGENCY DEPARTMENT ALGORITHM
Patient Presentation
Last revised: 06/2015
Last reviewed: 06/2015
Contact CCKM for revisions.
Neonatal Jaundice – Neonatal – Inpatient/Ambulatory Clinical Practice Guideline
Inclusion Criteria:
* Well appearing
* Age < 14 days
* Born at > 35 weeks gestational age
* Concern for jaundice
Perform Initial Assessment including:
ξ Blood glucose if indicated
ξ Total bilirubin with conjugated fraction. Consider heel stick.
ξ If high risk for hemolysis*, consider obtaining a CBC without differential, blood type and
screen, direct antibody test or direct Coomb’s test, or reticulocyte count.
ξ Determine exchange transfusion threshold using AAP nomogram and phototherapy threshold.
NOTE: Supplemental IV fluids NOT routinely
indicated. Consider formula supplementation
or NG feedings if not eating well.
Admit to General Care
Ongoing ED Management
ξ Encourage feeding, however the infant should not be removed from bili lights for > 20 minutes in any 3 hour period. Use
bottle if needed. Consider NG tube.
ξ Do NOT interrupt phototherapy for patients nearing exchange transfusion threshold or with rapidly rising total bilirubin
ξ Use maternal EBM for supplemental feeds, if indicated.
ξ Consider 20 mL/kg NS bolus and maintenance IV fluids for patients that meet NICU Consult Criteria or show
cardiovascular compromise due to dehydration.
ξ If available, initiate phototherapy while waiting for admission.
Exclusion Criteria:
* Direct hyperbilirubinemia
* Suspected sepsis or ill-appearing
* Meets NICU Direct Admit Criteria
STEP 4
Automatic NICU Admission Criteria
ξ Signs of moderate-severe acute
bilirubin encephalopathy or total
bilirubin > 2 mg/dL above exchange
transfusion threshold
STEP 1
Evaluate for Discharge from ED
ξ Total bilirubin below phototherapy
threshold
ξ Follow-up appointment arranged for
next day
ξ Feeding adequately
ξ No concern for significant hemolysis
STEP 3
Evaluate for NICU Consult Criteria
ξ Total bilirubin within 2 mg/dL of
exchange transfusion threshold
ξ Age < 24 hours
ξ High suspicion for or lab evidence
of hemolysis (i.e., DAT positive)
ξ History of NICU admission or stay
STEP 2
Evaluate for Inpatient Admission
ξ Total bilirubin above phototherapy
threshold but not within 2 mg/dL of
exchange transfusion threshold
(i.e., at 72 hours of age, exchange
transfusion threshold 24 and total
bilirubin 21)
ξ Consider phone consultations with
patient's primary care physician to
determine if appropriate for
outpatient management
Admit to NICU
(Outside guideline scope)
Discharge from ED
Acuity
warrants admission
as determined by
NICU attending
physician?
No
Yes
*Risk factors for hemolysis:
ξ Family history of G6PD or
other hemolytic disorders
ξ Maternal blood type O
ξ Patient age < 24 hours
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:CCKM@uwhealth.org 06/2015

Neonatal Jaundice for Infants > 35 Weeks Gestational Age
POST NEWBORN DISCHARGE AFCH INPATIENT
GENERAL CARE ALGORITHM
Patient Admitted
Inpatient Management
ξ If direct admit, obtain baseline total bilirubin with conjugated fraction (if not already completed).
Consider RN heel stick.
ξ Place in giraffe warmer.
ξ Place under phototherapy as soon as possible (goal < 60 minutes from admission)
ξ Continue effective phototherapy until total bilirubin at least 3 mg/dL below phototherapy threshold.
ξ Encourage feeding. The infant should not be removed from bili lights for > 20 minutes in an 3 hour
period. Use bottle if needed. If mild dehydration or weight loss > 10% from birth weight and not
feeding well, consider NG feedings.
ξ Consider IV fluids for patients not tolerating enteral feeds or with ongoing cardiovascular signs of
dehydration.
Patient meets NICU
Consult Criteria?*
ξ Measure total bilirubin
every 4 hours until total
bilirubin falling.
ξ Measure G6PD (for
unexplained hemolysis)
Yes
Measure total bilirubin 4-6
hours after starting
phototherapy (or with
routine AM labs)
No
Total
bilirubin below
phototherapy
threshold?
Discharge
Confirm the following:
- Follow-up appointment scheduled for next day
- No concern for significant ongoing hemolysis
- Patient feeding well
Last revised: 06/2015
Last reviewed: 06/2015
Contact CCKM for revisions.
Neonatal Jaundice – Neonatal – Inpatient/Ambulatory Clinical Practice Guideline
Inclusion Criteria:
* Well appearing
* Age < 14 days
* Born at > 35 weeks gestational age
* Concern for jaundice
NOTE: Supplemental IV fluids
or IV placement are NOT
routinely indicated.
Exclusion Criteria:
* Direct hyperbilirubinemia
* Suspected sepsis or ill-appearing
* Meets NICU Direct Admit Criteria
Criteria for NICU
Transfer:
- Signs of moderate-
severe acute bilirubin
encephalopathy
- Total bilirubin > 2 mg/
dL above exchange
transfusion threshold
*NICU Consult Criteria:
- Total bilirubin within 2
mg/dL of exchange
transfusion threshold
- High suspicion for or
lab evidence of
hemolysis
(i.e., DAT positive)
- Concerning vital signs
(i.e., apnea > 20 sec.,
bradycardia < 100 bpm,
frequent O2 sat. < 90%)
- If patient still requires
hospitalization after 48
hours
**Indications for rebound
total bilirubin measurements:
- Slow resolution of
hyperbilirubinemia with
phototherapy
- Uncertainty regarding ability
for post discharge bilirubin
measurements
- Hemolysis suspectedIndications for
rebound total
bilirubin?**
Yes
Continue
phototherapy.
Measure total
bilirubin in 6-12
hours.
No
Measure total
bilirubin for
rebound.
Yes
No
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 06/2015CCKM@uwhealth.org