MoonDragon's Pediatric Information
(Instruction For Midwives)
Information obtained from "Heart and Hands" by Elizabeth Davis
For Informational Use Only.
For more detailed information, contact your health care provider
about options that may be available for your specific situation.
NEONATAL JAUNDICE INTRODUCTION
Neonatal jaundice is not the consuming concern it was a decade ago. We now recognize the vast majority of cases to be physiologic jaundice, unassociated with the dangerous rise in bilirubin characteristic of pathological types.
Jaundice, the yellowing of the whites of the eyes and skin, is caused by a chemical called bilirubin. Newborn jaundice is very common. A large percentage of newborns do develop jaundice to some degree. Bilirubin is formed from the breakdown of red blood cells. The liver is responsible for processing the bilirubin. Newborns livers are not fully functioning. Jaundice occurs when the newborn's immature liver inefficiently processes the bilirubin.
Most newborn jaundice will go away without intervention. there are some factors that can make jaundice worse and would alert your pediatrician to monitor your newborn closely. Pediatricians are not only concerned with the absolute level of jaundice, but how fast the levels are rising, as high levels of jaundice can cause some problems.
PHYSIOLOGIC JAUNDICE CAUSES
While in utero, the baby's need for oxygen is met by a high level of red blood cells in its circulation, higher than for most adults. Once the baby is born and breathing oxygen directly, excess red blood cells must be broken down and eliminated from its system. A byproduct of this breakdown is bilirubin, which imparts a yellow tinge to the baby's skin. This is physiologic jaundice. It generally manifests on the second or third day postpartum, and is remedied when the mother's milk comes in to flush the baby's system clean.
OTHER TYPES OF JAUNDICE
ABO INCOMPATIBILITY JAUNDICE
Another kind of jaundice that seldom requires treatment is due to ABO incompatibility. This phenomenon is similar to Rh sensitization: if blood from a type-O mother transfers to her A or B type baby during delivery, the baby may develop excess bilirubin.
Breast milk jaundice is yet another non-threatening condition caused by a hormone in mother's milk which can interfere with the baby's ability to break down bilirubin by inhibiting the enzyme glucuronyl transferase, which is needed for breaking down (conjugation) of bilirubin. Unlike most other varieties of jaundice, it is unique in that it manifests after the milk comes in. Breast milk jaundice incidence is less than 0.5 percent of full-term newborns. It occurs after the mature breast milk has come in and may last up to 6 weeks. The levels of unconjugated bilirubin rises beyond physiological limits (15 to 20 mg/dl) by the seventh day. If the nursing is discontinued for 12 to 24 hours. the levels will subside by 5 to 10 mg, and 3 to 5 days pass before the previous level is again reached. It is not necessary for the mothers to completely discontinue breastfeeding and women should not be made to feel that their milk is pathological to their babies.
In contrast, pathological jaundice is caused by obstructed bile duct, liver disease, infection, or Rh hemolytic disease. This is easy to differentiate from physiologic jaundice as it generally manifests within the first 24 hours. However, jaundice from ABO incompatibility may also appear at this time. To be on the safe side, refer any jaundice on day one to a pediatrician. If jaundice is pathological, high levels of bilirubin may be nearly impossible for the baby to eliminate and may seep into the basal ganglia of the brain, leading to kernicterus, or permanent brain damage.
(Total Serum bilirubin levels)
Up to 24 hours 2 to 5 mg/dl Nose: 3 mg
Face: 5 mg
Up to 48 hours 9 mg/dl Chest: 7 mg Up to 3 to 5 days Less than 12 mg/dl Abdomen: 10 mg
Legs: 12 mg
Up to 7 days Usually less than 15 mg Palms: 20 mg
Although physiologic, ABO, and breast milk jaundice are essentially normal and self-correcting, they can occasionally cause the baby to become lethargic and disinterested in nursing. If the characteristic yellow tinge is noted on the baby's face and neck but runs no lower than the nipple line, encourage the mother to nurse often and expose the baby to sunshine (with its body naked and eyes protected) for 30 minutes twice daily. If the baby's extremities appear jaundiced, consult a pediatrician.
NEONATAL HEPATIC SYSTEM
Conjugated bilirubin (direct, soluble bilirubin): The conjugated form of bilirubin is excreted from liver cells. Along with other components of bile, direct bilirubin is thus excreted into the biliary tract system, beginning with the smallest of these ducts (the bile canaliculi) and ultimately ending at the common bile duct, which inserts into the duodenum. There, by the action of the bacterial flora, bilirubin is converted to urobilirubinogen and stercobilin and eliminated by way of the urine and feces.
Unconjugated bilirubin (indirect): The unconjugated bilirubin circulates bound to plasma albumin. Unbound bilirubin leaves the vascular bed and is deposited in body tissues (e.g., all organs, the skin, the sclera, oral mucous membranes), the resultant yellow coloring is termed jaundice.
Total serum bilirubin is the sum of conjugated and unconjugated bilirubin.
Hepatic immaturity, increased erythocyte (red blood cell) destruction, or the availability of inadequate serum albumin binding sites can result in hyperbilirubinemia (high bilirubin levels)
CONVENTIONAL MEDICAL MANAGEMENT
PHOTOTHERAPY - BILI -LIGHTS
Depending on the degree and type of jaundice, the baby may be hospitalized for treatment. The most commonly used treatment is ultraviolet light exposure (phototherapy), in which the infant is placed under an ultraviolet lamp for a few hours each day. The ultraviolet light breaks down bilirubin into a form which the infant liver can process and excrete. If the baby is placed under bili-lights, it will have blood drawn periodically to assess bilirubin levels. If the bili-lights are used, it is crucial that the baby's treatment be properly supervised, as dehydration, burning, and possible genetic damage can occur with excessive exposure.
PHOTOTHERAPY - BILIBLANKET
The newer mechanism of providing phototherapy for newborn jaundice is the biliblanket. The biliblanket is a blanket that can be wrapped around the baby or may be a pad which the baby can lie on. It uses a form of light that is found in sunlight, but the harmful ultraviolet light has been filtered out. The lighted blanket is placed directly against your newborn's skin and absorption of the light leads to the excretion of the bilirubin. This convenient and safe form of treatment can be used while your newborn is clothed, held or even nursed. Normally, newborns under phototherapy will have frequent, loose bowel movements as this is the way that the bilirubin is removed from the baby. The length of time the biliblanket is needed is determined by your health care practitioner based on the severity of the newborn's jaundice.
When an infant is jaundiced, a biliblanket that is used continuously at home may help to decrease the bilirubin. The biliblanket is a long pad that shines a full spectrum fiber-optic light and it will not burn or harm your baby.
USING THE BILIBLANKET
1. Attach the hose to the machine by inserting it into the circular opening and then twisting it so that it remains securely in place. Attach power cord to machine.
2. Cover the pad with one of the disposable cloths provided. Place the white side of the cloth onto the clear side of the pad (side without writing).
3. Place the skin of the baby's back onto the white side of the covered pad. Your baby's head should not be placed on the pad, only the back. the hose should go towards the legs.
4. You may either wrap the flaps that have an adhesive strip around the baby's chest to keep it in place or you ca choose not to use the flaps by removing them or tucking them under the pad.
5. Wrap a blanket snugly around your baby, keeping the biliblanket directly against your baby's skin. The blanket should keep you from seeing the light from the biliblanket. The baby may also lie skin to skin on you with the biliblanket over the baby's back, but be sure to cover both of you with a blanket to keep the light away from your eyes.
6. Plug the unit in and turn it on.
7. Remove the biliblanket from the baby when changing diapers or bathing. However, the biliblanket should remain on as much as possible throughout the day and night. This will increase the chance that your baby's jaundice will improve by the next laboratory check.
Babies kept in darkened rooms for the first few days tend to have higher bilirubin levels than those liberally exposed to sunlight. Lack of light is probably a more significant factor in extreme physiological jaundice than the favored theoretical cause, late cord clamping. Most midwives clamp the cord after it has ceased pulsing, and after placing the baby on the mother's belly or chest. They have very rarely had problems with severe jaundice except when lack of light has been a determining factor.
Cold stress (it is important to keep newborns warm), asphyxia neonatorium (newborn respiratory distress syndrome or respiratory failure), and neonatal hypoglycemia contribute to pathological levels of bilirubin by interfering with albumin binding of bilirubin. Babies born to mothers whose labors have been induced or augmented with pitocin must be watched carefully. Pitocin Competes with bilirubin for binding sites, rendering elimination difficult. The same is true of certain drugs, such as diazepam, sulphonamides, steroids, and salicylates. Jaundiced babies also have increased risks of infections.
NEWBORN JAUNDICE & AUTISM
Jaundice in the newborn period puts children at greater risk for autism, according to a study from Denmark. The researchers looked at over 700,000 full term newborn babies born between 1994 to 2004. They found that newborns that were jaundiced had higher rates of developing autistic spectrum disorders later in life. The risk was greater in newborns born to mothers who had previous children and to newborns born between October and March.
The data is interesting, but how newborn jaundice and autism relate is a mystery. The study does not support a cause and effect relationship. It does not state that newborn jaundice causes autism, just that it might be related. It does seem, however, that newborn jaundice might be another piece of the confusing puzzle of how autism develops, and hopefully this puzzle can be figured out over the next few years.
NOTIFY YOUR MIDWIFE OR HEALTH CARE PROVIDER
You or your family member has questions about postpartum care and newborn jaundice.
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