Synopsis
Distinguish unconjugated transitional jaundice from cholestasis, identify pale stool and dark urine early and accelerate specialist investigation of biliary atresia while protecting nutrition and fat-soluble vitamins.
- Prolonged jaundice means more than 14 days at 37 weeks gestation or above, and more than 21 days below 37 weeks.
- Ask parents to describe or show stool and urine directly; pale chalky stool and dark staining urine are the highest-yield cholestasis clues.
- First-line tests under NICE are conjugated bilirubin, FBC, maternal and infant blood groups and DAT, with urine culture when UTI is suspected and confirmation of newborn metabolic screening.
- Conjugated bilirubin above 25 micromol/L needs expert advice because it may indicate serious liver disease.
- Do not stop breastfeeding merely to test breast-milk jaundice and do not use visual bilirubin assessment alone.
- Suspected biliary atresia needs same-day discussion with paediatric gastroenterology or a specialist liver centre; early investigation preserves the chance of effective Kasai surgery.
- Specialist evaluation uses liver tests, coagulation, glucose, infection and metabolic studies, expert ultrasound and sometimes biopsy or operative cholangiography.
- Kasai portoenterostomy removes fibrotic extrahepatic remnants and drains bile through a jejunal loop; earlier surgery generally offers better native-liver drainage.
- Cholestatic infants need high-energy feeding, specialist fat formulation and measured supplementation of vitamins A, D, E and K, with ongoing monitoring.
Key red flags
Jaundice lasting beyond 14 days in a term baby or 21 days in a preterm baby requires prolonged-jaundice assessment.
Pale chalky or white stool and dark urine that stains the nappy indicates conjugated cholestasis until proved otherwise.
Any conjugated bilirubin above 25 micromol/L warrants expert advice under NICE, regardless of total bilirubin appearance.
Poor feeding, faltering growth, hepatosplenomegaly, bleeding or bruising strengthens concern for significant liver or metabolic disease.
Fever, lethargy, irritability or reduced urine can indicate UTI or sepsis causing or accompanying jaundice.
Do not reassure from breastfeeding or a well appearance when stool is pale; biliary atresia can initially coexist with apparently good health.
Investigation priorities
Distinguish conjugated cholestasis from predominantly unconjugated prolonged jaundice.
Management branches
Jaundice persists beyond the gestation-specific NICE threshold.
- Inspect stool and urine and examine growth, liver, spleen and systemic state.
- Measure conjugated bilirubin, FBC, groups and DAT, assess UTI and confirm metabolic screening.
- Seek expert advice for direct bilirubin above twenty-five or immediately for pale stool or clinical deterioration.