of Prolonged and Late-Onset Jaundice
|Reviewed by Carl
- 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.
- Physical examination, including evaluation of growth
and feeding since birth
- Examination of stool colour and enquiry about
- Total bilirubin AND conjugated
- Full blood count and blood film
- To evaluate for haemolytic anaemia and possible
- 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)
- Glucose-6-phosphate dehydrogenase screen (in selected
- Check that the
Screening Test has been done.
- 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.
Management if Baby is Well
and Investigations are Normal
- 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
- 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.
Management if Any Investigations are Abnormal
- The baby may have a
pathological cause for jaundice and urgent further assessment is indicated.
||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
||Hannam S, McDonnell
M, Rennie JM. Investigation of prolonged neonatal jaundice. Acta Paediatr
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