Patient's question:
Details: The baby was born at the County People's Hospital in Hunan, China (about 6 days earlier than the due date). On the fifth day, the umbilical cord had not fallen off yet, with a small amount of moisture remaining. The doctor said the umbilical cord was slightly inflamed and that jaundice might be caused by this. As a result, the baby was hospitalized. The doctor cut off the umbilical cord and administered anti-inflammatory injections. ★ The hospital measured the bilirubin level at over 290, so the baby underwent three blue light treatments: The first treatment lasted 24 hours, and the measurement after that was 204. The second treatment lasted 12 hours, and the measurement after that was 152. After the second treatment also lasted 12 hours, the measurement was 138. ★ During the light treatment, blood was drawn to test liver function, and the results were reported as positive for the "five in two" test.Doctor's answer:
Bilirubin levels of 170 umol/L or less are classified as mild jaundice, while levels greater than 340 umol/L are classified as severe jaundice. Levels between mild and severe are classified as moderate jaundice. With a bilirubin level of over 290, it falls under moderate jaundice. The symptoms of jaundice in children and kernicterus are different. Jaundice is likely caused by an umbilical cord infection, hemolysis, or medication effects. It is recommended to continue treatment and observation in the local hospital's internal medicine department. Jaundice can subside after infection control.References: Manual for Seeking Medical Care and Laboratory Tests
In the neonatal period, if any cause leads to a serum indirect bilirubin level exceeding 20 mg%, the indirect bilirubin can enter the brain tissue, causing brain damage and kernicterus (also known as bilirubin encephalopathy). This typically occurs between 4 to 10 days after birth, with younger infants being more susceptible. It rarely occurs after the 12th day of life. Therefore, newborns with severe jaundice should be monitored for kernicterus, especially premature infants (infants born before 37 weeks of gestation with a birth weight of less than 2,500 grams and a length of less than 45 cm). The younger the infant, the higher the incidence. Symptoms such as lethargy, drowsiness, poor appetite, weak sucking, reduced muscle tone, weakened or absent reflexes, vomiting, and poor feeding may appear 12 to 48 hours after severe jaundice. If treated promptly, full recovery is possible. If jaundice worsens, fever, restlessness, and further symptoms such as staring, irritability, numbness in the limbs, sharp crying, high-pitched screaming, and eventually continuous convulsions, upward rolling of the eyes, and backward tilting of the head may occur. Severe cases may even lead to respiratory failure.
Prenatal examinations should be conducted to prevent premature and difficult births. Avoid the unnecessary use of vitamin K and sulfonamide drugs before delivery. Newborns, especially premature infants, should not be routinely given vitamin K, sulfonamide drugs, sodium benzoate, caffeine, or salicylic acid. To prevent infection, avoid chloramphenicol, neomycin, and sulfisoxazole.
To prevent kernicterus, newborns within the first 4 to 10 days of life must be closely monitored for jaundice progression, with blood bilirubin levels tested regularly. Daily observation under natural light can help monitor jaundice. Press the forehead, chest, and palms/hands for 1–2 seconds, then release to observe the skin's yellowing. If the whites of the eyes, diapers, or tears turn yellow, it indicates jaundice beyond the normal range, and immediate medical attention should be sought.
Neonatal Jaundice Diagnosis
(1) Differentiating Physiological or Pathological Jaundice
Suspect pathological jaundice if the following conditions are met:
1. Jaundice appears within 24 hours of birth.
2. Total bilirubin increases by more than 85.5 umol/L per day.
3. Total bilirubin exceeds 205 umol/L (full-term infants) or 239.4 umol/L (premature infants).
4. Jaundice persists for more than 1 week (full-term infants) or 2 weeks (premature infants).
(2) Timing of Jaundice Onset
1. Jaundice appearing within 24 hours of birth is often neonatal hemolysis, with infants typically showing decreased hemoglobin (anemia).
2. Jaundice appearing on the 2nd to 3rd day is often physiological, with familial non-hemolytic jaundice being rare.
3. Jaundice appearing on the 3rd to 7th day is often seen in sepsis or other infections.
4. Jaundice appearing after 1 week may indicate sepsis, hepatitis, biliary atresia, biliary dilation, galactosemia, congenital spherical or non-spherical hemolytic anemia, or breast milk jaundice.
5. Persistent jaundice within the first month may suggest cholestasis syndrome, hepatitis, biliary atresia, biliary dilation, or galactosemia.
(3) Differentiating Elevated Indirect or Direct Bilirubin
If elevated direct bilirubin is the primary cause, consider congenital biliary atresia, neonatal hepatitis, or cholestasis syndrome. In severe cases, the infant's skin may appear dark yellow-green. If elevated indirect bilirubin is the primary cause, consider neonatal hemolysis, physiological jaundice, breast milk jaundice, or familial non-hemolytic jaundice. In severe cases, the infant's skin may appear bright yellow or orange.
(4) Family History
Congenital metabolic disorders and familial non-hemolytic jaundice often have a family history. Red blood cell enzyme defects (e.g., G6PD deficiency) are common in families (or close relatives) with similar conditions. Sepsis and urinary tract infection-induced jaundice may accompany indirect, direct, or mixed hyperbilirubinemia, with jaundice often accompanied by significant systemic infection and toxicity symptoms such as fever, poor appetite, poor responsiveness, and grayish complexion. Some sepsis infants may have moderate jaundice but normal mental responsiveness and appetite. Only pyuria may also cause significant jaundice.
Infants infected via the umbilical cord (cord) are commonly colonized by Escherichia coli and Staphylococcus aureus. Those infected via the mother's vagina or cervix infection leading to chorioamnionitis are more likely to be infected with E. coli, Listeria monocytogenes, and Streptococcus B. These cases are often severe and may develop suddenly within 24 to 72 hours after birth, with jaundice appearing.
References: Pediatric Symptom Differential Diagnosis (People's)
Common Diseases Causing Neonatal Jaundice
1. Neonatal Hemolytic Disease – Immune hemolytic jaundice caused by ABO, Rh, or other blood type incompatibilities. Jaundice appears early and is severe.
2. Physiological Jaundice – Appears 2 to 3 days after birth with other normal conditions, usually resolving within 1 week.
3. Hepatocellular Jaundice
(1) Asphyxia: Hypoxia can impair liver enzyme activity, disrupting metabolism, leading to severe jaundice 2 to 3 days after birth.
(2) Infection: Neonatal sepsis and other bacterial infections can cause toxic hepatitis and hemolysis, resulting in both conjugated and unconjugated bilirubin in the serum. Jaundice may subside after infection control.
4. Medications – Vitamin K3, sulfonamide drugs, and neomycin can cause jaundice during the neonatal period.
5. Breast Milk Jaundice – Jaundice persisting beyond 2 weeks is termed prolonged jaundice and may involve other causes such as breast milk jaundice. Historically, breast milk jaundice accounted for only 1% or less of breastfed infants but has gained more attention in recent years. The exact cause is unclear, but it is believed to be related to high levels of β-glucuronidase (β-GD), primarily from breast milk, with activity that reduces conjugated bilirubin to unconjugated bilirubin, increasing enterohepatic recirculation and causing jaundice. It may persist after physiological jaundice improves or worsen, peaking 2 to 4 weeks later and lasting for weeks to months. Generally, no other symptoms are present. Increasing breast milk intake and enhancing intestinal motility can help jaundice resolve naturally. If necessary, breastfeeding can be temporarily or partially reduced for 2 to 4 days, combined with phototherapy, after which breastfeeding can resume without abandoning it due to jaundice.
6. Congenital Biliary Atresia – Usually appears 2 to 3 weeks after birth, with jaundice gradually worsening.
Differential Diagnosis of Neonatal Jaundice
Jaundice appearing within 24 hours of birth should first be considered neonatal hemolysis due to blood type incompatibility. If jaundice appears on the 3rd to 4th day, is mild, progresses slowly, and without significant hepatosplenomegaly, physiological jaundice should be the primary consideration. Be vigilant to avoid misdiagnosing or overlooking pathological jaundice. Since jaundice is common in newborns and often mixed with physiological jaundice, this symptom should be taken seriously. Differential diagnosis should involve a detailed history and physical examination. Pathological jaundice is currently classified into two major categories based on bilirubin metabolism: hyperbilirubinemia with elevated unconjugated bilirubin and hyperbilirubinemia with elevated conjugated bilirubin. Further examination of which metabolic step is impaired can help clarify the diagnosis. Necessary laboratory tests, imaging studies, and even biopsy may be considered. For example, the rapidly developing B-type ultrasound is safe, fast, and easy to perform. A report from the Pediatrics Department of Chongqing Medical University found that 93.3% of 106 neonatal jaundice cases were correctly diagnosed, especially for biliary atresia, gallbladder enlargement, stones, tumors, and biliary dilation. Nuclear isotope scanning and CT also have diagnostic value for liver size, biliary vascular malformations, and gallbladder dilation.
Preventing Jaundice in High-Risk Newborns
Low birth weight infants, asphyxiated infants, and those with blood type incompatibility should be closely monitored for serum bilirubin levels after birth, with phototherapy administered if necessary. This is the first critical step that neonatal medical and nursing staff in maternity hospitals must ensure. Newborns with short hospital stays and early discharge should also be informed that severe or rapidly progressing jaundice requires prompt medical attention. In some countries, to avoid separation of mother and infant, preventive home phototherapy for 5 to 7 days is offered to high-risk infants.
Treatment
Most cases of neonatal jaundice can be treated medically, except for a few cases of congenital biliary atresia that require surgical intervention.
1. Traditional Chinese Medicine – Neonatal jaundice is called "" in TCM and is primarily treated with Artemisia scoparia. A decoction of Artemisia scoparia sanhuang decoction (9g Artemisia scoparia, 4.5g Scutellaria baicalensis, 4.5g Phellodendron amurense, 1.5g Coptis chinensis, 1.5g Rhubarb, 3g Gardenia jasminoides) can be taken orally, once daily, in small, frequent doses. Alternatively, Artemisia scoparia huanglian injection diluted with 10% glucose can be administered intravenously. This can gradually reduce jaundice.
2. Phototherapy
3. Preventing Reabsorption of Intestinal Bilirubin – Early feeding and establishing gut flora can break down intestinal bilirubin into urobilinogen, promoting faster meconium excretion and reducing intestinal bilirubin reabsorption, thus alleviating jaundice. Activated charcoal (0.75g, every 4 hours) can be given to reduce reabsorption of conjugated bilirubin via the enterohepatic circulation, with better results when combined with phototherapy.
Physiological Jaundice
Clinical Manifestations
Physiological jaundice typically appears on the 3rd day after birth, with the earliest onset on the 2nd day and the latest on the 5th day. Jaundice appearing within 24 hours of birth should first be considered Rh hemolysis. Jaundice appearing after the 5th day should be more cautiously considered pathological. Mild physiological jaundice appears pale yellow, limited to the face and neck, or may involve the trunk, with sclera also appearing yellow. It usually resolves within 2 to 3 days, with skin returning to normal by the 5th to 6th day. Severe jaundice may first appear on the head and then spread to the limbs, affecting the entire body, with vomit and cerebrospinal fluid also appearing yellow. It may persist for more than 1 week, with some premature infants continuing to have yellow stools and no bilirubin in the urine for up to 4 weeks. Jaundice persisting beyond 2 weeks is termed prolonged jaundice and should be evaluated for other causes such as breast milk jaundice. Increasing oral glucose can accelerate jaundice resolution. However, if jaundice is deep, phototherapy and further evaluation should be considered to rule out pathological jaundice.
References: Practical Pediatrics (6th Edition)