Prolonged jaundice guideline

Jaundice persisting beyond day 14 of infant’s life is common occurring in 2-15% of all neonates and 15-40% of those who are breastfed. In most occasions it is normal but it is important to exclude serious conditions such as Biliary Atresia and G6DP that can benefit from prompt diagnosis and management.

The initial referral will have been taken by consultant / ANNP holding bleep 6123 and an assessment / referral sheet commenced with relevant details. (See below).

• Term babies who remain visibly jaundiced beyond 14 days and preterm babies beyond 21 days require further assessment.
• The referral / assessment form should be started by the person taking the initial call and emailed to the CCN team. The consultant of week is to be identified as the responsible consultant and copied in to the referral email to the CCN.
• CCN team should see term babies by D21 and preterm by D28 if no clinical red flag identified.
• If there are no obvious clinical concerns the main consideration at this point is to know the total bilirubin split between conjugated and unconjugated.
• Clinical assessment, including measurement of the weight (if possible), should be carried out and points of history taken prior to the visit reviewed and clarified.
• Stool colour chart and some pathological reasons for prolonged jaundice are attached.
• NB Breast milk jaundice can take up to 12 weeks to resolve, it is not a reason to stop breast feeding.

In the absence of any other concerns, further investigations at this time are limited to:

Split Bilirubin

Parent should be informed they will be contacted with results and given the information leaflet within this document.

The blood samples should be identifiable by handwritten name and CHI on tube, returned to the BGH and handed to the ANNP / Dr carrying 6123 to request, label and send. The baby should be admitted to ACU with a note identifying community bloods. This person is then responsible for checking results, phoning the parents and completing a TRAK letter for HV/GP.

The blood should be taken from a capillary sample, using the baby’s heel.
Blood should be collected into an orange capillary tube for the bilirubin.

A capillary sample is a blood sample collected by puncturing the skin and collecting the blood from the tiny blood vessels which are near the skin surface.

It can be used when small volume samples are required, and can help preserve peripheral veins.

Both Serum Bilirubin and Full blood counts can be taken this way.

Good technique is important to avoid sample problems and the requirement of a repeat specimen.

Consideration for the baby:

• painful procedure
• local trauma
• infection
• damage to nerves blood vessels and bones
• blood loss.

To help with the pain EBM / formula can be given prior to the procedure or it can be carried out while the baby is feeding or use of pacifier to encourage sucking.

Equipment

• Non sterile gloves
• Cotton wool
• Blood tubes: orange lithium heparin, red EDTA
• Blood lancet for puncturing skin (Tender foot)
• Clean disposable tray for equipment
• Sharps box

Procedure

• Wash hands and put on non sterile gloves.
• Ensure the baby is settled, give consideration to pain relief.
• A warm and well perfused heel will give the best opportunity for successful procedure.
• Hold the heel securely with the skin under tension, clean the site with an alcohol wipe and allow to dry
• Puncture skin in a steady, firm and intentional manner on the lateral aspect of heel, the areas shaded on diagram below
• Wipe away the initial drop of blood.
• Allow gravity to help, keep the foot hanging down to aid blood flow.
• Compress the heel gently but firmly allowing time for refill between compressing.

A good flowing specimen will aid processing of sample, any haemolysis will impact on the result and the laboratory may not be able to process it at all.

• Continue process until sufficient blood is obtained.
• If the blood flow stops, clean the site of old blood allow time for capillary refill, reapply pressure. If blood flow does not restart the procedure may need repeating at a different site.
• Once the sample has been obtained apply pressure to the site with cotton wool or gauze until the bleeding is stopped.
• Ensure the baby is left comfortable.
• Dispose of equipment and wash hands.
• Ensure sample brought to the hospital for analysis as soon as possible.

Stool colour chart:

Biliary atresia: a guide - Children's Liver Disease Foundation

Prolonged jaundice screen form to download

Parent information leaflet to download

What is prolonged Jaundice?

Jaundice is described as a yellowing of the skin, and sometimes of the whites of the eyes. It occurs in 90% of newborn infants. Prolonged jaundice is the term for jaundice which is still present after 2 weeks in term babies (>37 wk) and 3 weeks in preterm babies.

What causes prolonged jaundice?

Jaundice is caused by a buildup of bilirubin, a dark yellow substance. This is a natural waste product of the normal breakdown of red blood cells. Before birth, the mother’s liver removes the product, but after birth the baby’s liver must get rid of it on its own.

However, the liver is still immature in newborns, so it is less efficient at clearing waste products.  These can build up in the skin and appear as jaundice.

Jaundice usually appears after 2-3 days and gradually disappears on its own by 14 days. However jaundice can often last longer, especially in the breastfed or preterm baby.

Does prolonged jaundice matter?

Prolonged jaundice is usually related to breast milk feeding and is harmless. In this case, jaundice will disappear in the coming weeks and you should continue breastfeeding your baby.

Very rarely prolonged jaundice can be a sign of liver, thyroid, metabolic or blood problem. This is very uncommon but must be investigated so that treatment can be given if required.

If your baby develops dark urine, pale stools or is not thriving seek advice from health visitor or GP

What to expect if your baby remains jaundice?

Term babies who remain jaundice at 15 days and preterm babies who remain jaundice at 22 days will be referred to the children’s dept at the BGH to be reviewed by a member of the neonatal team within the following week.

If prior to this appointment there are any clinical concerns an urgent referral for review should be
made via HV/GP/NHS 24.

Jackson A. WoS Jaundice Neonates. West of Scotland MCN for Neonatology 2016.  Updated 2021

NICE Guideline. Jaundice in newborn babies under 28 days (CG98), 2010 (last updated October
2016)

NICE guidelines on neonatal jaundice: at risk of being too nice The Lancet, Volume 376, Issue
9743, Page 771, 4 September 2010 doi:10.1016/S0140-6736(10)61376-1

Detection and treatment of neonatal jaundice The Lancet, Volume 375, Issue 9729, Page 1845, 29
May 2010 doi:10.1016/S0140-6736(10)60852-5

Tyler W, McKeirnan PJ. Prolonged jaundice in the preterm infant. What to do when and why?
Current Paediatrics 2006; 16: 43-50

Raeside L Capillary blood sampling West of Scotland MCN for Neonatology 2013, reviewed 2019