Breastfeeding, infant hyperbilirubinemia, statistical graphics, and modern medicine

2010 May 17

So by now the cat is out of the bag, so to speak. My son Nicolas was born Tues May 4, 2010, so I am going to add a new topic to the blog to do with science and medicine related to Pediatric care. I am very interested in the transition that medicine is undergoing from a purely model driven art to an evidence and model driven science. You might think that this would have happened say in the 1940's or so at the dawn of modern medicine (development of vaccines and antibiotics) but it really hasn't even now become a hard science based endeavor. This is in part due to the difficulty of ethical experimentation on humans.

For now, what I want to talk about is related to our experience in the local hospital (to remain anonymous). After arriving in Maternity my wife was on some IV opiate painkiller and recovering from the opiates used in the spinal anesthesia. Unsurprisingly after many many hours of labor followed by C-Section and soforth, she was asleep for quite a few hours, perhaps from 11 AM to 5 PM. The baby, also tired from the whole process, and swaddled by the nurses, slept the whole time as well. Nicolas was born at about 3.5 kg and full term, with 8-9 Apgar score (indicating excellent health) so we were not concerned at this point, we were primarily tired.

Now my wife is exclusively breastfeeding our child, which means that the child's intake of fluids is limited to whatever early colostrum is available. That was counter to the main experience at this hospital. Most people seem to exclusively bottle feed and infants have a very high fluid intake immediately. The hospital room had an HVAC vent running continuously providing perhaps 20% humidity air, acting as an excellent dessicator and a staff of nurses whose primary experiences are with bottle-fed formula babies and many of the nurses spoke English as a second language. We spent much of our waking hours begging for drinking water which was only available behind a locked kitchen door. As an infant, the surface area to volume ratio is much higher, so infants dehydrate even faster than adults. This, together with a total lack of early explanation about the nurses expectations led to a lot of concern on the part of the nurses that the child would become unhealthy through dehydration and starvation. I believe at this point that the nurses dropped the ball in terms of communication, and the ball would stay dropped until the day nurse on Thursday who spoke with a very understandable accent and who clearly cared about communication and was more on board with the breastfeeding experience.

In any case, Wed morning at about 24 hours of age, the nurse came to take a bilirubin screening. This is done with some kind of photometry directly through the skin via a contact probe. Based on the measurement levels from the screening (8 to 10 mg/dL) they decided to do a heel-stick and get a quantitative blood total serum bilirubin level. This came back at about 7.5 mg/dL (if I remember correctly). Based on this reading the nurse station had a chart provided by the AAP (American Academy of Pediatrics) which looks like this:

Bilirubin Risk Chart from AAP

Bilirubin Risk Chart Used by Nurse Station

As you can see from the chart, at 24 hours a 7.5 mg/dL reading would plot in the "high intermediate risk zone". What does that mean? It is my belief that it turns out that no-one really knows what this nomograph means. If you go to the AAP guidelines article (linked above) it appears that this nomograph is designed to help decide whether or not the infant needs bilirubin monitoring (and of course the parents would need jaundice education), it is not an indicator of the need for treatment. An infant that falls in the low risk zone can pretty much be ignored, an infant in higher categories has a risk of developing hyperbilirubinemia requiring treament. The word risk does not refer at this point to the babies health, but rather that there is a probability that phototherapy and other treatment will eventually be required. However, this technical use of the term risk causes potentially quite high stress levels in both nurses and doctors, and then through them to the parents. These stress levels themselves interfere with frequent breastfeeding, which is of course the primary treatment that would be recommended for an otherwise healthy infant since bilirubin is excreted into the gastrointestinal tract and the urine.

Why such a fuss about bilirubin? It's a common issue that babies experience some amount of jaundice. This can be caused by a variety of factors which you can read about elsewhere. However the wikipedia article points out that in infants, especially pre-term infants, the blood-brain barrier is not well established, and therefore bilirubin can enter the brain where it can cause brain damage if it remains high enough.

The AAP guidelines go on beyond this initial nomograph to figures 3 and 4 which are the guidelines for starting phototherapy, and then for initiating an exchange transfusion, a highly invasive operation in which the baby's blood is replaced with donor blood to prevent Kernicterus, a kind of permanent brain damage. These graphs look like this:

For Initiation of Phototherapy:

Phototherapy initiation chart (AAP)

Chart published by AAP for initiation of phototherapy

For Transfusion:

AAP chart for initiation of exchange transfusion

AAP chart for initiation of exchange transfusion

Back to the Story:

After reading off the initial "High Intermediate Risk Zone" measurement, the Pediatrician was notified.

In the meantime, my wife had an intensive 2 hour one on one session with a lactation consultant who seemed underemployed at this hospital but was extremely helpful and respectful. The net result was that we discovered the main difficulty of getting little Nicolas to eat was his strong sleep response to the warm conditions of swaddling by the somewhat old-fashioned tues evening and wednesday morning nurses.

Throughout the day tues and wed we were asked to keep a record of breastfeeding (time and duration for each breast) and diaper changes (time and color and fluid content), and of course this log was mis-used by the nurses to misinterpret our infrequency of breastfeeding. The form is fairly rigid requiring you to fill in certain boxes for start time, and duration and soforth. There was no way to put in for example a description of the 2 hour lactation consultation in which the baby suckled for say 3 minutes at a time every 15 minutes continuously for 2 hours. Also it was impossible to say that we tried for 1/2 hour on each breast in order to get say 10 mins of total suckling time. At this point I began to keep a more free form journal of the same information but with more extensive comments.

By the afternoon the Pediatrician had ordered continuous dual phototherapy and a second morning heelstick early Thurs to get total serum bilirubin levels after a full night of phototherapy. Practically speaking this means two different lights were to be on him at all times when he was not being breastfed. This pediatrician seemed to be somewhat dismissive of our concerns that this was overkill and would interfere with proper bonding and breastfeeding. She informed us that he was almost in a high risk category (which she clearly interpreted as high risk to his health) and that she wanted us to breastfeed as often as possible and to have the continuous therapy to prevent any danger. Since then, having had plenty of time to carefully read through the guidelines and things I now know what went wrong, and I blame the AAP and their choice of communications methodology. Edward Tufte would not be amused. More on that below.

A plastic temperature controlled incubator was brought into the room, and a combination of a blue/UV fluorescent light and a halogen bulb were trained on him for the duration of the night. To protect his eyes he would wear a so called "Biliband" which is a sort of velcro fastened eye-mask. For the next 12 hours or so (from about 9 PM to 9 AM) he would stay in the incubator (held at 32 degrees C) with these lights shining on him continuously. The UV fluorescent clearly produced ozone in the room which we could smell, and was potentially damaging to our eyes and lungs. The plastic of the incubator most likely protected Nicolas from the UV content but when we asked the nurses they weren't sure what we were talking about, even the NICU nurse who helped set up the incubator. Apparently the blue spectrum of the light is relatively more active at converting bilirubin in the skin into a water soluble form that can be easily excreted. However, the warm temperature of the incubator of course compounded Nicolas' sleepiness and made getting him to suckle more difficult. So while the bilirubin was being solubilized by the light, the heat was preventing us from giving him the food and moisture he needed to excrete it.

Luckily we had brought a copy of the Merk Manual where we could look up some information about bilirubin, and we found that the general levels at which phototherapy were recommended were much higher than the ones quoted to us from the heel stick, so our level of stress over the bilirubin itself was reduced, however the new stress became the frequency with which Nicolas would claw the biliband off his eyes and over his nose, and his resulting breathing distress. Throughout the night she breastfed him at between 1.5 and 3 hour intervals and we constantly had to adjust the band and calm him from struggling in the clearly uncomfortable and scary plastic box.

By Thursday morning the bilirubin level was at 10 mg/dL leaving him in the middle of the low and high intermediate risk zone on their first chart (an inappropriate chart for the use they were putting it to).  We were lucky enough to get a really first rate day nurse (mentioned above) who switched us to in-arm holding of the baby while using a single halogen light and removed the incubator. When the pediatrician returned, she approved the new setup but required a second halogen light. So for the next 12  hours or so Nicolas got breastfeedings while blindfolded and intensively irradiated by halogen lights with his mother and I wearing our sunglasses continuously. This continued throughout the day and next night, until the next morning's heelstick which came back in the low risk zone (again on the first chart). The doctor ordered a final heelstick that afternoon at 4:30 and discharged us after it too came back low risk.

What went wrong? A case of bad statistical communication

Decision making:

Knowing the basic biochemistry of bilirubin toxicity, and the fact that many infants have jaundice and the variety of causes for onset of jaundice is very different from being able to come up with guidelines for treatment. That is why the AAP has put together a specific study group on this problem and they have published the guidelines article above (one version in 1994 and an updated version in 2004). It would surprise me if the Pediatrician had never read the guidelines at all, but it would not surprise me if she were confused. Basically the article is confusing and especially the graphical displays. Contrast the 3 different charts and an associated flow chart for decision making with the following chart developed using the AAP 1994 recommendations at a Kaiser hospital in Colorado:

Mehl's comprehensive chart

Mehl 2004 comprehensive chart based on AAP's guidelines

This comprehensive chart attempts to be a full graphical communication of the essential decision making content of the AAP guidelines. For a given age (in days, x axis) and bilirubin content (presumably mg/dL vertical axis though the lack of a units label is inexcusable) the color zone keys you to a right hand group where the summary of the recommendation from the AAP guidelines (1994) is given. This chart completely ignores the so called "risk type" chart (the first chart from the AAP) which is totally unhelpful for clinical practice since it has nothing to say about actions to take. Instead this chart focuses on the recommendations for treatment. A 3500 g baby presenting with bilirubin levels of 7.5 mg/dL at 1 day age doesn't even qualify for considering phototherapy, even if he were as small as 1500 g less than half his actual size he would not qualify. And yet the first chart above puts such an infant into the "high intermediate risk zone" which no-one actually understands but everyone thinks they understand... in a manner totally devoid of consideration of the size of the infant.

Bilirubin is measured as concentration, which means for a larger infant, at the same concentration, there is more bilirubin, so it might at first seem to be irrelevant what size the infant is. However the toxicity of bilirubin is controlled in part by the undeveloped nature of the blood-brain barrier and other organs such as the liver and gut, so I interpret the AAP recommendations as implying that larger, more mature infants must have healthier organs and blood brain barriers and hence can tolerate more bilirubin.

Treatment:

Suppose for a moment that the guidelines did justify the start of phototherapy, or that the doctor wished to be more cautious due to the presence of the overenthusiastic HVAC or the greater difficulty that a mother with a C-Section delivery might experience in breastfeeding. Does science support the type and degree of phototherapy used?

First of all, what is known about how phototherapy works? We know that bilirubin in the skin is photo-isomerized into a more water soluble form, and then can be excreted more easily. How long does this transformation take? What are the kinetics of this reaction? Is it necessary to irradiate continuously or is it just as good to do intermittent irradiation? How about turning to get all of the skin evenly irradiated? These questions are of significant practical importance, since for the non-critical child, the parents will be caring for and feeding the child during the therapy, and any interference with the feeding and bonding can compound the child's problems.

I found that intermittent treatment is a somewhat controversial subject. This paper from 1984 used a small randomized trial and suggested that intermittent treatment about 1 hour out of 4 was just as good as continuous treatment. More recently, this paper on position changing (turning over) suggested that perhaps changing positions to irradiate more of the skin was actually counterproductive. The idea is that after the bilirubin in the skin has been thoroughly bleached out (about 150 minutes) the light can penetrate into the blood supply below the skin and directly convert a large amount of bilirubin in the blood. So from a practical perspective, perhaps the best method would be to do something like 3 hours at a time (180 mins) every 6 hours which is compatible with the usual breastfeeding schedule of every 2 or 3 hours.

Conclusion:

I'm not a doctor, and this is not to be considered medical advice, but I am a competent reader and interpreter of biological, scientific, and technical articles, and have worked with research biologists both casually and professionally. My reading of these things suggests the following summary:

  • Hyperbilirubinemia is a serious condition, requiring alertness and proper care when present.
  • The AAP has comprehensive clinical guidelines for treatment.
  • The AAP has done a terrible job of communicating their clinical guidelines. Especially graphically.
  • Most doctors and nurses may be unaware of the correct method for using the AAP provided statistical graphics, and standard chart packets may not even include the proper decision making graphs (no-one from the hospital showed me the other two charts at any point in time).
  • Breastfed babies are likely to have higher bilirubin but unless this level reaches action levels suggested by AAP, it is not an unexpected problem, and mothers should just be cautioned to try feedings frequently, and babies should be kept in a not-too-dry climate controlled room.
  • Except in cases of truly high bilirubin heading towards transfusion, intermittent phototherapy would seem to be much preferable due to its lower stress inducement and higher compatibility with parental bonding and breastfeeding. The truth is that the child will probably be on intermittently anyway, so the parents should not be made to feel as if they are compromising treatment.
  • Turning is apparently counterproductive. I think it makes sense to have the child breastfed while lying on his side with his back irradiated by halogen type light, but I could also see intermittent feeding followed by face-up irradiation of the stomach as a good alternative. (Elsewhere you can read about why babies should not sleep on their stomach due to SIDS risk).

I hope this article helps some doctors and nurses somewhere to improve their practice of care for breastfed infants, or helps the parents of newborns to better understand what the clinical reality vs. recommendations are. I also hope this article helps the AAP and doctors in general to improve their communications and to take the practice of statistical decision theory seriously, and consult with statisticians and visualization experts in developing their risk analysis and decision tools. Gone are the days when doctors have the luxury of spending a significant amount of time wading through multiple poorly designed charts and graphs to get to a practical decision. I applaud Mehl for making a strong effort to do a better job of summarizing the clinical guidelines in graphical form.

14 Responses leave one →
  1. May 18, 2010

    As a science student, you must be familiar with people who have no formal training in science, haven't spent their life immersed in scientific processes, but who nonetheless feel qualified to point out where existing scientific practice is "doing it wrong". It seems to me that you're doing the same thing here, but with medicine.

    I fully support parents/patients scrutinizing their medical care and being intimately involved in decision-making processes (something I've had to do several times with my own children too), but by writing this article you've gone quite a bit farther than that. You are suggesting how medical professionals can "improve their practice of care" by following *your* recommendations for bilirubin intervention instead of their current guidelines. This seems inappropriate to me and not something a responsible person would do without working with a medical professional, after they're out of the woods with their own child and able to survey the issue more broadly.

    As a case in point - my youngest son had a very complicated birth and spent about a week in the NICU after delivery. For some of the issues, including having the emergency c-section in the first place, we didn't really "see what the big deal was." And I'm a scientist, and my wife's a primary care pediatrician. However, with the benefit of hindsight and being able to put the whole picture together (something I believe the OB and neonatal team were doing on the spot), his story scares the shit out of me. He very easily could have not lasted through that first week if we had pushed too hard against the advice of his caregivers.

    I do hope you can follow up with a neonatal research physician and an expert in medical communications to further pursue this topic, and continue to share what you conclude, because I do agree that medical communication and decision-making is very difficult and needs a lot of work to improve as a field. But I also hope you can refrain from making ill-considered recommendations about medicine without a medical degree.

    Finally, to end on a positive note: congratulations on your son's birth, and I'm glad things worked out well for him in this story. =)

    • Daniel Lakeland
      May 18, 2010

      Ken, thanks for your comment. You suggest that I believe that "medical professionals can 'improve their practice of care' by following [my] recommendations". The actual case is that I think they would improve their practice by following their own recommendations. It's the AAP that makes the recommendations about when to treat and when not to treat, and I have no information that would improve on those recommendations. I do however have the time and critical reading skills to read through the AAP recommendations and realize that the hospital and doctors were not following those recommendations, and were using statistical charts given by the AAP in an manner that the AAP itself says is inappropriate.

      The big message that I would like to get through here is that it's not enough to analyze your data and come up with good recommendations, you also need to communicate them in a way that people can understand. That's something that the AAP completely failed to do apparently, and the attempt by Mehl in 2004 did a much better job.

      From the standpoint of the intermittent treatment and bilirubin kinetics portion of my article, the AAP itself recommends more aggressive treatment for more severe risk and there is a footnote to Mehl's chart that mentions that explicitly. My point there was to point out that over-aggressive treatment when it's not warranted by the recommendations is itself potentially a bad situation.

  2. Dennis Hazelett permalink
    May 19, 2010

    For the first couple months after the twins were born we used to fret a little that the girls were in the lowest 2%ile of the growth charts. Sometimes they dropped off the chart completely. After about six months of that I started tuning it out. Here's a thought: MY GIRLS ARE LITTLE. If I had a dime for every time some physician or sonar tech told me some finding put us in a "high intermediate risk" (or similar category) for some condition or other.... Anyway, you may be right, that there's some miscommunication between the organizations that create the standard of care and the care providers themselves.

  3. Vinod K. Bhutani permalink
    May 25, 2010

    It is unfortunate that your pediatric experience was not pleasant. Though I am pleased to note that you amassed some insight about a condition that is usually benign and non-intrusive but in some (those at risk) tragic, if unmonitored and untreated. Treatment does not always imply phototherapy. Also, phototherapy is not UV light. If you wish to read further, I can send you a copy of my recent article (Pediatric Health, 2009 (3): 369-379 at Future Medicine which addresses most of the questions that you have raised (and could have been addressed by your pediatrician) . Regardless, congratulations on the wonderful journey of fatherhood.

  4. Shirley Peek,BSN, RNC permalink
    March 12, 2012

    Using Wikipedia as one of your informational sites does not help your case. Hyperbilirubinemia is complex with multiple variables including birthweight , gestational age, ABO incompatibilities along with manner and success of feedings. The fact that all infants are routinely checked was a parent driven initiative. Infants can have a high systemic bilirubin level and yet not appear that way clinically. You appear to have a significant problem with nurses particularly ethnic nurses. To address issues with poor commication with a nurse that cannot be remedied by speaking with her; go up the chain of the command, charge nurse, house supervisor, etc. We will routinely use biliblankets which "sandwich" the infant with light. They can be fed, hugged, loved, and snuggled with them on. No harm to family bonding. Your piece makes it sound as if physicians place the nomagram on a board and throw a dart to determine treatment. It is a very concrete process following strict guidelines and standards of care.

    • Daniel Lakeland
      March 12, 2012

      Shirley, thanks for responding. I agree that Hyperbilirubinemia is complex, which is why I applauded the development of the all-in-one nomogram that I linked to. The real point of my post was to show how complex the process is and how many ways it can go wrong, and also how the statistical graphics/communication of the AAP can cause some of the "going wrong" by being confusing.

      Although it may be "routine" in your practice, at our hospital there were no biliblankets. There was a bilibed which had light coming from below, and was very well accepted by our child, and did not generate ozone (which the ancient 1970's era fluorescent tube light from the first night certainly did). One of the best nurses we had was a Chinese woman, but a Chinese woman who spoke excellent English. She suggested the bilibed and brought it to us, and things were going well, until the doctor arrived and reprimanded her severely and ordered it removed and a return to two hot halogen lights.

      You make it sound like the treatment of jaundice is a well understood and well orchestrated affair. I hope that *is* true in many cases, but it certainly was not true in my circumstance.

      Nursing is a profession that should involve a lot of communication. My sister is a Nurse Practitioner, and I have several NP friends. They take communication with the patient very seriously, usually much more so than most doctors I've dealt with. In our situation there was a severe lack of English speaking nurses. This was because the hospital we were in (the only one supported by our insurance) serves a predominantly east asian community (Chinese, Vietnamese, and the like). I'm sorry if it seems as if the ethnicity was the issue for me. By itself, it certainly wasn't, the best nurses we had were a black woman and the previously mentioned chinese woman, but we also had nurses who either spoke almost no english, or spoke with such an incredibly thick accent that it was impossible to communicate. Sometimes even the charge nurse was difficult to communicate with.

      As a nurse, you understand what the chain of command is and how and when to "go up the chain". As first time parents who had almost never even been to a hospital, and who had been awake for several days straight, we certainly did not understand that.

      I think based on the evidence available to me, that the variability in the understanding of how to treat jaundice can vary widely, including everything from the ability to read the nomograms, even the availability of the nomograms in the chart packets, to the type of equipment available, to the patient education, and to the communications between nurses and doctors and breastfeeding consultants. For example, in the desk chart packets that our nurses were using there were no copies of the second and third AAP nomograms (the ones for initiation of phototherapy and for initiation of transfusion). Now perhaps that hospital feels that the nurses who are charting are only supposed to do the risk monitoring and leave the initiation of therapy to the doctor, but considering that the nurses were fighting with the doctors over what type of phototherapy was acceptable, I still maintain that the level of integration of care can vary widely from what you are used to.

  5. Joshua permalink
    August 24, 2012

    Daniel, fantastic blog. I love that you and you have taken an active interest in your child's healthcare. Remember that no one, not even doctors and nurses, will ever care or have the invested interest that you do in your family's care.

    First, I'll let you know that I am a family physician. I finished residency this year, and during that three year period spent around around 20 weeks working between the obstetric/postpartum inpatient unit and the nursery. I was personally responsible during those three years for the care of over 100 infants, ranging from normal to level 2 care. This was not a NICU, though I did spend 4 weeks learning as an intern in the NICU as well (time not counted above).

    Now that you have some of my background, you will know where I am coming from in my response, which I think you will mostly agree with.

    First, I agree that at initial overview it would appear that there was a great deal of confusion in your son's care. This is not meant as a legal or other condemnation of the physicians and nurses involved. It is unlikely even if there had that you could prove harm anyway. And of course there is the possibility that some facts are misrepresented (unintentionally of course) or unknown in the case. I make it a point never to criticize another physician unless I am charged to do so by a medical board or legal obligation, and even then not before interviewing the physician, reviewing the chart, and getting to know the patients (if possible).

    Management of hyperbilirubinemia IS confusing. And it does involve a fair understanding of statistics and statistical graphics. The AAP guidelines, while confusing CAN be followed, and you seem to have developed a very good grasp of that here. I once again applaud you for your vigilance and efforts. I hope that your case will be a wake up call for pediatricians and family physicians who stumble upon it.

    I can assure you though, that at least in my training, a sound understanding and applicable knowledge of this subject was REQUIRED before completion of training. We had multiple unit tests, and comprehensive exams that covered this very topic, because it is so important. Even though pediatrics is only a portion of what family physicians do, this topic was considered critical knowledge. Not only were we required to know the difference between the graphs you have shown here, but we were required to understand how the graphs were generated, and read the core studies that were used to generate them. The topic has always been fascinating to me.

    And lastly, most interestingly to me, this topic recently hit home when my first son was born, and was found to be in the High Risk Zone at 48 hours. As any medical professional who is also a parent can attest, years of training can quickly fly out the window when confidence fades over the treatment of your own. And so, as any diligent father would I read the guidelines myself, once again reviewed the articles and graphs, and reasserted my knowledge on the subject.

    Thank you again for your post,

    Joshua

    • Daniel Lakeland
      August 24, 2012

      Thank you Joshua for your comments. The doctor we had was probably in her late 40's early 50's so that it's possible her training was not as intense on this particular subject, in part perhaps because the subject was less well developed during her initial training. I'm glad to hear that current training involves a comprehensive understanding of this topic.

      What is current training with respect to intermittent phototherapy, and turning vs exposing only one side?

      Finally, I hope like me your child is doing very well. Mine is 2+ years old now and a walking-talking-running-biking-jumping terrorizing-his-younger brother toddler! 🙂

  6. Joshua permalink
    August 24, 2012

    What you say about that physician's training may very well be true. There are other possibilities as well, it may be that this physician had recently relocated from a place or facility in which this wasn't a frequent concern, and or guidelines have changed. But rest assured, my training (which was btw at a hospital here in the midwest USA) was very thorough on the subject.

    In terms of intermittent phototherapy, this is largely dependent upon who the medical director of the nursery is. In the two different hospitals I worked at there were two different policies. From my understanding it can be situational depending on the suspected reason for the hyperbilirubinemia. For instance, if it is thought to be secondary to excessive stress from delivery (bruising) and exclusive breastfeeding (mild dehydration) as it was with my son, I would personally prefer that approach. If on the other hand it arises from an ABO compatibility issue, and the child is riding the line between lights and transfusion I would probably prefer continuous therapy. I do like the blankets which can expose both sides, unfortunately you never want to have a newborn sleeping or lying face down unattended, which means that depending on facilities and staffing, turning the infant might not be appropriate.

    And yes, my son is doing well. Only 3 days old at the moment, but as far as we can tell things are going well! We decided to supplement with some formula to alleviate the physiologic dehydration from exclusive breastfeeding, and when the milk truly drops we will go back to exclusive breast feeding. Thank you for the well wishes! And accept my congrats on a healthy kiddo as well, and my best wishes to your family 😀

    • Daniel Lakeland
      August 24, 2012

      Interestingly if you read through the various bits I've posted, there is a recent article I link to that seems quite convincing on the topic of turning to maximize exposure (they were against it based on good theoretical and experimental results). In particular they suggest that exposing only one side is better because after several hours exposure the pigmented bilirubin in the skin is bleached and the light penetrates deeper into the bloodstream and directly bleaches bilirubin in the blood, causing much more rapid conversion. The theory then is to use something like a bili-blanket or bili-bed to "bleach" the infant's back (while they lay face up) and then continue to expose their back long after the bleaching process (I think it was around 3 hours minimum). Alternatively if you only have overhead lights, then you leave the child on their back and bleach their tummy. Take a look for the article and pass it around to your Dr friends and see what you think of their model.

      Obviously more aggressive treatment for infants nearer to transfusion levels makes good sense. Thanks again for the comment.

  7. Joshua permalink
    August 24, 2012

    Oh certainly I agree that the blankets are better. My point was that leaving a newborn unattended (as some nurseries don't have the staff to attend at all time) on their belly or sides can be dangerous and is not recommended. So, if no bili-blanket is available leaving only direct lights, and if there is not enough staff to monitor telemetry or the infant directly I would advise against laying the newborn on its tummy to expose the back. I understand it may be more effective at treating hyperbilirubinemia, but I don't know whether it offsets the risks of unsupervised tummy-time in a neonate or premature neonate. Its about weighing the risk between the two.

    Of course if the bili-blanket is available, go for it!

  8. Zach permalink
    August 29, 2013

    Great post! My 5-day old daughter is flirting with 20 mg/dl bilirubin levels and the doctors are flipping out. As a professional statistician, I'm naturally a bit suspicious of the hype, given that my daughter does not have other risk factors, so I appreciate your careful analysis here.

    One thing for further exploration: bilirubin has an important role in the newborn, and much about this role is not understood. Here is a starting point: http://drjaygordon.com/pediatricks/newborns/bilirubin.html

    I wish the raw data were available: how many cases of kernicterus have ever been documented, and in how many of these cases involved high bilirubin but no other risk factors?

  9. Daniel Lakeland
    August 29, 2013

    Zach, I hope your daughter will be fine. All the indications on the charts suggest she should be on phototherapy, and there doesn't seem to be any bad effects of phototherapy when done well. Try to get the biliblanket, and irradiate the same side continuously for at least 3 hours, thereby bleaching the skin and allowing conversion of bili in the bloodstream. That's got to be the easiest way, I'd think.

    While I agree with you that the actual raw data would be interesting to us statistical analyst types, and the idea that bilirubin is beneficial in controlled levels is quite interesting, we definitely don't want kernicterus, so it's worth being cautious. Good luck! and I'm glad this post is still helping inform people. My two sons are now 3 and 2 and doing very well. The little guy who we were struggling with so much those first few days is now moving from his balance bike to his first pedal bike. Good luck to you and your wife and daughter.

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