Sunday, November 23, 2014
Newborn and Infant Care
Jaundice at two Month old
My baby is two month old and still is jaundiced. The total bilirubin level is 4.81 mg/dl and direct bilirubin level is 0.47 mg/dl. Are these levels dangerous? like brain damaging levels? Thank you.
Prolonged jaundice beyond three weeks of age is fairly rare. So it does deserve additional investigation beyond what what most newborns need and receive. However, the good news is that direct bilirubin is no danger to brain cells at all since it is bound to protein in the blood and cannot cross the blood-brain barrier. Although higher than normal, 4.81 mg/dl for the total bilirubin is not at a harmful level. Levels of 25 mg/dl and higher are associated with brain damage. Current guidelines for the management of increased bilirubin levels in newborns, if followed, provide for early recognition and treatment of rapidly rising serum bilirubin levels well before they reach 25mg/dl.
So what about the young infant who still has increased bilirubin levels but not at dangerous levels? What would be reasonable problems to consider? One might be an interaction between your breastmilk and your baby's digestive system such that bilirubin is less easily cleared from your baby's body. Not a lot is known about these unique interactions, but they are not rare and most all cases babies do not appear to be harmed since the bilirubin level is so low. Please do not at all take this to mean that your breastmilk is harmful to the baby. It is not. Each mother's milk is different as is each baby's digestive system's functioning. There is a range of what is normal.
Health problems that should also be considered include inherited problems with your baby's hemoglobin and red blood cell formation which might provide a constant source of extra damaged red blood cells for the baby's immature liver to process. This can be checked for through simple blood tests and may have already been checked in the newborn screening process in your state. States each select their own screening panels for newborns, so your state may or may not have already checked for these types of problems. Your baby's doctor will know and can explain this to you.
Other potential causes of prolonged jaundice include low thyroid hormone levels and inability of the baby's intestines to process galactose or milk sugar. Both of these are tested for at birth in most if not all states because they require early treatment to prevent brain damage. These results should be available by now to your baby's doctor.
Liver inflammation from hepatitis is possible. It can be tested for with blood tests of liver enzyme levels, also called liver function tests.
Problems with the bile duct can be identified with MRI, which does not expose the baby to radiation but is rather costly and usually requires sedation of the infant. Problems with gall stones can be identified with ultrasound, which is a simple and inexpensive test with no radiation exposure or baby sedation needed. Liver tumors are best identified with a CT scan, which while cheaper than MRI, does expose the baby to radiation but may not require sedation. If the liver is not enlarged, tumors are unlikely.
Finally, there are several relatively common inherited conditions associated with mild, prolonged jaundice. The first is Gilbert Syndrome which affects about 7% of all individuals but is usually not identified until the adolescent years and is a benign difference in bilirubin metabolism. The other is a metabolic problem called G6PD (glucose-6-phosphatase dehyrogenase deficiency), which does require special dietary management, especially when children are ill. It is part of a group of disorders of glucose metabolism. Glucose is the main source of energy for all of the cells in the body, so it is important to know when a child lacks the enzyme to keep the flow of glucose from food adequate for the growing, active baby. This problem is tested for in some states with newborn testing. Again, your baby's doctor will know if that was checked in your state or not.
The bottom line is that a good discussion with your baby's doctor to cover all of these issues and to plan any additional testing wisely would be a good place to start, knowing that the possibility of danger to the baby from the current bilirubin levels is very low to possibly none at all. I hope this information is helpful to you.
Mary M Gottesman, PhD, RN, CPNP, FAAN
Professor of Clinical Nursing
College of Nursing
The Ohio State University