NICE vs RCPCH: Management of Neonatal Jaundice (2025)
Neonatal jaundice is one of the most common conditions requiring assessment and management in newborn infants. In the UK, clinicians primarily rely on two key evidence-based guidelines: the National Institute for Health and Care Excellence (NICE) Clinical Guideline CG98 (updated in May 2022 with an addendum in 2024, current for 2025) and the Royal College of Paediatrics and Child Health (RCPCH) guideline "Neonatal Jaundice" (2016, with a 2022 evidence update). While both aim to standardise care and prevent kernicterus, their approaches have distinct differences in structure, detail, and practical application. This comparison provides a factual analysis for UK clinicians.
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Diagnosis and Assessment
NICE CG98 Approach
NICE provides a systematic, population-screening based approach. Its cornerstone is the recommendation that every baby should be assessed for jaundice at every opportunity, with a formal bilirubin measurement if jaundice is observed in the first 24 hours. Key assessment tools are:
- Timing: Visual assessment within 48 hours of birth and again at 72-120 hours (coinciding with the newborn blood spot test).
- Blanching the Skin: Explicitly recommends pressing the skin to check for underlying jaundice.
- Risk Factors: Emphasises the use of a risk factor chart (gestational age, postnatal age) to determine threshold for treatment, rather than a single value for all infants.
- Transcutaneous Bilirubinometers (TcB): Recommends TcB as an effective screening tool. If the TcB reading is below the 75th percentile for the baby's age in hours, it is unlikely the baby needs treatment.
RCPCH Approach
The RCPCH guideline also advocates for vigilant assessment but is more focused on the clinical signs of significant jaundice and the quantification of bilirubin levels.
- Clinical Progression: Stresses the importance of noting the cephalocaudal progression of jaundice (from head to toes).
- Transcutaneous Bilirubinometers (TcB): Supports the use of TcB but provides more detailed guidance on its limitations, particularly in darker-skinned infants and after phototherapy has commenced.
- Laboratory Measurement: Places a strong emphasis on the need for laboratory confirmation of serum bilirubin (SBR) for all infants at or above treatment thresholds.
Key Difference: NICE is more algorithmic and public-health focused, promoting universal screening with a clear risk-factor matrix. RCPCH offers more nuanced clinical detail on the limitations of assessment methods.
Treatment Thresholds and Phototherapy
NICE CG98 Treatment Charts
NICE uses two primary treatment threshold charts based on gestational age and postnatal age in hours. These are visually presented as graphs with different lines for different risk levels (e.g., ≥38 weeks vs. <38 weeks gestation).
- Thresholds: The thresholds are generally considered to be slightly higher (more conservative) than some international guidelines, meaning treatment may be initiated at a higher bilirubin level for a given infant.
- Practical Application: Clinicians must plot the baby's SBR on the appropriate chart to see if it is above the "phototherapy" line.
RCPCH Treatment Thresholds
The RCPCH guideline also uses treatment thresholds based on gestational and postnatal age. While the numerical values are very similar to NICE, the way they are presented and interpreted can differ slightly.
- Chart Presentation: The charts are structured similarly but may have subtle differences in the gradation between gestational age bands.
- Emphasis on Trend: RCPCH places a stronger emphasis on the rate of rise of bilirubin (>8.5 µmol/L/hour) as an indication for treatment, even if the absolute threshold has not yet been crossed.
Key Difference & Practical Takeaway: The absolute thresholds are largely aligned. The most significant practical difference is that RCPCH provides a clear numerical trigger for a rapid rate of rise, whereas NICE incorporates this more implicitly into its risk assessment. For a baby with a rapidly rising bilirubin, RCPCH offers a more explicit action point.
Special Situations
Jaundice in the First 24 Hours
Both guidelines agree that jaundice presenting within the first 24 hours is pathological and requires immediate investigation and senior review. NICE provides a more structured pathway for the investigations required.
Prolonged Jaundice (>14 days in term infants, >21 days in preterm)
This is a major area of divergence.
- NICE: Recommends routine measurement of conjugated bilirubin in all infants with prolonged jaundice to screen for rare but serious liver disease (e.g., biliary atresia). This is a key patient safety recommendation.
- RCPCH: Recommends checking conjugated bilirubin only if there are specific concerning features (e.g., pale stools, dark urine, hepatosplenomegaly, failure to thrive).
Key Difference: NICE takes a universal screening approach for liver disease in prolonged jaundice, while RCPCH uses a targeted approach based on clinical signs. This has significant implications for primary care and community paediatrics.
Haemolytic Jaundice (e.g., due to ABO or Rh incompatibility)
Both guidelines recommend lower treatment thresholds for infants with haemolytic jaundice due to the higher risk of rapid bilirubin escalation and kernicterus. NICE incorporates this into its "high-risk" line on the treatment chart.
Practical Clinical Flow for a Term Infant
1. Assessment: Visually assess all babies. Use a TcB if available and jaundice is suspected. If jaundiced in first 24 hours, measure SBR urgently.
2. Measurement & Plotting: For a jaundiced infant >24 hours, measure SBR (or use TcB as a screen). Plot the result and postnatal age on the NICE treatment threshold chart (the most widely used standard in England and Wales).
3. Treatment Decision:
- If SBR is above the phototherapy line, commence phototherapy.
- If SBR is below the line but rising rapidly (>8.5 µmol/L/hour), consider phototherapy as per RCPCH guidance and clinical judgement.
4. Management of Prolonged Jaundice: Adopt the NICE approach as a safety net: in any well infant with jaundice beyond 14 days, check a split bilirubin (total and conjugated) to exclude conjugated hyperbilirubinaemia.
Frequently Asked Questions (FAQs)
1. Which guideline should I follow in my hospital?
Most NHS Trusts in England and Wales base their local protocols on the NICE guideline, as it is the national standard. In Scotland, local health boards may integrate both. The practical approach is to use your local protocol, which will typically be NICE-based. Knowing the RCPCH nuances, especially regarding the rate of bilirubin rise, adds valuable clinical context.
2. The NICE and RCPCH treatment charts look different. Which one is correct?
Both are correct and based on evidence. The numerical thresholds are very similar. The key is to be consistent. Use the chart that your hospital has adopted into its electronic patient record or paper charts to avoid confusion and errors. Do not switch between them for the same infant.
3. How should I manage prolonged jaundice in a well, breastfed infant in the community?
This is the most common dilemma. Following the NICE guideline is safer to avoid missing rare liver pathology. The recommendation is to check a total and conjugated bilirubin. If the conjugated fraction is normal (<20% of total or <20 µmol/L), reassurance can be given. This provides objective evidence of benign physiological or breastmilk jaundice.
4. Are transcutaneous bilirubinometers reliable for decision-making?
Yes, for screening. Both guidelines endorse TcB. However, both also state that any TcB reading at or above treatment threshold must be confirmed by a laboratory SBR measurement before commencing phototherapy. TcB is less reliable in infants receiving phototherapy or with darker skin tones.
5. What is the single most important difference between the guidelines?
The most impactful difference for patient safety is the approach to prolonged jaundice. NICE's mandate to measure conjugated bilirubin in all cases creates a systematic safety net for detecting cholestatic liver disease early, whereas the RCPCH approach relies on the presence of clinical red flags.
Source Links
- NICE Guideline CG98 - Neonatal Jaundice: [https://www.nice.org.uk/guidance/cg98](https://www.nice.org.uk/guidance/cg98) (Full guideline, last updated May 2022).
- NICE Visual Treatment Threshold Charts: [https://www.nice.org.uk/guidance/cg98/resources](https://www.nice.org.uk/guidance/cg98/resources) (Downloadable PDFs of the graphs).
- RCPCH Neonatal Jaundice Guideline (2016): [https://www.rcpch.ac.uk/resources/neonatal-jaundice-guideline](https://www.rcpch.ac.uk/resources/neonatal-jaundice-guideline) (Full PDF document).
- RCPCH Evidence Update (2022): [https://www.rcpch.ac.uk/resources/neonatal-jaundice-evidence-update-2022](https://www.rcpch.ac.uk/resources/neonatal-jaundice-evidence-update-2022) (Review of new evidence confirming the 2016 recommendations remain valid).