Management of jaundice on the postnatal ward

• Jaundice can develop at any time over the first few days of life. All possible opportunities should be used to assess and monitor for jaundice.
• The degree to which a baby is jaundiced is difficult to assess visually and should be substantiated with a bilirubin value.
• Comparison with a previous measurement is more informative than a single measurement. Particular attention should be paid to babies at increased risk - this includes:
  • preterm (under 38 weeks)
  • intention to exclusively breastfeed
  • previous sibling treated for jaundice
  • known antibodies / rhesus negative mother
  • IUGR
  • infants of diabetic mothers
  • baby with bruising / trauma from delivery
  • ethnic group at risk for G6PD deficiency (African-American male, Greek/Mediterranean, Italian, Middle Eastern)

• Use the transcutaneous bilirubinometer (TCB) in babies with a gestational age of 35 weeks or more and postnatal age of more than 24 hours and less than 14 days of life.
• If the TCB is not available, measure the serum bilirubin.
• Always use serum bilirubin (SBR) measurement to determine the bilirubin level in babies who develop jaundice in the first 24 hours of life, who are less than 35 weeks gestational age or have had phototherapy treatment.

The result from the TCB should also be considered in context of the individual baby and its age regardless of the value of the reading.

• If a TCB measurement indicates a bilirubin level above or within 25 micromol/L of the phototherapy threshold (use treatment threshold graph) confirm the result by measuring the SBR.
• Always confirm result with SBR measurement if the TCB reads above 250 micromol/L, regardless of the age and gestation of the baby and where it plots on the graph.
• Repeat measurement is recommended for those with a SBR level within 50 micromol/L of treatment threshold. This allows the rate of rise to be determined and aid decision.
• Repeat should be done within 24 hours for standard risk baby and within 18 for those with increased risk (green line on badger graph).

A pragmatic approach can be taken for babies waiting for discharge home and in these cases individual circumstances should also be considered.

Options may be earlier repeat, giving indication of rate of rise, discharge home with plan to return for repeat.

• For babies whose level falls below the 50 micromol/L below treatment threshold, no routine repeat required unless clinically indicated, consideration should still be given to the context of the jaundice and individual circumstances.
• Rising levels on repeat should be considered for further repeat within 24 hours. If jaundice under 24 hours do initial repeat of SBR after 6 hours.

• Phototherapy can be administered on postnatal ward, either by paddle (under light) or giraffe (over light). The baby’s temperature should be monitored to ensure they remain warm enough.
• Ensure the babies are eyes protected and they are fed optimally.
• Phototherapy should be stopped once the SBR has fallen to a level at least 50 micromol/L below treatment threshold.
• Check for rebound bilirubin 12-18 hours after stopping phototherapy.

Again a pragmatic approach can be taken for babies waiting for discharge home and in these cases individual circumstances should be considered and appropriate plan made accordingly.

• If the bilirubin is continuing to rise despite phototherapy use multiple phototherapy.
• If rising trend repeat 6-8 hourly and if rate of rise >8 micromol/L/hr increase phototherapy.
• Babies on phototherapy should have a FBC Group and DAT checked with their first repeat SBR.

Remember to consider sepsis.

A pathway for the management of jaundice in the postnatal ward using the transcutaneous bilirubinometer is available here.

All results should be input to maternity badger.

1. Clean the tip of the probe with an alcohol swab.
2. Press the power switch on.
3. Select MENU, select MEASURE, and press OK. The letters AVE with the number of measurements selected will appear in the display.
4. Put in baby chi as ID number, nurse ID not required.
5. Select measurement site: the neonate’s mid-sternum is preferred but the forehead can be used.
6. Place the Jaundice Meter JM-105 probe tip flat against the baby’s skin, not at an angle, and press lightly until you hear a click. Lift the Jaundice Meter from the skin between measurements and pause until the green READY light illuminates again. Repeat the testing procedure until 3 measurements have been taken.
7. Plot the result on the gestation appropriate graph.
8. If the result is falls above or within 50 of the phototherapy treatment threshold a SBR is required.
9. Always check a serum bilirubin measurement if the TCB reads above 250 µmol/L regardless of age or gestation of the baby and where it plots on the graph.

1. Jackson A Jaundice management on the postnatal wards 2021 West of Scotland Neonatal MCN  
2. NICE Jaundice in newborn babies under 28 days (CG98) 2010 (last updated October 2016)