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Formal assessment for the causes of neonatal hyperbilirubinaemia

GDG translation from evidence
In term babies, jaundice at or beyond day 14 is defined as ‘prolonged jaundice’. In these babies,
a full clinical examination is crucial and key investigations include measurement of total and
conjugated bilirubin, urine culture and testing for G6PD deficiency (if appropriate).
The GDG is aware that many neonatal units use jaundice persisting at or beyond day 21 as the
definition of prolonged jaundice in preterm babies. There was no evidence available for review
on this aspect of prolonged jaundice, and hence the GDG saw no reason to change clinical
practice in this respect.
The importance of hypothyroidism as a cause of neonatal jaundice should be appreciated and
clinicians should check that babies with prolonged jaundice have undergone routine newborn
bloodspot screening. Infection and liver disease (e.g. biliary atresia and neonatal hepatitis) are
important underlying causes of prolonged jaundice and should be considered if conjugated
hyperbilirubinaemia is identified. Pale stools and dark urine staining the nappy are a well-
recognised and important clue to possible liver disease. The GDG is aware of the evidence
demonstrating better outcomes for babies with biliary atresia who are offered early surgery and
hence stresses the urgency of seeking specialist advice when a high level (greater than
25 micromol/litre) of conjugated bilirubin is found.
The GDG considered that, in the first instance, a consultant neonatologist or a consultant
paediatrician should be consulted and cases subsequently referred to a specialist liver disease
centre if clinically indicated after appropriate investigation.

Recommendations – 6.2 Formal assessment of babies with prolonged jaundice
In babies with a gestational age of 37 weeks or more with jaundice lasting more than 14 days,
and in babies with a gestational age of less than 37 weeks with jaundice lasting more than
21 days:
• look for pale chalky stools and/or dark urine that stains the nappy
• measure the conjugated bilirubin
• carry out a full blood count
• carry out a blood group determination (mother and baby) and DAT (Coombs’ test).
Interpret the result taking account of the strength of reaction, and whether mother received
prophylactic anti-D immunoglobulin during pregnancy.
• carry out a urine culture
• ensure that routine metabolic screening (including screening for congenital
hypothyroidism) has been performed.
Follow expert advice about care for babies with a conjugated bilirubin level greater than
25 micromol/litre because this may indicate serious liver disease.

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