Jaundice, neonatal, prolonged

DESCRIPTION

Jaundice (static or a rising bilirubin) present for more than 10 days in a term infant and 14 days in a preterm infant. The usual causes are:

  • breast milk jaundice,
  • hypothyroidism,
  • hepatitis,
  • galactosaemia, and
  • infections, e.g. UTIs.

Breast milk jaundice may be confirmed by substituting breastfeeding with formula feeds for 24–48 hours. The bilirubin level will always drop to a lower level and increase again when breastfeeding is resumed. However, the level will not rise to the original high level. Breast milk jaundice is an unconjugated hyperbilirubinaemia and the infant is always well and thriving.

Abnormal thyroid function, increased TSH and decreased T3 and T4, indicates hypothyroidism. Unconjugated bilirubin fraction is raised and the infant may have clinical signs of hypothyroidism e.g.:

  • lethargy,
  • constipation,
  • feeding difficulties,
  • hypotonia,
  • poor cry,
  • umbilical hernia,
  • nasal obstruction,
  • hypothermia, and
  • bradycardia.

Infants with galactosaemia usually present with:

  • a conjugated hyperbilirubinaemia,
  • vomiting,
  • refusal to feed,
  • hepatomegaly,
  • failure to thrive,
  • hypoglycaemia,
  • encephalopathy, and
  • cataracts (later).

DIAGNOSTIC CRITERIA

  • Hepatitis may be confirmed by abnormal liver function tests, i.e. raised values of:
    • AST,
    • ALP,
    • ALT,
    • bilirubin, mainly the conjugated fraction,
    • GGT.
  • Hepatomegaly or hepatosplenomegaly.
  • If conjugated hyperbilirubiniaemia – see above.

Investigations

  • Syphilis. See Syphilis, early congenital .
  • Thyroid function (see Chapter: Endocrine System, Hypothyroidism, congenital ), and
  • Urine for MCS (see Chapter: Nephrological/Urological Disorders, Urinary tract infections ).
  • Suspect galactosaemia if urine is positive for reducing substances but negative for glucose in a baby receiving lactose-containing feeds. A galactose-1-phosphate uridyl transferase assay will confirm the diagnosis.

GENERAL AND SUPPORTIVE MEASURES

  • Monitor bilirubin levels.
  • Treat the underlying cause.
  • Dietary adjustment for prolonged conjugated hyperbilirubinaemia to counteract the malabsorption of fat and fat soluble vitamins (A, D, E and K).
  • Avoid lactose containing feeds, i.e. breast milk and lactose containing formulae, when galactosaemia is suspected.
  • Regular follow up until the underlying condition has been resolved.

MEDICINE TREATMENT

All premature babies, day 15 to 1 year:

  • Multivitamin, drops, oral, 0.6 mL daily.

REFERRAL

  • Pathological jaundice, unconjugated and/or conjugated, where the underlying cause cannot be identified.
  • Serum unconjugated bilirubin at exchange transfusion level.
  • Jaundice, unconjugated and/or conjugated, not improving on adequate treatment.
  • Conjugated hyperbilirubinaemia due to conditions requiring surgical intervention e.g. biliary atresia.
  • Prolonged neonatal jaundice, excluding breast milk jaundice.