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From:
Rachel Myr <[log in to unmask]>
Reply To:
Lactation Information and Discussion <[log in to unmask]>
Date:
Tue, 30 Sep 2003 20:07:17 +0200
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Linda Pohl mentions the apocryphal story which I have also heard or read
'somewhere' about the nursery nurse (I think she was actually a nun too,
just for good measure) who noticed that the babies whose cots were near the
windows were seldom as jaundiced as babies who were placed in the interior
of the room.  This led to the development of phototherapy.  UVA and UVB
(tanning wavelengths) are not used for phototherapy; if they were, the
babies would have at least 2nd degree burns long before they were
unjaundiced.  They use fluorescent lights of a frequency I am unsure of;
daylight as filtered through ordinary windowpanes has the same effect.  One
needs to shield the baby's eyes from direct light in any case as it is just
too strong.  Even placing the baby in a room illuminated by indirect
daylight will have some effect.

Regarding the need for pediatric consults for newborns with jaundice, we
rely on the whole picture before calling in a doc or even drawing a bili
level.  Since about one third of newborns will be visibly jaundiced in the
first week of life, we would be doing a lot of needless consults with
specialists and a lot of unnecessary sticking of babies if we felt we had to
assume each baby was in imminent danger of kernicterus unless we did all the
worst case scenario stuff.  Our docs would come unglued if we called them
for every single one of these.
If mother is Rh positive and has no known antibodies, as ruled out by the
routine Ab screens done on all women in pregnancy here, and the baby is
term, feeding well, and less jaundiced on the lower body and lower
extremities than on the head and upper body, as determined by a clinical
examination, sometimes it's better not to know what the exact bili level is.
We don't treat term babies for bilirubins under 20, if they are at least 96
hours old. The level at which we start treatment in the first 96 hours
depends on baby's age, in hours.  We have had pediatricians who have trained
in the US, and they start phototherapy much earlier than the
Norwegian-trained docs, with the main difference in outcome being that
breastfeeding is profoundly disturbed due to early separation and regimented
feeding, not to mention the anxiety it causes the parents.

We monitor babies with marked physiologic jaundice by observing all the
above factors, especially feeding and pooping, plus blood levels, until they
are under 15 AND falling.  We do this on an outpatient basis if baby is
doing fine, and we don't check daily unless the levels are close to 20 -
like 19 and over.  We don't ever, ever, ever send a jaundiced baby home with
no planned follow up within a safe amount of time, and parents know what to
get alarmed about, in which case they get in touch.
For the record: our docs are very concerned about any baby who is not waking
spontaneously when hungry and feeding well, whether or not they are
jaundiced.  There has not been a case of kernicterus from our unit that I
know of in the time I have worked there - 15 years now, and we have about
2000 births/year.  Being the BF activist, I am sure I would be the first to
be told if a baby were injured from untreated hyperbilirubinemia. I don't
think our unit is unusual either.  Kernicterus has a hard time occurring
with multiple safety nets in place to protect the normal as well as detect
the abnormal.
Call me Pollyanna, but I prefer to assume a child is well until the opposite
is proven to be the case, rather than the other way around.  I use my finely
honed observational skills either way, but I prefer the 'healthy until
proven otherwise' approach to the 'only normal in retrospect' one, and I
think it is more conducive to normal birthing and breastfeeding, which rank
high on my list of cherished events.

Rachel Myr (IBCLC midwife for this post)
Kristiansand, Norway

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