Integrated Traditional Chinese Medicine Nursing Interventions Combined with Phototherapy for Damp-Heat Type Neonatal Jaundice

Summary

This protocol describes standard phototherapy and an integrated Traditional Chinese Medicine (TCM) nursing approach—including herbal bathing, acupoint massage, and touch therapy—in neonates with damp-heat type jaundice. The protocol demonstrates reduction in bilirubin, liver enzymes, and inflammatory markers, while maintaining comparable safety and efficacy.

Abstract

Neonatal jaundice is one of the most frequently occurring conditions in newborns. This protocol describes the clinical implementation of two common care interventions, including standard phototherapy and clear water bathing or a Traditional Chinese Medicine (TCM)-integrated nursing care, on the serum and inflammatory indicators in neonates with damp-heat type jaundice. This protocol was demonstrated using anonymized medical records of 120 neonates who received treatment between 2022 and 2023. Clinical outcome measures included total bilirubin (TBIL), indirect bilirubin (IBIL), alanine aminotransferase (ALT), aspartate aminotransferase (AST), gamma-glutamyl transferase (γ-GT), lactate dehydrogenase (LDH), and C-reactive protein (CRP). Significant reductions in these serum and inflammatory markers were observed in both treatment groups (p < 0.001). The effect sizes on total bilirubin are large: Cohen d = 5.31 (clear water) and 5.37 (TCM-integrated). Similarly, marked reductions were observed in indirect bilirubin with d = 4.41 and d = 4.07, respectively. Improvements were also observed in ALT, AST, γ-GT, LDH, and CRP levels (AST: d = 3.31-3.73). CRP reductions were observed in both groups (d = 2.72 versus 2.24). Mixed ANOVA demonstrated significant main effects of time across all markers (TBIL F = 3427.51, p < 0.001). Multivariate regression analysis showed that ΔCRP was significantly associated with treatment effectiveness, suggesting a possible association between reduced systemic inflammation and clinical improvement (β = -1.771, p = 0.010). The adverse events are comparable between groups (incidence of rash: 10% vs. 15%, p = 0.581). Integrated TCM nursing interventions combined with standard phototherapy demonstrated treatment outcomes comparable to clear water bathing combined with phototherapy in improving clinical and biochemical parameters associated with neonatal jaundice.

Introduction

Neonatal jaundice is a prevalent condition caused by the immaturity of bilirubin metabolism in newborns, manifesting as elevated serum bilirubin levels. This physiological jaundice typically arises from increased red blood cell turnover, immature hepatic uptake and conjugation processes, and enhanced enterohepatic circulation¹. The accelerated destruction of red blood cells—whose lifespan is approximately 80 days in neonates compared with 120 in adults—contributes significantly to bilirubin accumulation². In addition, hepatic immaturity is characterized by deficient Y and Z protein receptors and reduced uridine diphosphate glucuronosyltransferase (UDPGT) activity, which limits effective bilirubin conjugation. Immature gut flora, poor intestinal motility, and elevated β-glucuronidase activity further enhance bilirubin reabsorption³.

Pathological jaundice extends beyond physiological causes, with hemolytic diseases such as ABO and Rh incompatibility rapidly increasing bilirubin levels through enhanced erythrocyte destruction⁴. Other contributing factors include oxidative stress⁵, infection, neonatal hypoxia⁶, and feeding difficulties⁷. Delayed or insufficient breastfeeding may further impede bilirubin excretion, while elevated β-glucuronidase activity in breast milk can contribute to prolonged jaundice⁸. Genetic disorders such as G-6-PD deficiency and Crigler-Najjar syndrome also impair bilirubin metabolism, with more than 190 G-6-PD mutations reported globally^9,10.

The primary intervention for neonatal jaundice remains phototherapy, which transforms unconjugated bilirubin into water-soluble isomers through light exposure, particularly within the 425–475 nm (blue) and 510–530 nm (green) wavelength ranges¹¹. While non-invasive and effective for most cases, phototherapy's limitations are evident in severe hyperbilirubinemia, recurrence post-treatment, and side effects like diarrhea, skin irritation, and hypocalcemia¹². Adjunctive treatments include liver enzyme inducers, blood component infusions, and, in critical cases, exchange transfusion—though each carries risks, such as dependence, infection, and cardiovascular complications¹³.

In light of these constraints, complementary approaches rooted in Traditional Chinese Medicine (TCM) have gained renewed interest. Several national and international studies have reported potential benefits of TCM-based supportive therapies in neonatal jaundice management, including improved bilirubin reduction, shortened recovery duration, and reduced inflammatory markers when used alongside conventional phototherapy. Systematic reviews and meta-analyses evaluating herbal bathing, Yinzhihuang formulations, acupoint massage, and Tuina therapy have demonstrated clinically meaningful reductions in bilirubin levels across multiple neonatal populations. Herbal decoctions like Zhang Zhongjing’s “Yinchenhao Decoction” and its modern derivatives (e.g., Yinzhiguo Oral Liquid, a Traditional Chinese Medicine herbal formulation primarily used in China and East Asian integrative medicine settings) demonstrated high effectiveness in reducing neonatal bilirubin levels when used alongside conventional care¹⁴. Despite such efficacy, bitter flavors often lead to poor oral adherence, and excessive use of cold, bitter herbs like Rhubarb and Gardenia may damage immature organ systems. As an alternative, certain injectable TCM formulations have also been explored, but safety concerns—owing to allergic reactions and unregulated production—led to restrictions on infant use by China’s National Medical Products Administration in 2009, though off-label use persists¹⁵. Consequently, non-invasive external TCM supportive approaches such as herbal bathing and acupoint massage have gained increased attention because they avoid systemic drug exposure in neonates.

From a TCM standpoint, neonatal jaundice, especially the damp-heat type, reflects internal imbalances caused by maternal dietary influences, congenital spleen deficiencies, and yang excess—all of which conceptually align with biomedical notions of digestive and metabolic immaturity¹⁶. In TCM, “damp-heat type” neonatal jaundice refers to a syndrome pattern characterized by yellow discoloration, internal heat accumulation, impaired digestion, and abnormal fluid metabolism. Clinically, this presentation may be associated with feeding intolerance, irritability, delayed bilirubin clearance, and gastrointestinal dysfunction in neonates. Within TCM theory, damp-heat imbalance conceptually parallels aspects of hepatic and gastrointestinal immaturity described in modern neonatal medicine. In response, TCM nursing strategies such as herbal bathing, acupoint massage, and touch therapy have emerged as supportive, non-invasive adjunctive approaches for clinically stable neonates receiving standard phototherapy. These interventions are intended as complementary supportive care modalities used alongside standard phototherapy rather than replacement therapies for neonatal jaundice management. In China, supportive TCM nursing interventions such as herbal bathing, acupoint massage, and pediatric Tuina are commonly incorporated into integrative neonatal care practices in hospitals offering Traditional Chinese Medicine services. These approaches are generally implemented under institutional clinical protocols aligned with Traditional Chinese Medicine practice standards and supportive neonatal care principles. Existing Chinese consensus documents and integrative neonatal care recommendations emphasize careful neonatal monitoring, appropriate patient selection, and avoidance of these interventions in critically unstable neonates or those requiring emergency intensive care management.

TCM-based supportive interventions for neonatal jaundice have been used in China for several decades, particularly within maternal-child hospitals and integrative medicine departments. Herbal bathing, acupoint massage, and pediatric Tuina remain routinely practiced in many Chinese neonatal nursing settings as complementary supportive care approaches used alongside standard phototherapy and conventional neonatal monitoring.

These interventions are not intended to replace conventional treatment in severe hyperbilirubinemia, hemolytic disease, sepsis, or neonates requiring emergency intervention. Herbal baths utilize the absorption capacity of the skin and stimulation of meridians as a means to detoxify and reduce dependence on hepatic metabolism. Their effectiveness has been clinically proven in combination with phototherapy, with studies reporting improved bilirubin reduction compared with conventional care alone^17,18. Likewise, massage therapy and acupressure targeting specific meridians and acupoints may support gastrointestinal motility and bilirubin metabolism^19,20. Touch therapy also stimulates the vagus nerve, potentially enhancing gastrointestinal motility, meconium excretion, and reducing enterohepatic bilirubin circulation²¹. These effects are congruent with contemporary developmental care principles, as well as traditional meridian-driven TCM rationale.

A retrospective study design was selected to evaluate real-world implementation of integrated neonatal nursing interventions that had already been routinely applied within institutional clinical practice. This design allowed assessment of treatment-associated outcomes, procedural feasibility, and nursing protocol reproducibility using anonymized patient records prior to future prospective validation studies. Treatment group allocation reflected routine institutional neonatal care practices documented within retrospective medical records and was not based on randomized assignment. Consequently, potential confounding factors, including feeding patterns, postnatal age at bilirubin assessment, and baseline jaundice severity, may not have been fully controlled within the retrospective analysis.

The present retrospective study utilized anonymized neonatal clinical records obtained from an institutional care setting in which integrated TCM nursing interventions and phototherapy were routinely implemented as part of supportive neonatal jaundice management. Similar integrative neonatal care approaches have previously been evaluated in related institutional and multicenter Chinese clinical studies.

The present retrospective study aimed to evaluate the clinical outcomes associated with integrated Traditional Chinese Medicine nursing interventions combined with standard phototherapy in neonates with damp-heat type jaundice. Specifically, changes in bilirubin levels, liver function indicators, inflammatory markers, treatment effectiveness, and safety outcomes were compared between neonates receiving integrated TCM nursing care and those receiving conventional supportive care alongside phototherapy.

Protocol

Ethics statement:

This retrospective analytical and clinical nursing protocol was conducted using anonymized neonatal clinical records collected in accordance with institutional ethical standards and applicable clinical regulations. Patient-identifiable information was removed prior to analysis. The requirement for formal ethics committee approval and informed consent was waived because the study involved retrospective analysis of fully de-identified data collected during routine clinical care and did not involve direct patient contact or intervention.

This protocol describes the standardized clinical implementation and retrospective evaluation of routine nursing and phototherapy care for neonates with damp-heat type neonatal jaundice.

Patient selection

A total of 120 neonates meeting the predefined inclusion and exclusion criteria were retrospectively included in the study. The sample size was determined based on the total number of eligible anonymized neonatal cases available within the institutional study period from 2022 to 2023. The inclusion criteria were as follows: meeting the diagnostic criteria of pathological jaundice in modern medicine and the diagnostic criteria of damp-heat type jaundice in TCM; full-term neonates gestational age ≥ 37 weeks; age ≤ 28 days; birth weight > 2500 g; received phototherapy per institutional protocol; and clinical records containing complete treatment and outcome data that were anonymized before analysis.

The exclusion criteria included records with incomplete clinical data; neonatal jaundice combined with ABO or Rh hemolysis, obstructive jaundice, sepsis, genetic metabolic diseases such as G-6-PD deficiency, or mother-to-child transmission of viral hepatitis or skin ulceration or infection, heart failure, central nervous system injury, or concurrent serious systemic illness.

Routine care modalities

Based on the retrospective analysis of hospital records, two primary care approaches were identified among neonates diagnosed with damp-heat type neonatal jaundice. Both approaches were routinely implemented as part of standard nursing practice during the study period and were documented in the patients' medical records.

Clear water bath

Clear water bathing was administered once daily as part of general hygiene and comfort measures. The bath was typically administered in the morning, at least 1 h after feeding. Warm sterile water maintained at 37–39 °C was used in a sterile newborn bathtub, and a waterproof umbilical dressing was applied during the procedure. Bathing duration was approximately 10 min, and close attention was given to head and neck support, skin condition, body temperature, and signs of discomfort. Following bathing, neonates were dried with sterile gauze, kept warm, and returned to bassinets for continued observation.

Integrated TCM nursing interventions

The second intervention group received integrated TCM-based nursing interventions routinely applied within institutional neonatal care practices. Consistency of intervention implementation was retrospectively verified using standardized nursing records, daily treatment documentation, procedural checklists, and institutional neonatal care logs documenting administration of herbal bathing, acupoint massage, touch therapy, and phototherapy during hospitalization.

Herbal Bathing

A standardized herbal decoction containing Artemisia capillaris, Gardenia jasminoides, Scutellaria baicalensis, and Honeysuckle was prepared using approximately 10–15 g of each herb in 1000 mL of sterile water. The herbs were soaked for 20 min, boiled for 30 min, simmered for an additional 20 min, and filtered using sterile gauze before dilution with warm water to a final bathing volume of approximately 5 L. Bath temperature was maintained at 37–39 °C, and treatment duration was approximately 10 min once daily. Neonates were continuously monitored for skin irritation, temperature instability, excessive crying, respiratory discomfort, and feeding intolerance. Treatment was discontinued if adverse reactions or clinical instability occurred.

Acupoint Massage

Neonates were positioned supine in a warm and quiet environment. Gentle massage was administered by trained nursing personnel at Zhongwan, Zusanli, Tianshu, and Ganshu acupoints using circular clockwise movements with light pressure appropriate for neonatal skin sensitivity. Each acupoint was stimulated for approximately 1–2 min, with total session duration maintained at 10–15 min once daily. Massage was interrupted if neonates developed excessive crying, skin redness, respiratory instability, feeding intolerance, or temperature fluctuation.

Touch Therapy

Touch therapy was administered once daily in a temperature-controlled environment using sequential gentle tactile stimulation of the upper limbs, chest, abdomen, back, and lower limbs. Slow rhythmic movements were performed for approximately 10–15 min while monitoring neonatal temperature, skin condition, respiratory status, feeding tolerance, and behavioral responses throughout the procedure.

Phototherapy administration

Phototherapy was administered to neonates using a phototherapy unit emitting blue light in the wavelength range of 425–475 nm. The neonates were positioned approximately 30–45 cm below the light source while wearing protective eye coverings. Phototherapy sessions were administered according to institutional schedules with interruption for feeding, hydration assessment, diaper changing, and clinical monitoring. Body temperature, hydration status, stool frequency, feeding tolerance, skin condition, and signs of dehydration were monitored regularly throughout treatment. Phototherapy was discontinued according to institutional stopping criteria, including satisfactory bilirubin reduction, clinical improvement, or development of adverse reactions.

Outcome measures

The following variables were extracted from anonymized patient records to assess the clinical course and outcomes of neonatal jaundice management: (1) general clinical characteristics: gestational age at birth, age at enrollment, weight before and after treatment, and number of bowel movements per day. (2) symptoms and adverse reactions: degree of jaundice, treatment-related adverse reactions such as rash, peeling, and skin irritation. (3) serum total bilirubin (TBIL), indirect bilirubin (IBIL), alanine aminotransferase (ALT), aspartate aminotransferase (AST), gamma-glutamyl transferase (γ-GT), lactate dehydrogenase (LDH), and C-reactive protein (CRP) before and after treatment. Bilirubin markers served as the principal laboratory indicators of neonatal jaundice response, whereas liver enzymes and inflammatory markers were evaluated as exploratory secondary laboratory outcomes associated with hepatic and systemic inflammatory status. Laboratory and clinical outcome measures were retrospectively evaluated using values recorded at admission (pre-treatment) and following completion of the institutional treatment course prior to discharge (post-treatment).

Transcutaneous bilirubin (TCB) measurements were obtained according to routine institutional neonatal monitoring procedures. Because phototherapy may influence TCB reliability due to transient skin bleaching effects, serum bilirubin markers including TBIL and IBIL were additionally evaluated as complementary laboratory outcome measures where available within the retrospective dataset. Post-treatment bilirubin measurements were retrospectively extracted following routine interruption or completion of phototherapy sessions according to standard institutional neonatal monitoring practices.

Efficacy evaluation criteria

Treatment outcomes were retrospectively categorized based on recorded post-treatment TCB values in accordance to the "Clinical Disease Diagnosis and Efficacy Determination Criteria" (2012) (2012 edition) issued by the State Administration of Traditional Chinese Medicine of China. These criteria are commonly used in Chinese clinical practice for standardized evaluation of therapeutic effectiveness in TCM-associated clinical conditions. Treatment response categories, including “effective,” “improved,” and “ineffective,” were retrospectively assigned according to documented post-treatment bilirubin reduction and clinical symptom improvement recorded in the patient charts. These categorical evaluations were primarily used for descriptive assessment of overall treatment response and safety outcomes. Because the present study was retrospective in design, outcome categorization was based on available institutional laboratory records and documented clinical response criteria rather than prospective age-adjusted bilirubin nomogram assessment. Postnatal age-specific bilirubin interpretation systems, including Bhutani nomogram-based risk stratification, were not consistently available within the retrospective dataset. The classifications used were: (1) Efficacy: after treatment, the sclera and systemic jaundice of children were significantly reduced, TCB <5 mg·dL^-1 (85 µmol·L^-1). (2) Effective: after treatment, the scleral and systemic jaundice of children partially subsided, TCB was 5–12.9 mg·dL^-1 (85–221 µmol·L^-1). (3) Invalid: after treatment, the scleral and systemic jaundice of the child did not fade significantly, TCB >12.9 mg·dL^-1 (221 µmol·L^-1).

Data analysis

The collected data were organized using Excel to establish a database, and statistical analysis was conducted using SPSS Statistics 19.0. To evaluate within-group treatment effects, biochemical markers were analyzed using paired t-tests. Baseline and between-group comparisons were performed using independent samples t-tests. Because the study utilized a retrospective observational design, regression analyses were primarily exploratory and were performed to evaluate potential associations between laboratory marker changes and documented treatment response patterns rather than to establish causal predictive relationships. Available baseline variables, including neonatal age, gestational age, birth weight, and baseline bilirubin measurements, were reviewed where consistently documented within institutional records. Cohen’s d values represented standardized within-group pre-treatment versus post-treatment changes rather than direct comparative treatment effects between groups. Effect sizes were calculated using Cohen’s d. A two-way mixed ANOVA was used to assess time, group, and interaction effects. Post hoc comparisons were conducted using Tukey HSD tests. Univariate and multivariate regression analyses were performed, and odds ratios with 95% confidence intervals were calculated. The statistical significance level was set at p < 0.05 (two-tailed).

Results

Descriptive Statistics and Baseline Characteristics

Descriptive analysis of continuous variables demonstrated clear trends before and after treatment, as summarized in Table 1. A total of two study groups were included in the retrospective analysis: a clear water bathing group receiving standard phototherapy-based care and an integrated TCM nursing intervention group receiving herbal bathing, acupoint massage, touch therapy, and phototherapy. Each group includ...

Discussion

The present findings demonstrate that integrated TCM nursing interventions administered alongside standard phototherapy produced laboratory outcome trends comparable to those observed with clear water bathing combined with phototherapy. These outcomes are consistent with findings from prior clinical evaluations of TCM interventions in neonatal jaundice. A meta-analysis conducted in China by Wang et al. (2017), which included multiple neonatal clinical studies evaluating TCM washing combined with massage therapy, demonstr...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Artemisia capillaris (Yinchen)	Tongrentang Pharmaceutical Co., Ltd., Beijing, China	Herbal raw material grade	Herbal component used for damp-heat-clearing herbal bath decoction
Clinical chemistry analyzer	Beckman Coulter Inc., Brea, CA, USA	AU5800 Clinical Chemistry Analyzer	Used for measurement of total bilirubin (TBIL), indirect bilirubin (IBIL), alanine aminotransferase (ALT), aspartate aminotransferase (AST), gamma-glutamyl transferase (γ-GT), and lactate dehydrogenase (LDH)
CRP assay kit	Beckman Coulter Inc., Brea, CA, USA	hs-CRP Reagent Kit OSR6147	Used for quantitative measurement of C-reactive protein (CRP)
Digital water thermometer	Omron Healthcare Co., Ltd., Kyoto, Japan	TH-100 Digital Thermometer	Used to monitor bath water temperature (37–39 °C)
Gardenia jasminoides (Zhizi)	Tongrentang Pharmaceutical Co., Ltd., Beijing, China	Herbal raw material grade	Anti-inflammatory herb used in herbal bath preparation
Honeysuckle (Lonicera japonica)	Tongrentang Pharmaceutical Co., Ltd., Beijing, China	Herbal raw material grade	Anti-inflammatory herbal component used in bath decoction
Newborn bathtub	Hengkang Medical Equipment Co., Ltd., Jiangsu, China	HKN-NB01 Infant Bath Tub	Used for clear water bathing or herbal bathing of neonates
Phototherapy unit (blue/green LED light)	Dräger Medical GmbH, Lübeck, Germany	BiliLux LED Phototherapy Unit	Used for phototherapy treatment of neonatal jaundice (blue light wavelength 425–475 nm)
Scutellaria baicalensis (Huangqin)	Tongrentang Pharmaceutical Co., Ltd., Beijing, China	Herbal raw material grade	Used for heat-clearing and detoxification in TCM decoction
Serum separator blood collection tubes	Becton Dickinson (BD), Franklin Lakes, NJ, USA	SST™ II Advance Tube 367953	Used for neonatal blood sample collection and serum separation
SPSS Statistics software	IBM Corp., Armonk, NY, USA	Version 19.0	Statistical analysis software used for data processing and analysis
Sterile medical gauze	Winner Medical Co., Ltd., Shenzhen, China	300-G Sterile Gauze Pads	Used for drying neonates and maintaining hygiene after bathing
Waterproof umbilical patch	3M Health Care, St. Paul, MN, USA	3M Tegaderm Transparent Dressing 1624W	Applied to protect the umbilical stump during bathing procedures