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Well talk about management of indirect hyperbilirubinemia next. First thing is hydration, and I don’t’ care what the cause of indirect hyperbilirubinemia is, if you have a baby who is coming in with levels that are potentially approaching the exchange transfusion, you want to hydrate these kids. The key thing is that there is - unless they are very dehydrated or have some contraindications - the way you want to hydrate them is orally. You don’t want to give these kids IV fluids. Again, the reason you want to do that is you want to use the benefit of the enterohepatic circulation and get that stool and that bilirubin out of the gut as quickly as possible. So we’ll try to feed aggressively, bottle supplement if they are on breast feeding, and then consider even NG tube feedings if they can’t take in enough fluids. Another thing that I’ll do, a nice trick, is actually if they haven’t had a stool in awhile just give them a glycerin suppository in the hopes of increasing the stool output that you may get and get a bilirubin drop in that kind of way.
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The second is phototherapy. You aren’t probably going to get asked this on the Boards because it’s fairly controversial, not a lot of great studies recently. I think most people at this point are using different criteria for hemolytic and non-hemolytic hyperbilirubinemia. Full term babies, hemolytic, I think the goal is still to keep bilirubins less than 20. So if you have bilirubins that seem to be approaching 20, you may want to start phototherapy. With the advent of home phototherapy it often makes our life easier in terms of getting that accomplished. Non-hemolytic is .. I think people are probably willing to accept levels of 25 or even up to 29 or so without getting too alarmed. I tend to be a little more aggressive. So if you are getting bilirubins up into the 20’s even with early breast milk jaundice, I will go ahead and start phototherapy. Relatively benign intervention overall.
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The third intervention is one that we hope to avoid if at all possible, which is an exchange transfusion. Again, hemolytic, if you have levels that get much above 20 and you can’t bring them down with phototherapy, or you start phototherapy and they continue to rise, then you need to consider an exchange transfusion. If you are dealing with premature infants then you are going to need to think about using lower levels at which to do exchange transfusions. Non-hemolytic, very controversial. I think people have said that there has never been a case of kernicterus in early breast milk jaundice, and apparently there is one report recently where a level was 40 and a baby developed kernicterus. So I’m not sure we can say that absolutely, but it seems at least that kernicterus is quite unusual, if not virtually impossible in breast feeding jaundice. So because exchange transfusions have such high morbidity and really relatively high mortality rates as well, especially as we are doing them less and less often, it is probably … you really want to avoid doing an exchange transfusion for a baby who has jaundice just from late onset breast milk jaundice. Canadian viagra