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Neonatal jaundice

When assessing the baby for underlying disease consider whether the following tests are
clinically indicated:
• full blood count and examination of blood film
• blood glucose-6-phosphate dehydrogenase levels, taking account of ethnic origin
• microbiological cultures of blood, urine and/or cerebrospinal fluid (if infection is
suspected).

Do not use the albumin/bilirubin ratio when making decisions about the management of
hyperbilirubinaemia
Do not subtract conjugated bilirubin from total serum bilirubin when making decisions about
the management of hyperbilirubinaemia (see management thresholds in the threshold table
(Section 1.3) and treatment threshold graphs (Section 1.6)).

6.2 Formal assessment of babies with prolonged jaundice

Description of included studies
Three studies of EL 3 from Turkey 120;121 and the UK 122 have been included. Two were case
series 120;122 and one was a retrospective chart review. 121 The sample size ranged from 42 to 381.
Review findings

A UK case series 122 examined causes of prolonged jaundice, defined as jaundice persisting
beyond day 14. The mean gestational age of the 154 included babies was 39 weeks, the mean
birthweight was 3200 g and the mean age at referral was 16 days. Ninety-six (62.3%) were male
and 89 (57.8%) were white, 36 (23.4%) were black and 20 (13.0%) were Asian. The vast
majority (142; 92.2%) were breastfed and the remainder either bottle-fed or had mixed feeds.
Overall, initial assessment resulted in nine (5.8%) babies being referred on for further
investigation. Clinical examination identified one case of hepatoblastoma, and ultimately led to
the detection of trisomy 9p. Abnormal results for liver function tests identified one baby with
giant cell hepatitis. Three cases of G6PD deficiency and two cases of urinary tract infection
were identified. [EL 3]
A case series from Turkey 120 examined causes of prolonged jaundice in term and near-term
babies. Of 381 babies with hyperbilirubinaemia, 31 (8.1%) had prolonged jaundice and 26
were included in the study. The mean gestational age was 38 weeks, the mean birthweight was
3194 g, the mean age at presentation was 19 days and 15 (57.7%) of the group were male. The
mean serum bilirubin at presentation was 246 micromol/litre. One baby had conjugated
hyperbilirubinaemia and was referred for exclusion of biliary atresia. Seven babies (26.9%) had
blood group incompatibility and four (15.4%) had inadequate caloric intake. The remaining 14
(53.8%) had ‘breastmilk’ jaundice. [EL 3]
121
Causes of conjugated hyperbilirubinaemia were also reported in another Turkish study, a
retrospective review of 42 affected babies. The mean gestational age was 37 weeks and no other
demographic details were reported. The mean age at presentation was 20 days. The mean total
serum bilirubin was 292 micromol/litre and the mean conjugated bilirubin was 130 micromol/litre.
The causes of the conjugated hyperbilirubinaemia included culture-proven sepsis in 15 (35.7%)
babies, perinatal hypoxia–ischaemia in seven (16.7%), blood group incompatibility in five (11.9%),
trisomy 21 in three (7.1%), TPN-associated cholestasis in three (7.1%), neonatal hepatitis in two
(4.8%), metabolic liver disease in one (2.4%), biliary atresia in one (2.4%) and portal venous
thrombosis in one (2.4%). No cause was identified in four (9.5%) cases. [EL 3]

Evidence summary
First-line investigations for prolonged jaundice resulted in nine (5.8%) babies being referred on
for further investigation in a UK-based study. A Turkish study resulted in one baby (3.8%) being
referred for tertiary investigation while 14 (53.8%) were considered to have ‘breastmilk’
jaundice. In a second Turkish study, associated pathology was identified in 38 of 42 (90%)
babies with conjugated hyperbilirubinaemia.

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