No | Issue | Current Practice | New Protocol | Rationale for Change |
---|---|---|---|---|
1. | What clinical assessment and laboratory investigations are needed in the initial assessment of PNNJ? | Clinical assessment is not emphasised, and a routine list of laboratory investigation is done according to local/national protocol for all term babies with jaundice at 14 days of life. | Low risk babies At day 14: Do a complete clinical assessment using the assessment form and take total serum bilirubin with differential At day 21 if still jaundice: Repeat clinical assessment and carry out a simple list of lab investigation - Total serum bilirubin with differentials - Full blood count and reticulocyte count - Urine dipstick & microscopy test and - Free T4, TSH Intermediate/ high risk babies Refer to Paediatric team for further management | New system aims to focus on good clinical assessment. In well, breastfed term babies half of them will have jaundice resolved by 21 days of life [30]. Prompt referral of babies with risks and unwell babies to paediatricians. |
2. | Is there a checklist for clinical assessment? | No | Yes, serves both as a checking list and referral sheet. | Ensure all essential clinical assessments are done for risk stratification |
3. | Where could the initial assessment take place? | Paediatric clinics only. | Any nearby health clinics or district hospitals. | This aims to empower health clinics/ district hospitals to do the initial clinical assessment and workup and follow up on the low-risk babies. Specialist clinics will focus more on intermediate or high-risk cases. |
4. | Heel prick capillary bilirubin vs total serum bilirubin with differential | Babies with PNNJ undergo repeated heel-prick capillary bilirubin in the health clinics, until the jaundice resolved. | Total serum bilirubin with differential is needed at 14 days and only repeated as necessary | Main aim of total serum bilirubin with differential is to pick up conjugated hyperbilirubinaemia [2] Heel-prick capillary bilirubin is not useful in the management of PNNJ. |
5. | Urine sampling | Babies with PNNJ undergo urine culture, whereby sampling is done by clean catch, bladder catheterization or suprapubic aspiration. | Only urine dipstick & microscopy test and is needed. Sampling via urine bag is acceptable. Urine culture will be considered for suspected cases [18]. | The incidence of UTI in asymptomatic, afebrile and jaundiced babies ranged from 5.5–21% [31]. There is a role of urine dipstick & microscopy only in the screening of UTI in well, jaundiced babies [18]. |
6. | Thyroid function tests (Free T4/ TSH) | This is conducted for all babies with PNNJ at day 14 | This is conducted for all intermediate or high-risk babies and low risk babies if still jaundice at day 21 | Thyroid function test is necessary to detect congenital hypothyroidism cases that are missed by the newborn screening programme [32]. |
7. | Full blood picture | This is conducted for all babies with PNNJ at day 14 | Full blood count and reticulocyte counts are conducted for all intermediate or high-risk babies and low risk babies if still jaundice at day 21. Full blood picture is considered only if there is a suspicion of ongoing or significant haemolysis (eg: low haemoglobin / pallor/ hepatosplenomegaly/ family history/ significant neonatal jaundice) | No more routine full blood picture in the workup for PNNJ. |
8. | Assessment of stool colour by history or inspection | Not emphasised | Assessment of stool colour by history or inspection is emphasised. | Pale stool signifies obstructive jaundice [21]. |
9. | Is warning signs for serious conditions (especially biliary atresia) routinely given? | No | Yes | This is to create awareness and serves as a safe-netting mechanism. |
10. | Follow-up plans for well babies who are still jaundice (low risk cases) | No. Babies are rendered heel-prick capillary bilirubin till jaundice resolves. | If day-21-tests were normal, the baby could be discharged with warning signs and reviewed during routine medical examination at 1 and 2 months old. | This will reduce unnecessary investigations, clinic visits and improve compliance to follow up. |