Introduction

This guideline relates to liver dysfunction in paediatric patients and jaundice in infants. For more information, please see: Clinical Practice Guidelines: Jaundice in early infancy

When to refer

• Patients aged 0-16 years
• Newborn with persistent jaundice (> 2 weeks) with a conjugated fraction > 20% (with or without pale stools and/or dark urine)

           Note: presence of pale stools warrants immediate contact with the on-call gastroenterologist for advice

• Acute hepatitis with worsening liver function tests
• Chronic hepatitis
• Unexplained hepatosplenomegaly
• Unexplained cirrhosis
• Liver lesion on ultrasound with normal liver function tests
• Liver disease treatment required that is outside the referrer’s scope of practice (e.g., viral hepatitis, autoimmune liver disease, primary sclerosing cholangitis, Wilson’s disease, metabolic diseases)
• Suspected steatotic liver disease or metabolic-associated fatty liver disease (MAFLD

If any of the following are present or suspected, please direct the patient to the Emergency Department (no referral required):

• Acute liver failure (e.g. INR > 1.5 and encephalopathy or INR > 2, in the absence of pre-existing liver disease)
• Acute paracetamol toxicity
  Note: referral is indicated to paediatrician if no liver synthetic dysfunction
• Chronic liver failure with fever or sepsis
• Jaundice with confusion
• Newborn with persistent (> 6 weeks), severe, recurrent unconjugated hyperbilirubinemia (despite phototherapy) or newborn with conjugated hyperbilirubinemia (20% of total bilirubin)
  Note: phone on-call gastroenterologist for advice
• Post-transplant jaundice with fever or sepsis
• Sudden onset, obstructive jaundice
  

Services available closer to home

Other hospitals with public paediatric general medicine/gastroenterology services include:

• Austin Hospital
• Box Hill Hospital (Eastern Health)
• Monash Medical Centre
• The Northern Hospital
• Sunshine Hospital (Western Health)

Referral criteria/required information

• Detailed history and assessment, including duration of symptoms, alcohol intake (if relevant) and vaccination history
• Relevant family history
• Risk factors for viral hepatitis
• Use of nutritional supplementation and/or over-the-counter and herbal medicines
• Blood tests:
  • Liver function test results (current and previous)
  • Full blood count (FBC)
  • Coagulation profile
  • Hepatitis A serology (HAV IgG)
  • Hepatitis B serology (HBV sAg, sAb, cAb)
  • Hepatitis C serology (HCV Ab)
  • Iron studies
  • Epstein-Barr virus (EBV) and cytomegalovirus (CMV) serology
  • Additional tests if able:
    • HbA1c
    • Creatine kinase (in presence of elevated transaminases)
    • Autoimmune hepatitis (ANA, anti-smooth muscle antibody, anti LKM)
    • Wilson’s disease (serum copper and ceruloplasmin)
    • Alpha antitrypsin deficiency (alpha 1 antrypsin level, Pi typing)
• Any previous investigations including:
  • Upper abdomen ultrasound
  • CT or MRI

How to refer

RCH Specialist Clinics Referral.pdf

Please complete the above and submit via:

• Fax (03) 9345 5034 or
• Email screferrals@rch.org.au
• Urgent referral or clinical query call ED admitting officer or Gastroenterology Outpatient Consult Fellow (03) 9345 5522. If after hours ask for Gastroenterology fellow on call

Resources and links

• Clinical Practice Guidelines : Abdominal pain - acute
• Clinical Practice Guidelines : Abdominal pain - chronic
• Clinical Practice Guidelines : Jaundice in early infancy

Acknowledgements

The development of this guideline was coordinated by the Department of Gastroenterology (A/Prof. George Alex). Guideline reviewed in July 2025.