Jaundice in newborns who are not yet full term (within 28 days of birth) is medically referred to as neonatal jaundice and is the most common clinical problem in newborns. Approximately 50% of full-term infants and 80% of preterm infants can have varying degrees of jaundice. Most of the jaundice can subside spontaneously, but due to the neurotoxic nature of bilirubin, a small number of children may suffer from severe hyperbilirubinemia causing bilirubin encephalopathy, resulting in neurological damage and functional disability, causing great harm to society and families.
During clinical visits, we often encounter two types of parents: those who are unaware of the possible hazards of jaundice and are not aware of the jaundice value, which often delays the best time for intervention, and those who are very anxious about the possible hazards of jaundice, which leads to unnecessary treatment.
To avoid bilirubin encephalopathy and to reduce unnecessary treatment and waste of medical resources, the new clinical guidelines for the treatment of neonatal jaundice at ≥35 weeks established by the American Academy of Pediatrics (AAP) in 2004 and the expert consensus on the principles of neonatal jaundice treatment in China were revised in 2014. Based on the above two important literatures, the frequently encountered problems of parents are summarized as follows.
What are the main causes of physiological jaundice in newborns?
The primary cause of physiologic jaundice arises because the majority of bilirubin is derived from our red blood cells. As the fetus is in the intrauterine environment, too many red blood cells are produced in the blood, and these red blood cells are fetal red blood cells, which are gradually destroyed and replaced with adult red blood cells after the baby is born, and the destroyed red blood cells cause too much bilirubin production. At the same time, on the other hand, our bilirubin has to be metabolized in the liver and gallbladder and excreted out of the body, and newborns often have immature liver and gallbladder development, which can lead to abnormal metabolism of bilirubin, resulting in a condition characterized by yellow staining of the skin, mucous membranes and sclera.
What are the main differences between physiologic and pathologic jaundice?
The difference between physiological jaundice and pathological jaundice, for parents need to pay attention to several aspects.
1, time of occurrence: physiological jaundice mostly occurs 2-3 days after birth, if jaundice appears within 24 hours after birth, pathological jaundice should be considered, often due to hemolysis and other causes, especially if the mother is type O and the child is type A or B blood, the chances of this occurring are higher.
2, the degree of jaundice: physiological jaundice is generally light to moderate jaundice, if severe jaundice, we should pay attention to exclude pathological causes of jaundice, a simple method is that if only the head and face of jaundice, generally mild, head, face, trunk jaundice is generally moderate, the development of jaundice to the end of the four branches, generally severe. Of course, naked eye observation is often not allowed, so the need to actively check the value of jaundice is very important.
3, delayed remission or receding and reappearing: most physiological jaundice gradually recede in about 2-4 weeks, full-term infants generally 2 weeks, premature infants generally 4 weeks, pathological jaundice is often more than 2-4 weeks. Physiological jaundice does not recur or worsen after it has receded, while pathological jaundice may reappear after the jaundice has been reduced for a time.
When does neonatal jaundice require treatment?
The definition of physiologic and pathologic jaundice is the key to deciding whether intervention is needed. The diagnostic criteria for physiologic jaundice in newborns still used by many medical institutions in China are: bilirubin values ≤220.6 μmol/L (12.9 mg/L) in term infants and ≤255 μmol/L (15.0 mg/L) in preterm infants, but because in some cases it is lower than the current criteria for physiologic jaundice, there is a possibility of bilirubin encephalopathy, for example, in preterm infants. Therefore, the use of bilirubin ≤205-255 μmol/L as a criterion for differentiating physiological from pathological jaundice in newborns is no longer applicable. Therefore, it is no longer applicable to use a fixed value as the intervention criteria for neonatal jaundice, and domestic guidelines have been synchronized with foreign countries in the understanding of physiological and pathological jaundice.
The intervention criteria for neonatal jaundice should be multiple dynamic curves that vary with gestational age, daytime age and birth weight, such as the reference curve of phototherapy for neonates ≥35 weeks at different gestational ages, daytime ages and with or without risk factors developed by the American AAP (see figure below).
How to determine breast milk jaundice?
Now that breastfeeding is promoted, the chance of breast milk jaundice has increased, and the incidence is about 30%, which means that about 1/3 of breastfed children will develop jaundice, so this is one of the problems we often encounter in the clinic. To determine breastfeeding jaundice requires several prerequisites, one is exclusive breastfeeding or breastfeeding-oriented, the second is generally good, eating, playing and sleeping basically normal, the third is no liver damage and other manifestations of the examination.
The third requires a visit to the hospital for examination. If you do not want to draw blood for examination, transdermal bilirubin measurement is a mild to moderate jaundice of the child, consider not except when breastfeeding jaundice, you can try to suspend breastfeeding for 3 days, if the jaundice drops significantly, it means that the possibility of breast milk jaundice is high.
What should parents do if it is breast milk jaundice?
Currently, if breast milk jaundice is diagnosed, it is generally not necessary to stop breastfeeding. Generally speaking, breast milk jaundice is basically harmless to the body, but in the case of severe jaundice in individual cases of breast milk jaundice, hospital consultation is still recommended, and individual children may still need active treatment, such as temporary change to formula or phototherapy.
In children with breastfeeding jaundice, the jaundice decreases after breastfeeding is stopped, and if breastfeeding is repeated, the jaundice may worsen again in a wavy pattern, if the jaundice does not worsen very significantly, breastfeeding can be continued. Breastfeeding jaundice is generally divided into two types: early-onset and late-onset. Early-onset jaundice is generally similar to physiological jaundice in newborns in that it appears 2 to 3 days after birth and is most pronounced on days 4 to 6, then subsides within two weeks. It is often overlooked by parents and clinics.
If the jaundice lasts up to 12 weeks and subsides, it is called late-onset breast milk jaundice. Therefore jaundice beyond 12 weeks jaundice still does not subside, it is recommended that the hospital for further examination.
Parental attitude toward neonatal jaundice?
1, active observation: newborns are usually tested for jaundice during their initial hospitalization, and must be carefully observed after discharge. In natural light, if jaundice is found on the palms of the hands and feet, it is generally severe and must be further examined in the hospital.
2, active monitoring: especially in the 1-2 weeks after birth, bilirubin in more than 20mg/dl, easy to pass the blood-brain barrier and damage brain cells, so in the 1-2 weeks after birth, it is recommended to routinely go to the community hospital for transcutaneous bilirubin monitoring.
3, active feeding: hyperbilirubinemia, often due to insufficient intake, resulting in increased bilirubin enterohepatic circulation, so encourage breastfeeding, which helps to reduce yellowing.
4.Rational treatment: When treatment is needed, blue light therapy is still the preferred treatment option. The need for infusion or other medication needs to be decided by the doctor after a comprehensive judgment of the condition.
Common misconceptions about the treatment of jaundice?
1, sun exposure: newborns have thin and tender skin and are prone to sunburn, and the duration of light exposure is limited, so the effect is limited and not recommended.
2, stop breast milk: early neonatal jaundice is often insufficient breast milk intake, bilirubin through the urine and stool excretion is not much, resulting in increased bilirubin intestinal and hepatic circulation, so that the jaundice increased is not easy to subside. After the amount of breast milk is sufficient, if breast milk jaundice is considered, and the value of jaundice <15mg/dl, it is still recommended to continue breastfeeding.
3, oral gardenia jasminoides: from the perspective of Western medicine because of the lack of evidence-based, coupled with the complexity of the composition of Chinese medicine, easy to have adverse reactions, so the domestic and foreign jaundice treatment guidelines are not recommended. However, from the perspective of Chinese medicine, gardenia jasminoides is still a common medicine for the treatment of neonatal jaundice, and parents need to pay attention to observe whether there are adverse reactions.