LETTER

Skin colour: a barrier to early referral of infants with biliary atresia in the UK BACKGROUND Biliary atresia (BA) is a disease of infancy which, if untreated, is fatal. When diag-nosed, an attempt is made to restore bile flow by excision of the affected biliary rem-nants and portoenterostomy.1 The baby ’s age at surgery is critical to the outcome, forestalling or removing the need for liver transplantation.2 BA presents as a combination of pro-longed neonatal jaundice, pale stools and dark urine. Jaundice is a key clinical sign that is detectable first in the sclera and with increasing severity in the skin. Despite conventional clinical teaching that recom-mends scleral examination to demonstrate jaundice, healthcare professionals comment on skin pigmentation to diagnose jaundice. This practice may work well for children with lighter skin, but not for babies with dark skin. We have observed in the referral letters that delayed detection of jaundice and, hence, delayed diagnosis of BA, was attributed to the dark skin in non-white children. Therefore, we conducted a retro-spective cohort study to investigate the rela-tionship between skin colour and age of referral in BA