Laurie writes of a case she is working on:
"Her baby had a bilirubin level of 23 in less than 24 hours. The
pediatrician has done only CBC and bili levels and treated with double
phototherapy which has been effective. My thought is
that this is obviously pathologic and in absence of positive Coombs test
what might the diagnosis be? Is it wise for the family to pursue what the
pathology might me? Would you as the LC suggest this? The baby has been a
poor bottle feeder per the nursery nurses."

Has the pediatrician measured bilirubin levels in a way that can distinguish
between conjugated and unconjugated bilirubin?  In physiologic jaundice
there is almost no conjugated bili. to be found because it is rapidly
excreted.  If there is another cause, the ratio might be different.  There
could be anomalies in bilirubin metabolism, or a congenital disorder in the
biliary system, or infectious disease (remote).  The baby would not improve
with phototherapy in that case, though if the baby has physiologic jaundice
superimposed on a pathologic jaundice, it might seem to improve.

There is always the possibility that the lab result was wrong; the machine
was out of calibration or something.  I expect a result this high would make
a good lab double-check both the test and its equipment.

If it is simply a pronounced physiologic jaundice, I would expect the baby
to have a high hemoglobin and hematocrit, and/or a hematoma somewhere that
is overwhelming the system for bilirubin excretion by dumping a huge bolus
of red blood cells out of circulation all at once, as with vacuum
extractions.  The mother could have polycythemia, or there could have been
an excess of blood transferred to the baby before the cord was clamped.
Depending on the routines for cord clamping and treatment of third stage,
babies have varying hematocrits the first days after birth.  If oxytocics
are routinely used in third stage and babies held lower than the placenta
without the cord being clamped, they can get quite a lot more blood in their
systems than if they are held level with the placenta and it is expelled
spontaneously, without the aid of extra strong, oxytocin-induced
contractions.

I don't know whether the LC could bring this up as I don't know the rules of
etiquette in your hospital, but a nurse certainly should be able to.  And if
the baby's condition is affecting its ability to feed, it is an issue for
the LC too.

BTW, at our hospital that baby would have had an exchange transfusion on the
first day of life, and that has only happened a couple of times in the 15
years I have worked here.
Rachel Myr
Kristiansand, Norway

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