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October 15, 2002

Yellow Baby Caution

From: Hartford Courant, CT
Oct. 15, 2002

By HILARY WALDMAN, Courant Staff Writer

IN recent decades, jaundice in newborns has been regarded as only a trifle more troublesome than diaper rash or spitting up.

New mothers may fret about their yellow-tinged babies, but health professionals have assured them it's usually nothing to worry about.

Lately, however, some of the nation's top health care organizations, from the American Academy of Pediatrics to the U.S. Centers for Disease Control and Prevention, have warned that newborn jaundice should be taken more seriously.

Jaundice occurs when a newborn's underdeveloped liver is unable to efficiently process a pigment called bilirubin, which is a byproduct of the body's normal breakdown of red blood cells. High levels of bilirubin in the blood can cause the skin to appear yellow, or jaundiced.

For most of the 60 percent of newborns who look a bit suntanned or yellow during their first week of life, the liver eventually turns on and flushes out the pigment naturally. But a tiny fraction of children will suffer devastating disability if the bilirubin accumulates in their brains and causes damage.

The threat can be virtually eliminated by quickly recognizing the problem and treating it, most commonly by bathing the baby in bright, ultraviolet light.

But with newborns now typically discharged from hospitals when they are only 2 days old, it has become possible for dangerously high bilirubin levels to go unnoticed and untreated for too long.

While the number of children damaged by jaundice may be fewer than 10 out of the 4 million babies born in the United States each year, pediatricians, parents and health care regulators say even one unnecessarily damaged child is too many.

"It's devastating to have a child with this condition," said Dr. Jeffrey Maisels, chairman of pediatric services at Beaumont Hospital in Royal Oak, Mich., and a nationally recognized expert on newborn jaundice. "These are profoundly disabled children and the very sad part is a majority of these can be prevented by relatively simple techniques."

But exactly what techniques are best and most cost-effective is now the topic of heated debate.

Maisels is chairman of a subcommittee of the American Academy of Pediatrics, which is re-writing the professional group's guidelines for jaundice prevention. While a number of new products are being developed to detect dangerous jaundice problems early, the group is likely to recommend only that pediatricians be more vigilant in monitoring newborns, especially those at high risk for trouble.

Babies who are breast-fed, born just a few weeks shy of the normal 40-week gestational period or born with a certain type of bruising are considered to be at highest risk for jaundice.

While Maisels refused to disclose what his subcommittee would recommend, an article by committee members suggests a conservative approach.

Every baby should be seen by a pediatrician within two to three days after hospital discharge, the committee wrote. Doctors should be even more vigilant with high-risk infants. Hospitals also should consider a blood test for bilirubin levels at discharge and offer breast-feeding support to mothers. While too much red blood cell breakdown is one cause of jaundice, it also can be caused by inefficient breastfeeding, which leads to dehydration.

Dr. Antoinetta Capriglione, chief of neonatology at New Britain General Hospital, says she is not waiting for the new guidelines, due within a few months. At her recommendation, the hospital has purchased a $20,000 machine to predict possible jaundice problems in a baby 18 hours after birth.

The device measures the amount of carbon dioxide in the baby's exhaled breath. A high level of carbon dioxide can be a warning that the baby's body is breaking down too much hemoglobin, putting it at risk of a bilirubin overload.

But an article published last year in Pediatrics, the journal of the American Academy of Pediatrics, found that the device is only marginally useful as an early warning system.

Its greatest value, the authors said, is to help doctors figure out whether a bilirubin overload is caused by too much hemoglobin breakdown or by dehydration resulting in the inability to naturally flush out bilirubin. Knowing the cause of jaundice may allow better treatment decisions.

New Britain General also checks the bilirubin level in every baby's blood before discharge - a practice Maisels recommends. The blood is drawn from the heel as part of required newborn screening for metabolic disorders such as PKU, eliminating the need to stick the baby more than necessary, Capriglione said.

Stacy Lucas, a mother from Lexington, Mass., whose daughter, Krista, is seriously disabled as a result of a bilirubin overload, said parents should demand a blood test before discharge, even if it is not part of the hospital routine.

When Krista left the hospital three days after her birth in 1991, a nurse noticed that the little girl's face appeared yellow. But she did not unwrap the baby to see if the yellow tone stretched down her trunk, another warning sign, Lucas said.

Krista's condition deteriorated at home. She became more yellow, then lethargic and not interested in nursing. Before the Lucases rushed her to the emergency room she had started grunting and throwing up. Eventually, she was transferred to Children's Hospital in Boston, where her blood was drained and replaced with fresh blood through multiple transfusions.

But her brain was already damaged. Today, Krista cannot walk or talk. Her intellect is normal, but her hearing is not good, making it impossible for her to communicate verbally. She understands sign language, but her spastic muscles make it impossible for her to reply with more than groaning sounds, her mother said.

"She's stuck in a body," said Lucas, who is on the board of directors of a parents' group that has demanded attention from some of the nation's most influential health-care organizations. Last year, at the parents' request, the powerful Joint Commission on Accreditation of Healthcare Organizations issued a bulletin urging hospitals to be more aggressive about monitoring for jaundice.

"It's important because a lot of medical personnel think the whole issue was eliminated in the '70s," Lucas said. "We feel the medical community needs to be a little more aggressive and alert because [babies] are leaving [the hospital] so soon."

Copyright © 2002 by The Hartford Courant