NEONATAL CONDITIONS
Prolonged Jaundice
A practical guide for SCN clinical staff · Jaundice still there at two weeks - the split bilirubin that must not be missed
BILIRUBIN -
EXCLUDE ATRESIA
Breast-milk jaundice
Factors in breast milk increase enterohepatic recycling and inhibit conjugation; unconjugated bilirubin stays mildly raised for weeks in a well, thriving baby.
Reduced conjugation
Hypothyroidism slows bilirubin conjugation and clearance - usually caught on the newborn screen, but worth confirming.
Ongoing production
Continuing haemolysis (G6PD, spherocytosis, isoimmune disease) keeps the unconjugated bilirubin up.
Infection
A urinary tract infection, and other sepsis, can present as prolonged jaundice.
Impaired bile flow (conjugated)
Biliary atresia, neonatal hepatitis, a choledochal cyst, metabolic disease and TPN cholestasis block bile flow - the conjugated fraction rises and stools lose colour.
CLINICAL FINDINGS
- Still visibly jaundiced at 14 days (term) or 21 days (preterm)
- Assess feeding, weight gain and general wellbeing
- Look at stool and urine colour - pale stools and dark urine are the key clue
- Hepatomegaly, poor weight gain or bleeding suggest a liver / conjugated cause
- Signs of hypothyroidism: poor feeding, constipation, a large fontanelle
THE PROLONGED JAUNDICE SCREEN
- Split bilirubin (conjugated + unconjugated) - the essential first test
- FBC, blood film, reticulocytes and DAT
- Blood group (mother and baby)
- TFTs, or confirm the newborn screening result
- G6PD assay
- LFTs; if conjugated, urgent liver work-up
- Urine MCS (UTI) and urine reducing substances (galactosaemia)
RED FLAGS
- Any conjugated fraction (>20 µmol/L or >20% of total) - never normal
- Pale, chalky stools with dark urine - obstructive until proven otherwise
- Biliary atresia: refer urgently - the Kasai works best before 6-8 weeks
- A jaundiced baby who is unwell, feeding poorly or not gaining weight
- Bleeding or bruising (vitamin K malabsorption in cholestasis)
MANAGEMENT
Confirm it is truly prolonged, send a split bilirubin, and split your thinking: conjugated means an urgent liver work-up; unconjugated means the prolonged jaundice screen.
Conjugated (urgent)
- Any conjugated jaundice needs an urgent work-up - do not wait
- Refer to a paediatric liver / surgical service to exclude biliary atresia
- The Kasai portoenterostomy works best before 6-8 weeks of age
- Give vitamin K and watch for bleeding in cholestasis
Unconjugated screen
- TFTs, G6PD, FBC / film / DAT, blood group
- Urine MCS and urine reducing substances
- Treat the cause you find (hypothyroidism, UTI, haemolysis)
- Reassess if the baby is unwell or not thriving
Breast-milk jaundice
- A diagnosis of exclusion in a well, thriving, breastfed baby
- Unconjugated jaundice with a normal screen
- Reassure and continue breastfeeding
- Safety-net and arrange review rather than stopping feeds
Safety-net
- Ensure feeding and weight gain and document a follow-up plan
- Tell parents to return for pale stools, dark urine or poor feeding
- Escalate a deepening colour or any unwell baby
- A clear plan matters - prolonged jaundice is often managed as an outpatient
Why does every prolonged jaundice need a split bilirubin?
What are the stool and urine clues to a conjugated (obstructive) cause?
Why is biliary atresia so time-critical?
How do you safely make a diagnosis of breast-milk jaundice?
Take-home message: Prolonged jaundice is jaundice beyond 14 days (term) or 21 days (preterm). The single essential test is a split bilirubin: a conjugated fraction is always pathological and must trigger an urgent work-up to exclude biliary atresia, where the Kasai works best before 6-8 weeks. Prolonged unconjugated jaundice needs the prolonged jaundice screen (TFTs, G6PD, haemolysis, UTI); breast-milk jaundice is a diagnosis of exclusion in a thriving baby. Always check the stools and urine.
For educational purposes only. Always align management to current ANZCOR/NRP guidelines and your local SCN/NICU or NETS protocols.