Dr. Bob: My new baby, my third, had obvious jaundice. My first two babies were put under the lights for their jaundice. I expected the same for this child, but the doctor said that a new protocol was being used and that the lights were not necessary. I’m confused. Please explain.
Answer: I can understand your confusion but please be reassured that it is not unusual for treatment protocols to change as new information comes along. Plus, I will not be second guessing your physician here since I do not have the information about your baby at hand. Rather let me explain the reason for phototherapy for jaundice and how treatment has changed.
Jaundice or yellowness to the skin is very common in the newborn period. It predominantly reflects some immaturity in the liver getting rid of the breakdown products of red blood cells. Remember babies tend to have a high hemoglobin at birth reflecting their need to carry extra oxygen while still in utero. After birth, the hemoglobin in red blood cells breaks down and is converted to chemicals that can be excreted after being changed in the liver. Sometimes this conversion process is delayed, and bilirubin builds up in the skin causing jaundice. Breastfeeding can also delay the conversion at times.
If the bilirubin levels get too high, we do know that brain injury can occur. In our effort to avoid such problems, we have been quick to use phototherapy to bring the bilirubin blood levels down. The special lights help the conversion process and subsequent excretion of the excess bilirubin while the liver quickly gets up to speed. We now know that we have been too aggressive in the past with phototherapy for “routine” jaundice.
Well, there has been increasing evidence that the level to cause brain damage (what we call chronic bilirubin encephalopathy) is much higher than we used to think it was. We still don’t want to even approach that level, but we have usually treated jaundice for levels far below that toxic level. We now know that it is safe to use a higher threshold before starting phototherapy. By avoiding phototherapy, it is easier for babies to be discharged, for feeding especially breastfeeding to be initiated, and for families to adapt to the already hectic life of handling a newborn. These new phototherapy protocols were published in 2022.
I must add some qualifiers to the above paragraph. We need to factor in the baby’s gestational age and weight and days of age. We need to see if other health issues are present. We have to check to be sure that the elevated bilirubin is not due to an active breakdown of the blood (what we call hemolysis) instead of a normal breakdown of the blood and liver immaturity. If hemolysis is present, all bets are off and we need to be very vigilant about the bilirubin and whether phototherapy might help. Hemolysis usually occurs because of some incompatibility between mom’s blood and the baby’s blood, like a difference in the ABO blood types. Other incompatibilities can occur also. There might be a change in a certain enzyme (G6PD) that can cause jaundice problems.
So, things indeed have changed. It is most likely that your third child’s bilirubin was well below the threshold level to start phototherapy even in the presence of jaundice. The good news is that we can still be safe (avoiding brain injury) and avoid phototherapy a good bit of time.
Dr. Saul is Professor of Pediatrics (Emeritus) at Prisma Health and his website is www.mychildrenschildren.com. Contact Dr. Bob at askdrbobsaul@gmail.com with more questions.