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Separating Fact from Fiction in the Not-So-Normal Newborn Nursery: Newborn Jaundice

intensive-phototherapy

Photo by Mike Blyth

By far the most common medical problem in newborn infants is jaundice, typically appreciated as a yellowish discoloration of the skin caused by increased blood levels of a pigment called bilirubin. In my role as a newborn hospitalist, I manage jaundice every day. If I am not treating jaundice, in every single baby I see I am at least determining the risk of the child developing jaundice severe enough to require treatment. I then use that assessment to help guide my recommendations on when the infant should follow up with their primary care pediatrician after discharge home.

Fortunately for the millions of infants who develop jaundice every year, in the vast majority it is a self-limited process and often considered to be just a normal part of the first few days of life. But in a significant minority of them, careful management is required in order to prevent complications. Some infants need treatment to prevent neurological symptoms from developing, and to reverse them when they do occur. And in a very small percentage of babies who develop severe jaundice, permanent brain damage and even death can occur.

Because newborn jaundice tends to resolve without any intervention, and complications are now uncommon, it isn’t surprising that a variety of myths and superstitions have arisen that involve preventing or curing the condition. And naturally there are practitioners of unproven alternative medical modalities that can be found claiming to be able to manage it as well. As expected, if you’ve spent any time reading Science-Based Medicine or researching the nonsensical claims of chiropractors, homeopaths and their ilk, their understanding is limited and their recommendations potentially dangerous.

But first a crash course on newborn jaundice.

What is jaundice?

Jaundice occurs when there is an elevation in the amount of bilirubin in the blood. In older kids and adults, anything above 1 mg/dl is considered abnormal. But virtually all babies have levels higher than this within a day or two of birth, and often considerably higher. I routinely see bilirubin levels in newborns of 15-20 mg/dl and occasionally much higher.

The higher the level of bilirubin in the blood, generally the more jaundiced a baby looks and the lower down on the body it progresses. But using a visual assessment is problematic because it doesn’t reliably predict levels in the blood in all babies. We have all been fooled by little pumpkins with low levels as well as babies with high levels despite little apparent jaundice. It can be particularly challenging in infants with more natural pigment in their skin to begin with.

Of course long before the development of techniques to measure serum bilirubin levels, people noticed that newborn infants often developed a transient yellow discoloration of the skin with no apparent associated symptoms. Historically this bore the name Icterus neonatorum, which is based on ikteros, the Greek work for what we now know as jaundice. The word jaundice is derived from the French word for yellow, jaune .

Also known to physicians of the past was a more severe form of newborn jaundice given the name Icterus gravis. They noted severe anemia, neurological effects and typically death in addition to the yellowish skin. It would be many years before the cause of this condition, as well as the many risk factors associated with jaundice in general, would be understood by medical scientists and incorporated into our care of newborns.

Why newborns?

Bilirubin in the human body, at least about 90% of it, is a by-product of the breakdown of hemoglobin from our blood. Once produced, bilirubin is bound by the protein albumin in the blood and transported to the liver where it is prepared for excretion by undergoing conjugation with glucuronic acid by the enzyme UGT1A1. This more water-soluble conjugated bilirubin is excreted into the intestines via bile from our gallbladder and leaves our bodies as metabolic waste in our feces.

In the newborn human, there is a problem at every step in this process, which is why even perfectly healthy babies are at risk of developing jaundice. Newborns make more bilirubin normally than at any other time during the lifespan because they have, on average, more hemoglobin than at any other time. Babies can even be born with too much hemoglobin, leading to a condition called polycythemia where the increased viscosity of their blood can reduce oxygen delivery to vital organs. Fetal red blood cells also have a shorter life span than adult. So more blood, and more breakdown of that blood, leads to more bilirubin in the blood.

The ability of the newborn to conjugate bilirubin in the liver is impaired because of a deficiency of the necessary enzyme. This occurs in all babies but can actually be worse in some populations, particularly in families designated as Eastern Asian. It takes over three months for the liver to reach adult capacity to conjugate bilirubin. So babies produce more bilirbubin, and more of it stays in the blood in the unconjugated form that can cause problems. It’s important to note that patients of all ages can develop a buildup of conjugated bilirubin in the blood as well which is typically related to a variety of liver diseases. That, however, is a horse of a different color. Well, technically it’s still yellow.

Finally, there are even problems with the bilirubin that does make it into the gut in the conjugated form. Older kids and adults further break conjugated bilirubin down with the help of bacterial enzymes, but it takes time for the newborn gut to become colonized. As conjugated bilirubin sits in their intestines, a human-produced enzyme deconjugates it, thus allowing it to be reabsorbed back into the body in a process called enterohepatic circulation.

We call the end result of these normal barriers to removing bilirubin from the body “physiologic jaundice” to differentiate it from the many disease states and environmental factors that can also lead to severe elevations in bilirubin. Again, this occurs in every single baby to varying degrees. It can, even without any pathological assistance, lead to jaundice bad enough to cause symptoms or require treatment, although alone it would be extremely unlikely to lead to permanent injury or death. Physiologic jaundice tends to peak at around the fourth day of life, although that peak can be higher and further out in premature and Eastern Asian infants.

What is pathologic jaundice?

There are a variety of diseases and environmental insults which can exacerbate physiologic jaundice in newborns or lead to severely elevated levels of bilirubin all by themselves. Rather than give an exhaustive review, I’ll focus on the two most important. Increased production of bilirubin from excessive destruction of red blood cells is the most common cause of pathologic jaundice. This typically occurs when the blood type of the mother and baby are mismatched, usually with the mother having O+ blood while the baby is A+ or B+, leading to the production of maternal antibodies. These antibodies can cross the placenta and signal baby red blood cells for destruction in the spleen.

ABO incompatibility can be severe, but often isn’t. But there is an extremely severe and often deadly form of this kind of mismatch which I’ve never seen thanks to advances in modern medicine. Rh incompatibility, when a mother with negative blood gives birth to a baby with positive blood, used to kill a lot of babies prior to the development of Rho(D) immune globulin (RhoGAM) because the maternal immune response is so intense. The first use of Rho(D) immune globulin in a mother, which facilitates destruction of fetal red blood cells before an immune response can occur, was in 1968. Research and treatment of Rh disease in the three decades leading up to that year is credited as the impetus for the development of neonatology as a unique specialty within pediatrics.

The second most common cause of pathologic jaundice is known as “breastfeeding jaundice”. Unfortunately, it is a well-established fact that breastfeeding is a major risk factor for the development of a severe elevation of bilirubin, which is why pediatricians tend to want earlier follow up visits after discharge from the nursery with breastfed babies. The process by which breastfeeding can negatively impact bilirubin levels is by increasing the enterohepatic circulation I mentioned earlier. If things are going well with breastfeeding, the risk is actually not much higher than in babies receiving formula. But when breastfeeding is going poorly during the pivotal first few days of life, the inadequate intake of calories and fluid leads to more unconjugated bilirubin being reabsorbed from the gut back into the blood.

The possibility of breastfeeding-failure jaundice is something we take very seriously in the newborn nursery. It isn’t the only reason why there is such a push for improving breastfeeding support of course, but it is a big part of it. We provide extensive education on lactation, document successful latching, track weight loss and the number of wet and dirty diapers, and troubleshoot a variety of potential roadblocks such as nipple pain and maternal fatigue. We are especially careful with breastfeeding premature infants, who are at increased risk of breastfeeding failure and physiologic jaundice already tends to be more pronounced.

A related but benign cause of jaundice in young infants, typically occurring during the 2nd week of life, is “breast milk jaundice.” It occurs after breastfeeding has been well established in exclusively-breastfed babies when physiologic jaundice persists after the usual rapid decline of bilirubin around the fifth day of life, and it can last for several weeks without intervention. Although the exact cause is unknown, it is believed that there is a component within breast milk that promotes intestinal absorption of bilirubin. A brief interruption in breastfeeding, usually just one to two days, leads to rapid resolution, although many pediatricians do not recommend this as there is no harm from the elevated bilirubin at that point.

How does jaundice affect newborns?

In most newborns with jaundice and even moderately elevated levels of bilirubin in the blood, there are likely no adverse acute or long term effects. The standard approach to screening and treatment of the condition, which admittedly can seem overly aggressive at times, is primarily geared towards preventing a very rare outcome known as kernicterus. This involves permanent damage to specific regions of the brain and can result in death in some cases. We believe that it should never happen, that it should be preventable virtually 100% of the time. In fact, The Joint Commission, who certifies health care institutions and programs, designates it as a sentinel, or “never” event.

As with many medical conditions, there is a spectrum of severity when it comes to symptomatic jaundice. At a certain point in any baby, the bilirubin in the blood can reach such a level that it is able to cross the blood-brain barrier and begin binding to neural tissue, which leads to cell death. The more brain tissue involved and the longer a child goes untreated, the more severe the symptoms. Although we can never perfectly predict at what level this will begin to occur in for any individual child, we tend to see subtle symptoms when levels hit around 20 mg/dl, with the more overt injury evident at 25-30 mg/dl. Anything that can impact the permeability of the blood-brain barrier, such as prematurity or infection, can lower the level that causes brain injury.

Bilirubin-induced neurologic dysfunction (BIND) can be broken down into acute encephalopathy, which is reversible with appropriate treatment, and kernicterus, which isn’t. At first, babies with increasing bilirubin levels become sleepy and begin to feed poorly. They may seem floppy or have a different sounding, high-pitched cry. As things progress, a baby can develop fever and extreme lethargy, or they may become extremely irritable and jittery. They may have no suck at all or develop an aggressive suck. Their cry may become more high pitched and urgent sounding and they may be very difficult to console. Stiffness can set in, the first sign of which is often arching of the neck and body when touched.

Without emergency treatment at this point, the damage will become irreversible. They will begin to have periods without respiratory effort and will stop feeding altogether. Fever and seizures are common as they become more persistently stiff and arched at the neck and back and progress into a comatose state. They will ultimately die from either respiratory failure or prolonged seizure activity.

Kernicterus is diagnosed when signs of brain injury become evident during the first year of life. Because bilirubin deposition in the brain tends to occur predominantly in the areas that regulate movement (basal ganglia) and hearing, cerebral palsy and hearing loss are common, as are difficulties with eye movement. The development of the teeth can also be affected. Cognition tends to be unaffected but there is some controversy regarding the possibility that even moderate levels of bilirubin elevation are a risk factor for neurologic problems later in life. At this time, the evidence is mixed but trending against any association with autism, learning disabilities, ADHD or any other psychological disorders.

How is newborn jaundice evaluated?

The key to managing newborn jaundice is awareness of risk factors, such as prematurity, genetics and whether or not the baby is being breastfed. Most hospitals incorporate universal pre-discharge bilirubin screening into our decision-making process and always attempt to establish appropriate follow up post-discharge. Our goal is the prevention of severe elevations of bilirubin in order to prevent the development of symptoms and ultimately of kernicterus.

Since the early 1990s, a systematic approach to newborn jaundice has been recommended. Every baby goes through the process of screening, risk assessment, breastfeeding evaluation (if breastfeeding), and use of an established treatment algorithm based on the bilirubin level and the infant’s hours of age. This has led to a decrease in the number of babies that develop severe elevations of bilirubin. The rarity of kernicterus has made it difficult to assess whether our interventions have successfully decreased its incidence, but it is reasonable to use severe bilirubin elevation as a surrogate outcome for kernicterus. The US Preventive Services Task Force disagrees with the AAP on this, and does not recommend universal screening, which I believe is a good example of the difference between evidence-based and science-based medicine.

I can certainly understand the hesitancy in initiating universal screening of pre-discharge bilirubin levels. Historically this has required a heel stick to obtain a few drops of blood from the baby. Heel sticks hurt without proper procedural pain measures such as use of a pacifier and sucrose, and probably aren’t that comfortable even with them. Labs aren’t free either. A fairly recent development in the management of newborn jaundice has significantly ameliorated these concerns, however.

Rather than the testing of a baby’s blood for elevated bilirubin, an increasing number of hospital nurseries are now using transcutaneous bilirubinometers (TcB). These handheld devices use multiwavelength spectral reflectance from the skin to estimate the level of bilirubin in the blood. A number of large studies have demonstrated their accuracy in various ethnic groups, but they aren’t perfect. They are unreliable once a baby has started phototherapy, possibly even if they’ve just been exposed to direct sunlight, and they have decreased accuracy at high bilirubin levels.

The typical approach to use of TcB is to confirm the bilirubin level with a blood test if the result is greater than the 75th percentile on the standard bilirubin nomogram. My personal rule of thumb is to add 3 to the result, and if that changes my management I confirm the level with a heel stick. Use of these devices significantly decreases the number of heel sticks performed, and they save money in the hospital, but they have not been recommended for use in the outpatient setting yet.

There are a variety of additional tests often incorporated into the evaluation of risk for severe jaundice, such as the infant blood type and presence of maternal antibodies when there is a mismatch. This is often performed whenever a mother has the O blood type. And naturally there are diagnostic tests when other pathology is suspected, such as red blood cell membrane defects, enzyme abnormalities, or genetic/metabolic conditions. We sometimes get even fancier. Some facilities are able to measure the amount of carbon monoxide, another break down product of hemoglobin, exhaled through the nose as a very sensitive test for abnormal destruction of red blood cells.

How is newborn jaundice treated?

Historically the treatment of jaundice was time and perhaps prayer. Infants who developed “icterus gravis” either died or had severe lifelong disability. As medical science advanced and we determined that elevated bilirubin was the underlying cause of symptomatic jaundice, a means of removing it from the blood was developed. The exchange transfusion, where blood is removed from the baby in small aliquots, dumped and then replaced with suitable donor blood, became the treatment of choice. Unfortunately the procedure was, and is, risky although its safety has improved greatly.

Fortunately, as is often the case in science, hard work, keen observation and a measure of luck led to the discovery and development of means to prevent many severe cases and safer treatment alternatives that have become the gold standard. As I’ve already mentioned, the implementation of screening of maternal blood type and use of Rho(D) immune globulin has rendered Rh disease almost nonexistent in developed nations. Again, in ten years of practice I’ve never seen a case of it.

The second advance was the realization, as infant formula was introduced and became a common alternative to breastfeeding, that breastfeeding difficulty increased the risk and severity of jaundice. Greater focus on improving breastfeeding, and at times strategic use of infant formula and mechanical breast pumping, has prevented many cases of severe jaundice. The final significant advance was phototherapy. This combination of interventions has drastically reduced the need for exchange transfusion. I’ve participated in only one. As the intern on the team it was my duty to sit in sterile gown and gloves at the bedside for 6 hours while performing the transfusion manually.

What is phototherapy?

While the practice of exchange transfusion did revolutionize the treatment of severe jaundice, and certainly improved the outcomes of thousands of newborns, it was risky. And we now know that it was done too often in babies that likely would never have developed kernicterus. This was a time before established risk factors and handy iPhone app algorithms to determine the need for treatment.

But in 1956 a nurse in England, working in the nursery at Rochford General Hospital, noticed that babies placed in sunlight for extended periods of time were less jaundiced. Biochemists in the lab were also perplexed by oddly-low serum bilirubin levels in blood samples left sitting in the sunlight. The rest is history. In 1968, a landmark randomized controlled trial published in Pediatrics by Jerold Lucey showed that phototherapy was a safe and effective treatment for newborn jaundice.

The history of phototherapy after that publication, and the struggle between two factions of practitioners over the direction of jaundice treatment is fascinating. Led by “princes of light and dark” at dueling hospitals in New York City during the decade after the paper came out, the battle over phototherapy was heated but ultimately the evidence won out and the exchange transfusion has nearly gone the way of the Dodo. And I “light kids up” weekly.

How does phototherapy work?

Phototherapy isn’t just regular light, and despite what you can find written on numerous alt med websites it isn’t ultraviolet light either. Phototherapy is blue-green light, although more recent evidence has supported a shift over to predominantly blue light, specifically between 460 and 490 nanometers. When this light hits bilirubin molecules in the infant’s skin, bilirubin is affected in three ways.

The most important effect is the irreversible conversion of bilirubin into a more soluble form via structural isomerization. The new form, lumirubin, passes into the gut and urine for excretion without the need for conjugation. Furthermore, phototherapy alters some of the bilirubin into a less neurotoxic form via a reversible photoisomerization. This doesn’t result in an appreciable drop in the level but reduces the risk of brain injury. Finally, photo-oxidation of bilirubin converts some to a form that is excreted only in the urine. This likely only accounts for a small percentage of the drop in total levels however. All in all, and please pardon the pun, phototherapy is brilliant. It is a safe, effective and all-natural treatment but it does line the pockets of “Big Light.”

“Alternative” approaches to newborn jaundice

So now you know the science-based approach to newborn jaundice. It is an approach which does “medicalize” some children that would not go on to develop symptomatic jaundice or kernicterus, but it is extremely safe and effective. Now let’s explore what some of our friends in the world of complementary and alternative medicine have to say about this common condition. Just a quick perusal, as an exhaustive discussion would both take up too much of your time and ruin my day, the first day that actually feels like spring up here.

Practitioners of craniosacral therapy get partial credit, describing jaundice as “yellowness of the skin due to the fact that the baby’s young and small liver is unable to process and [sic] excess of blood and so has to use the skin as it’s [sic] organ for release instead of the intestines or urine.” They make the common mistake of describing phototherapy for jaundice as “ultra-violet”, which if true would cause horrendous skin injury during the many hours a baby requiring therapy will typically spend under the lights. Phototherapy does not burn or increase freckling or mole development. And modern versions don’t even produce much heat as they are LED lights, thus the infant is not at risk of dehydration. Despite a lack of any evidence, they claim that CST can improve clearance of bilirubin, which could lead to false reassurance and a delay in seeking out appropriate medical care.

Believers in traditional Chinese medicine have a unique approach to newborn jaundice:

The causative factors of icterus neonatorum are dampness-heat and cold-dampness which are affected from the mother, or during delivery, or after birth. The hypofunctioning organs, particularly the spleen, fail to eliminate dampness-heat, leading to its retention in the liver and gallbladder and its distribution to the skin. Moreover, on the basis of the deficiency of healthy qi which results from congenital insufficiency or longstanding disease, the maladies of dampness-heat and cold-dampness may lead to the deficiency of spleen-yang and then the retention of the evils, and jaundice results.

Unfortunately, phototherapy has yet to be proven effective for “retained evil.”

One practitioner of homeopathy claims to be able to prevent and treat jaundice using a variety of nonexistent remedies. Please do not try to decipher which remedy is appropriate for your baby yourself, however. Only a fully trained homeopath can tell the difference between sluggish bowels and constipation.

This particular practitioner recommends letting your baby “bask” in the sunlight to treat jaundice, but I can’t just pick on homeopaths about this. The question of using natural sunlight for mild jaundice comes up frequently when caring for newborns. I don’t have data on this, but my best guess would be that a recommendation to put a kid in the sun is as common as recommendations to alternate acetaminophen and ibuprofen for fever, with most pediatricians doing it. And similar to alternating fever medicines, it isn’t recommended by experts because of risk and efficacy concerns.

We know that sunlight lowers bilirubin levels, that isn’t the issue. The problem is that in order to achieve that end, a child would need to be placed naked in direct sunlight for hours. This would place a baby at risk for hypothermia and/or sunburn. It also may only make the skin appear less jaundiced while not necessarily lowering the level of bilirubin in the blood appreciably, giving a false sense of security and potentially delaying care. This happens with conventional phototherapy as well. Once a kiddo is lit up, we have to rely on blood tests instead of a transcutaneous level.

The advice I hear most frequently given to parents, to put a baby in sunlight through a window for 10-15 minutes 3-4 times a day, would be very unlikely to lower bilirubin levels any faster than doing nothing. But because jaundice so often resolves on its own, it is easy to see why so many people think sunlight or any alternative approach “works.”

Naturopath Dr. Christopher and his son David, who “generated new ideas on the management of high blood pressure, diabetes and auto-immune diseases, and was one of the first to discourage the use of Prozac in favor of natural methods”, provide us an example of a natural approach to infant jaundice. It demonstrates a fundamental lack of any understanding of the concept. Here are a few of their pearls of wisdom:

  1. Jaundice is caused by drugs given to the mother during the birth process.
  2. Physiologic jaundice only affects blond babies, Native American babies, drug babies, premature babies, and babies not allowed to breastfeed.
  3. Catnip, comfrey and dandelion tea are excellent treatments for newborn jaundice.
  4. Wheat grass juice is also helpful.
  5. Phototherapy causes irritability and sluggishness, diarrhea, lactase deficiency, intestinal irritation, dehydration, feeding problems, riboflavin deficiency, disturbance of bilirubin-albumin relationship, poor visual orientation with possible diminished responsiveness to parents, DNA-modified effects and it might even make their lungs bleed.
  6. Severe jaundice can cause brain damage, and the best approach is to follow your maternal intuition.

Here is the scariest chiropractic “case report” I’ve ever read. It involves the chiropractic treatment of an unresponsive and jaundiced 36-hour-old infant with a heart rate in the 70′s (chest compressions are recommended when the heart rate is < 60 beats per minute in a newborn). The baby responded to the adjustments with an increase in heart rate, immediate resolution of his jaundice and a hearty breastfeed. And he was removed from the list of likely “candidates for SIDS.” But that isn’t the best part:

Interestingly, his testicles had also descended within that hour. That may have been a coincidence, but it seems noteworthy given all the other healthy indicators we witnessed as a result of the adjustments.

These examples are scary, and a little funny, but I realize that they don’t represent all practitioners of alternative medicine. Like few other fields of practice, alternative medicine is comprised of so many disparate and mutually-exclusive approaches to health that their ability to hang out under the same tent is a testament to just how much they don’t like conventional medicine. Trust me, if somehow they won and regular medicine faded away into history, it would be a bloodbath as they turned on each other in an effort to become the dominant modality.

Conclusion

Jaundice is the most common medical problem in the newborn, and though typically benign it can result in severe complications with permanent injury to the brain and even death a possibility if mismanaged. The pathophysiology of jaundice in babies is unique, fascinating, and simple enough that almost anyone can get a handle on it. Even more interesting is the history of how we came to understand the cause of jaundice and the progression from being unable to offer any treatment to only having the risky exchange transfusion as an option, and finally to the safe and effective use of phototherapy.

As our understanding of the many risk factors which play a role in the development of severe jaundice has advanced, the management of newborn jaundice has become more nuanced but also systematic and streamlined in such a way that it is essentially a process on autopilot these days. All babies are assessed for risk and, at least with the vast majority of births, universal screening of bilirubin levels is obtained prior to discharge home from the nursery. Even the decision when to treat can be made with the use of handy algorithms that take seconds to master.

Unfortunately, once we step outside the borders of science-based medical practice there are any number of practitioners of so-called alternative medical modalities that have essentially no understanding of how and why jaundice develops, which babies are most at risk and what are the most safe and effective approaches to treatment. Babies subjected to their machinations are at risk of poor outcome because of a delay in appropriate medical care.

Posted in: Science and Medicine

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55 thoughts on “Separating Fact from Fiction in the Not-So-Normal Newborn Nursery: Newborn Jaundice

  1. pwndchemist says:

    It’s interesting comparing this to my experience in Alberta, Canada. They assessed my first born at the hospital, by basically pressing what looked like a bingo dabber into his forehead, and judged that his level of jaundice was minimal. In my health region, RN’s follow up at home with a new mom upon discharge from the hospital. So, with the 5 or 6 home visits I received over the first 2 weeks, they would continually assess his jaundice levels, breastfeeding struggles and any other concern I might have. I even received a pamphlet from the hospital addressing some of these common misconceptions about jaundice and phototherapy (for instance, they say straight out that sunlight is not effective).

  2. Dan Hocson says:

    Can you or anyone else elaborate on the subject of TcB devices not being recommended for use in the outpatient setting? Our clinic just got one and the comparisons our lab ran to compare to TSB are all over the map.

  3. Clay Jones says:

    Sunlight could be effective, although not for kids with severe jaundice from a hemolytic process. And for kids in areas without access to modern treatments like phototherapy, it probably plays a role for some. I found this, but I think I don’t think it means much: http://www.ncbi.nlm.nih.gov/pubmed/11722753

  4. Clay Jones says:

    Dan, I think the issue is the possibility that the kid coming in from home may have been exposed to direct sunlight which may throw off the TcB.

  5. Zoe says:

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC300791/#!po=10.7143

    Anybody have any thoughts on this article in BMJ? I could be wrong, but the OP seems slightly over cautious to me. I know it was stated that it’s usually mild, but all three of my babies had jaundice, were breastfed, and all three resolved without treatment within a few days. There was also no mention of the benefits of breastfeeding of premature infants, only risks. I admit to have reading this a little fast. Thanks for delving into the subject!

  6. Babydoc mom says:

    Thank you for an excellent article. I have to admit that, despite also having patients on phototherapy regularly, I have yet to be asked about alternative treatments for jaundice other than sunlight.

    Just one picky point. You state that a newborn with a heart rate lower than 100 should get chest compressions. The Neonatal Resuscitation Protocol recommends compressions for heart rates below 60/minute. Several revisions ago the recommendation was for compressions below 80. Term newborns may have heart rates below 100, particularly when asleep. Though I agree that a heart rate of 70 would certainly usually be a red flag for a very sick newborn.

    I have had the (dis)pleasure of doing more exchange transfusions than I care to remember. Very glad that I haven’t had to do one in almost a decade!

    1. Clay Jones says:

      Yes, thank you for catching that. A heart rate less than 100 is certainly of concern in a child as described in the vignette, and would be an indication during neonatal resuscitation to intervene with something more likely to help than a chiropractic adjustment. I blame my lapse in accuracy on stagnant chi. My innate was a tad off that day as well.

  7. kaitch says:

    I read just recently of (IIRC) a woo-infused “midwifery” school that states bilirubin is beneficial as it is a potent antioxidant…yikes.

    1. Clay Jones says:

      I need to look into that.

      1. kaitch says:

        It’s somewhere on http://www.thematrona.com, I think. Given that the metabolites of bilirubin aren’t even spelled correctly, I don’t hold much hope for the rest of the article.

  8. Thor says:

    …difference between evidence-based and science-based medicine.

    This one could use a bit more clarity for more as I thought they are one and the same?
    thanks

    1. Andrey Pavlov says:

      …difference between evidence-based and science-based medicine.

      This one could use a bit more clarity for more as I thought they are one and the same?
      thanks

      If you need a longer answer, perhaps someone else can help out, but in a quick nutshell SBM is EBM + prior plausibility. Meaning that instead of doing a Cochrane analysis on homeopathy and concluding that “more studies are needed” because the clinical data is equivocal, SBM concludes “homeopathy does not work” because bench science informs the answer well enough. As Dr. Gorski puts it, EBM works fantastically well but is predicated on the idea of intellectual honesty in terms of what is researched and what is not. If research is done on tooth fairies, however, EBM fails to look at the idea of whether a tooth fairy exists in the first place and is content to comment on the downstream effects of tooth fairies. SBM says, wait a minute! does it even make sense that there is a tooth fairy in the first place?

      1. Thor says:

        Andrey
        Ok, got it. Thanks for that. Kind of like a benign treatment for a self limiting illness and claiming the treatment worked, and not that in actuality doing nothing at all would have done the same thing.

        1. Andrey Pavlov says:

          Thor,

          Glad to be of help.

          1. Zoe says:

            RE: evidence versus science based medicine. The article I posted above in BMJ, from one widely known experton jaundice, (Thomas Newman) talks about doctors being over cautious because of over dependence on stories rather than statistics. It’s an older article from 2003, but it goes into a lot of these issues. The truth is, for example, that universal screening for jaundice has downsides as well. That was one of the articles, long before I started reading SBM 3 years ago, that made me start questioning. I still wonder sometimes if my own personality/ philosophy better fits in with EBM because prior plausibility is… What? It isn’t bias is it, or anecdote? I know this has been talked about here before, and I always am interested in what other skeptics have to say!

            1. Andrey Pavlov says:

              I still wonder sometimes if my own personality/ philosophy better fits in with EBM because prior plausibility is… What? It isn’t bias is it, or anecdote? I know this has been talked about here before, and I always am interested in what other skeptics have to say!

              Sure, that is definitely an issue that is relevant to SBM. But abandoning it in favor of EBM is throwing out the baby with the bathwater. You can, and should reasonably, argue that the specific prior plausibilities involved should be rigorously decided upon and have a solid evidence base themselves. But the idea of prior plausibility in principle shouldn’t get thrown out.

              Precisely which ideas stated as prior plausibility are bias and anecdote vs legitimate is something that intelligent and intellectually honest people can sometimes disagree on. There is nothing wrong with that. But saying the argument shouldn’t even be had is not a solution.

            2. Sawyer says:

              There’s a really good post explaining this back from the early days of this site but I don’t have it at my fingertips. I think it was from Kim Atwood.

              1. Andrey Pavlov says:

                I believe you are referring to this which is the first part of a 4-part series by Kimball Atwood.

              2. Zoe says:

                RE: SBM vs EBM

                Yes, I read that series by Atwood a few years ago. Maybe my bias is because I have been reading about EBM for far longer than this website. I suppose I did use some semblance of SBM however, in a recent discussion about acupuncture with someone I really like and who is incredibly smart- and a scientist. He uses it and I would never. First I asked for evidence that it worked, pub-med style. Lo and behold, tons of studies came back that I skimmed showing that it helps things like headaches, stress, and knee pain. Then I asked for some explanation about how or why it worked. His answer? Science doesn’t explain everything. Oh well.

              3. Andrey Pavlov says:

                Then I asked for some explanation about how or why it worked. His answer? Science doesn’t explain everything. Oh well

                Partly placebo, partly regression to the mean, partly reporting bias, partly study artifact.

    2. Clay Jones says:

      http://saveyourself.ca/articles/ebm-vs-sbm.php

      Essentially, just because there isn’t a heap of RCT evidence that checking bilirubin levels and using phototherapy prevent kernicterus, using logic and basic science knowledge of how kernicterus happens we can safely say that high levels are a useful surrogate.

  9. Thor says:

    On a side note. Our third child had to have the lights and let me tell any parent who rooms-in with their child through this. Bring plenty of ibuprofen cause you get one hell of a headache.

    1. Clay Jones says:

      Sunglasses. It also messes with your color perception for a bit once you step out of the room. Everything seems oddly faded.

      1. Thor says:

        I just took the ones off our baby and wore those. I mean the baby can not see clearly yet anyways. (kidding)

        1. Clay Jones says:

          Their vision is about 20/400 and black and white only. That’s why they shouldn’t be allowed to drive.

          1. Missmolly says:

            Particularly if they’ve been drinking. We all know what crying for no reason, being unable to walk and spontaneously vomiting all the time means :) (apologies to Ben Elton)

  10. David says:

    I’m not interested in this particular article, rather my inquiry falls into the field of lifestyle correlation to ones health, and well being. Having been diagnosed with type II diabetes in 2006, I began to question the treatment/management of my condition, and the way our healthcare professionals are truly “practicing” medicine. I was told that I was a “textbook diabetic” requiring me to ingest a group of pharmaceutical compounds to relieve my symptoms and trick my body into functioning in a more normal fashion. I asked if there was any alternative, and his response was “that’s what the medical community suggest is the best approach”? I stopped taking my med’s and began exercising daily, and controlling my caloric intake by limiting carbohydrates, and in some instance eliminating grains all together. I would be more than willing to submit myself to your “scientific method” in hopes gaining a better understanding, if you’ll agree to report uncensored the findings? It’s my belief there’s a higher correlation between lifestyle and health than even your community is aware of, and doctors certainly aren’t in the business of eliminating their perceived benefit? ALL medicines have side effects, and we are given a tradeoff of their benefits without any notion of an alternative! Who’s interest is being served in all this? I’m interested to see if you respond?

    1. Chris says:

      “I’m not interested in this particular article,”

      Then why did you bother posting on this article and not others that are more pertinent? Like one of these articles or thoes articles?

      “I asked if there was any alternative, and his response was “that’s what the medical community suggest is the best approach”? I stopped taking my med’s and began exercising daily, and controlling my caloric intake by limiting carbohydrates, and in some instance eliminating grains all together. ”

      You should have changed doctors. When my husband was found to be pre-diabetic he was told to lose weight with diet and exercise by our family doctor. In the last two years his numbers have improved and he has not been put on any medication.

      If you have read the articles on this blog, including using the search function at the top of the page, you would have realized that diet and exercise is something that is suggested by “real science” and the medical practitioners who blog here. Plus you would learn that posting off topic comments is frowned upon.

      1. Chris says:

        “Plus you would learn that posting off topic comments is frowned upon.”

        Except for the ones that divert to fun/interesting things. Though they usually are extensions of the topic. like the cooking hints in the microwave article and the use of antibiotics in livestock in a recent homeopathy article.

      2. David says:

        Marty Hammod MD was the physician I’m referring to. My issue isn’t with the entire scientific community, but rather with the stark contrast among its participants. Referring to my comments as “ignorance” only displays your inability to understand my questions or concern. If you feel compelled to insult me, is this really the place? I’m not suggesting that the entire medical community is at fault, but the conflicting understanding of how the human body is supposed to exist, and how we’re not executing on that existence seems to be the dilemma. I had hernia surgery in Dec of 2012. My surgeon asked about my diabetes, and applauded my self therapy with no apparent concern for any of these side effects mentioned by Madison MD? The day of the surgery, I was condemned by both the nurse, and the anesthesiologist for not taking any med’s for my condition. The nurse was visibly disappointed upon checking my glucose to find it quite normal. I’m speaking from the standpoint of a patient, not an expert in the confusing delivery of care that affects my life in such a profound way. I did notice no one wanted to take on any of my statements about pharmaceutical compounds and there trade off’s as the apparent “first line” of treatment for any condition? My children are both struggling with mysterious digestive conditions, that none of the doctors they’ve seen have any explanation for, but they continually offer prescription to relieve the symptoms?

        1. Dave says:

          Please narrow the focus of your enquiry.
          I did notice no one wanted to take on any of my statements about pharmaceutical compounds and there trade off’s as the apparent “first line” of treatment for any condition?”

          Sometimes medications are first line therapy. If you have bacterial meningitis or endocarditis you get antibiotics or you get a coffin, 100% of the time. If you have appendicitis or nonmetastatic colon cancer you get surgery. Numerous diseases are not curable at present and require medication to control the symptoms – Parkinsonism, multiple sclerosis, hypothyroidism, etc. What is done in each individual case depends on the disease and the patient.

          As far as diabetes, which seems to be the drift of your question, there are reams of information written about the various medications, their ability to lower A1C levels, the evidence that they do or do not prevent macrovascular and microvascular complications of diabetes, and the various risks of these meds – cardiac risks with sulfonylureas and glitazones, weight gain with many of the meds, GI effects from others, multiple cautions about when to hold metformin, etc. This has to be balanced against the risk of having uncontrolled sugars. If you don’t understand these risks just take a trip to a pathology department some week and view the necrotic toes, feet and limbs which arrive, go to an ophthalmolgist’s office where they deal with retinopathy, talk to a pharmacist about the mountains of rather insufficient meds prescribed for painful diabetic neuropathy, or talk to a cardiologist who spends half his life taking care of cardiac complications from diabetes. If you have a particular medication you have an issue with it might be addressed in a post.

        2. Chris says:

          “Referring to my comments as “ignorance” only displays your inability to understand my questions or concern. If you feel compelled to insult me, is this really the place?”

          Only because you did not take the really big hint to take your concerns to a more appropriate article. Did you notice those lists of articles that were embedded in the blue text?

          Though this may be a hint that you feel like a jaundiced infant.

        3. weing says:

          “I’m not suggesting that the entire medical community is at fault, but the conflicting understanding of how the human body is supposed to exist, and how we’re not executing on that existence seems to be the dilemma.”

          Teach us, oh wise one. How is the human body supposed to exist? Why didn’t you get rid of and prevent your hernia with diet and exercise?

        4. Windriven says:

          “My issue isn’t with the entire scientific community, but rather with the stark contrast among its participants. Referring to my comments as “ignorance” only displays your inability to understand my questions or concern.”

          Now let’s see… You’ve taken your degree in Applied Mystical Nonsense, just about as non-scientific a course of study as one might imagine, and on that basis you reckon that you have standing on which to judge “the entire scientific community” or any part of it.

          You might be the ‘best’ chiropractor to ever put on a white coat, but that only makes you king of the charlatans. As a judge of anything scientific, you don’t quite make jester to the fools.

          ” If you feel compelled to insult me, is this really the place?”

          You come into a community of scientists and arrogantly make infantile proclamations about what you think of medical science, then complain that scientists don’t treat you with deference? Ass. Book yourself a nice adjustment. That’ll make it all better.

          1. Chris says:

            Are you mixing him up with “Jeff” in the supplement article? The one who claims that his perfect health was earned, yet will not address Dr. Hall’s list of ailments.

            1. Windriven says:

              “Are you mixing him up with “Jeff” in the supplement article?”

              Probably. Are we approaching some sort of mutant syzygy? I swear the kooks and nut jobs have been thicker than black flies at a Minnesota Fourth of July.

              (Emily Litella voice): Never mind.

              1. Chris says:

                “I swear the kooks and nut jobs have been thicker than black flies at a Minnesota Fourth of July.”

                It just looks that way with Rodriguez’s spamming. I just ignore him. The other two each have a different kind of Dunning Kruger Syndrome. “Jeff” needs to answer some questions about how genetically associated disorders can be prevented (especially through chiropractic “science”) , and the “David” here needs to figure out how to post on the appropriate article.

                Though I do like imagining someone who can access the internet and type a complaint while still being an infant with jaundice.

    2. Windriven says:

      “I’m not interested in this particular article,”

      I’m not interested in this particular comment because it thoroughly misstates the medical understanding of Type II diabetes. I don’t know who you asked or even if you asked but I find it hard to believe that any medical doctor told you that your disease could not be managed without a load of pharmaceuticals. Diet and exercise are first line approaches. If you are managing your diabetes this way, congratulations, you’re doing it right.

      ” I would be more than willing to submit myself to your “scientific method” in hopes gaining a better understanding, if you’ll agree to report uncensored the findings?”

      There is enough stupid packed into this single sentence that I had to reread it to be sure you weren’t kidding. But no, inflated with the arrogance of profound ignorance, you’re going to school the scientific community on just what’s what on the relationship between diet and health – all on the strength of managing your diabetes.

      I bow to your brilliance.

    3. Dave says:

      Pick up ANY medical textbook and you will find that diet and lifestyle changes are step number one in taking care of diabetes. Sometimes this alone can control diabetes. Most individuals with diabetes will eventually require pharmacologic therapy at some point. Here is what UpToDate has to say about diet (they have a similar section on exercise which I’m not going to report):

      ” Besides contributing to microvascular and macrovascular disease, hyperglycemia adversely and reversibly affects both insulin resistance and insulin secretion [2,3]. Weight reduction, diet, and exercise can all be used to improve glycemic control, although the majority of patients with type 2 diabetes will require medication over the course of their diabetes [4].

      Weight reduction

      Diet — Dietary modification can improve many aspects of type 2 diabetes, including obesity, hypertension, and insulin release and responsiveness. The improvement in glycemic control is related both to the degree of caloric restriction and weight reduction [5,6]. Modest weight reduction may also improve liver function in nonalcoholic steatohepatitis, which is associated with insulin resistance and type 2 diabetes. (See “Natural history and management of nonalcoholic fatty liver disease in adults”, section on ‘Weight loss’.)

      The immediate effect of caloric restriction is not well understood but may be related to depletion of hepatic glycogen stores, thereby reducing hepatic glucose output, the main determinant of fasting blood glucose. However, this benefit will persist only if negative calorie balance and weight reduction are continued.

      Several studies have evaluated the long-term efficacy of diet (alone or with exercise) in patients with newly diagnosed type 2 diabetes. (See “Nutritional considerations in type 2 diabetes mellitus”.) In the UKPDS, for example, all patients were given a low calorie, low fat, high complex carbohydrate diet [7]. After three years, only 3 percent of those treated with diet alone had achieved and maintained the desired fasting blood glucose concentration below 108 mg/dL (6 mmol/L). Furthermore, the mean glucose value was substantially higher with diet alone than with diet plus an oral hypoglycemic drug or insulin.

      The likelihood of a successful response to diet is determined in large part by the initial fasting blood glucose. In the UKPDS, the degree of weight loss required to normalize the fasting blood glucose was 10 kg (16 percent of initial body weight) if the initial value was 108 to 144 mg/dL (6 to 8 mmol/L), versus 22 kg (35 percent) if the initial value was 216 to 252 mg/dL (12 to 14 mmol/L) (figure 2). Of note, any degree of weight loss is likely to improve glycemia and/or decrease the need for medications.

      Despite the clear benefit of weight loss, only a small percentage of patients with type 2 diabetes are able to attain and maintain substantial weight loss [5,8,9]. This difficulty results from both limited success in long-term adherence to calorie-restricted diets, plus an apparent effect of weight loss in lowering the metabolic rate, thereby retarding further weight loss. (See “Dietary therapy for obesity”, section on ‘Maintenance of weight loss’.) There are, however, impressive successes reported with intensive dietary intervention [10,11].”

      As an aside, it is quite easy to access information about standard medical treatment recommendations for things like diabetes. Congratulations that you are one of the people who have been able to control their problem with diet and exercise.

    4. MadisonMD says:

      I wonder what David’s HgbA1c is? One does’t feel ill with DM2 until years of hyperglycemia ravage the body. My father-in-law ignored his, then died of it after years of dialysis, amputation, heart disease and chronic infection.

  11. Emily says:

    Many years ago, my friend’s sister gave birth to a baby who was diagnosed with jaundice. Because jaundice was so common, the hospital had a pamphlet to give the parents explaining the situation. It was entitled “I Am Curious, Yellow.” You have to be a baby-boomer or older to get the joke.

    1. matt says:

      Or just someone who likes strange foreign film. I worked at a video rental store when I was just out of high school in 1999 and I was able to take home three movies at a time. The foreign film section was my favorite. Although, I never found the companion movie, “I Am Curious, Blue”. That’s a funny reference though.

  12. Calli Arcale says:

    This typically occurs when the blood type of the mother and baby are mismatched, usually with the mother having O+ blood while the baby is A+ or B+, leading to the production of maternal antibodies.

    That’s interesting. I was jaundiced when I was a newborn. (And, reportedly, the hospital staff at the hospital were a bit startled at how yellow I became, as my Swedish ancestry made me easily the least pigmented baby they’d had in a while there. We’re quite pasty white in my family; we barely even tan, even if we burn.) My mother is O+, and I’m A-. So perhaps the ABO mismatch led to the jaundice. Interesting!

    I was also breastfed, and was several weeks early. I don’t know if I got phototherapy, but I would guess so.

    1. Teresa says:

      Almost certainly the blood mismatch was the cause. I too am A- with an O+ mom, and I did have to have the lights. Mom has often told me the story of having to travel an hour to get to the only hospital around that had them, as the one I was born in didn’t. They told here at the time that it was a really common thing and they were surprised she hadn’t been told to be on the look out as soon as they figured out my blood type, as O+ with A- or B- *usually* results in jaundice.
      Mom to this day is convinced her lack of insurance is the only reason she was sent home the same day she gave birth with a blood type mismatch baby.

      1. Clay Jones says:

        ABO incompatibility actually doesn’t cause problems that often. Even when a mom is sensitized, the immune response usually isn’t that robust. But it can in some cases be severe so we are definitely more cautious when it comes up. When we determine the need for phototherapy there are three risk levels which depend on a variety of factors of which ABO mismatch is one. The same bilirubin level may be nowhere near light up in a low risk kid but well above in a high risk kid.

  13. Fotis says:

    Good article… As a layperson I came face to face with Jaundice with our first born. On discharge in an almost routine delivery (water ruptured prematurely and the labour had to be induced) we were discharged after the nurse had a final check of the results.

    First learning as a parent. Study the medical persons face and listen to the messaging. The nurse said in a straight face “the doctor said he should be fine”.

    After some a couple of days of problems with feeding at home, our son would sleep for 4 hours nurse for 5 minutes and go back to sleep without eating much… We went to the emergency room…. The doctor said we should go home and “relax”

    Second lesson. Insist on being admitted when you are convinced it is required. As trained SW engineer I worked out all the causality paths and came to the firm conclusion that being sent home was nothing more than wishful thinking on the doctors path. He could not substantiate his recommended course of action and explain to us how it was any different than what we had been doing. He effectively threatened us that admitting him would require a spinal tap as they would have to rule out encephalitis. Funny seeing as he was trying to send us home. Given our situation we considered all options and were admitted.

    Test showed he was in the 25-30 mg/d range and that because of the lethargy brought on by the Jaundice he had become mildly dehydrated. He spent 3 days under the lights and the rate had started decreasing so were scheduled to be discharged but a false positive on a blood test required us to spend another 3 days in hospital and have a consult from the infectious disease specialist.

    Our pediatrician gave us a follow up blood test 4 weeks later and the rate was 20 mg/dl; concerning but improving. After 8 weeks values were closer to normal.

    1. Clay Jones says:

      For arguments sake, assuming your details are accurate, there is so much wrong with that scenario I don’t even know where to begin. Half of my job, maybe more, is communicating uncertainty. When a child is readmitted to the hospital, how we discussed expectant management with the family makes the difference between them being angry at how the medical system failed and being mentally prepared for the possibility and grateful for the thoughtful care.

      1. Windriven says:

        ” [H]ow we discussed expectant management with the family makes the difference between them being angry at how the medical system failed and being mentally prepared for the possibility and grateful for the thoughtful care.”

        Our friend Stephen Rodrigues is fond of asking “where is the art of medicine.” It seems to me that Dr. Jones captured some of it in that sentence. The “art” part of medicine isn’t found in trying to manipulate patients with theatrical placebos, Some of it is understanding the patient and their family and helping them to manage expectations.

        1. Clay Jones says:

          Don’t get me started on “the art of medicine”. That actually is likely going to be the topic of my next post. The concept needs to be retired with extreme prejudice.

  14. Geek Goddess says:

    Clay, although I know the RhoGam shots are offered first by a woman’s obstetrician, have you run across the anyone who refuses them because (ahem) the Rh factor is medical hype and can be taken care of by diet, exercise, and some random herbal supplements?

    1. Clay Jones says:

      I haven’t Naomi. Plenty of vitamin K, hep B, eye ointment and vaccine refusal.

  15. tiny says:

    You’d think that AltMed types would totally love LIGHT therapy, I mean, it’s LIGHT! But no, it happens in hospitals and is accepted mainstream, so it must be the one light therapy that’s evil, while all the other light therapy is so goooood.

  16. Newcoaster says:

    An interesting review on a topic that I haven’t dealt with since med school and residency. Since obstetrics has never been part of my practice, neither has neonatology.

    One annoyance is you forget you are dealing with an international audience, not just an American one, and the units you site for bilirubin levels ( mg/dl ) , like Farenheit for temperature, or feet and inches for distance, are not used in the rest of the industrialized world. It would be nice to have international units listed as well in articles on SBM.

  17. There will be an interesting article in Pediatrics next month (currently published online) about the “Safety and Efficacy of Filtered Sunlight in Treatment of Jaundice in African Neonates.”

    They placed jaundiced infants under a canopy and “Sunlight was filtered with commercial window-tinting films that remove most UV and significant levels of infrared light and transmit effective levels of therapeutic blue light.”

    They concluded that it could be considered an alternative in places where they didn’t have conventional PT.

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