Phototherapy Treatment and Exchange Transfusion for Severe Hyperbilirubinaemia

In TERM infants mostcases of Kernicterusoccur when SBR greaterthan 425umol/l.

SBR > 425umol/l or SBRat exchange transfusionlevel is a medicalEMERGENCY.

Immediate ExchangeTransfusionrecommended if signs ofacute bilirubinencephalopathy or ifSBR above exchangetransfusion line andunresponsive tophototherapy.

Contraindications toPhototherapy:

Congenital porphyria or afamily history ofporphyria, use of drugsthat are photosensitisers.

Plot Serum Bilirubin(SBR) level on Phototherapy Chart-AAP orNICE

If above treatment line start Phototherapy.

Re-check Serum Bilirubin(SBR) within 2-6 HoursIf SBR > 425umol/l re-check SBR within 3 hours.

Continue Phototherapy until SBR at least 50umol/l below thephototherapy treatement line level as per AAP or NICE

guidelines.

If DCT Positive: Repeatclinical assessment,

including SBR, within 24hours.

If DCT positive the infantneeds review and Hbcheck within 2 weeks.

If Direct Coombes Test(DCT) negative:Repeat clinical

assessment within 48hours.

OR

Transcutaneous Bilirubin(TCB) should NOT beused to guidephototherapy.

If SBR continues to risedespite intensivephotopherapy thissuggests haemolysis.

Longer Phototherapy willusually be necessary ifDCT Positive.

If SBR is rising rapidly orSBR within 50umol/l ofexchange transfusionlevel, consider IVIG 0.5-1g/kg , this can berepeated in 12 hours.

Consider multiple lightsand fibre optic blanket iflevel approachingexchange transfusionlevel, Fluid requirementsmay increase because ofinsensible losses.

Paediatrics and Neonatology Clinical Programme Algorithms

For infants less than 35 weeks gestation, and for exchange transfusion graphs we recommend use of NICE Guidelines Neonatal Jaundice TreatmentThreshold Graphs http://guidance.nice.org.uk/CG98/treatmentthresholdgraph/xls/English

References:

1. Alkalay AL, Simmons CF. Hyperbilirubinaemia in term infants. Pediatr 2005;115:824.

2. Neonatal Jaundice, Clinical Guidelines. National Collaborating Centre for Women’s and Child Health. NICE 2010.

3. Guidelines for detection, management and prevention of hyperbilirubinaemia in term and late preterm infants. Fetus and Newborn committee,Canadian Paediatric Society. Pediatr Child Health 2007;12:401-7.

This care pathway has been produced by the National Paediatric and Neonatology Clinical Programme. It is aimed at medical, nursing andallied health professionals working in Irish neonatal units.

Algorithm number:

Revision number:

Date of Last Update:

Approval date:

N19

2.0

Oct 2013

13/01/14

Document drafted by:

Document Status:

Document approved by:

Revision date:

National Paediatric and Neonatology Clinical Programme

Approved

Paediatric and Neonatology Clinical Programme Working GroupNeonatal Clinical Advisory Group

13/01/16