Definition

Prolonged jaundice is defined as
- >14 days in term infants
- >21 days in preterm infants
Persisting jaundice is more common in breastfed infants than artificially-fed infants. At least 9% of breastfed infants are still jaundiced at 28 days of age. ¹
Jaundiced breast-fed infants who are well are unlikely to have serious disease. ² However, a diagnosis of breast milk jaundice is a diagnosis of exclusion, after investigation as below.
In artificially-fed infants, prolonged jaundice should be aggressively investigated.
Jaundice which has not previously been apparent and then appears after day 7 should be investigated carefully.

Assessment

Physical examination, including evaluation of growth and feeding since birth
Examination of stool colour and enquiry about urine colour
Total bilirubin AND conjugated (direct) fraction
Full blood count and blood film
- To evaluate for haemolytic anaemia and possible infection.
Thyroid function tests (TSH and T₄)
- The newborn screening test in NZ screens for congenital hypothyroidism and evaluates only TSH.
- This test is less reliable in preterm infants, and does not screen for hypopituitary hypothyroidism.
Urine sample for microscopy and culture
- Be aware that a bag urine may yield ambiguous results which may require further (potentially invasive or unnecessary) investigation.
Glucose-6-phosphate dehydrogenase screen (in selected infants).
Check that the Newborn Screening Test has been done.

Notes:

Liver function tests are not indicated unless there is a conjugated hyperbilirubinaemia. LFTs are often abnormal in the newborn period in breastfed infants with no pathological cause for jaundice.
A Coomb's test is not required if the baby is not anaemic, did not have early jaundice, and does not have evidence of haemolysis on the FBC.

The phototherapy charts are not validated in infants of this age. Bilirubin levels which are above treatment levels at 4 days may not require phototherapy at 14 days.
If approaching treatment levels, recheck the bilirubin within 1-2 days to ensure that it is decreasing.
- Otherwise repeat weekly or less often as indicated by clinical examination.
- If persistent, recheck the conjugated fraction
Parents may need reassurance that the jaundice itself is not harmful. They should be asked to contact their GP or LMC if they have concerns about their baby’s growth or health.
Although temporary cessation of breastfeeding may reduce or eliminate prolonged jaundice associated with breast milk, we do not currently recommend this.

The baby may have a pathological cause for jaundice and urgent further assessment is indicated.

1	Crofts DJ, Michel VJ-M, Rigby AS, Tanner MS, Hall DMB, Bonham JR. Assessment of stool colour in community management of prolonged jaundice in infancy. Acta Paediatr 1999;88:969-74.
2	Hannam S, McDonnell M, Rennie JM. Investigation of prolonged neonatal jaundice. Acta Paediatr 2000;89(6):694-7.

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