Gail Neuman posts about a baby with a bilirubin of 20.7 at 10 days whose
mother is being counseled by the pediatrician to stop breastfeeding for a
few days and feed soy formula instead.
I would want to know how alert the baby is, how breastfeeding is going, and
how weight gain is looking before considering feeding anything but
breastmilk. We use a limit of 20.6 for phototherapy for term babies (<37
weeks) from age 96 hours. Before that the threshold for phototherapy is
lower, starting at about 7 at birth and increasing linearly until 96 hours.
When we do bilirubin checks we check the value according to the baby's age
in hours and that will determine whether baby gets treated or just followed
attentively until the bili starts to fall. Once it has gone down to 14.7 we
stop taking blood tests and just wish them well, turning over care to the
well-baby clinics.
The baby in Gail's case would be followed as an outpatient to monitor weight
gain (as a measure of feeding effectiveness) and bilirubin, and the
frequency of such checks might be daily at this point, slacking off a bit
when the bili really starts to fall, so we don't have to torment the mother
and baby with daily blood tests to follow every little reduction. I've been
following a baby who finally on day 12 is down to 16.5, YEA! But she still
is 3 ounces under birthweight and looks thin. (I think she has grown in
length, but I don't have a length measure in my office, we only stretch them
out to full length for the birth report and the measuring device is in the
labor ward.) She is vigorous, feeds eagerly, and mother seems to have ample
supply. We scheduled the next check for five days from now, to give baby
time to fall even more convincingly (and, I hope, to gain a bunch of
weight!).
We don't call prolonged physiologic jaundice anything but newborn jaundice
and I can barely remember the last time a mother was advised to stop
breastmilk to see if bili levels dropped. But staff are way too quick to
supplement babies who are slightly jaundiced, 'to get the bilirubin out of
their systems'. Then when the babies lose interest in feeding, mothers may
be told 'he's drowsy because of the jaundice' when he is really just knocked
out on formula, argh.
We expect bili levels to show a rise in the first 24 hours after stopping
phototherapy, and we just hope they don't rise so high that we have to start
treatment again because it is a royal bore and we don't have the option of
sending them home with a light device. Phototherapy doesn't stop the
process leading to jaundice, it merely accelerates excretion of bilirubin,
and if the baby is still on the upward slope of the curve followed by
bilirubin in physiologic jaundice, it will continue to rise until at least
the 4th day of life, sometimes even longer, though that is often a flag for
ineffective feeding.
BTW, to get the European values for bilirubin, you multiply US values by 17.
Our limit is thus a bilirubin value of **350** from three days of age :-)
It's lower for pre-term babies. Even so, I firmly believe that the greatest
risks 95% of these babies face as a result of their jaundice are those of
infection at the heel-prick site, and getting involved in a road accident on
their way to and from blood tests.
Rachel Myr
Kristiansand, Norway
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