SH CP 53 Version: 3 Summary: Keywords (minimum of 5): (To assist policy search engine) Target Audience: This document defines the guideline for management of jaundice and the early identification of liver disease in infants. Neo-natal, jaundice, neo-natal jaundice guidelines, guidelines All members of Health Visiting Teams, Family Nurse Partnership Teams and their managers Next Review Date: January 2019 Approved & Ratified by: Children s Division Quality and Safety Board Date of meeting: 15 Date issued: Author: Sponsor: Loraine Edwards Clinical Team Lead Claire Foreman Health Visitor Practice Teacher Members of the Policy Group Director of Integrated Services 1
Version Control Change Record Date Author Version Page Reason for Change 30.6.11 Sherry Tonkin 2 Julia Huggan 2 Irene Patience 2 Sharon 2 Update due to organisational change Hargreaves 16/11/16 Claire Foreman 3 Update due to organisational change Reviewers/contributors Name Position Version Reviewed & Date Sherry Tonkin Health Visitor/PT 30.6.11 Julia Huggan Health Visitor/PT 30.6.11 Irene Patience Community Nursery Nurse 30.6.11 Sharon Hargreaves Locality Clinical Manager 30.6.11 HV Policy Group 13.7.11 Kath Clark Locality Clinical Manager 07.9.11 Loraine Edwards Health Visitor/CTL 16/11/16 Claire Foreman Health Visitor/PT 16/11/16 Members of the Policy Group 14/12/16 2
Contents Page 1. Introduction 4 2. Scope 4 3. Definitions 5 4. Duties/ responsibilities 7 5. 6. Professional Accountability Main Policy Content 7 7 7. Training requirements 8 8. Monitoring compliance 9 9. Policy Review 9 10. Associated documents 9 11. Supporting References 9 Appendices A1 Prolonged Jaundice Screen Guidelines 10 3
1. Introduction Jaundice is one of the most common conditions needing medical attention in new born babies and is rarely serious; however for some infants it may be the first sign of a more serious liver disease and accurate diagnosis of the cause of jaundice is essential to improve treatment and prognosis. Jaundice affects 60% of term and 80% of preterm babies in the first week of life (NICE, 2010); with a prevalence of severe neonatal hyperbilirubinemia of 0.7:1000 births. The yellow colouration of the skin and the sclerae (whites of the eyes), which is characteristic of jaundice, is caused by the accumulation of bilirubin in the skin and mucous membranes. Prolonged neonatal jaundice is defined as jaundice persisting beyond the first 14 days in a term baby and three weeks in a premature baby (defined as gestational age less than 37 weeks) (CLDF, 2013). Babies presenting with prolonged jaundice will require assessment and monitoring of bilirubin levels which should not rely on visual assessment alone, as these have been found to be insufficient. There are many causes of neonatal jaundice, including breast milk jaundice, physiological jaundice and that which is caused by infection or hypothyroidism. Neonatal jaundice normally reaches its peak at around four days of life and then gradually disappears in most babies by the time they are two weeks old. Early physiological jaundice is not an indication of an underlying disease, with about 10% of breastfed babies remaining jaundiced at 1 month (NICE, 2010). Breastfed babies are more likely than bottle-fed babies to develop physiological and/or prolonged jaundice. Late diagnosis of childhood liver disease has potentially life changing consequences. Biliary atresia is the most common cause of end-stage liver disease in children and affects around 1 in 15,000 live births in the UK.. If biliary atresia is diagnosed early, corrective surgery, can take place in order to establish bile flow; the best results are achieved before 8 weeks of age. Consequently, it is important to identify and act in a timely manner to avoid unnecessary morbidity. This guidance is based on the National Institute for Health and Care Excellence guideline for professionals on jaundice in young babies (NICE, 2010) which has been developed to prevent well meaning, but misguided reassurance that jaundice is always normal and nothing to worry about. 2. Scope 2.1 All health visitors and Family Nurses will observe babies at the New Birth Contact for the presence of prolonged jaundice. Prolonged jaundice is defined as jaundice persisting beyond 14 days in babies with a gestational age of 37 weeks or more and jaundice lasting more than 21 days in babies with a gestational age of less than 37 weeks. 2.2 Health visiting teams and Family Nurses should be aware that there are many causes for prolonged jaundice in infants; Physiological jaundice Breastmilk jaundice Jaundice caused by liver disease Jaundice from other causes e.g. Haemolysis 4
Jaundice caused by infection Jaundice caused by hypothyroidism All infants with prolonged jaundice should have a split bilirubin test (appendix 1). 2.3 Health visiting teams and Family Nurses should be aware of the importance of urine and stool colour. A jaundiced baby with pale stools and yellow urine can appear completely healthy. The baby may have potentially lethal liver disease. All infants with pale stools and yellow urine should be referred for investigation see referral pathway (appendix 1). Normally a baby s urine is colourless; dark urine that stains the nappy requires investigation The stools of a breast fed baby should be bright green/daffodil yellow colour; the stools of a bottle fed baby should be bright green/english mustard colour. Persistently pale coloured stools may indicate liver disease and should always be investigated. 2.4 Health Visiting teams need to ensure that they liaise with Midwives, General Practitioners (GP), Paediatricians and other relevant partner agencies to ensure that babies receive timely, appropriate care when neonatal jaundice is suspected. 2.5 Parents should have the opportunity to make informed decisions about their baby s care and treatment, in partnership with their health visitor. This information should be provided through verbal discussion backed up by written information which can be downloaded from the Children s Liver Disease Foundation website. Care should be taken to avoid causing unnecessary anxiety to parents or carers. Information should include: Factors that influence the development of significant hyperbilirubinemia The fact that neonatal jaundice is common, and reassurance that it is usually transient and harmless Reassurance that breastfeeding can usually continue. 3. Definitions 3.1 Health Visiting Teams A team of Specialist Community Public Health Practitioners- health visitors and associate practitioners who deliver a transformed 4-5-6 model of preventative public health services to all children and families who are resident in Hampshire, from pregnancy until school entry. Each GP Practice, Children s Centre and Birth to Three network has a named Specialist Community Public Health Practitioner health visitor, to ensure optimal information sharing across the Children s workforce. Team members include the following practitioners: Health Visitor Clinical Team Lead [CTL] - A qualified Specialist Community Public Health Nurse who leads a health visiting team and coordinates the delivery of the Healthy Child Programme pre-birth to 5 within a defined locality Specialist Community Public Health Nurse [SCPHN] A qualified nurse with an additional specialist public health qualification and skills and expertise of assessing community health needs and working with children and young people from pre-birth to 5 years of age. 5
Community Nursery Nurse [CNN] Trained in child development and skilled in delivering parenting interventions and healthy lifestyle advice as delegated by the SCPHN Administrator Provide SMART clerical processes to support the delivery of the Healthy Child programme within the health visiting teams. 3.2 Healthy Child Programme: Pregnancy and the First 5 Years of Life (DH 2009); Best Start in Life and Beyond: Improving public health outcomes for children, young people and families (PHE 2016) and Early Years Six High Impact Areas (DH 2014) These documents describe the transformed 4-5-6 health visiting universal preventative model which focuses on giving every child the best start in life. The documents provide a framework for collaborative working to improve health, wellbeing and parenting in early life stages, providing families with screening, immunisation, health and development reviews, prevention and early intervention. Health visitors lead the delivery of the Healthy Child Programme 0-5 in partnership with parents and other agencies. 3.3 Family Nurse Partnership team The FNP team consists of a supervisor, Family Nurses and a Quality Support Officer. The supervisor is responsible for the leadership of team learning, providing weekly supervision and team management as well as holding a small clinical caseload. Family Nurses work with a maximum of 25 families and receive specialist training to deliver the FNP programme and record data as part of the license. The team is supported by a Quality Support Officer in terms of Data Collection and general administrative and office support. 3.4 Personal Child Health Record (PCHR) Individualised record of a child s health from birth, held by parent/carer. 3.5 Electronic Patient Record (EPR) and Family and Child Assessment Form Practitioners are required to keep clear and accurate records as detailed in the NMC Code (2015): Complete all records contemporaneously, at or as soon as possible after an event (ideally within 24 hours) Records should clearly identify any risks or problems that have arisen and the steps taken to deal with them, so that colleagues who use the records have all the information they need Complete all records objectively, accurately and without any falsification, taking immediate and appropriate action if you become aware that someone has not kept to these requirements Attribute any entries made in the EPR to the named practitioner, complying with the RiO Smartcard user requirements, making sure they are clearly written, dated and timed, and do not include unnecessary abbreviations, jargon or speculation. The Family and Child Assessment Form is contained within the EPR as a record of the assessment of health, wellbeing and wider factors that may impact on outcomes for parent/ unborn child. It provides a summary of information gathered, risk analysis and plan for future level of care provided within the 4, 5, 6 health visiting model. 6
4. Duties / Responsibilities 4.1 Southern Health Board Southern Health Board has the responsibility to ensure that the health contribution to Health Visiting Services is discharged across Southern Health through the commissioning process. 4.2 Director for Integrated Services Division (ISD) The Director for the ISD has the overall strategic and operational accountability for delivery of Southern Health NHS Foundation Trust Children s 0-19 Health Services. 4.3 Senior Management Team Lead in all aspects of the 0-19 Services and will ensure there is adherence to relevant clinical policies. 4.4 Clinical Team Leaders Clinical team leaders have the daily operational management of the 0-19 service and are required to ensure all staff are suitably trained and competent to deliver this role and that relevant policies are adhered to. Compliance to the guideline will be audited annually and exceptions to service delivery will be raised to the Senior Management team. 4.5 Professional Leads and Practice Teachers Professional Leads and Practice Teachers support the high quality delivery of the HCP, and service/ workforce development. 5. Professional Accountability All staff must follow Trust policies and professional codes and guidelines relevant to their qualification and role e.g. Nursing and Midwifery Council: The Code professional standards of practice and behaviours for nurses and midwives [2015]. The NMC Code states that UK nurses and midwives must act in line with the Code at all times. The four themes of the Code are: prioritise people, practice effectively, preserve safety and promote professionalism and trust. 6. Main Policy Content 6.1 The Antenatal Period It may be appropriate to discuss baby jaundice with parents in the antenatal period as experience has shown that when baby jaundice is explained in the antenatal period parents are less anxious if their babies become jaundiced. 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. Babies may be more likely to develop significant hyperbilirubinemia if they have any of the following factors: gestational age under 38 weeks 7
a previous sibling with neonatal jaundice requiring phototherapy mother's intention to breastfeed exclusively visible jaundice in the first 24 hours of life. (NICE CG98) 6.2 New Birth Contact The presence, or not, of jaundice should have been recorded by the midwife on the baby discharge summary, via the HV Team nhs.net account or verbally to the HV on transfer to the Health Visiting Team. Every baby should be assessed by the health visitor for signs and symptoms of jaundice by: Checking the sclera of the eyes and the baby s skin colour Discussion about the colour, consistency and volume of the baby s urine and stools with the parents/ carers. To improve early diagnosis of liver disease, the Children s Liver Disease Foundation have produced a Yellow Alert app and stool charts which remove the subjectivity associated with assessing abnormal stool colour (Stools should be pigmented yellow or green. If pale or clay coloured the baby should be referred for investigation, Appendix 1). The findings of the HV assessment should be documented in the EPR and the PCHR. 6.3 Action In The Event of Prolonged Jaundice Prolonged jaundice is indicated in a term baby of 14 days with yellow sclera or a preterm baby (<37/40) of 21 days with yellow sclera and these babies should be referred according to local policy and pathways (Appendix 1 ). The following babies with prolonged jaundice should be referred to a GP or paediatrician: A baby who is unwell and/or not progressing normally. A baby with abnormal stool colour and/or urine of any age. Any baby with prolonged jaundice that has not been investigated It is recommended the Health Visiting Team include the following information in the referral: Feeding history whether the baby is exclusively breast fed, mixed fed or formula fed The baby s weight The baby s stool and urine colour 7. Training Requirements 7.1 At local induction all new members of the Health Visiting Team will be made aware of the contents of this guideline and training needs identified. 7.2 On-going training needs will be identified at yearly Personal Development Reviews and Management Supervision. 7.3 Training needs will be addressed in the Children s Service Training Needs Analysis. Any identified training needs will be delivered through the Learning and Development team. 8
8. Monitoring Compliance 8.1 This will be carried out through Personal Development Reviews and Management Supervision by ensuring staff are aware of this guideline. Compliance will be monitored through the Trust s audit programme. 9. Policy Review This guideline will be reviewed in three years. 10. Associated Documents SH CP 56 Safeguarding Childrens Policy SH CP - 60 GP Communication Guideline SH CP - 65 New Birth Contact Guidelines SH CP - 89 Infant Feeding Policy SH CP - 105 Family Disengagement in Relation to Children Guideline SH CP - 173 Children s Services - Standard Operating Procedure 11. Supporting References NICE Clinical Guidelines 98 Neonatal Jaundice 2010 http://www.nice.org.uk/nicemedia/live/12986/48578/48578.pdf Children s Liver Disease Foundation (2013) Jaundice in the newborn: Yellow Alert. http://www.yellowalert.org/baby-jaundice Children s Liver Disease Foundation 2007 www.childliverdisease.org Jaundice protocol: Early identification and referral of liver disease in infants September 2013 www.childliverdisease.org (accessed 15/11/2016) Baby Jaundice and Liver Disease, a guide. March 2014 www.childliverdisease.org (accessed 15/11/2016) Healthy Child Programme: Pregnancy and the first five years, Department of Health 2009 http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/pro d_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_11 8525.pdf Department of Health (2009) Reference guide to consent for examination or treatment (second edition) https://www.gov.uk/government/publications/referenceguide-to-consent-for-examination-or-treatment-second-edition Morton A, Taylor A (2015) Yellow Alert: Improving early diagnosis of childhood liver disease. Journal of health Visiting. 3(5): 524-528 Public Health England (2015) Rapid review to update evidence for the Healthy Child Programme 0-5 https://www.gov.uk/government/publications/healthy-childprogramme-rapid-review-to-update-evidence 9
National Health Visitor Service Specification 2014/15, NHS England March 2014 http://www.england.nhs.uk/wp-content/uploads/2014/03/hv-serv-spec.pdf UNICEF UK Baby Friendly Initiative 10
Appendix 1 Prolonged Jaundice, Health Visiting Team early identification Algorithm Midwife will liaise about infants with jaundice to Health Visiting team at point of discharge from midwifery service or on day 14 if not yet discharged by midwife Jaundiced baby Term :>14 days old Preterm:> 21 days Health Visitor to carry out general assessment: Feeding History Baby s weight Document Stool and Urine Colour Baby well Health Visitor to arrange for baby to have Split bilirubin blood test in accordance with local pathway: Health Visitor to explain reason for blood test to parents and that they should contact GP for result of test 48hrs after it is done Health Visitor to open managing minor illness care plan and review when blood result received Baby unwell Refer to Paediatrician: Health Visitor to liaise with GP to ensure referral to paediatrician for Full history and examination, Prolonged jaundice screen, And/or other investigations Health Visitor to open managing minor illness care plan and review when blood result received Result received by GP GP will liaise result to Health Visitor GP to liaise result and any required actions to parents Conjugated SBR >20% (25/ micromoles/l) OR Conjugated SBR<20% (25 micromoles/l) of total bilirubin and total bilirubin >200 micromoles/l GP will refer to Paediatrician Conjugated SBR <20% (25 micromoles/l) GP will monitor weekly until jaundice resolved Health Visitor should: Follow up families who do not attend for blood test in accordance with disengagement policy Re refer to GP/ Paediatrician for repeat blood tests any infant who s jaundice remains unresolved one week after previous blood test 11