Jaundice in children can be quite common

All parents hope that their babies would be healthy. So when they notice a yellowish tone to the skin of their babies, they will be understandably anxious.
This yellow discolouration in a newborn is called jaundice, and it’s a common issue.
Jaundice is a term used to describe a condition where there’s yellowish discolouration of the skin, mucosa and sclera due to accumulation of excess bilirubin in serum.
This is clinically detectable when the serum bilirubin levels are greater than 85 μmol/L.
A survey of government hospitals and health centres under the Health Ministry in 1998 found that about 75% of newborns were jaundiced in the first week of life, and the incidence was higher in pre-term babies.
Most jaundice is physiological and due to increased breakdown of red blood cells and immature liver function in neonates.
At physiological levels, jaundice is harmless. It presents two to three days after birth, and slowly disappears within seven to 10 days.
However, when the bilirubin level is very high, the excess bilirubin crosses the blood-brain barrier and may result in cerebral palsy, deafness, varying degrees of mental retardation and even death if the jaundice is not treated aggressively.
When jaundice persists more than 14 days in term babies, and more than 21 days in preterm babies, it is known as pathological jaundice, which requires further investigation.
About 80% of pathological jaundice is due to medical causes, while 20% is due to surgical causes.
Medical causes of jaundice
• Infection – antenatal, perinatal or postnatal infection.
• Blood-related disorders – G6PD (glucose-6-phosphate dehydrogenase) deficiency, rhesus incompatibility, thalassaemia.
• Metabolic disease – galactosaemia, alpha-1 antitrypsin deficiency, cystic fibrosis.
Surgical causes of jaundice
• Biliary atresia – obstruction of the bile duct.
• Biliary hypoplasia – narrowing of the bile duct.
• Choledochal cyst – dilatation of the bile duct.
• Inspissated bile – blocked by thick bile or sludge.
• Spontaneous perforation of the bile duct.
Signs and symptoms of jaundice
• Prolonged jaundice (more than 14 days in term babies; more than 21 days in preterm babies)
• Pale stools
• Tea-coloured urine
• Enlargement of the liver or spleen (late presentation)
Bile pigments produced by the liver give stool its characteristic yellowish or greenish colour in neonates.
In neonates with biliary atresia, the stool will become pale in about a few days or weeks due to the obstruction of bile flow.
Laboratory investigations for jaundice include:
• Total serum bilirubin with conjugated fraction of bilirubin.
• Liver function test – To look for evidence of hepatitis and cholestatic disease.
• Haemoglobin, haematocrit and reticulocyte count – To look for evidence of haemolysis.
• Peripheral blood film – To look for evidence of blood disorder based on erythrocyte morphology.
• Congenital infection screening – To look for infections acquired in utero or during the birth process such as toxoplasmosis, rubella, cytomegalovirus, herpes simplex and syphilis.
• Hepatitis infection screening – To look for maternal-infant transmission of hepatitis B or hepatitis C.
• Urine culture and sensitivity – Urinary tract infections can cause prolonged neonatal jaundice.
• Urine reducing substance – Screening test for galactosaemia (metabolic cause)
• Thyroid function test – Insufficient thyroid hormone (hypothyroidism) can cause prolonged neonatal jaundice.
Imaging investigations include the following:
• Ultrasound of the hepatobiliary system – This is to assess the bile duct. It’s useful in detecting a cystic dilated bile duct due to a choledochal cyst.
• Hepatobiliary Iminodiacetic Acid (HIDA) radionuclide scan – To look for excretion of the radioisotope into the intestine. Results are better if performed after six weeks of age.
Surgical investigations include the following:
• Percutaneous transhepatic cholecysto-cholangiography – Can only be carried out in a specialised centre. Contrast is injected into the liver/gallbladder to outline the biliary tree.
• Operative cholangiography – This is done under anaesthesia, and contrast is injected into the gallbladder to outline the entire biliary tree.
• Liver biopsy – A sample of liver tissue is retrieved for histopathology examination.