You should’ve seen the unease in our pediatrician’s face when they told us Maverick’s bilirubin levels went down, and we said, “oh so he’s just yellow because he’s Asian then.” We never fail to make people feel uneasy with our Asian jokes. But with all of that aside, the word hyperbilirubinemia can already be scary to someone who can barely break it down to pronounce it correctly. So I’ll try to do a quick breakdown on what it is.
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A tough time trying to be the mom and not the nurse of Maverick
Maverick had to be under the phototherapy lights for 2 nights. The first night we had him back in our room was extremely difficult on me and Sean. We were up every 2 hours to go to the NICU and feed Maverick on the first night and we were up the entire first day after delivery. We were extremely excited to have him in the room with us, but he was not excited about the phototherapy lights. I thought I would do okay with this since I’ve helped treat so many “bili-babies” as a nurse, but I was so wrong. The emotional attachment that I had as a mother was hard to overcome. Every time Maverick started crying, my first instinct was to take him out. It was extremely hard to not soothe my baby. When I would breastfeed him, I’d still hold the bili-blanket underneath him, but even that irritated him.
His level at initial testing was 11.4, and after one night of therapy it went down to 11.3. Not much progress was made and that was probably due to the fact that breastfeeding was new to us both, and because we kept pulling him out from the lights. We opted to put him back in the NICU for phototherapy hoping that a more controlled environment would help him get better. His levels did go up to 15 the second day, but since he was getting older, the threshold for therapy went up as well. It wasn’t enough to keep him admitted for phototherapy, so we changed the treatment to breastfeeding with formula supplementation and was seen the next day as an outpatient. When we came back, his level dropped a little bit, and we decided to treat his tongue tie by having the pediatrician do a frenulectomy. After a few days of great breastfeeding sessions, formula, and sunbathing, we noticed his jaundice start to go down. At his first well-child check up, they drew labs and said the would call us if his levels were abnormal. It’s been a week since the lab was drawn and we’ve heard nothing back, so it looks like we’re in the clear!
What is hyperbilirubinemia, and is it normal in babies?
So let’s just break down the word: Hyper as in excess of; bilirubin as in the compound that is made due to the breakdown of RBCs (red blood cells); and -emia as in the suffix that refers to something to do with blood. So basically, there is an excess of the remnants of broken down blood cells circulating in babe’s blood. It isn’t uncommon that a baby will be slightly jaundiced after birth. The reason that babies appear yellow when jaundiced is because bilirubin is pigmented yellow!
When a baby is in utero, the placenta works hard at removing bilirubin from the baby’s bloodstream. After delivery, the baby’s liver takes over and sometimes needs a little time to catch up. Don’t be surprised if your baby is more jaundiced after a more traumatic delivery that causes bruising or a hematoma. There is a certain level that babies have to reach to receive phototherapy, so not all jaundiced babies need to be put under lights.
How is hyperbilirubinemia tested and treated?
So this is where nursing comes in! Aside from physical assessment of the skin every shift, at the 24-hour mark, every newborn is screened. This screening includes things like hearing screen, congenital heart disease test, PKU (phenylketonuria) screening, and a TcB test. TcB stands for Transcutaneous Bilirubin. This is done with a device that is pressed against the newborn’s forehead and takes a reading of how much bilirubin is detected through the skin. If the levels are above the facility's recommended threshold level, that’s when the nurse will draw a TSB, or Total Serum Bilirubin. This is done with w a heel stick and drawn in a pediatric blood tube.
American Academy of Pediatrics
The American Academy of Pediatrics has a chart showing the serum level vs neonatal age and what the risk zones for treatment are. If the TSB levels are high enough then phototherapy will be started. If they are considered low-risk, encouragement of breastfeeding with supplementation of formula may be recommended. This is because bilirubin is excreted in stool and urine. This could be another reason why it is more common for exclusively breastfed babies to become jaundiced after birth. It can be the learning curve that momma and baby have as they begin their breastfeeding journey and waiting for mommy’s milk to come in. So if your baby does require more than just frequent breastfeeding sessions and supplementation, your pediatrician will go over what phototherapy is.
What is phototherapy? Can it be dangerous?
The risk of putting your baby under phototherapy lights is pretty low. Proper precautions are taken to monitor the baby’s well-being under the lights, such as an eyemask, continuous temperature monitoring, and a new one I’ve seen, continuous pulse ox. Phototherapy lights are blue spectrum lights that mimic what the sun would do for Baby. It helps breakdown the bilirubin through the skin, which will come out in Baby’s diaper as soiled diapers. Most facilities have triple light therapy which just means in addition to the two lights that are placed above Baby, a special blue light fiber-optic blanket will be placed under Baby. Baby will only be wearing a diaper while receiving light therapy to maximize skin exposure. This is why it is important to monitor Baby’s temperature to make sure that it isn’t too hot or too cold under the lights. I hadn’t seen continuous pulse ox monitoring until Maverick received phototherapy. They told me it was because they wanted to make sure they could see his oxygenation was normal since the blue lights could cause him to be mistaken for cyanosis. I didn’t think it made any sense, so I just appreciated the continuous pulse ox since he had been admitted to the NICU for oxygen therapy. Good thing I’m a nurse, right?
So if it’s so common, why should we be worried about jaundice in a newborn?
Though most of the time jaundice in newborns an be harmless, the reason to treat aggressively is to prevent any brain damage. When severe jaundice is left untreated, the excess bilirubin can cause seizures and brain damage. Kernicterus is the name of the disease when bilirubin levels reach too high of a limit and cause this brain damage. Signs and symptoms of kernicterus include drowsiness, fatigue, fever, uncontrollable or high-pitched crying, trouble feeding, fever, abnormal muscle tone/spasms, and abnormal eye movement.
So if you are concerned that your newborn could be developing jaundice after you have been discharged from the hospital, make sure that you bring it up at the first well-child check up, or sooner if you’ve got a few days before.