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23 Tammuz 5762 - July 3, 2002 | Mordecai Plaut, director Published Weekly
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Home and Family
Your Medical Questions Answered!
by Joseph B. Leibman, MD

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 sores hurt and Zovirax is now over the counter -- that means it is safe and proven. While the cream works great, don't forget the pills and liquid form can make a big difference in chicken pox. This form is called Valtrex and is a second generation antiviral -- meaning it is even more effective.

 

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