Page 135 - 16Neonatal Jaundice_compressed

Neonatal jaundice

Existing guidelines vary in their recommendations on how frequently to monitor serum
bilirubin, when to discontinue phototherapy and how often to monitor for rebound jaundice.

GDG translation from evidence
The evidence base was not adequate to inform the GDG regarding recommendations for
monitoring of jaundice after discontinuation of phototherapy and checking for rebound. One
good-quality study looked at discontinuation of phototherapy but used the Bhutani nomogram
and was not relevant to UK practice.
The RCTs reviewed in Section 7.2 generally adopted the practice of discontinuing phototherapy
once the bilirubin levels were below the threshold value on two successive measurements. The
GDG reached a consensus opinion. Consideration was given to the potential for rapidly rising
bilirubin in the presence of haemolysis, and the interval between testing was determined with
this in mind. Expert advice is that a threshold of 6 hours between tests allows safe differentiation
between sequential results in order to measure a true rate of increase.

The GDG recommends a serum bilirubin level be taken 12–18 hours after stopping
phototherapy to check for rebound jaundice, because of their decision (see Section 7.1.1) to
stop phototherapy once bilirubin levels at least 50 micromol/l below the age-appropriate
threshold are reached. This provides for a ‘safety net’ for measurement errors and to identify the
occasional baby with increased bilirubin production even after apparently successful
phototherapy.

Threshold table Consensus-based bilirubin thresholds for the management of babies of 38 weeks or
more gestational age with hyperbilirubinaemia
Age (hours) Bilirubin measurement (micromol/litre)
0 > 100 > 100
6 > 100 > 112 > 125 > 150
12 > 100 > 125 > 150 > 200
18 > 100 > 137 > 175 > 250
24 > 100 > 150 > 200 > 300
30 > 112 > 162 > 212 > 350
36 > 125 > 175 > 225 > 400
42 > 137 > 187 > 237 > 450
48 > 150 > 200 > 250 > 450
54 > 162 > 212 > 262 > 450
60 > 175 > 225 > 275 > 450
66 > 187 > 237 > 287 > 450
72 > 200 > 250 > 300 > 450
78 > 262 > 312 > 450
84 > 275 > 325 > 450
90 > 287 > 337 > 450
96+ > 300 > 350 > 450

Action Repeat bilirubin Consider Start phototherapy Perform an exchange
measurement in phototherapy and transfusion unless the
6–12 hours repeat bilirubin bilirubin level falls
measurement in below threshold while
6 hours the treatment is being
prepared

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