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Table 1 Differences between the current practice and the new protocol for PNNJ

From: Impact of a standardized protocol for the Management of Prolonged Neonatal Jaundice in a regional setting: an interventional quasi-experimental study

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.
  1. Abbreviations: T4 Thyroxine, TSH Thyroid-Stimulating Hormone, PNNJ Prolonged Neonatal Jaundice, UTI Urinary Tract Infection