Newborn Jaundice Protocol

PLACE LABEL HERE NEWBORN JAUNDICE PROTOCOL

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked. Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

1.  If any of the following risk criteria are met: q An infant who appears significantly jaundiced before 24 hours of life q An infant with a cord bilirubin level of ≥ 4 q Maternal history of anti E or anti C antibodies q Maternal blood type is O and baby A, B or AB q Rh+ infant with mother who is Rh negative and mother did not receive Rhogam q Rh+ infant with mother who is Rh negative and it is unknown if mother received Rhogam q Family history of any other cause of hemolysis in the newborn (e.g. G6PD deficiency or spherocytosis) a. Obtain a transcutaneous bilirubin (TcB) level at 12 hours of life b. Obtain a total and direct bilirubin at 24 hours of life (coordinate with Newborn Bloodspot screen) c. Obtain a total and direct bilirubin at 36 hours of life d. Plot all results on the Nomogram for Managing Indirect Hyperbilirubinemia in Newborns to determine next steps (see # 4 below)

0 6 2.  For late-preterm (35 /7 weeks - 36 /7 weeks gestation): if 24 hour TcB and serum bilirubin is > 6 mg/dL: a. Obtain a total and direct bilirubin at 36 hours of life b. Plot all results on the Nomogram for Managing Indirect Hyperbilirubinemia in Newborns to determine next steps (see # 4 below)

0 3.  For term (37 /7 weeks or more): if 24 hour TcB and serum bilirubin is > 8 mg/dL: a. Obtain a total and direct bilirubin at 36 hours of life b. Plot all results on the Nomogram for Managing Indirect Hyperbilirubinemia in Newborns to determine next steps (see # 4 below)

Order writer’s initials ______

*3-42889* FORM 3-42889 REV. 09/2017 Page 1 of 2 PLACE LABEL HERE NEWBORN JAUNDICE PROTOCOL

Order writer’s initials ______

*3-42889* FORM 3-42889 REV. 09/2017 Page 1 of 2 PLACE LABEL HERE NEWBORN JAUNDICE PROTOCOL

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked. Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

4. Plot every bilirubin measurement obtained (plasma or TcB) on the Nomogram for Managing Indirect Hyperbilirubinemia in Newborns (Policy 7008-06, Attachment A). A. For an infant 35-36 weeks EGA: 1. If the level plots at or above the red line, a. If the bilirubin is plasma, notify the provider immediately. This is an emergency. b. If the bilirubin is TcB, then obtain a stat plasma total and direct bilirubin, plot the stat result, and take action as indicated for the stat result. 2. If the level plots at or above the orange line (and below the red line), a. If the bilirubin was from plasma, start phototherapy and notify the provider b. If the bilirubin was TcB, obtain a stat plasma total and direct bilirubin, plot the stat result, and take action as indicated for the stat result. 3. If the level plots at or above the green line (and below the orange line), a. If the bilirubin was from plasma, no action needed; continue follow-up bilirubin testing as ordered b. If the bilirubin was TcB, obtain a stat plasma total and direct bilirubin, plot the stat result, and take action as indicated for the stat result. 4. If the level plots below the green line, then continue jaundice assessment as ordered based on risk criteria. B. For an infant ≥ 37 weeks EGA: 1. If the level plots at or above the red line, a. If the bilirubin is plasma, notify the provider immediately. This is an emergency. b. If the bilirubin is TcB, then obtain a stat plasma total and direct bilirubin, plot the stat result, and take action as indicated for the stat result. 2. If the level plots at or above the purple line (and below the red line), a. If the bilirubin was from plasma, start phototherapy and notify the provider b. If the bilirubin was TcB, obtain a stat plasma total and direct bilirubin, plot the stat result, and take action as indicated for the stat result. 3. If the level plots at or above the green line (and below the purple line), a. If the bilirubin was from plasma, continue follow up bilirubin testing as indicated on order set b. If the bilirubin was TcB, obtain a stat plasma total and direct bilirubin, plot the stat result, and take action as indicated for the stat result. 4. If the level plots below the green line, then continue jaundice assessment as ordered based on risk criteria. C. If a patient needs phototherapy, then apply phototherapy at a minimum dose of 30 μW/cm2/nm

______Date Time Physician Signature PID Number

FORM 3-42889 REV. 09/2017 Page 2 of 2