Tuesday, December 12, 2017

The Golden Child

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by Anna Lee, MD
May 2011

“He looks yellow”, says my husband the day after we brought our second child home from the hospital. “He’s fine, just a little jaundice… he’ll be okay”. I reassured him. But the scientist in my husband wanted data. “We should have him tested”. Despite my initial protest, we took him in for the blood test to determine his bilirubin level. To my surprise, our baby’s bilirubin level was high enough that he needed phototherapy. My husband keeps that story like a trophy and shares it eagerly with whoever will listen!

So what is neonatal jaundice and why do we care whether a newborn baby has that lovely, golden glow?

Jaundice is the description of the yellowing of the skin, caused by an elevation of bilirubin in the blood circulation. Most infants will develop mild to moderate jaundice due to physiologic changes from being inside the uterus to being outside the womb. Bilirubin is more or less a byproduct of red blood cells that are naturally degrading. However bilirubin is also a neurotoxin that at high levels can cause harm to developing brains. This is called Kernicterus. While inside mom’s uterus, the fetus’s bilirubin is taken across the placenta and into maternal circulation, which then enters mom’s liver where it will eventually be excreted through her gut. In the first few days after birth, a newborn’s bilirubin starts to build in the circulating blood for multiple reasons. First, the baby’s liver and the intestines need to work together to eliminate bilirubin. But the lack of bacteria in the baby’s gut, the small amount of oral intake of breast milk or formula (due to small size of a baby’s stomach and lack of initial breast milk production), and subsequent dehydration can all increase bilirubin levels. This typical physiologic jaundice rises and peaks at about the 4th to 6th day, and starts to decrease as the baby starts to take in more milk (with mom’s breast milk finally coming through) and has more bowel movement of transitional to yellow colored stools.

There are other less common factors that can increase the risk of higher bilirubin levels. First, an infant may have increases in bilirubin load due to hemolysis of his or her red blood cells. Mother and baby’s blood type (ABO) incompatibility or when mom is Rh negative (with Rh antibody) and the baby is Rh positive can cause mild to severe hemolysis. A large area of bruise sustained during delivery as in facial bruising or scalp bruising can also increase the load of bilirubin to be cleared. Increase in load of bilirubin often presents with jaundice within the first 24 hours from birth and requires close monitoring and likely early intervention. Conditions that slow down gut motility can also increase bilirubin level. This is most notable in neonatal infection or other significant postnatal illnesses and less commonly in metabolic disorders.

Because jaundice is visible on the face early on and tends to spread as levels increase from the head to the toe direction, most pediatricians will try to “eyeball” the newborn to estimate what the bilirubin level might be. However, given this is very subjective and can leave room for error, most hospitals (both Saddleback Memorial and Mission Hospital included) now use a device to obtain transcutaneous bilirubin (TcB) level. This is a simple, painless device placed on the baby’s skin that will give a fairly accurate measurement of the serum bilirubin. If this level is elevated enough to be a concern, blood samples will be obtained to confirm or discredit the transcutaneous level.

There is no one level that is “abnormal” for a newborn. This is because the level needs to be put into context of how old the baby is. For example, a bilirubin level of 8 mg/dl is perfectly reasonable at day 3 of life, but not so in less than 24 hrs of birth. However, the peak of bilirubin level to be of concern would be near 20 mg/dl for a full term infant. In premature infants, the bilirubin level that raises concern is even lower due to their increase risk for kernicterus.

So what do we do with a golden child? In most mild to moderate cases, increasing oral feeds to increase gut motility and observation is all that is needed. In the past, sun exposure was also recommended. However, given the risk of hypothermia by full body exposure in a cold environment, or sun burn due to too much exposure, or not effective exposure due to newer windows that filter out the needed wavelength of light all make it a controversial recommendation at best.

For more concerning levels of bilirubin, in context of the days from birth, phototherapy is the recommended treatment. Phototherapy is done usually with an infant in an isolette to control the ambient temperature while the baby lays naked with a diaper only “sunbathing” with shades on his or her eyes. In less concerning levels, babies may be allowed to stay with their mom or go home with a “biliblanket” that provides the light source on the baby by a paddle that gets wrapped with the baby. The specific wavelength of the light source helps to convert bilirubin into a form that is more easily excreted by the liver and kidneys.

So in summary, in the majority of cases, mild to moderate jaundice is very common and resolves without any complications. Breastfeeding frequently with occasional supplementation with formula for significant weight loss, and keeping track of bowel movements all help to actively monitor a baby’s rise and fall of physiologic jaundice. With the use of TcB levels, we can now better monitor babies more objectively without doing blood work and determine who may need further assessment before the baby leaves the hospital. Jaundice detected within the first 24 hrs of life needs to be watched more closely and will likely need early intervention. Phototherapy is an effective way of treating elevated bilirubin. Given most jaundice resolves by 2 weeks of life, notable jaundice beyond 2 weeks of life should also be evaluated by your pediatrician.

Our little golden child eventually recovered from his neonatal jaundice within days and now has a “golden tan” from spending so much time outdoors in this sunny Southern California weather—with sunscreen of course!

The contents of this web site are provided as an informational tool. This is not intended to replace medical advice or care administered by a healthcare professional. Common sense should always be used when referencing this site. If, at any time, you feel your child is experiencing a medical emergency, call 911 immediately.

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