Dr Julia Thomson

Treatment

Jaundice occurring < 24 hours of age is likely to be caused by haemolysis and requires close monitoring.
Jaundice occurring > 24 hours of age is usually due to other, more benign, causes but never be complacent.

Points to Remember

1. Early onset jaundice is often due to haemolysis. Any baby with a rapid rise in bilirubin level (greater than the gradient of the phototherapy line) in the first 24 hours of life needs to be transferred to NICU for possible exchange transfusion.
2. Babies with known Rhesus disease and Hb < 12g/dl in the first 48 hours of life need to go to NICU. All Rhesus negative women now get anti-D in pregnancy which makes all their cord blood DCTs positive. This does not necessarily mean that the baby is haemolysing; a cord blood DCT has lost all its specificity as a test and should therefore be abandoned as a routine test. A DCT is however indicated if the baby is jaundiced. Where the mother has been found to have antibodies antenatally, you do need to take cord blood for DCT, group and a bilirubin. The upper limit of normal bilirubin in cord blood is 35micromol/L. Repeat these babies' bilirubin 4 hours after birth.
3. There may be a family history of spherocytosis or splenectomy
4. G6PD deficiency cannot be diagnosed for several weeks after a blood transfusion
5. Babies should be treated according to their total bilirubin level (ie do not subtract the direct bilirubin component)
6. Gilbert's syndrome is common (42% heterozygotes in the population and 5-10% homozygotes, particularly high in Greece and Eastern Europe) and may exacerbate other causes of jaundice.
7. Babies presenting with kernicterus need an exchange transfusion even if bilirubin levels are lower than those normally accepted for obligatory exchange. Blood will take at least 4 hours to arrive from Colindale therefore start continuous triple phototherapy immediately to prevent levels rising still further. See separate protocol for a practical guide to exchange transfusion.
8. Cases of kernicterus are increasing (and delayed lactation is sometimes the only cause) - do not shy away from doing exchange transfusions on babies with very high bilirubin levels. Plot the baby on the appropriate chart, move the baby to NICU, start triple phototherapy and involve senior neonatologists.

Phototherapy

Phototherapy should be given continuously although the baby may come out for breastfeeds if the bilirubin levels are not very high. The eyes should be covered and a 10-20% increase in fluids, although not mandatory, can be considered if the baby is dehydrated.

Phototherapy has its greatest effect in the first 24-48 hours of treatment. If bilirubin levels have not dropped by 25-50% by then, think about compliance, haemolysis, sepsis or conjugated hyperbilirubinaemia.

SBRs should be taken 4 to 6 hourly if the baby is less than 24 hours old, 6 to 8 hourly if more than 24 hours old. 12 hourly SBRs significantly delay discharge from the postnatal ward.

Stopping phototherapy:

It is usual, but not mandatory, for babies to have 2 bilirubin measurements 'below the line' prior to stopping lights and to have 2 'rebound' readings still below the line prior to sending home. Many babies will not need to be managed so conservatively; take the baby's risk factors and age into account and use the Bhutani nomogram to guide your decision making. Discuss cases with senior neonatologists if there are concerns and document clinical decisions in the baby's notes.