Diplomate, Board Certification of Emergency Medicine
Chairman, Department of Emergency Medicine Ma'ayenei Hayeshua
Hospital
I know nothing about neonatal problems, that is problems at
birth, as these are generally not treated in the emergency
department but rather in the nursery itself. So when I
received a letter from my number one correspondent, Mrs. R.
from Bnei Brak, on bilirubin in newborns, I shuddered.
However, I became a quick expert on the subject when my new
daughter (our first child in seven years, our eighth but our
first sabra, and named for her grandmother who just passed
away six months ago) developed this condition. I will answer
your questions as best as I can.
Bilirubin is a breakdown product and comes in two flavors:
indirect and direct. Indirect is usually due to a breakdown
of blood cells and direct is used for digestion of fats.
These materials are processed in the liver and stored in the
gall bladder. This is located in the upper right side of the
abdomen (pain there may indicate a stone or other
blockage).
When bilirubin accumulates, either due to a blockage or
overproduction, it turns the skin a characteristic yellow
color which is usually most noticeable in the whites of the
eyes. That is half of the story.
Now, babies have their type of blood, which is called fetal
hemoglobin, and it mixes in the placenta with mother's blood
to get the nutrients it needs. When the baby is born, if the
mother's blood is not the same type, the baby must break down
any mother's blood that accumulated. This can increase
bilirubin levels on day 3 and on.
Babies who are nursed can also develop high bilirubin. This
seems to be because a fat in the milk competes with bilirubin
for excretion, causing bilirubin to accumulate. So one will
often hear that stopping nursing will reduce levels, and
indeed a two-day rest does seem to do the trick. However,
some hold that since bilirubins increase in babies not
getting enough calories, and since bilirubins are put out in
the stool, increased nursing is the answer. This will
increase stool production and decrease bilirubin production.
Have I totally confused you yet?
So let's summarize: Bilirubins increase from nursing and from
blood breakdown, but increased nursing seems to help. By the
way, sugar water worsens the situation. This is all a normal
situation that usually gets better by itself.
If, however, the bilirubin continues to rise, some babies
need ultraviolet light therapy, which is done in the
hospital. If it reaches super high concentrations, then an
exchange transfusion is done -- that is all of babies' blood
is exchanged for new blood. Some families are at higher risk
for this. By three weeks, most babies have normal adult
bilirubin levels.
Why is bilirubin so concerning? High levels are toxic to
young brains. However, this is only at super high levels, so
why lower levels still prevent a bris from being done
is unknown to me.
High bilirubin, especially the direct type, can be from other
more dangerous causes such as infection, but usually all
these tests are done in the nursery or there will be some
other indication on physical exam. A feared cause is biliary
atresia, where the whole apparatus does not develop fully.
These patients usually need a liver transplant to make it to
adulthood.
I apologize if this hasn't been my clearest column, but hey,
I'm new at all this. Now, if only I could remember, after
seven years, how to change a baby! Write me in care of the
Yated.
A message from Glaxo, sponsor of this column. Cold
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