Original Title: Mesure et suivi d’une bilirubine sérique totale chez un nouveau-né qui présente des signes suggestifs d’un ictère néonatal

Authors' objectives: Neonatal jaundice is a common condition affecting about 60% of newborns of 35 or more weeks' gestational age. It is generally benign and can resolve on its own with proper hydration or be treated with phototherapy. In rare cases, the presence of certain risk factors combined with a high total serum bilirubin level can lead to the development of severe hyperbilirubinemia and even acute or chronic bilirubin encephalopathy with serious neurological sequelae (kernicterus). Monitoring newborns showing signs of jaundice is therefore essential for the early detection and the prevention of severe hyperbilirubinemia, as it permits the rapid referral for phototherapy for newborns who require it. The monitoring of neonatal jaundice is carried out mainly by nurses as part of early postnatal monitoring. This is often done during home visits, but also in hospital during the first few days after birth. Since decisions regarding therapeutic management requires a total serum bilirubin measurement, the use of a collective prescription to initiate a diagnostic measurement is essential to these health professionals’ work. To this end, the Ministère de la Santé et des Services sociaux (MSSS) has asked the Institut national d'excellence en santé et en services sociaux (INESSS) to develop tools to support frontline professionals and harmonize practices across the province for measuring and monitoring total serum bilirubin levels in newborns with signs suggestive of neonatal jaundice.

Authors' results and conclusions: RESULTS: Upon the completion of the analysis of all the gathered data and the iterative process with the advisory committee, the following key findings and messages were considered to have the potential to support the harmonization of the clinical practice and to facilitate neonatal jaundice monitoring. (#1 THE QUÉBEC NATIONAL MEDICAL PROTOCOL IS FOR FULL-TERM OR SLIGHTLY PREMATURE NEWBORNS WHO ARE, OVERALL, IN GOOD HEALTH ): This protocol is for newborns of 35 or more weeks' gestational age. In this population, a total serum bilirubin measurement should be ordered for those with signs suggestive of neonatal jaundice who are less than 24 hours old or for whom a transcutaneous bilirubin measurement cannot be performed, and for newborns whose transcutaneous bilirubin measurement needs to be cross-checked. Newborns over 14 days of age, those with risk factors for neurotoxicity, those who have undergone or are undergoing phototherapy, a blood transfusion or an exchange transfusion, and those with warning signs should be managed on an individual basis instead. They are therefore not included in this protocol. (#2 TRANSCUTANEOUS BILIRUBIN MEASUREMENTS SHOULD BE CORRECTED SO THAT THEY AGREE MORE CLOSELY WITH TOTAL SERUM BILIRUBIN MEASUREMENTS ): Transcutaneous bilirubinometers provide transcutaneous bilirubin measurements that correlate, more or less precisely, with laboratory total serum bilirubin levels. The transcutaneous bilirubin measurement should therefore be corrected for this uncertainty to increase the result’s reliability. The correction factor to be used differs from one bilirubinometer to another and according to the laboratory that performs blood bilirubin tests. It should therefore be provided by the institution or the clinical biochemistry laboratory that performs them. (#3 A TOTAL SERUM BILIRUBIN MEASUREMENT IS NECESSARY BEFORE CONSIDERING THERAPEUTIC MEASURES): In situations that suggest that treatment might be considered, the total serum bilirubin should be measured to confirm the course of action. For example, for newborns less than 24 hours old with signs suggestive of neonatal jaundice and for those whose corrected transcutaneous bilirubin measurement is at or above the upper limit of the monitoring zone, a total serum bilirubin measurement is urgently required, and the subsequent management should be individualized. A total serum bilirubin measurement should also be obtained within hours of a transcutaneous bilirubin measurement approaching the upper limit of the monitoring zone. (#4 THE PRESENCE OF RISK FACTORS FOR SEVERE HYPERBILIRUBINEMIA SHOULD PROMPT CLOSE MONITORING OF THESE NEWBORNS, BUT NOT A CHANGE IN THE PHOTOTHERAPY THRESHOLD): Two types of risk factors influence the monitoring and management of icteric newborns. Neurotoxicity risk factors are associated with an increased risk of developing bilirubin encephalopathy, this at lower bilirubin levels. The therapeutic threshold therefore differs for these newborns, which explains why they are not included in this protocol. On the other hand, risk factors for severe hyperbilirubinemia are associated, as their name suggests, with a higher risk of developing this serious condition. These newborns can be monitored as part of the Québec national medical protocol by adjusting the monitoring frequency to take this risk into account. However, these bilirubin measurement results are interpreted according to gestational age, using the same curve as that for newborns without these risk factors, since these infants are not more vulnerable to bilirubin. CONCLUSION: The creation of clinical tools for measuring and monitoring total serum bilirubin in newborns of 35 or more weeks’ gestational age with signs suggestive of neonatal jaundice is based on the clinical practice recommendations, which were enriched with the perspectives of the stakeholders consulted and contextualized for Québec practice. These tools should help harmonize the practice and contribute to the effective management of newborns with signs suggestive of neonatal jaundice. UPDATE: To ensure consistency with the Canadian recommendations, this report and the related clinical tools may be updated when the Canadian Paediatric Society publishes new guidelines. Should there be no earlier update of these items, the advisability of updating them will be assessed in four years, that is, in the spring of 2027, in light of the advances in the scientific data, the evolution of practices or the introduction of new interventions, and the healthcare system’s needs.

Authors' recommendations: Following the iterative process with the advisory committee, during which clinical information and the recommendations from the literature, contextual information and the perspectives of the different stakeholders consulted were triangulated, a series of findings and recommendations were drawn up regarding the measurement of total serum bilirubin in newborns with signs suggestive of neonatal jaundice, and the necessary follow-up. These recommendations appear in boxes throughout this report and are incorporated into the clinical tools stemming from this project: a Québec national medical protocol, an accompanying collective prescription template, and a monitoring sheet for front-line professionals managing newborns with signs suggestive of neonatal jaundice. This project did not cover neonatal jaundice screening. Therefore, institutions that wish to include screening instructions in a collective prescription will have to do so in tandem with the use of the tools created by INESSS.

Authors' methods: A systematic review of the best clinical practices literature on neonatal jaundice monitoring was carried out according to INESSS’s usual standards. As well, information on the framework and scope of practice of the healthcare professionals who share reserved activities in this field was gathered by visiting the professional orders’ websites. The data were analyzed from the perspective of contextualizing Québec practice, using mainly legislative, regulatory and organizational contextual elements specific to Québec, and the perspectives of the different stakeholders consulted. To gather these perspectives, an advisory committee consisting of clinicians from different specialties and areas of expertise was created. Lastly, the overall quality of the work, its acceptability and its applicability were assessed by external reviewers specializing in the field of interest, and by future users who did not participate in the project.

Project Status: Completed

URL for project: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/mesure-et-suivi-dune-bilirubine-serique-totale-chez-un-nouveau-ne-qui-presente-des-signes-suggestifs-dun-ictere-neonatal.html

Year Published: 2023

URL for published report: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/mesure-et-suivi-dune-bilirubine-serique-totale-chez-un-nouveau-ne-qui-presente-des-signes-suggestifs-dun-ictere-neonatal.html

English language abstract: An English language summary is available

Publication Type: Other

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: L'Institut national d'excellence en sante et en services sociaux (INESSS)