1. Implementing NICE guidance
Neonatal jaundice
Implementing NICE guidance
ABOUT THIS PRESENTATION:
This presentation has been written to help you raise awareness of the NICE clinical guideline on neonatal jaundice. This guideline has been written for all healthcare professionals and other staff who care for neonates with jaundice.
The guideline is available in a number of formats, including a quick reference guide. We recommend that you hand out copies of the quick reference guide at your presentation so that your audience can refer to it. During the presentation, your audience will need to specifically refer to the threshold table on page 3, the investigation pathway on pages and the phototherapy and exchange transfusion pathways on pages We also recommend that you hand out copies of the treatment threshold graphs that can be found on the NICE website in a separate document and also as an implementation tool in an excel spreadsheet. The guideline, quick reference guide and all implementation tools are available on the NICE website – CG98. See the end of the presentation for ordering details for the quick reference guide.
You can add your own organisation’s logo alongside the NICE logo.
We have included notes for presenters, broken down into ‘key points to raise’, which you can highlight in your presentation, and ‘additional information’ that you may want to draw on, such as a rationale or an explanation of the evidence for a recommendation. Where necessary, the recommendation will be given in full.
DISCLAIMER
This slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself.
PROMOTING EQUALITY
Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties.
2010
NICE clinical guideline 98

2. What this presentation covers
Key definitions
Background
Scope
Key priorities for implementation
Costs and savings
Discussion
Find out more
NOTES FOR PRESENTERS:
In this presentation we will start by defining some key terms and providing some background to the guideline and why it is important.
We will then present the key priorities for implementation. The NICE guideline contains nine key priorities for implementation, which you can find on pages 7-8 of your quick reference guide.
Next, we will summarise the costs and savings that are likely to be incurred in implementing the guideline.
Then we will open the meeting up with a list of questions to help prompt a discussion on local issues for incorporating the guidance into practice.
Finally, we will end the presentation with further information about the support provided by NICE.
Please note that this slide set focuses on the key priorities for implementation, although other recommendations have been detailed in the notes for presenters.

3. Key definitions Term – 37 weeks or more gestational age
Near-term – 35 to 36 weeks gestational age
Preterm – less than 37 weeks gestational age
Kernicterus – clinical features of acute or chronic bilirubin encephalopathy, including cerebral palsy, hearing loss and visual problems
Prolonged jaundice – jaundice lasting more than more than 14 days in term babies and more than 21 days in preterm babies
Significant hyperbilirubinaemia – an elevation of the serum bilirubin to a level requiring treatment
Visible jaundice – jaundice detected by visual inspection
NOTES FOR PRESENTERS:
Other key definitions can be found on page 6 of the QRG.

4. Background
Approximately 60% of term and 80% of preterm babies develop jaundice in the first week of life.
For most babies, this early jaundice is harmless.
Babies with very high bilirubin levels are at risk of developing kernicterus. Kernicterus is also known to occur at lower levels of bilirubin in term babies who have risk factors, and in preterm babies.
NOTES FOR PRESENTERS:
Key points to raise:
The reasons for developing the guideline are that:
Clinical recognition and assessment of jaundice can be difficult, this is particularly so in babies with darker skin tones.
Once jaundice is recognised, there is uncertainty about when to treat, and there is widespread variation in the use of phototherapy and exchange transfusion.
There is a need for more uniform, evidence-based practice and for consensus-based practice where such evidence is lacking.
Additional information:
Jaundice refers to the yellow colouration of the skin and the sclerae (whites of the eyes) caused by the accumulation of bilirubin in the skin and mucous membranes. Jaundice is caused by a raised level of bilirubin in the body, a condition known as hyperbilirubinaemia.
Prolonged jaundice is generally harmless, but can be an indication of serious liver disease.

5. Scope
Recognition, assessment and treatment of neonatal jaundice for all babies with jaundice from birth up to 28 days of age.
Special attention has been given to the recognition and management of neonatal jaundice in babies with dark skin tones.
NOTES FOR PRESENTERS:
Key points to raise:
The guideline does not cover babies with jaundice that lasts beyond the first 28 days of life, babies with jaundice that requires surgical treatment to correct the underlying cause and babies with conjugated hyperbilirubinaemia.

6. Key priorities for implementation
Information for parents and carers
Care for all babies
Additional care for babies at risk
How to measure bilirubin in all babies with jaundice
How to manage hyperbilirubinaemia
Care of babies with prolonged jaundice
NOTES FOR PRESENTERS:
The NICE guideline contains lots of recommendations about how care can be improved, but the experts who wrote the guideline have chosen key recommendations that they think will have the greatest impact on care and are the most important priorities for implementation. They are divided into seven areas of key priority and within these there are nine recommendations that we will consider in turn.

7. Information for parents and carers
Factors that influence the development of significant hyperbilirubinaemia  
How to check the baby and what to do if they suspect jaundice
The importance of recognising jaundice in the first 24 hours and of seeking urgent medical advice
The importance of checking the baby’s nappies for dark urine or pale chalky stools
The fact that neonatal jaundice is common and usually transient and harmless
Reassurance that breastfeeding can usually continue.
NOTES FOR PRESENTERS:
Key points to raise:
A parent information factsheet about neonatal jaundice is available on the NICE website. This can be printed off and given to parents and carers of all newborn babies. It can be adapted locally if necessary. A version of the guideline for parents and carers is also available (Understanding NICE Guidance). These can be found at CG98.
Recommendation in full:
Offer parents or carers information about neonatal jaundice that is tailored to their needs and expressed concerns. This information should be provided through verbal discussion backed up by written information. Care should be taken to avoid causing unnecessary anxiety to parents or carers. Information should include:
• factors that influence the development of significant hyperbilirubinaemia
• how to check the baby for jaundice
• what to do if they suspect jaundice
• the importance of recognising jaundice in the first 24 hours and of seeking urgent medical advice
• the importance of checking the baby’s nappies for dark urine or pale chalky stools
• the fact that neonatal jaundice is common, and reassurance that it is usually transient and harmless
reassurance that breastfeeding can usually continue. [1.1.1]   

8. Care for all babies
Examine all babies for jaundice at every opportunity especially in the first 72 hours.
Identify babies as being more likely to develop significant hyperbilirubinaemia if they have any of the following factors:
• gestational age under 38 weeks
a previous sibling with neonatal jaundice requiring phototherapy
• mother’s intention to breastfeed exclusively
• visible jaundice in the first 24 hours of life.
NOTES FOR PRESENTERS:
Key points to raise:
Breastfeeding contributes to the health of both mother and child, in the short and long term. For example, babies who are not breastfed are many times more likely to acquire infections and mothers who do not breastfeed have an increased risk of breast and ovarian cancers. ‘Maternal and child nutrition’ (NICE public health guidance 11)
Exclusive breastfeeding is an important factor in neonatal jaundice. The reasons for the link are not fully understood, but one reason may be breast milk passing more slowly through the gut whilst feeding is being established, with some babies experiencing relative dehydration.
Encourage mothers of breastfed babies with jaundice to breastfeed frequently, and to wake the baby for feeds if necessary.
Provide lactation/ feeding support to breastfeeding mothers whose baby is visibly jaundice.
Refer to ‘Routine postnatal care of women and their babies’ (NICE clinical guideline 37) and ‘Maternal and child nutrition’ (NICE public health guidance 11) for information on breastfeeding support.
Recommendation in full:
Identify babies as being more likely to develop significant hyperbilirubinaemia if they have any of the following factors:
• gestational age under 38 weeks
• a previous sibling with neonatal jaundice requiring phototherapy
• mother’s intention to breastfeed exclusively
• visible jaundice  (jaundice detected by visual examination) in the first 24 hours of life. [1.2.1]
 In all babies:
• check whether there are factors associated with an increased likelihood of developing significant hyperbilirubinaemia soon after birth
• examine the baby for jaundice at every opportunity especially in the first 72 hours. [1.2.3]
 When looking for jaundice (visual inspection):
• check the naked baby in bright and preferably natural light
• examination of the sclerae, gums and blanched skin is useful across all skin tones. [1.2.4]

9. Additional care for babies at risk
Ensure babies with factors associated with an increased
likelihood of developing significant hyperbilirubinaemia:
receive an additional visual examination by a healthcare professional during the first 48 hours of life
NOTES FOR PRESENTERS:
Recommendation in full:
Ensure babies with factors associated with an increased likelihood of developing significant hyperbilirubinaemia receive an additional visual examination by a healthcare professional during the first 48 hours of life. [1.2.9]

10. Measuring bilirubin in all babies with jaundice
Do not rely on visual inspection alone to estimate the
bilirubin level in a baby with jaundice.
NOTES FOR PRESENTERS:
Key points to raise:
Current practice seems to be to assess the degree of jaundice by visual inspection alone for most babies.
Recommendation in full:
Do not rely on visual inspection alone to estimate the bilirubin level in a baby with jaundice. [1.2.6]

11. How to measure the bilirubin level - 1
Use a transcutaneous bilirubinometer (TCB) in babies with a gestational age of 35 weeks or more and postnatal age of more than 24 hours. 
If a TCB is not available, measure the serum bilirubin.
If a TCB measurement indicates a bilirubin level greater than 250 micromol/litre check the result by measuring the serum bilirubin.
Do not use an icterometer.
NOTES FOR PRESENTERS:
Key points to raise:
Do not measure bilirubin levels routinely in babies who are not visibly jaundiced.
Urgent additional care for babies with visible jaundice in the first 24 hours:
Measure and record the serum bilirubin level urgently (within 2 hours) in all babies in the first 24 hours of life with suspected or obvious jaundice. [1.2.10]
Continue to measure the serum bilirubin level every 6 hours for all babies with suspected or obvious jaundice in the first 24 hours of life until the level is both below the treatment threshold, and stable and/or falling. [1.2.11]
Arrange a referral to ensure that an urgent medical review is conducted (as soon as possible and within 6 hours) for babies with suspected or obvious jaundice in the first 24 hours of life to exclude pathological causes of jaundice. [1.2.12]
Care for babies more than 24 hours old:
Measure and record the bilirubin level urgently (within 6 hours) in all babies more than 24 hours old with suspected or obvious jaundice. [1.2.14]
Additional information:
The use of transcutaneous bilirubinometers (TCBs) to monitor bilirubin levels, where clinically indicated, presents additional benefits over the use of serum bilirubin tests because:
transcutaneous bilirubin measurement is less invasive than blood sampling
test results are available immediately, avoiding the problems associated with taking and acting on blood samples in the community
the procedure is more acceptable to parents and clinical staff.
An icterometer is a tool used to estimate the level of jaundice. It consists of perspex strips in graded bands of yellow.
These are placed against the baby’s skin, and the band whose colour is closest to the baby’s actual skin colour is used to indicate the severity of the jaundice. NICE recommends that these are not used.

12. How to measure the bilirubin level - 2
Always use serum bilirubin measurement :
to determine the bilirubin level in babies with jaundice in the first 24 hours of life
• to determine the bilirubin level in babies less than 35 weeks gestational age 
• for babies at or above the relevant treatment threshold for their postnatal age, and for all subsequent measurements 

13. How to manage hyperbilirubinaemia
Use the bilirubin level to determine the management
of hyperbilirubinaemia in all babies.
Refer to the guideline for the:
threshold table
treatment threshold graphs
investigation pathway
phototherapy and exchange transfusion pathways
NOTES FOR PRESENTERS:
Note to presenter – Refer your audience to the threshold table on page 3 of the QRG, the investigation pathway on pages of the QRG and the phototherapy and exchange transfusion pathways on pages of the QRG. Your audience will also need to refer to the treatment threshold graphs, they can be found on the NICE website in a separate document and also as an implementation tool in an excel spreadsheet. The guideline, quick reference guide and all implementation tools are available on the NICE website – CG98.
Key points to raise:
There is currently uncertainty about when to treat babies with jaundice, and there is widespread variation in the use of phototherapy and exchange transfusion.
Additional information:
There are additional recommendations about:
Information for parents or carers on phototherapy
General care of the baby during phototherapy
Starting phototherapy
Phototherapy equipment
See pages of the QRG.

14. Care of babies with prolonged jaundice
Follow expert advice about care for babies with a
conjugated bilirubin level greater than 25 micromol/litre
because this may indicate serious liver disease.
NOTES FOR PRESENTERS:
Key points to raise:
Prolonged jaundice – jaundice lasting more than more than 14 days in term babies and more than 21 days in preterm babies.
Additional information:
In babies with a gestational age of 37 weeks or more with jaundice lasting more than 14 days, and in babies with a gestational age of less than 37 weeks and jaundice lasting more than 21 days:
look for pale chalky stools and/or dark urine that stains the nappy
measure the conjugated bilirubin
carry out a full blood count
carry out a blood group determination (mother and baby) and DAT (Coombs’ test). Interpret the result taking account of the strength of reaction, and whether mother received prophylactic anti-D immunoglobulin during pregnancy.
carry out a urine culture
ensure that routine metabolic screening (including screening for congenital hypothyroidism) has been performed. [1.7.1]
Recommendation in full:
Follow expert advice about care for babies with a conjugated bilirubin level greater than 25 micromol/litre because this may indicate serious liver disease. [1.7.2]

15. Costs and savings Testing £2,555 Purchase of TCBs £10,200
Significant annually recurring costs per 100,000 population
Testing
£2,555
Significant non-recurrent costs per 100,000 population
Purchase of TCBs
£10,200
Estimated savings
Per case of kernicterus avoided
£5.5 million
Reduced use of exchange transfusion
Unquantified
ADAPTING THIS SLIDE FOR LOCAL USE:
We are aware that local factors such as incidence and baseline can vary considerably when compared with the national average. NICE has provided a costing template for you to calculate the financial impact this guideline will have locally. We encourage you to calculate the local impact of this guideline by amending the local variations in the template such as incidence, baseline and uptake. You can then remove the national figures from the table and replace them with your local figures to present to your colleagues.
NOTES FOR PRESENTERS:
The information on this slide has been extracted from the NICE costing report, which has been provided by NICE to support implementation of this guidance. It was developed after careful consideration of the available data and by working closely with the guideline developers and other people in the NHS. It is not NICE guidance. Assumptions used in this report are based on assessment of the national average and it is recognised that local practice or circumstances may differ from this. The costs published in this report are estimates only and are not to be taken as the Institute's view of desirable, or maximum or minimum figures.
NICE has also provided a costing template to help calculate the local costs associated with implementing this guideline. The costs per 100,000 population are summarised in the table.
Key points to raise:
The NICE neonatal jaundice costing report focuses on recommendations considered to have the greatest resource impact, which would require the most additional resources to implement or which could potentially generate savings. These recommendations refer to: testing babies for hyperbilirubinaemia, and the purchase of TCBs (transcutaneous bilirubinometers) to test bilirubin levels.
Please also note:
TCBs are already in use in several areas to test bilirubin levels
The cost of TCBs used in the costing template is based on quotes obtained from the suppliers. It should be noted that the procurement of medical equipment is complex and prices are driven by a range of factors. Meters may be provided with substantial discounts.
It has been difficult to estimate the number of TCB meters required to implement the guideline. The exact number required will be determined by local conditions and service delivery strategies.
Additional information:
Implementing the clinical guideline will bring the following benefits:
a reduction in the incidence of kernicterus and thus a reduction in the social and medical care costs of supporting people with kernicterus (the estimated lifetime cost of care for cases of kernicterus is £5.5 million per case);
a reduction in the use of exchange transfusion to treat hyperbilirubinaemia.
Please see the costing report for full details of how these calculations have been made.
We recognise that implementation of the recommendations may take place over a number of years.
For further information please refer to the costing template and costing report for this guidance on the NICE website.
Compliance with NICE guidelines is one of the criteria indicating good risk reduction strategies and, in combination with meeting other criteria indicating good risk management, could lead to a reduction in payments to the NHS Litigation Authority schemes, including the Clinical Negligence Scheme for Trusts (CNST).

16. Discussion
Where does our current practice differ from the recommendations made by NICE about the recognition and assessment of neonatal jaundice?
When and how often do we currently measure serum bilirubin? What changes do we need to make to enable us to measure serum bilirubin as outlined in the NICE guideline?
How does our current practice compare to the treatment thresholds recommended by NICE?
NOTES FOR PRESENTERS:
These questions are suggestions that have been developed to help provide a prompt for a discussion at the end of your presentation – please edit and adapt these to suit your local situation.
Where does our current practice differ from the recommendations made by NICE about the recognition and assessment of neonatal jaundice? Do we examine all babies for jaundice in the first 72 hours? Do we identify babies that have factors associated with an increased likelihood of developing significant hyerperbilirubinaemia, and make sure that they receive an additional visual examination in the first 48 hours of life? Do we ever rely on visual examination alone to estimate the bilirubin level in a baby with jaundice? Do we ever use icterometers? Do we currently use TCBs? If not, how many do we need to purchase?
When and how often do we currently measure serum bilirubin? What changes do we need to make to enable us to measure serum bilirubin as outlined in the NICE guideline?
How does our current practice compare to the treatment thresholds recommended by NICE?
You may find it helpful to stimulate discussion by using a few different scenarios. For example, you could break your audience up into small groups or pairs to consider action that would be taken to:
assess all newborn babies for jaundice
manage a preterm baby with hyperbilirubinaemia
manage a term baby with hyperbilirubinaemia
manage a baby that has developed jaundice in the first 24 hours of life
manage a baby that still has jaundice after two weeks.
The overall objective being to compare current practice with how they would need to manage these cases in line with the NICE guideline, drawing out what needs to change in your local area. To assist discussion refer your audience to the threshold table on page 3 of the QRG, the investigation pathway on pages of the QRG and the phototherapy and exchange transfusion pathways on pages of the QRG. Your audience will also need to refer to the treatment threshold graphs which can be found on the NICE website in a separate document and also as an implementation tool in an excel spreadsheet. The guideline, quick reference guide and all implementation tools are available on the NICE website – CG98.

17. Find out more Visit www.nice.org.uk/CG98 for: the guideline
the quick reference guide
‘Understanding NICE guidance’
costing report and template
audit support
a parent information factsheet
treatment threshold graphs
NOTES FOR PRESENTERS:
You can download the guidance documents from the NICE website.
The NICE guideline – all the recommendations.
A quick reference guide – a summary of the recommendations for healthcare professionals.
‘Understanding NICE guidance’ – information for patients and carers.
The full guideline – all the recommendations, details of how they were developed, and reviews of the evidence they were based on.
For printed copies of the quick reference guide or ‘Understanding NICE guidance’, phone NICE publications on or and quote reference numbers N2143 (quick reference guide) and/or N2144 (‘Understanding NICE guidance’).
NICE has developed tools to help organisations implement this guideline, which can be found on the NICE website.
Costing tools – a costing report gives the background to the national savings and costs associated with implementation, and a costing template allows you to estimate the local costs and savings involved.
Audit support – for monitoring local practice.
A parent information factsheet – to provide basic information about what neonatal jaundice is, to show parents and carers how to check their baby for jaundice and tell them what to do if they think their baby has jaundice and to provide information about how jaundice is treated.
Treatment threshold graphs – an interactive spreadsheet that enables clinical staff to identify treatment thresholds in relation to the baby’s age, gestational age and bilirubin levels.