Jaundice including Vitamin Deficiency Bleeding in the Newborn

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					This is an official Northern Trust policy and should not be edited
                             in any way

   Jaundice including Vitamin K Deficiency
          Bleeding in the Newborn –
  Policy on Recognition and Management of
        early, prolonged and late onset
Reference Number:

NHSCT/10/320
Target audience:

Paediatrics, Neonatology, Health Visiting, Midwives and Obstetricians
Sources of advice in relation to this document:

Dr H Lambrechts, Associate Specialist Neonatology
Dr S Bali, Consultant Neonatologist
F Brown, Head of Children’s Nursing
J Quigg, Advanced Neonatal Nurse Practitioner
A Cubit, Advanced Neonatal Nurse Practitioner
F Mc Closkey, Lead Nurse Acute Paediatrics and Neonatology
P Mc Bride, Lead Public Health Nurse
M Maxwell, Head of Midwifery & Gynae
S O'Kane, Lead Midwife for Inpatient Services
B Lagan, Clinical Midwife Specialist
Replaces (if appropriate):

Vitamin K Deficiency in the Newborn (legacy Causeway, Homefirst and United),
Recognition and Management of Early Jaundice (Causeway) and Recognition
and Management of Prolonged or Late Onset Jaundice (Homefirst and United)
Type of Document:

Trust Wide
Approved by:

Policy, Standards and Guidelines Committee
Date Approved:

16 June 2010
Date Issued by Policy Unit:

26 August 2010
                         NHSCT Mission Statement
 To provide for all the quality of services we would expect for our families
                                and ourselves

                                                                           0
     POLICY ON RECOGNITION AND
  MANAGEMENT OF EARLY, PROLONGED
 AND LATE ONSET JAUNDICE INCLUDING
 VITAMIN K DEFICIENCY BLEEDING IN THE
               NEWBORN




June 2010



                                        1
POLICY ON RECOGNITION AND MANAGEMENT OF EARLY, PROLONGED
  AND LATE ONSET JAUNDICE INCLUDING VITAMIN K DEFICIENCY
                 BLEEDING IN THE NEWBORN


                          CONTENTS                               Page


Introduction                                                      3

                Recognition and Management of Early Jaundice      4
PART ONE        Appendix 1 – Lighter Touch Bilirubin Chart and
                                                                  9
                Results Sheet
                Recognition and Management of Prolonged and
                                                                 11
                Late Onset Jaundice
                Appendix 2 – Prolonged Jaundice Clinic
PART TWO                                                         16
                Proforma
                Appendix 3 – Clinical Guideline for Prolonged
                                                                 17
                Jaundice Clinic
                Management of Vitamin K Deficiency in the
                                                                 19
                Newborn
PART THREE
                Appendix 4 – Vitamin K Parent Information
                                                                 22
                Leaflet

Glossary of Terms                                                23


References                                                       25




                                                                        2
POLICY ON RECOGNITION AND MANAGEMENT OF EARLY, PROLONGED
  AND LATE ONSET JAUNDICE INCLUDING VITAMIN K DEFICIENCY
                 BLEEDING IN THE NEWBORN


                                      Introduction



This guidance brings together the management of Early Jaundice, Prolonged Jaundice
and Vitamin K Deficiency Bleeding (VKDB) in infants for the Northern Trust, to ensure
a consistent Trust-wide approach to management.


It emphasises the importance of recognising pathological causes of early and
prolonged jaundice which require prompt investigation and intervention. In particular, a
pathological cause for jaundice needs to be excluded in the first 24 to 48 hours of life
(sepsis and haemolysis), and infants with prolonged jaundice need to be fully
investigated to exclude pathological causes of jaundice in particular liver disease and
biliary atresia.


All newborn infants are at risk of VKDB and this is why all babies receive vitamin K at
birth. It is important to remember that infants with liver disease are at increased risk of
VKDB.




                                                                                           3
     PART ONE – RECOGNITION AND MANAGEMENT OF EARLY JAUNDICE


Jaundice


Many babies will show signs of jaundice around the third day following delivery.
Providing they are alert and feeding well with good muscle tone, this will only require
close observation and the jaundice will resolve spontaneously. Regular feeding is
encouraged and complementary feeds are rarely necessary.


Women should be advised that if their baby is jaundiced, or the jaundice is worsening,
or the baby is passing pale stools, this should be reported to a healthcare professional.


Jaundice in the first 24 hours, jaundice in an unwell infant, jaundice first
developing after 7 days or jaundice persisting for more than 14 days requires
investigation (see prolonged jaundice section).


1. Causes and types of jaundice


Physiological Jaundice


Physiological jaundice results from the breakdown of fetal haemoglobin, liver
immaturity and increased intestinal re-absorption of bilirubin. The condition can be
exacerbated by:


•   Prematurity
•   Excessive bruising e.g. from complicated delivery
•   Inadequate or delayed feeding
•   Birth asphyxia
•   Mother’s use of certain drugs e.g. diazepam.




                                                                                          4
Haemolytic Disease of the Newborn


Haemolytic disease of the newborn is commonly caused by an incompatibility between
the mother’s and infant’s blood groups. This incompatibility causes transplacental
transfer of antibodies to the infant’s red blood cells and in return, causes an increase in
the breakdown of those red cells, putting excessive demands on the immature liver of
the neonate.


Haemolytic disease is caused by:


•   ABO incompatibility
•   Rhesus incompatibility


This type of jaundice usually becomes clinically apparent within the first 24 hours of
life.



Infection


This is caused by the extra stress placed on the immature liver by the infection
inhibiting conjugation of bilirubin. There may also be reduced feeding in the sick infant.


‘Breast Milk Jaundice’


‘Breast milk jaundice’ normally appears towards the end of the first week of life and
improves by the end of the third week. However, a few babies will remain jaundiced for
two to three months. There are many theories about the cause of breast milk jaundice,
but the cause is still not really known. There is no evidence of breast milk jaundice
harming the baby unless the bilirubin level reaches exchange level, mothers therefore,
should be encouraged to continue breastfeeding. Other causes of jaundice need to
be eliminated before the diagnosis of breast milk jaundice can be made.




                                                                                          5
Care of a Jaundiced Baby


Care by the Midwife/ Nurse in the acute hospital environment includes:


•   Close observation of the baby, particularly of its colour (which should include
    observation of all of the infant’s body and limbs), feeding and behaviour.


•   If a baby develops jaundice, the intensity of the jaundice should be monitored 24
    hours later and systematically recorded along with the baby’s overall well being
    with regard to hydration and alertness.


•   A breastfed baby who has signs of jaundice should be actively encouraged to
    breastfeed frequently, and woken to feed if necessary5.


•   Breastfed babies should not be routinely supplemented with formula, water or
    dextrose for the treatment of jaundice5.


•   Artificial feeds should continue as per demand (at least four hourly). There is no
    evidence to support the provision of additional fluids.


•   Obtain a serum bilirubin (has to include direct fraction) blood sample (midwife,
    paediatrician or Nurse Practitioner) after obtaining informed consent from the
    mother. NB if consent is declined the paediatrician/ nurse practitioner must be
    asked to review the baby.


•   Plot the result of serum bilirubin on a ‘Neonatal jaundice – a lighter touch’ bilirubin
    chart (see Appendix 1). If the result falls into or above the phototherapy line the
    paediatrician must be informed. It is important to note that the lighter touch chart
    should only be used in well, term infants. In preterm or unwell infants the bilirubin
    charts (according to birth weight) should be used.


•   If the result is just below the line or there is concern regarding the baby’s condition,
    the paediatrician/ nurse practitioner must be informed and the test may be repeated
    at a later stage.


•   Remember sepsis (including Group B Strep infection) should always be
    considered, especially if jaundice develops in the first 24 to 48 hours of life
    and should be looked for/ risk factors considered.




                                                                                              6
Where the result indicates that phototherapy is required the following
management should be instigated:


•   Inform mother/parents of serum bilirubin result and plan of action. Explain possible
    causes for jaundice and probable duration of phototherapy.


•   Obtain verbal consent (see above). NB Involve an interpreter if the mother/parents
    do not speak or understand English.


•   Phototherapy can be commenced (providing the paediatrician/ nurse practitioner)
    has been informed)


•   To provide maximum skin exposure the baby should be nursed naked in an
    incubator, with the eyes covered or on a biliblanket.


•   The baby’s position should be changed frequently to ensure that all areas of the
    baby’s skin are exposed


•   The general condition of the baby should be frequently observed e.g. temperature,
    checking that eyes are covered.


•   Observe for side effects, such as rash, diarrhoea and hypothermia.


•   Breastfeeding should continue as per demand (at least three hourly).
    Supplementary feeds should not be necessary5.


•   Artificial feeds should continue as per demand (at least four hourly). There is no
    evidence to support the provision of additional fluids.


•   SBR should be repeated daily unless otherwise indicated.


•   The need to give phototherapy should not result in separation of the mother and
    baby


•   Ensure incubators/phototherapy lights/ biliblankets are cleaned and stored when
    phototherapy has been discontinued as per NHSCT infection control policy.



Action by Paediatrician/ Nurse Practitioner includes


•   Explanation to the mother/parents regarding causes and outcomes.
                                                                                         7
•   History and physical examination of the baby and then at least daily review unless
    condition suggests more frequently.


•   Blood analysis usually includes:
              • Full blood count
              • CRP
              • Blood Group
              • Direct Coombs
              • Blood culture if indicated (especially jaundice < 24 hours age)
              • Other investigations are done where clinically indicated


•   Documented instruction regarding frequency of SBR tests and length of
    phototherapy treatment.


•   If the bilirubin level exceeds 350umols (term baby) or 250umols (preterm baby) or
    continues to rise despite phototherapy, the senior paediatrician (registrar,
    Associate Specialist, Staff Grade or Consultant) must be informed.




                                                                                        8
                                                                                                            Baby’s Name (or affix ID Label):
                                                                                                            _____________________________

                                                                                                            DOB/ Unit No:

                            APPENDIX 1: Neonatal Jaundice – Bilirubin Chart

                            Age         1 Day        2 Days        3 Days    4 Days     5 Days      6 Days        7 Days
                     500
                                   Consider Exchange Transfusion (TERM)


                     450




                     400

                                                                                                        Phototherapy (TERM)
                                   Consider
                     350           Exchange
                                   Transfusion
                                   (Pre-Term)
                     300
                                        Phototherapy
Bilirubin ( mol/l)




                                         (PRE-TERM)

                     250




                     200



                     150



                     100



                      50



                       0
                             0     12     24    36     48     60     72     84   96   108   120   132    144   156   168

                           Hours
                           REF: Finlay HVL, Tucker SM. 1978 Neonatal plasma bilirubin chart. Arch Dis Child.53: p90-91
                           cited in: Meberg A. 1997. Hyperbilirubinaemia – a controversial topic. Experiences with new
                           guidelines for phototherapy and exchange transfusion. Nor J Epidemiol 7(1): p85-91. (Modified
                           from the Hillingdon Hospital Bilirubin Chart, England).




                                                                                                                                  9
Neonatal Jaundice: Bilirubin Result(s) and Management

                                     /         /                                                  hrs
Date of Birth                                            Time of Birth

Gestational Age                          +         wks   Birth Weight
                                                                                    Kgms


Method of Feeding


                                                    Rh                              Neg.        Pos.
Baby’s Blood Group (If                                          Direct
Known)                                                          Coombs

Mothers Blood Group                  Rh                  Antibodies   No    Yes     (specify)
                                                                      ________________




Date     Time         Age       *SBR                 Action / Management / Comments                     Sig.
         Taken       (hrs)      Result




*Plot SBR result on Bilirubin Chart Overleaf




                                                                                                   10
PART TWO – MANAGEMENT OF PROLONGED AND LATE ONSET JAUNDICE


   1. DEFINITION

       Prolonged jaundice is defined as jaundice persisting beyond two weeks of age
       in term infants and three weeks in pre-term infants (Children’s Liver Disease
       Foundation).

   2. CAUSES

       There are many causes for jaundice in infants. It is important to determine the
       ratio of conjugated (direct) to unconjugated (indirect) bilirubin to exclude
       obstructive jaundice or hepatitis syndrome. A raised conjugated bilirubin could
       be an early sign of biliary atresia especially when associated with pale stools
       and dark urine.

Causes of unconjugated jaundice:

   •   Breast milk jaundice
   •   Physiological jaundice
   •   Prematurity
   •   Hypothyroidism
   •   Haemolysis: spherocytosis
   •   Sepsis
   •   Gastro-intestinal obstruction: pyloric stenosis
   •   Inherited disorders of bilirubin metabolism: Gilbert’s Syndrome,
       Crigler-Najjar Syndrome


Causes of conjugated jaundice:

   •   Biliary obstruction: biliary atresia
   •   Infection: Urinary tract infection (may present with jaundice
       alone), viral, hepatitis, congenital TORCH
   •   Chromosomal abnormality: Turner’s, Trisomy 18 and 21
       Syndromes
   •   Inherited and metabolic disorder: Cystic Fibrosis,
       Galactosaemia


Note: Breast milk jaundice is the commonest reason for prolonged jaundice in the
newborn. The jaundice can persist for several weeks after birth. It is not a
contraindication to breastfeeding. However, if jaundice persists beyond two weeks in
well term infants or three weeks in preterm infants referral must be made to the
Prolonged Jaundice Clinic in Antrim/ Paediatrician in Causeway or Mid Ulster Hospital




                                                                                    11
3.URINE AND STOOL COLOUR

 Midwives, Nurses and Health Visitors should be aware of the importance of urine
 and stool colour:

  •   Normally a baby’s urine is colourless
  •   Persistently yellow urine which stains the nappy can be a sign of liver disease
  •   Normally a baby’s stools are green or yellow
  •   Persistently pale coloured stools may indicate liver disease


           A jaundiced baby with pale stools and yellow urine

           can appear completely healthy. The baby may have a

           potentially lethal liver disease.


 This guideline accepts that the interpretation of the colour of stools can be
 subjective. The colour chart below will help to overcome this problem.




 A healthy baby’s stools can be any of these colours. Do not worry   In babies with liver disease,
 about green stools. Breast-fed babies often pass watery stools.      A the stools may be one of
 sudden change to frequent watery stools of any colour may mean      these colours. Do not worry
 the baby is unwell.                                                 about one or two that look
                                                                     unusual.




      4. THE ANTENATAL PERIOD

      Experience has shown that when baby jaundice is explained in the antenatal
      period, parents are less anxious if their baby becomes jaundiced. In addition,
      they are knowledgeable about the course of action to be taken in the event of
      prolonged jaundice i.e. beyond two weeks of age in a term infant and three
      weeks pre-term. Midwives and Health Visitors should explain ordinary
      baby/physiological jaundice to all parents and inform parents about the
      management of prolonged jaundice.




                                                                                          12
    5. FIRST POSTNATAL VISIT AND ASSESSMENT BY MIDWIFE AND/OR
    HEALTH VISITOR

    •   Every baby should be checked for jaundice by looking at the sclera of the
        eyes and skin colour.

    •   The presence of jaundice in an infant should always be recorded in the
        relevant midwifery/health visiting record and PCHR.

    •   On transferring a baby from the midwife to health visitor the CHS4 or
        Community Midwife’s Report to Health Visitor form should state that an
        assessment for the presence of jaundice has been carried out.


    •   If the baby is jaundiced, stools and urine should be checked and seen by
        the health visitor and/or midwife.

    •    A baby’s urine should be colourless. If yellow, this should be investigated.

    •     Stools should be pigmented yellow or green. See chart on page 3. If pale
        or clay-coloured this should be investigated.

             If the stools and urine in a jaundiced baby are abnormal in

             colour, the baby should be referred to a paediatrician

             immediately.



    6. PROLONGED JAUNDICE

    Action in the event of prolonged jaundice


             Health professionals must seek medical advice as a priority
             for infants who present with prolonged jaundice and are
             unwell.


•   If the baby is well, referral should be made to the Prolonged Jaundice Clinic in
    Antrim/ Consultant Paediatrician in Causeway/ Paediatrician Mid Ulster
    Ambulatory Unit by following the referral process guideline.


    REFERRAL GUIDELINE

•   When the health professional assesses that the well infant is presenting with
    prolonged jaundice, an explanation of the investigation procedure and the
    parent information leaflet will be given to the parent/carer. They will be advised
    that a referral will be made for a clinical examination and further investigation.
    A minimum of two consultations will be required.

•   The Advanced Neonatal Nurse Practitioners (ANNP) will run the Well Infant
    with Prolonged Jaundice Clinic supported by Medical Staff at the Antrim
    Hospital site. In the Mid Ulster area, infants can be referred to the Ambulatory
    Unit, Mid Ulster Hospital. In the Causeway area, infants are referred to the
    Consultant Paediatrician.

                                                                                    13
Once referred, investigation and management of well infants with prolonged
jaundice will follow the Child Health Directorate Guideline.
(Appendix 3).



 Referral Process for Antrim facility

1.   The Referrer to telephone the Neonatal Unit 9442 4170 and ask for Alison
     Cubitt, ANNP or Jackie Quigg, ANNP. If not available, ask for Designated
     Contact for the Prolonged Jaundice Clinic.

2.   Give verbal referral to include: infant’s name, address, date of birth,
     parents/carers name and contact details, referrer name and contact details and
     GP name and contact details.

3.   The Midwifery/Health Visiting contact and referral to be documented in the
     Midwifery/Health Visiting Records and PCHR.



 Feedback to Referrers from Clinic
1.   The Referrer and GP will receive a copy of the Clinic Proforma (Appendix 1)
     supplying relevant details of the outcome of the investigation for prolonged
     jaundice and any subsequent follow-up.

2.   When it is necessary to admit an infant for further investigation, the Referrer will
     be informed. It is the responsibility of the Referrer to inform the GP.

3.   When a clinic appointment has been made for a child, and the child does not
     attend for investigation, the ANNP/ Paediatrician will contact the Referrer to
     follow up with the parent/carer as a matter of priority.

4.   If the parent/carer refuses to attend or repeatedly fails to attend clinic
     appointments, the Referrer will document this in the midwifery/health visiting
     records, inform the infant’s GP in writing and inform their line manager and child
     protection nurse specialist.

     Further action will be determined in consultation with the Referrer, GP, ANNP,
     Paediatrician and the parents/carers based on the ‘best interests’ of the child
     (The Children NI Order, 1995).




                                                                                      14
                                          5.       Early Identification Flow Chart

                                                            Assessment                                Unwell baby referral to
                                                                                                      Paediatrician
                                               •   Skin colour/sclera of eyes
                                               •   Urine/stool colour
                                               •   Document



                                                    Well Baby with Jaundice

                                                         Term >2 Weeks old
                                                       Pre-Term >3 Weeks old




                                                                                                           Causeway Paediatric
Paediatric Ambulatory                                                                                      OPD
                                          Refer to Prolonged Jaundice Clinic Antrim
Unit
                                      •   Explanation to Parents/Carers                                    •     Explanation to
• Explanation to                      •   Parent Information Leaflet                                             Parents/carers
  Parents/carers                      •   Telephone referral to Neonatal Unit 9442 4170                    •     Parent Information
• Parent Information                  •   Document                                                               Leaflet
  Leaflet                                                                                                  •     Telephone referral
• Telephone referral                                                                                       •     Document
• Document
                                                   •     Examination
                                                   •     Investigation




                  Investigations                           Investigations                     Does not attend
                     Normal                                  Abnormal                     •   Feedback to Referrer
                                                                                          •   Follow up by Referrer




                                                                                               Clinic Declined
                  Feedback                                 Feedback
                    to Referrer                              to Referrer


                  No further action
                                                                                           Document & Inform
                                                            Paediatric                    GP/Line Manager/CPNS
                                                            Review


                                                                                           Further Action based on
                                                                                          Outcome of Professional &
                                                                                            Parental Consultation




                                                                                                                   15
Appendix 2

                                                                                     Prolonged Jaundice Clinic (Well Babies)
                                                                                   Checklist for History, Examination and Results


 Name and Address: (Affix label)                                                          Contact Details (Where Applicable):

                                                                                          Midwife:………………………………………

                                                                                          Health Visitor:………………………………...

                                                                                          Parent/ Guardian:……………………………...


 GP:                                                                                      Bloods/ Investigations requested:



 Date of Clinic Visit:                                   Age:                             Results:



 Current Weight:                                         Birth Weight:



 Feeding Details:                                        Vitamin K Status:
 Breast / Bottle

 Stool Colour:                                           Urine Colour:                    Further Action Required? Yes/ No
 Dark / Pale                                             Light / Dark / Changing
                                                                                          Detail:
 Family history: Jaundice / Anaemia / Bleeding Disorder
 Detail:

 Other relevant History:




 Examination

 Evidence of Dehydration?............................................

 Hepatosplenomegaly?..................................................

 Evidence of Bleeding or Bruising?..............................

 Other relevant findings:

                                                                                    Review?............................................................
                                                                                    Copied to Community Midwife/ HV?...........
                                                                                    Copied to GP?................
Signature for initial assessment;                                        Signature for Results Action:

Signed……………………………………..                                                   Signed.............................................................
 Print Name and Date                                                     Print Name and Date




                                                                                                                                               16
Appendix 3
                                      Child Health Directorate

                                        Prolonged Jaundice


      1.0 INTRODUCTION

         This guideline is intended to support medical, nursing and midwifery practitioners
         in the management of infants with Prolonged Neonatal Jaundice

             1.1   The Aims of the guideline are:
                   • To allow early detection of pathological causes of prolonged jaundice
                      which require prompt intervention such as biliary atresia
                   • To be aware that jaundiced babies are at increased risk of
                      haemorrhagic disease of the newborn due to Vitamin K deficiency

             1.2   Prolonged jaundice is defined as jaundice > 2 weeks in term infants and > 3
                    weeks in preterm infants.

             1.3   This guideline should be read in conjunction with Policy on Recognition and
                    Management of Early, Prolonged and Late Onset Jaundice including
                    Vitamin K Deficiency Bleeding in the Newborn.


      2.0 CLINIC ASSESSMENT and INVESTIGATION of Well Breastfed Infant

              2.1 Assessment and documentation will be as set out in the Clinic Proforma
                  (Appendix 1).

              2.2 Though breastfeeding is the most common reason for prolonged jaundice
                  in the newborn, it remains important to remember that this is a diagnosis of
                  exclusion. Therefore it is important to rule out other potentially serious
                  underlying causes.

              2.3 Well breastfed infants will be assessed using the clinic proforma. If history
                  and examination are typical of breast milk jaundice and the infant appears
                  well, a split bilirubin test only will be required.

              2.4 If Total SBR < 250 and Direct SBR < 20% of total, no further immediate
                  intervention/ investigation will be required although the infant will be
                  reviewed in one to two weeks for clinical assessment and repeat SBR if
                  appropriate. This is to make sure jaundice is settling. If this is not the
                  case, further management will be discussed with a senior Paediatrician
                  and investigation for unconjugated jaundice considered.

              2.5 If conjugated fraction is > 20% and/ or there are signs of obstructive
                  jaundice (dark urine, pale stools), discuss management with a Senior
                  Paediatrician and consider hospital admission, if appropriate, for
                  investigation of Conjugated Hyperblirubinaemia/ Neonatal
                  Cholestasis.




                                                                                               17
3.0 CLINIC ASSESSMENT and INVESTIGATION of Well Bottle-fed Infant

      3.1 As bottle-fed infants with prolonged jaundice are more likely to have a
          pathological cause, they will receive a split bilirubin but also a first line
          prolonged jaundice screen (to include FBC, LFT, Urine Culture).

      3.2 Should infant on assessment be unwell or any immediate concerns
          identified, care should be discussed with senior medical staff and, if
          appropriate, infant admitted to hospital for further management.

      3.3 If Total SBR < 250 and Direct SBR < 20% of total, no further immediate
          intervention/ investigation will be required although the infant will be
          reviewed in one to two weeks for clinical assessment of jaundice as well as
          review of first line screen results and repeat split SBR if appropriate. If
          results are abnormal or bilirubin levels not settling, further management will
          be discussed with a senior Paediatrician and investigation for
          unconjugated jaundice considered.

      3.4 If conjugated fraction is > 20% and/ or there are signs of obstructive
          jaundice (dark urine, pale stools), discuss management with a Senior
          Paediatrician and consider admission to hospital for the investigation
          of conjugated Hyperbilirubinaemia/ neonatal Cholestasis.


4.0 RESULTS ACTION

      4.1 The medical staff or nurse practitioner will obtain blood results the morning
          after consultation and enter these on the Clinic Proforma.

      4.2 Copies of the Proforma will be forwarded to the Referrer and GP and
          original will be retained in the infant’s chart.

      4.3 Abnormal results requiring action will be discussed with senior medical
          staff for further management as above.


5.0 REVIEW

      5.1 All infants will be reviewed at least once to ensure jaundice continues to
          settle.

      5.2 Appointment for the following one to two weeks will be issued at the first
          visit.

      5.3 Results of this second visit will be communicated to the referrer/ GP via an
          Outpatient Attender Sheet.

      5.4 Should further follow-up be required, this will be arranged through the
          appropriate Consultant.




                                                                                          18
 PART THREE – MANAGEMENT OF VITAMIN K DEFICIENCY IN THE NEWBORN


Rationale:


Available evidence indicates that Vitamin K prophylaxis is effective and prevents
significant morbidity and mortality due to Vitamin K Deficiency Bleeding (VKDB) in
newborn babies.


VKDB may present in one of three ways:

                  Early onset within the first 24 hours of birth.

                  Classical within the first week after birth and typically presenting with
                  oral, umbilical, rectal or circumcision bleeding.

                  Late onset after the first week, almost exclusively in breast fed
                  infants and often in those with liver disease or malabsorption.
                  Intracranial bleeding occurs in more than 50% of babies who are
                  diagnosed with late onset VKDB.


Multiple large studies have not shown any detrimental effects.          In particular the
suggestion made in an earlier study (Golding et al, 1992) of a link between
intramuscular (IM) Vitamin K and childhood cancer was never repeated. A review of
data from the UK Children’s Cancer Study Group in 2003 concluded that Vitamin K is
not associated with childhood cancer or leukaemia whether it is given by injection or by
mouth.


Objective:

To prevent babies from developing VKDB.




                                                                                        19
Policy:

   • Copies of the Vitamin K leaflet must be given to all women at their booking visit.
     Midwife must record in Antenatal checklist and sign.

   • Verbal consent must be obtained and documented in the intrapartum section of
     the mother’s obstetric record prior to the administration of Vitamin K after birth.

   • The intramuscular (IM) route of administration is strongly recommended
     (NICE Clinical Guideline 37, July 2006) and clinical practice must reflect this.
     This is especially important in babies at particular risk of VKDB (birth asphyxia or
     bleeding problems, those born to mothers with liver disease or taking enzyme
     inducing anticonvulsant drugs)

   • Please note that separate guidelines exist for Very/ Extremely Low Birth Weight
     (VLBW/ ELBW) infants in the neonatal unit setting.

   • The dose of intramuscular vitamin K is as follows:

          o   Babies 36 weeks gestation and after:
                 1mg (0.1ml) IM at birth of Phytomenadione 2mg/0.2ml (Konakion
                 MM Paediatric)

          o   Babies less than 36 completed weeks gestation:
                 0.5mg (0.05ml) IM at birth of Phytomenadione 2mg/0.2ml (Konakion
                 MM Paediatric)

   • Where as a result of informed parental choice the baby is to receive oral Vitamin
     K the dose is as follows:

          o   Formula-fed babies: Two doses of Phytomenadione 2mg/0.2ml (Konakion
              MM Paediatric),
                        First dose: 2mg (0.2ml) orally at birth.
                        Second dose: 2mg (0.2ml) orally at one week of life.

          o   Exclusively breast fed babies:      Three doses of Phytomenadione
              2mg/0.2ml (Konakion MM Paediatric),
                        First dose: 2mg (0.2ml) orally at birth.
                        Second dose: 2mg (0.2ml) orally at one week of life.
                        Third dose: 2mg (0.2ml) orally at 4 to 6 weeks of life.

   • The 1st dose of oral vitamin K must be given at birth by the Midwife attending
     the delivery following verbal consent as outlined above for IM vitamin K. The 2nd
     dose must be given at 1 week of life by the Community Midwife (or the postnatal
     ward/ Neonatal Unit should the infant still be in hospital). The 3rd dose (if
     applicable – breast fed infants) must be administered by the infant’s Health
     Visitor. The oral Vitamin K must be prescribed and dispensed prior to discharge
     from hospital.

   • Parents or guardians who make an informed decision not to give their babies
     Vitamin K in any form must be given information by a paediatrician of middle
     grade level or above about the early warning signs of VKDB/ Haemorrhagic

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  Disease of the Newborn as this can be important in obtaining early treatment to
  reduce the severity of the disorder. This parental choice and subsequent
  discussion with the paediatrician must be carefully documented in the medical
  notes, noting in full the information given to the parents.

• The method of administration and the dosage of vitamin K must be recorded on
  the Delivery Record from where it is transferred to the Neonatal Discharge Form
  (CHS3b).




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  VITAMIN K – An Essential vitamin for all babies – Guidance notes for parents


What is Vitamin K?
Vitamin K helps the blood to clot and helps to prevent serious bleeding occurring.


Why does my baby need Vitamin K?
When a baby is born he/she has very low levels of Vitamin K and needs to be given
supplements to boost these levels. Low levels of Vitamin K can lead to a rare but serious blood
disorder called Vitamin K Deficiency Bleeding of the Newborn (also called VKDB), occurring in
about 1:1000 babies not given this essential vitamin.


How is this essential vitamin given?
Babies receive their Vitamin K by a single intramuscular injection. This is the easiest and most
reliable way to give Vitamin K to babies and will provide adequate protection. It is also the
method recommended by National Guidelines (www.nice.org/cg037). Should you have any
concerns about this injection, please discuss it with your Midwife or Doctor.


What happens if I don’t want my baby to have the injection?
Vitamin K can be given by mouth although this is a less effective way of giving Vitamin K as
several doses by mouth are essential to give enough protection. The choice about whether
your baby has the injection is yours – our role is to give you enough information to allow you to
make the right decision for you and your baby. Giving Vitamin K to your baby is your choice –
should you decide not to give your baby Vitamin K at all, you will need to speak to a senior
Paediatrician (Baby Doctor) to discuss this and to alert you to the possible danger signs.


What happens if my baby does not get Vitamin K?
A baby who isn’t given Vitamin K is at risk of serious bleeding. The baby can bleed into any
part of his/her body and this can result in serious illness or even death within the first few
months of life.


Are there any risks?
Multiple large studies have not shown any detrimental effects. In particular, a suggestion made
in an earlier study of a link with childhood cancer was never repeated. Also, a review of data
from the UK Children’s Cancer Study Group in 2003 concluded that Vitamin K is not associated
with childhood cancer or leukaemia whether it is given by injection or by mouth.




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Glossary of Terms

Preterm - Defined as infants born < 37 completed weeks gestation.

Bilirubin – Red cell destruction releases unconjugated (indirect) bilirubin. This
is conjugated in the liver to make it water soluble and therefore makes excretion
possible in bile. It is then converted to stercobilinogen in the gut and excreted
in the stool or reabsorbed and excreted in the urine as urobilinogen. Any
obstructive process (like biliary atresia) or liver disease (like neonatal hepatitis
syndrome) will therefore lead to overspill of conjugated (direct) bilirubin into the
blood.

Biliary atresia – The biliary duct between the liver and the intestine fail to
develop and is completely blocked – this leads to conjugated jaundice. Early
recognition is very important for surgery to have a chance of being successful –
late recognition leads to liver failure and need for liver transplant.

Breast milk jaundice – This is the most common cause of unconjugated
prolonged jaundice. It might be attributed to steroid inhibitors present in breast
milk which are thought to inhibit the action of glucoronyl transferase and thus
the conjugation of bilirubin is delayed.

Physiological jaundice – Most babies get some degree of jaundice after 48
hours – this is due to many factors: Reduced red cell survival, polycythaemia,
bruising, enterohepatic circulation, reduced liver enzyme activity, etc. Jaundice,
however, usually does not persist beyond 2 weeks of life in term infants and 3
weeks in preterm infants.

Hypothyroidism – This is due to congenitally underactive thyroid gland – it
leads to unconjugated (indirect) jaundice. It is tested for on the newborn
bloodspot test. If not recognised, it can lead to growth failure, learning
difficulties and developmental problems and therefore should not be missed.

Haemolysis – This is increased breakdown of red cells (for a variety of
reasons) which can lead to unconjugated jaundice.

Spherocytosis – This is a genetic disorder of the red cell membrane leading to
an abnormally shaped red cell which can cause increased breakdown of red
cells therefore leading to anaemia, unconjugated jaundice and enlargement of
the spleen. It is more common in people of Northern European descent.

Sepsis – General term referring to infection in the bloodstream.

Pyloric stenosis – This is a condition where the muscle at the outlet of the
stomach (the pylorus) thickens and causes obstruction of the flow of milk from
the stomach to the gut. It is slightly more common in boys, usually presents at
4 to 6 weeks of age with projectile vomiting and there is often a family history.

Gilbert’s Syndrome – Rare, benign inherited form of non-haemolytic
unconjugated Jaundice.

Crigler-Najjar Syndrome – Rare form of congenital, non-haemolytic
unconjugated jaundice (Autosomal recessive).

TORCH – Congenital infection – Toxoplasmosis, Rubella, Cytomegalovirus,
Herpes – may lead to microcephaly, rashes, hepatosplenomegaly, neonatal
jaundice, etc.

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Turner’s Syndrome – Chromosomal abnormality where, in a female, there is
the loss of one X chromosome leading to short stature, infertility and sometimes
learning difficulty.

Trisomy 13, 18 and 21 – Synonymous for Patau, Edwards and Down’s
Syndrome.

Cystic Fibrosis – CF is the UK’s most common, life-threatening inherited
disease. One in 20 people in Northern Ireland is a carrier. As its inheritance is
autosomal recessive, when both parents are carriers, risk of their baby being
affected is 1:4. CF mainly affects the lungs and digestive system, but can
present in the neonatal period with prolonged jaundice and failure to thrive.

Galactosaemia – Another autosomal recessive condition caused by the
absence of the enzyme galactose- 1 – phosphate uridyl transferase. It has a
UK incidence of 1/60000. Affected infants are normal at birth, but on
commencement of milk feeds the majority suffer: jaundice, vomiting, diarrhoea,
failure to thrive.




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References

1. Children’s Liver Disease Foundation (2007) Yellow Alert Jaundice Protocol,
   Birmingham.

2. Keffler S, Kelly DA, Powell JE, Green A. Population screening for neonatal liver
   disease: a feasibility study. J Pediatr Gastroenterol Nutr. (1998) Sep;27(3):306-
   11.

3. McKiernan PJ, Baker AJ, Kelly DA. The frequency and outcome of biliary atresia in
   the UK and Ireland. Lancet. (2000) Jan 1; 355(9197):25-9.

4. Davenport M, De Ville de Goyet J, Stringer MD, Mieli-Vergani G, Kelly DA,
   McClean P, Spitz L. Seamless management of biliary atresia in England and
   Wales (1999-2002). Lancet. (2004) Apr 24;363(9418):1354-7.

5. Routine postnatal care of women and their babies; NICE clinical guideline 37; July
   2006

6. BNF for Children 2006

7. Roberton’s Textbook of Neonatology; Fourth Edition 2005

8. Royal Jubilee Maternity Service Vitamin K Policy; 2006




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