Learning About Jaundice
Bainbridge Island, Washington, USA
From: NEW BEGINNINGS, Vol. 10 No. 1, January-February 1993, pp. 12-13
We provide articles from our publications from previous years for reference for our Leaders and members. Readers are cautioned to remember that research and medical information change over time.
During the first and second day of my son's life we cuddled and nursed freely in our bed. On the third day my son moved into a plastic bassinet with bilirubin lights for a roof and clear plastic for walls. He lived in there for three days; my husband and I could take him out only every two hours to monitor his temperature, change his diaper, and nurse him on a schedule.
Normal physiologic newborn jaundice was our doctor's diagnosis; he ordered phototherapy and water supplements.
Jaundice is a common, usually normal, yellowing of a newborn's skin and the whites of his eyes. Usually jaundice disappears without treatment, but health professionals agree that frequent breastfeeding and skin exposure to daylight can both prevent and treat jaundice.
If needed, medical tests can determine the type and degree of jaundice; most newborn jaundice is normal physiologic jaundice. The degree of any type of jaundice is measured in milligrams of bilirubin per deciliter of blood. Bilirubin is an orange-yellow pigment and it is a byproduct of the breakdown of red blood cells.
In short, babies with normal physiologic jaundice turn yellow because they cannot process and excrete bilirubin as fast as they break down the extra red blood cells that they no longer need once they are born and taking in plenty of oxygen on their own.
In contrast to normal physiologic jaundice (which usually disappears without treatment) abnormal pathologic jaundice often requires medical treatment to slow a rapidly rising bilirubin level. High levels of bilirubin are of greatest concern with premature or sick babies.
My husband and I had not noticed our son's jaundice. It was our midwife who noticed a yellowish cast to his skin on a routine thirty-six hour home visit. She suggested that we take him to see a doctor the next day.
Early the next morning the doctor walked with us out into the bright Arizona sunshine so that he could get a good look at the baby's color. He poked his skin gently and told us that our baby did look jaundiced.
The doctor asked us exactly when Francis had turned yellow. Physiologic jaundice usually appears on the second to fourth day in normal full-term babies. In contrast, abnormal or pathologic jaundice is often visible at birth or within the first twenty-four hours.
We could not tell the doctor exactly when Francis had turned yellow, because we had not looked for or noticed the yellowing. So, the doctor ordered blood tests to rule out pathological jaundice.
At a nearby lab, the technicians took Francis' blood for testing. I had asked Dr. Cabin to avoid puncturing Francis' veins and to only take blood from a heel stick if possible. After the technicians assured us that they were experienced with newborns, they pinned Francis down to a table to prick his heels with the tiny tubes that draw blood through capillary action and store it.
Francis screamed; it was an urgent pain howl that I had never heard before. Tears poured from my unbelieving eyes and I ached to hold or at least touch him. This precious baby, caught by my husband, nurtured at my breast, lovingly examined by our midwife and our doctor was now being repeatedly jabbed in the heels by strangers.
They could not get enough blood for the bilirubin test by heel sticks, although this method usually works. Finally, these two lab workers talked about drawing blood from Francis' veins instead of his heels and they asked why the doctor ordered no vena puncture. When I told them that order started with my request, they implied that I had caused the heel stick fiasco. I consented to the vena puncture and finally after puncturing both arms, they got some blood. We left.
My husband and I were anxious to get home and recapture some of our shattered peace. In retrospect, we should have gone to the medical library instead; the next day our ignorance about jaundice cost us again.
When the doctor called with the test results we were relieved to hear that Francis' jaundice was almost certainly normal jaundice. We were relieved for only a moment; then the doctor said he wanted more blood tests to see if Francis' bilirubin level was falling from the 16.1 mg/dl that the lab had measured. My husband and I did not want to go back to the lab for more blood taking. In desperation we asked for home phototherapy lights; we thought treatment with lights would end the need for testing. Our doctor was wonderful and if we had talked with him more we probably could have avoided both the lab and the bilirubin lights. He had told us at the outset of our consultations that he wanted to avoid bilirubin lights, if possible. Unfortunately we did not discuss all options with the doctor. So, although we avoided the lab, Francis still needed heel sticks twice a day and three days of phototherapy.
Phototherapy, even though it was at home, was difficult for our family. I missed the easy bliss of sleeping with my baby. Instead I slept next to this plastic bassinet in the glare of the bilirubin lights. I missed sleeping and waking on our own schedule. Instead I was awakened every two hours on the phototherapy schedule.
Every two hours my husband or I took Francis out of his chamber, took his temperature, and I breastfed him. We would take off the patches that protected his eyes and hold him close. Francis breastfed well from the first few minutes after his birth. We avoided nipple confusion by breastfeeding exclusively with no pacifiers or bottles. From our midwife we learned that frequent and exclusive breastfeeding helps prevent jaundice. When we told our doctor about this research he approved skipping the water supplements that he had initially recommended.
My husband and I did not even think to follow Francis' natural wake-sleep patterns. We were too scared and too ignorant to modify the instructions that our doctor and home health care people gave us. The arbitrary schedule quickly exhausted me. It seemed as though every time I began to dream, it was time for the two-hour break.
Somehow I muddled through those days and we even learned how to get a good heel prick: I held Francis upright against my chest, my husband warmed Francis' entire foot and leg with a warm wet diaper, the nurse pricked his heel. Francis always cried out briefly--a simple cry of pain and surprise--and the tube filled with blood in just a few seconds.
Francis' bilirubin level peaked at 17mg/dl and we continued to monitor and treat him with phototherapy until it retreated to about 14 mg/dl. That took about three days so Francis was nearly a week old when our doctor gave orders to stop phototherapy and testing.
We now know that many experts believe a normal full-term baby can safely experience bilirubin levels of 20-25 mg/dl before intervention is warranted.
A recent review article on jaundice (Newman and Maisels 1990) indicates there was essentially no evidence of adverse effects on IQ, neurological assessment, or hearing in term infants who had been jaundiced. (This conclusion was based on studies that included more than 30,000 infants.)
In an article in the November 1990 issue of BREASTFEEDING ABSTRACTS, Kathi Kemper, MD, MPH, suggests that prolonged hospitalization, phototherapy, and the interruption of breastfeeding may be unnecessary and even harmful for the mother and for the infant with normal neonatal jaundice. She writes, "In the case of healthy term infants who are jaundiced, the treatment could be worse than the disease."
My husband and I came to that same conclusion ourselves. Before our daughter, Delsa, was born we had researched jaundice. We had also established a good relationship with our doctor. After Delsa was born we worked to prevent jaundice with frequent breastfeeding and plentiful skin exposure to daylight.
Delsa still turned yellow with jaundice, but we knew enough to communicate daily with our doctor who had also attended Delsa's birth. We told her exactly when, on Delsa's second day, Delsa began to yellow; we told her what parts of Delsa were yellow (first her head and then her torso); and we reported on Delsa's general condition (she was often alert and breastfed vigorously).
We were concerned about the jaundice, but we were convinced that frequent breastfeeding and exposure to daylight were the best things for Delsa. We talked to her doctor every day until after the yellowing diminished. This took more than a week, but it was a peaceful week, compared to the first week of my son's life.
Frequent breastfeeding, lots of information, and a good doctor-parent relationship helped Delsa through physiological jaundice. That should surprise no one, because physiological jaundice is normal, it is not a disease.
Kemper, Kathi. Neonatal jaundice in the development of the vulnerable child syndrome. BREASTFEEDING ABSTRACTS 1990; 10(3)7.
Newman, T., B. and M. J. Maisels. Does hyperbilirubinemia damage the brain of healthy full term infants? Clin Perinatol 1990; 17(2):331-58.