T. Newman,
1.
Use the jaundice meter (Minolta JM-103) frequently. Just make sure you
wash your hands, clean the tip with alcohol, and examine the baby and guess the bilirubin first. It is fun to find a colleague and see who is
closer! This way a) you can hone your
clinical skills and b) you can repeat the TcB and consider a TSB if the result
does not match your exam. You can
estimate the bili by how far down the jaundice goes: face ~5; umbilicus ~10; groin ~12; knees: 15.
2.
Interpret all bili levels according to the baby’s age in
hours. Do NOT use "day of
life" terminology when dealing with
jaundice. Go to www.bilitool.org to get help calculating
the baby’s age in hours and see the baby’s risk group and what the AAP
recommends. You can download bilitool to
your PDA.
3. Think about a
differential diagnosis. I know we see physiologic or breast-feeding
jaundice all the time. But if jaundice
is an issue, at the very least you should know the Mom's blood type and
antibody screen (and baby's type and Coombs, if Mom is group O or Rh negative),
the baby’s percent weight change since birth and the initial hematocrit (if it
was done).
4. To find the AAP's
handout for parents, just Google AAP
jaundice parents. It’s a good start,
but I've found that parents often appreciate a bit more detail. Let them know the baby's bili level, and at
what level the AAP recommends phototherapy at that age. If the baby needs phototherapy, consider
showing the family the AAP graphs for phototherapy and exchange transfusion, so
they can see where he or she is. The key
message is that both phototherapy and exchange transfusion are done to keep the bilirubin from rising to a
dangerous level, not because the bilirubin already is at a dangerous level.
5.
Don't just give homoeopathic phototherapy. My position is: if
you are going to do phototherapy, give a lot and get it over with! (This applies primarily to term babies, whose
only reason for being in the hospital is to get phototherapy.) That means
maximizing light intensity and surface area exposed. I generally use a blanket below and at least
2 spotlights above. Bring the spotlights as close to the top of the incubator
as you can. The sooner the bilirubin comes down, the sooner the baby goes back
home to Mom where he or she belongs!
6.
Don't start an IV unless the baby needs it. Certainly some
degree of dehydration is not uncommon in breast-fed babies with high bilirubin
levels. But I've often seen 10% weight
loss from birth weight equated with being 10% dehydrated. This is not the case, of course, because
5-10% weight loss is normal. On the
other hand, if the baby is heading towards an exchange, vigorous IV hydration
is worthwhile.
7.
Check an albumin level on babies whose bilirubin is high
enough to use phototherapy. One rule of thumb is that the exchange level
(in term, well infants) should be about 8 times the albumin. The data on this aren't great, but I would
certainly be much more worried about a baby with a low albumin.
8.
Think about G6PD deficiency in babies with bilirubin levels
much higher than their risk factors would suggest (e.g., bottle fed babies, black babies) or those with sudden
increases in total serum bilirubin (TSB) after the first day.