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Sunday
Apr042010

Jaundice (Hyperbilirubinemia)

Two-day old baby with a good case of jaundice.

Jaundice is an extensive topic, one that student midwives need to research on their own. Here, I will share the bare basics, merely enough to act as a springboard to the enormous amount of information out there. Even as an experienced midwife, when I have babies with jaundice, I head onto the Net to check for new information and to reinforce/remind me what I have already learned. (The article linked to the word "jaundice" has an extremely comprehensive, medically-oriented, but understandable article. Bookmark it.)

Jaundice can be benign or serious. The causes are generally the distinction between the two, but even normal jaundice can be exacerbated by outside influences. Jaundice that occurs within the first 24 hours is cause for serious investigation.

Benign types of jaundice include:

Normal physiologic jaundice  - When the baby's liver is too immature to keep up with the bilirubin that's breaking down in the blood.

Breast milk jaundice - Breast milk is thought to have properties that inhibit the breakdown of bilirubin, causing some babies to develop jaundice between four and seven days in that first week and lasting several weeks. From what I have found, there hasn't ever been a case of kernicterus (Kernicterus is a form of brain damage caused by excessive jaundice) with breast milk jaundice.

Breastfeeding jaundice - This mimics normal physiologic jaundice but seems to abate once the mother's milk is in. Too often, babies are taken off the breast for a couple of days, waiting for the milk to come in, before allowing the baby with a higher bili count to nurse again. Of course, we know that delaying nursing delays the milk coming in and interferes with mother and baby togetherness.

The more serious types of jaundice can be:

ABO Incompatibility - When the mom has the blood type O and the baby does not.

Birth trauma - Bruising that occurs during the birth, including the cranial suffusion caused by a shoulder dystocia, can set the baby up for serious jaundice.

Premature babies - The liver is what helps process the bilirubin, so in a premie, the liver is already  immature and unable to keep up with the needs of their new neonatal body; most premature babies deal with jaundice after birth.

Bilirubin is measured in the blood by any or all of these tests:

  • Total bilirubin count
  • Complete blood count
  • Coomb's test
  • Measurement of levels of specific types of bilirubin
  • Reticulocyte count
  •  

    The fear of a bili level getting too high is kernicterus (mentioned briefly above). Kernicterus can cause brain damage and even death in babies. One serious issue with kernicterus is there is no absolute number when a baby topples into it; each baby has their own threshold, meaning some babies will be treated needlessly, whereas others should have been treated earlier. Guidelines do exist regarding when to initiate treatment with Bili-Lights (phototherapy), but I have found that each hospital and even each doctor seems to have their own numbers in mind. (I am sure that, as with all us birthy folks, they are a product of their experiences and if they had a baby with kernicterus at a lower-than-standard number, they might act more conservatively than the recommendations suggest.)

    Treatment for serious jaundice is putting the baby under bili-lights (pic below), sometimes for days, until the bili level drops to a safer number. 

    The bili-lights help to break down the bilirubin in the system, lowering the numbers faster than if left alone. (This is an extremely simplistic explanation.) The set-up seen above has been used for decades. Today, with a bili count in the moderate range, the doctor might prescribe a BiliBlanket instead. Both the blanket and overhead lights can now be done at home as long as the baby isn't terribly ill; insurance would rather pay the lower cost of home bili treatment anyway.

    As I said, please use this minimal information as a beginning to learn about newborn jaundice. This is, in no way, enough information for you to make a decision about you and your baby.

    But, I loved the picture at the beginning and wanted to share it. I haven't gotten a really great pic of a yellow baby; glad I have one now.

    Reader Comments (7)

    I think sometimes the fear of jaundice is oversold. My oldest son was "yellow" when he was born and the hospital staff rushed to intervene. Unfortunately they forgot to take into account his Mediterranean heritage. There was no jaundice and in the end I went home with a SUNBURNED baby!

    April 4, 2010 | Unregistered CommenterMartin

    Don't forget Rhesus factor. Theoretically problems in that regard should have been caught earlier, but it can sneak through.

    April 4, 2010 | Unregistered CommenterLily

    (long time reader of your blog)

    Good overall explanation of jaundice and the issues that come along with it. I work as an LC in a hospital setting and dealing with jaundice is a headache. Scary to the uninformed parents, a nuisance to breastfeeding. Another issue is the cycle of poor feeds as a result of potential sleepiness as a result of jaundice - which results in more jaundice, more sleepiness, less feeding, less stooling, more jaundice.
    In a hospital where there are two day inductions often ending in C-sections, this additionally impacts readiness to feed, and increases maternal fatigue. Many times, seems to result in delayed lactogenesis as a result of the birth interventions. All of which results in less breastfeeding and more jaundice.

    Since I'm an RN LC in a hospital setting with 90% epidural rate, 25% primary C-section rate, I wonder if the unmedicated moms have better feeds resulting in less jaundice. I rarely see an unmedicated mom where I work. :(
    (And as a mom who breastfed 4 kids during the 1980s following unmedicated deliveries (no inductions - 41 wks) - I just did not seem to deal with any jaundice in my kids - it leaves me wondering what was different.)

    April 4, 2010 | Unregistered CommenterValerie

    Three things I learned after we had a baby with ABO-incompatibility jaundice (that I wish we'd known ahead of time):

    1. The main difference between the ABO-incompatible babies that get severely jaundiced, and the ones that don't is simply how well they are eating. Severe jaundice is strongly linked to breastfeeding problems for this group. I suspect that some of the so-called success of bili-lights is actually from the prescribed formula supplementation that often goes along with it.

    2. Kernicterus is actually quite rare. I found one study where the authors said, "We don't really know what the kernicterus rate is, so we'll assume various rates..." 1 in 100,000 was the highest rate for kernicterus that they used. One in a million is probably closer to the real rate.

    3. The antibodies in the Rhogam shot can cause a weak positive result for the Coombs test. The interaction between Rh-incompatibility and ABO-incompatibility is interesting. ABO-incompatibility can actually help prevent against Rh-sensitization: fetal blood cells that cross into the mother's bloodstream will probably get destroyed on account of being ABO-incompatible before they can trigger Rh-sensitization. (I still get Rhogam shots, because there's a chance that some of our babies will be type O, as I am.)

    April 5, 2010 | Unregistered CommenterPeggy

    I'm a proud mom of two daughters, both born at home attended by wonderful midwives. (9lbs,2oz; 8lbs,12oz) Though I received wonderful support, unfortunately I experienced shoulder dystocia twice. As a result both of my babies displayed signs of pronounced jaundice beginning around day 3. I nursed, nursed, & nursed like crazy. Plus, during the first week of their lives, I exposed their naked bodies to direct sunlight (7 min/per side) front & back twice a day. I'm not quite sure if the links below will work, but these are two snapshots of my newborns w/ jaundice. (My midwives were wonderful resources for all of questions about newborn care & kept a close watch on our new family until the jaundice disappeared.
    http://www.facebook.com/home.php?filter=lf#!/photo.php?pid=457092&id=1216605028
    http://www.facebook.com/home.php?filter=lf#!/photo.php?pid=457032&id=1216605028&fbid=1169606479783

    April 5, 2010 | Unregistered CommenterApril Lloyd

    How timely!

    I had my 4th baby 13 days ago and she is quite jaundice at the moment but is clearing it well by herself and didn't need to spend time under lights. All 4 of my babies have been jauniced, developing day 3 and the older 3 have stayed jaundiced until 10-13 weeks. I (and their father) are quiet pale so their jaundice is quite obvious, much like you picture and they stay a horrid colour for sucj a long time.

    April 6, 2010 | Unregistered CommenterMarie

    Hey April, my daughter also suffered (severe) shoulder dystocia (though no jaundice) when she was born at the hospital after a transfer from a planned home birth. My MW said that because of the primary SD, I should birth in the hospital next time, which makes me very sad. Would you be willing to talk about your experience having a second HB (and SD) after the first one with me? I'd really appreciate hearing from someone who's been there (my email is above)
    Vanessa

    April 7, 2010 | Unregistered CommenterVanessa

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