# Prolonged neonatal jaundice (beyond 14 days) - Category: acute - Review status: reviewed (every claim checked against a document named on this page) - Sources: Neonatal Jaundice - StatPearls (NCBI Bookshelf NBK532930) - https://www.ncbi.nlm.nih.gov/books/NBK532930/ · Biliary Atresia - StatPearls (NCBI Bookshelf NBK537262) - https://www.ncbi.nlm.nih.gov/books/NBK537262/ · Prolonged neonatal jaundice - disease-level clinical article (prolonged-neonatal-jaundice-full.txt) · Prolonged neonatal jaundice - disease-level clinical article (prolonged-neonatal-jaundice-clinical.txt) - Verified date: 2026-08 ## Verified against - Neonatal Jaundice - StatPearls (NCBI Bookshelf NBK532930) - https://www.ncbi.nlm.nih.gov/books/NBK532930/ - Biliary Atresia - StatPearls (NCBI Bookshelf NBK537262) - https://www.ncbi.nlm.nih.gov/books/NBK537262/ - Prolonged neonatal jaundice - disease-level clinical article (prolonged-neonatal-jaundice-full.txt) - Prolonged neonatal jaundice - disease-level clinical article (prolonged-neonatal-jaundice-clinical.txt) ## Treatment metadata - Split (fractionated) bilirubin and cholestasis assessment (no drug therapy) - Referral & safety-netting (no drug therapy) ## Complete treatment card ```text PROLONGED NEONATAL JAUNDICE (BEYOND 14 DAYS) Sources: Neonatal Jaundice - StatPearls (NCBI Bookshelf NBK532930) - https://www.ncbi.nlm.nih.gov/books/NBK532930/ · Biliary Atresia - StatPearls (NCBI Bookshelf NBK537262) - https://www.ncbi.nlm.nih.gov/books/NBK537262/ · Prolonged neonatal jaundice - disease-level clinical article (prolonged-neonatal-jaundice-full.txt) · Prolonged neonatal jaundice - disease-level clinical article (prolonged-neonatal-jaundice- clinical.txt) Review status: REVIEWED against 4 sources listed above (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (3) - Major AAP risk markers include a pre-discharge bilirubin in the high-risk zone, jaundice in the first 24 hours, and blood-group incompatibility [jaundice] - Further major risk markers are gestational age under 36 weeks, a phototherapy family history, birth bruising, exclusive breastfeeding, and Asian ancestry [bruising] - Lesser risk markers include a bilirubin in the high-intermediate range, being a large baby of a diabetic mother, polycythemia, male sex, and a mother over 25 SIGNS - what you find (4) - Jaundice should ideally be assessed in daylight, since visual grading is unreliable, especially after phototherapy or in dark-skinned infants [jaundice] - Findings that suggest a pathologic cause include pallor, petechiae, cephalohematoma, extensive bruising, an enlarged liver or spleen, weight loss, and dehydration [bruising · dehydration · hepatomegaly · pallor · petechiae · weight loss] - Poor feeding, lethargy, disrupted sleep, abnormal tone, and seizures suggest bilirubin encephalopathy, though up to 15% of affected infants look outwardly well [kernicterus · lethargy · poor feeding · seizures] - Multisystem involvement in a jaundiced infant points toward the workup needed for cholestasis TESTS (11) - Bilirubin should be checked 24 to 48 hours after birth, or before discharge if the infant leaves earlier than that - A blood draw for serum bilirubin is warranted once the transcutaneous reading passes the 95th percentile on the nomogram or 75% of the phototherapy threshold - Transcutaneous bilirubin cannot capture the direct fraction, so it cannot diagnose cholestasis on its own - A hemolysis workup for unconjugated hyperbilirubinemia includes maternal and infant blood type, a Coombs test, CBC with reticulocyte count, a blood smear, and G6PD screening - Serum albumin, a stand-in for free bilirubin, should be checked as the level nears the exchange-transfusion threshold - The bilirubin-to-albumin ratio can help predict kernicterus risk and guide escalation of care or exchange transfusion - Brain MRI is highly sensitive for bilirubin encephalopathy, with the posteromedial globus pallidus border being the most sensitive site for signal change - With conjugated hyperbilirubinemia, raised transaminases point to liver-cell injury while raised alkaline phosphatase and GGT suggest bile-duct obstruction - PT, INR, and albumin assess hepatic synthetic function in a cholestatic infant - A triangular cord sign on liver ultrasound is highly sensitive and almost 100% specific for biliary atresia - Liver biopsy remains the gold standard for neonatal cholestasis; an experienced pathologist correctly diagnoses 90% to 95% of specimens examined IF NOT THIS - what else fits (1) - A diet heavy in beta-carotene can turn an older infant's skin yellow like jaundice, but unlike true jaundice the sclera stays white and it never appears at birth Source StatPearls "Neonatal Jaundice" - disease-level clinical article Status traced to the source above 1. SPLIT (FRACTIONATED) BILIRUBIN AND CHOLESTASIS ASSESSMENT (NO DRUG THERAPY)[1st line] Adult Source Prolonged neonatal jaundice - disease-level clinical article (prolonged-neonatal- jaundice-full.txt) Why Jaundice that outlasts two weeks is a laboratory question before it is anything else. The biliary atresia article sets the trigger: past 14 days, jaundice should not be called physiological, and it needs prompt evaluation for cholestatic liver disease. The jaundice article sets the stakes: a conjugated hyperbilirubinaemia in an infant is always pathological, and always points to something medical or surgical underneath. The single test that separates them is the split bilirubin. Caution THE TEST IS A SPLIT BILIRUBIN, NOT A TOTAL. A transcutaneous meter cannot read the direct fraction, and it is that fraction the diagnosis of neonatal cholestasis turns on. (Neonatal Jaundice - StatPearls - NCBI Bookshelf, NBK532930) A transcutaneous reading, or a total serum bilirubin on its own, cannot answer this question. WHAT A RAISED DIRECT FRACTION MEANS - the biliary atresia article's laboratory picture is a conjugated hyperbilirubinaemia, with the total and the direct bilirubin both up. (Biliary Atresia - StatPearls - NCBI Bookshelf, NBK537262) Suspect neonatal cholestasis readily, read the split bilirubin, the liver enzymes and the imaging without delay, and get the baby to paediatric surgery and hepatology quickly. (Biliary Atresia - StatPearls - NCBI Bookshelf, NBK537262) THE REST OF THE WORKUP, as the jaundice article sets it out: the serum aminotransferases can show injury to the hepatocytes where the hyperbilirubinaemia is conjugated; a raised alkaline phosphatase and GGT point to obstruction in the biliary channels; and the prothrombin time (PT), the international normalised ratio (INR) and the serum albumin are the measures of what the liver is still synthesising and how it is functioning. (Neonatal Jaundice - StatPearls - NCBI Bookshelf, NBK532930) ASK ABOUT THE NAPPY AND THE URINE - the assessment of a jaundiced newborn opens with a careful history: what complicated the pregnancy, what runs in the family, how the delivery went, when the symptoms started, whether feeding is going well, and the mother's serology. The colour of the stool and of the urine can itself indicate which kind of jaundice this is. (Neonatal Jaundice - StatPearls - NCBI Bookshelf, NBK532930) NO PHOTOTHERAPY DOSE IS PRINTED HERE. Unconjugated hyperbilirubinaemia is treated principally by phototherapy and by exchange transfusion - both given as an inpatient, both dosed off a nomogram, and neither a primary-care prescription. A baby who needs them needs a hospital. Prolonged jaundice with a NORMAL split bilirubin still needs an explanation. The article's causes of unconjugated jaundice include hypothyroidism present from birth; the sulfa drugs, ceftriaxone and the penicillins; obstruction of the intestine and pyloric stenosis; jaundice of breast milk; and simply not taking enough at the breast. (Neonatal Jaundice - StatPearls - NCBI Bookshelf, NBK532930) Check the newborn thyroid screen before calling it breast-milk jaundice. 2. REFERRAL & SAFETY-NETTING (NO DRUG THERAPY) [1st line] Adult Source Biliary Atresia - StatPearls (NCBI Bookshelf NBK537262) - https://www.ncbi.nlm.nih.gov/books/NBK537262/ Why Biliary atresia is the reason prolonged jaundice is a time-critical presentation rather than a review appointment, and the window is measured in weeks. Caution RED FLAG - THE THREE SIGNS: biliary atresia usually declares itself in the newborn weeks as jaundice that persists past the second week of life, stools that are pale or without pigment, dark urine, and a large liver. Pale stool plus dark urine in a jaundiced baby is a same-day referral. Jaundice together with clay-coloured stools and dark urine means the baby is investigated for biliary atresia and referred properly to a specialist centre. THE CLOCK - doing the Kasai procedure early, and ideally before the 60th day of life, is strongly linked to better bile flow, less cholangitis, and a native liver that survives longer. Every week of delay costs liver. Operate within 10 weeks of birth and the child is less likely to come to liver transplantation. A NORMAL-LOOKING NAPPY TODAY DOES NOT CLEAR IT - the early picture can be faint, and several studies make the point that some infants pass pigmented stool at first, which loses its colour as the bile flow fails; that is one of the reasons the diagnosis arrives late. Ask the family to keep watching the stool colour and to come back. GIVE THE PARENTS A COLOUR TO WATCH FOR - organised screening using infant stool colour cards (SCC), as done in Japan, Taiwan, Switzerland, France and Germany, lets parents spot a stool without pigment early and brings the assessment forward. REFER, DO NOT INVESTIGATE INDEFINITELY - a baby with neonatal cholestasis goes to a paediatric gastroenterologist without delay. RED FLAG - BILIRUBIN ENCEPHALOPATHY, which is the other way a jaundiced baby dies: every jaundiced infant is examined for its clinical signs - feeding poorly, lethargy, a changed sleep pattern, abnormal tone, and fits. And as many as 15% of neonates with kernicterus show nothing clinically in the newborn period. Miss pathological jaundice, or leave it untreated, and the result can be bilirubin encephalopathy with the neurological damage that follows it. Biliary atresia is not rare enough to gamble on: it is the cause of cholestatic jaundice found most often in the newborn period, and the article's estimate puts it at 25% to 40% of every case. Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)