I was working in a newborn nursery, and of course a part of this position involved an exam of all of the newborns brought into the nursery. We would give them their first of three hepatitis B injections and then do their first physical exam. We checked them out for any cardiac abnormality, genetic defect, problems with jaundice (yellowing of the newborn’s skin), and removed any extra finger digits they may have inadvertently been born with.
Most newborns do not have any problems. A few will have cardiac abnormalities which can be anything as benign as their patent ductus arteriosus having not closed (a valve between the newborn’s pulmonary and systemic circulation) to the newborn having tetralogy of fallot (4 defects to their heart), to their not developing the left side of their heart (hypoplastic left heart syndrome). They can also have an opening between their two lower ventricles (what is called a VSD, or ventricular septal defect), an opening in their two upper chambers (an atrial septal defect), or a problem with one of the heart valves.
Genetic defects in a newborn run the gamut from down’s syndrome (mild mental retardation) from having an extra portion of chromosome 21, to a deadly trisomy 18 defect, which means that the child has extra portions of chromosome 18, in which many of these children not living beyond the first week of life. Then there are those children who have genetic defects which are visible to us on examination and these include skeletal deformities or brittle bones (these children can be born with a broken shoulder for instance, or by just holding them they can break a bone). This disease is called osteogenesis imperfecta.
Much more common is the jaundiced newborn. Jaundice occurs in newborns due to their having a higher red blood cell count than adults and their having breakdown of these red blood cells sooner than adults. Most adults have red blood cells that last for 120 days, newborns have red blood cells that last for 85 days. This combined with initially a low enzyme level in the newborn’s liver which is responsible for catabolizing the red blood cells components, is what gives the newborn jaundice. If the newborn’s bilirubin goes above 25.0 then they are at risk for having neurological involvement, in other words, their brain is affected by the bilirubin in their blood.
Newborn bilirubin will typically peak at 48-96 hours of age with a level of 7-9.0. A normal adult level for bilirubin is 1.0. It can take up to two weeks for the newborn’s jaundice to resolve completely.
Typically the newborns would come into the nursery and after having their first physical exam the newborn would be wrapped up in small blanket and placed in a bassinet. After about 2-3 hours we would take the newborn back into the maternity ward, to bond with mom and begin teaching mom about how to appropriately breast feed their newborn.
We taught them the appropriate ‘latch’ technique. If the mom ended up having problems with her newborn latching on, so they could feed properly, then when the mom was sent home we would give them the local ‘La Lache’ Society (breastfeeding moms) phone number whom they could call if they had a problem. We also make sure that these mothers would be seen in our follow-up clinic a week after their newborns were discharged. At that time, we not only addressed any remaining problems with breastfeeding but we made sure the moms had made an appointment for their newborns to be seen by their pediatrician at two weeks of age.
Of course, I saw many newborns who had jaundice and I would explain to the new moms what jaundice was all about. Many of these new moms would be concerned about it, so we also saw these newborns in our follow-up clinic one week after we discharged them.
A typical scenario I ended up handling was a newborn I remembered who had a bilirubin of 22, at one day of age. We put him under the ‘bili-lights’ with an eye shade on. He had a scheduled lab draw every 12 hours for his bilirubin level. We only would take him out from under the ‘bili-lights’ when we brought him into to see his mom for his breastfeeding.
‘Bili-lights’ is phototherapy for jaundice. Direct intense light upon a newborn, who is typically only dressed in a diaper will help the newborn’s system break down the byproducts of the red blood cells and therefore aid the newborn in getting rid of it. Once their own system is able to rev up their own production of the liver enzyme which is responsible for handling the byproducts of the broken down red blood cells, then they no longer need the direct light upon them.
When a newborn has jaundice we also have to explain to the breastfeeding mother that the mere act of breastfeeding can increase the newborn’s jaundice. Their bilirubin can go up. We know this, understand this, accept this and work with it. The bonding and the nutrition the newborn acquires from breastfeeding far outweighs any negative they could acquire from having their bilirubin bumped a little bit up from the breast milk.
It took two days for the newborn’s bilirubin I saw, to begin to safely come down, to the point of where we felt he could go home. When we discharged him his bilirubin was 12. We advised the mom to make sure to expose him to direct sunlight during the afternoon. With the sun shining on him, it would continue to help to resolve his bilirubin. We told her to also make sure his eyes were covered while she did this. We also told her to leave him in the sunlight with only his diaper on so that he would get as much skin exposure as possible.
She brought him back into our follow-up clinic 5 days after his discharge, which was day 8 of his life. His bilirubin at that time had come down to 8 and he was doing better. So we made sure that she was comfortable breastfeeding her newborn and understood that even though breastfeeding could increase his ‘yellow skin’ look, breastfeeding him was the best nutrition for him overall. She left the clinic happy and contently holding her newborn in her arms.