Guidance

Recommendations

Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Threshold table

Consensus‑based bilirubin thresholds for management of babies 38 weeks or more gestational age with hyperbilirubinaemia

Note that there is variability between assays from different manufacturers in reported bilirubin measurement. Healthcare professionals should consult their local pathology laboratory when interpreting threshold tables.

Age (hours) Bilirubin measurement (micromol/litre)

0

>100

>100

6

>125

>150

12

>150

>200

18

>175

>250

24

>200

>300

30

>212

>350

36

>225

>400

42

>237

>450

48

>250

>450

54

>262

>450

60

>275

>450

66

>287

>450

72

>300

>450

78

>312

>450

84

>325

>450

90

>337

>450

96+

>350

>450

Action

Start phototherapy

Perform an exchange transfusion unless the bilirubin level falls below threshold while the treatment is being prepared

1.1 Information for parents or carers

1.1.1

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. [2010]

1.2 Care for all babies

1.2.1

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. [2010]

1.2.2

Ensure that adequate support is offered to all women who intend to breastfeed exclusively. For information on breastfeeding support, see NICE's guideline on postnatal care. [2010]

1.2.3

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. [2010]

1.2.4

Parents, carers and healthcare professionals should all look for jaundice (visual inspection) in babies. [2016]

1.2.5

When looking for jaundice (visual inspection):

  • check the naked baby in bright and preferably natural light

  • examine the sclerae and gums, and press lightly on the skin to check for signs of jaundice in 'blanched' skin

  • be aware that changes to skin pigmentation because of hyperbilirubinaemia may be harder to see in darker skin. [2016, amended 2023]

1.2.6

Do not rely on visual inspection alone to estimate the bilirubin level in a baby with suspected jaundice. [2016]

1.2.7

Do not measure bilirubin levels routinely in babies who are not visibly jaundiced. [2010]

1.2.8

Do not use any of the following to predict significant hyperbilirubinaemia:

  • umbilical cord blood bilirubin level

  • end‑tidal carbon monoxide (ETCOc) measurement

  • umbilical cord blood direct antiglobulin test (DAT) (Coombs' test). [2010]

Additional care

1.2.9

Ensure babies with factors associated with an increased likelihood of developing significant hyperbilirubinaemia receive an additional visual inspection by a healthcare professional during the first 48 hours of life. [2010]

Urgent additional care for babies with visible jaundice in the first 24 hours

1.2.10

In all babies with suspected or obvious jaundice in the first 24 hours of life, measure and record the serum bilirubin level urgently (within 2 hours). [2010]

1.2.11

In all babies with suspected or obvious jaundice in the first 24 hours of life, continue to measure the serum bilirubin level every 6 hours until the level is both:

  • below the treatment threshold

  • stable and/or falling. [2010]

1.2.12

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. [2010]

Care for babies more than 24 hours old

1.2.14

Measure and record the bilirubin level urgently (within 6 hours) in all babies more than 24 hours old with suspected or obvious jaundice. [2010]

How to measure the bilirubin level

1.2.15

Use serum bilirubin measurement for babies:

  • in the first 24 hours of life or

  • who have a gestational age of less than 35 weeks. [2016]

1.2.16

In babies who have a gestational age of 35 weeks or more and who are over 24 hours old:

  • use a transcutaneous bilirubinometer to measure the bilirubin level

  • if a transcutaneous bilirubinometer is not available, measure the serum bilirubin

  • if a transcutaneous bilirubinometer measurement indicates a bilirubin level greater than 250 micromol/litre, measure the serum bilirubin to check the result

  • use serum bilirubin measurement if bilirubin levels are at or above the relevant treatment thresholds for their age, and for all subsequent measurements. [2016]

1.2.17

Do not use an icterometer to measure bilirubin levels in babies. [2016]

1.3 Management and treatment of hyperbilirubinaemia

Information for parents or carers on treatment

1.3.1

Offer parents or carers information about treatment for hyperbilirubinaemia, including:

  • anticipated duration of treatment

  • reassurance that breastfeeding, nappy‑changing and cuddles can usually continue. [2010]

1.3.2

Encourage mothers of breastfed babies with jaundice to breastfeed frequently, and to wake the baby for feeds if necessary. [2010]

1.3.3

Provide lactation/feeding support to breastfeeding mothers whose baby is visibly jaundiced. [2010]

How to manage hyperbilirubinaemia

Note that there is variability between assays from different manufacturers in reported bilirubin measurement. Healthcare professionals should consult their local pathology laboratory when interpreting threshold tables.

1.3.5

Do not use the albumin/bilirubin ratio when making decisions about the management of hyperbilirubinaemia. [2010]

1.3.6

Do not subtract conjugated bilirubin from total serum bilirubin when making decisions about the management of hyperbilirubinaemia (see management thresholds in the threshold table and the treatment threshold graphs). [2010]

1.4 Measuring and monitoring bilirubin thresholds before and during phototherapy

Before starting phototherapy

1.4.1

In babies who are clinically well, have a gestational age of 38 weeks or more and are more than 24 hours old, and who have a bilirubin level that is below the phototherapy threshold but within 50 micromol/litre of the threshold (see the threshold table and the treatment threshold graphs), repeat bilirubin measurement as follows:

  • within 18 hours for babies with risk factors for neonatal jaundice (those with a sibling who had neonatal jaundice that needed phototherapy or a mother who intends to exclusively breastfeed)

  • within 24 hours for babies without risk factors. [new 2016]

1.4.2

In babies who are clinically well, have a gestational age of 38 weeks or more and are more than 24 hours old, and who have a bilirubin level that is below the phototherapy threshold by more than 50 micromol/litre (see the threshold table and the treatment threshold graphs), do not routinely repeat bilirubin measurement. [new 2016]

During phototherapy

1.4.4

During phototherapy:

  • repeat serum bilirubin measurement 4–6 hours after initiating phototherapy

  • repeat serum bilirubin measurement every 6–12 hours when the serum bilirubin level is stable or falling. [2010]

Stopping phototherapy

1.4.6

Check for rebound of significant hyperbilirubinaemia with a repeat serum bilirubin measurement 12–18 hours after stopping phototherapy. Babies do not necessarily have to remain in hospital for this to be done. [2010]

Type of phototherapy to use

1.4.7

Do not use sunlight as treatment for hyperbilirubinaemia. [2010]

1.4.8

Use phototherapy (phototherapy given using an artificial light source with an appropriate spectrum and irradiance. This can be delivered using light-emitting diode [LED], fibreoptic or fluorescent lamps, tubes or bulbs) to treat significant hyperbilirubinaemia (see the threshold table and the treatment threshold graphs) in babies. [new 2016]

1.4.9

Consider intensified phototherapy (phototherapy that is given with an increased level of irradiance with an appropriate spectrum. Phototherapy can be intensified by adding another light source or increasing the irradiance of the initial light source used) to treat significant hyperbilirubinaemia in babies if any of the following apply [new 2016]:

  • the serum bilirubin level is rising rapidly (more than 8.5 micromol/litre per hour)

  • the serum bilirubin is at a level within 50 micromol/litre below the threshold for which exchange transfusion is indicated after 72 hours or more since birth (see threshold table and the treatment threshold graphs)

  • the bilirubin level fails to respond to initial phototherapy (that is, the level of serum bilirubin continues to rise, or does not fall, within 6 hours of starting phototherapy). [2010]

1.4.10

If the serum bilirubin level falls during intensified phototherapy to a level 50 micromol/litre below the threshold for which exchange transfusion is indicated reduce the intensity of phototherapy. [2010]

Information for parents or carers on phototherapy

1.4.11

Offer parents or carers verbal and written information on phototherapy including all of the following:

  • why phototherapy is being considered

  • why phototherapy may be needed to treat significant hyperbilirubinaemia

  • the possible adverse effects of phototherapy

  • the need for eye protection and routine eye care

  • reassurance that short breaks for feeding, nappy changing and cuddles will be encouraged

  • what might happen if phototherapy fails

  • rebound jaundice

  • potential long‑term adverse effects of phototherapy

  • potential impact on breastfeeding and how to minimise this. [2010]

General care of the baby during phototherapy

1.4.12

During phototherapy:

  • place the baby in a supine position unless other clinical conditions prevent this

  • ensure treatment is applied to the maximum area of skin

  • monitor the baby's temperature and ensure the baby is kept in an environment that will minimise energy expenditure (thermoneutral environment)

  • monitor hydration by daily weighing of the baby and assessing wet nappies

  • support parents and carers and encourage them to interact with the baby. [2010]

1.4.13

Give the baby eye protection and routine eye care during phototherapy. [2010]

1.4.14

Use tinted headboxes as an alternative to eye protection in babies with a gestational age of 37 weeks or more undergoing phototherapy. [2010]

Monitoring the baby during phototherapy

1.4.15

During phototherapy:

  • using clinical judgement, encourage short breaks (of up to 30 minutes) for breastfeeding, nappy changing and cuddles

  • continue lactation/feeding support

  • do not give additional fluids to babies who are breastfed.

    Maternal expressed milk is the additional feed of choice if available, and when additional feeds are indicated. [2016]

1.4.16

During intensified phototherapy:

  • do not interrupt phototherapy for feeding but continue administering intravenous/enteral feeds

  • continue lactation/feeding support so that breastfeeding can start again when treatment stops.

    Maternal expressed milk is the additional feed of choice if available, and when additional feeds are indicated. [2016]

Phototherapy equipment

1.4.17

Ensure all phototherapy equipment is maintained and used according to the manufacturers' guidelines. [2010]

1.4.18

Use incubators or bassinets according to clinical need and availability. [2010]

1.4.19

Do not use white curtains routinely with phototherapy as they may impair observation of the baby. [2010]

1.5 Factors that influence the risk of kernicterus

1.5.1

Identify babies with hyperbilirubinaemia as being at increased risk of developing kernicterus if they have any of the following:

  • a serum bilirubin level greater than 340 micromol/litre in babies with a gestational age of 37 weeks or more

  • a rapidly rising bilirubin level of greater than 8.5 micromol/litre per hour

  • clinical features of acute bilirubin encephalopathy. [2010]

1.6 Formal assessment for underlying disease

1.6.1

In addition to a full clinical examination by a suitably trained healthcare professional, carry out all of the following tests in babies with significant hyperbilirubinaemia as part of an assessment for underlying disease (see threshold table and the treatment threshold graphs):

  • serum bilirubin (for baseline level to assess response to treatment)

  • blood packed cell volume

  • blood group (mother and baby)

  • DAT (Coombs' test). Interpret the result taking account of the strength of reaction, and whether mother received prophylactic anti‑D immunoglobulin during pregnancy. [2010]

1.6.2

When assessing the baby for underlying disease, consider whether the following tests are clinically indicated:

  • full blood count and examination of blood film

  • blood glucose‑6‑phosphate dehydrogenase levels, taking account of ethnic origin

  • microbiological cultures of blood, urine and/or cerebrospinal fluid (if infection is suspected). [2010]

1.7 Care of babies with prolonged jaundice

1.7.1

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

  • consider a urine culture if there is clinical suspicion of a urinary tract infection

  • ensure that routine metabolic screening (including screening for congenital hypothyroidism) has been performed. [2010, amended 2023]

1.7.2

Follow expert advice about care for babies with a conjugated bilirubin level greater than 25 micromol/litre because this may indicate serious liver disease. [2010]

1.8 Intravenous immunoglobulin

1.8.1

Use intravenous immunoglobulin (IVIG) (500 mg/kg over 4 hours) as an adjunct to continuous intensified phototherapy in cases of rhesus haemolytic disease or ABO haemolytic disease when the serum bilirubin continues to rise by more than 8.5 micromol/litre per hour. [2010]

1.8.2

Offer parents or carers information on IVIG including:

  • why IVIG is being considered

  • why IVIG may be needed to treat significant hyperbilirubinaemia

  • the possible adverse effects of IVIG

  • when it will be possible for parents or carers to see and hold the baby. [2010]

1.9 Exchange transfusion

1.9.1

Offer parents or carers information on exchange transfusion including:

  • the fact that exchange transfusion requires that the baby be admitted to an intensive care bed

  • why an exchange transfusion is being considered

  • why an exchange transfusion may be needed to treat significant hyperbilirubinaemia

  • the possible adverse effects of exchange transfusions

  • when it will be possible for parents or carers to see and hold the baby after the exchange transfusion. [2010]

1.9.2

Use a double‑volume exchange transfusion to treat babies:

1.9.3

During exchange transfusion do not:

  • stop continuous intensified phototherapy

  • perform a single‑volume exchange

  • use albumin priming

  • routinely administer intravenous calcium. [2010]

1.9.4

Following exchange transfusion:

1.10 Other therapies

1.10.1

Do not use any of the following to treat hyperbilirubinaemia:

  • agar

  • albumin

  • barbiturates

  • charcoal

  • cholestyramine

  • clofibrate

  • D‑penicillamine

  • glycerin

  • manna

  • metalloporphyrins

  • riboflavin

  • traditional Chinese medicine

  • acupuncture

  • homeopathy. [2010]