Letters from Maine

The Unjaundiced Eye


 

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Here on the coast of Maine, the clam diggers fear a “red tide.” This natural phenomenon is the result of a toxic algal bloom that doesn't harm the clams, but makes them dangerously inedible to humans. Some pediatricians seem to have a similar, but less rational, fear of a “yellow tide” known as neonatal jaundice.

Currently, this natural phenomenon has prompted a yellow alert. Some physicians are recommending baseline bilirubin sampling on all newborns prior to discharge from the nursery. Others are suggesting that we test every newborn who appears yellow, regardless of age or nutritional status. Nursery nurses are being encouraged to be proactive and order bilirubin tests whenever they have any suspicion of jaundice.

The result of this yellow phobia is that hundreds of new families must remain in the hospital waiting for lab results. Scores of already anxious parents are being made more anxious by informational chats about jaundice with well-meaning nurses and physicians. Focus shifts from breast-feeding to battling the dread yellow tide. Who knows how many breast-feeding experiences have been jeopardized or destroyed by this unfortunate shift in attention?

Maintaining close physical contact between mother and baby is difficult and ad lib breast-feeding is impossible if phototherapy is prescribed. Marginal results may be achieved with daily trips to the lab, which are not fun for new mothers with sore bottoms or healing abdominal wounds. Mothers and babies who should be home sleeping and nursing find themselves sitting in hard plastic chairs in laboratory waiting areas.

In the 1970s, the yellow tide of worry ebbed as some sensible neonatologists cautioned the rest of us about irrational “vigintiphobia” (fear of bilirubin levels greater than 20) and many of us relaxed. I began ordering fewer bilirubin tests and started paying more attention to learning how I could better support breast-feeding. The “bili lights” moved into the storage room behind the nursery and were wheeled out only on rare occasions.

However, when economic forces shrunk hospital stays and some physicians failed to adequately compensate with timely outpatient follow-up visits, there was an increase in the number of very yellow babies. The tide of concern turned from ebb to flow, and along with it came the new recommendations for more aggressive testing.

I have resisted the encouragement from the various committees that pontificate on such matters of color and have continued to ignore the color of all but the most pumpkin-colored newborns. I admit that I have had a small and lingering worry that my color blindness may have prevented some of my patients from doing as well as their peers on the college SATs. But I have trouble imagining that a phenomenon as common as neonatal jaundice is something to fear.

Galloping onto the stage in their white hats to rescue me from nagging worry are T. B. Newman et al. from the University of California in San Francisco (N. Engl. J. Med. 2006;354:1889–900). They have collected 140 neonates with bilirubins greater than 25 (10 had levels of 30 or greater). When these neonates were compared with the control group, the investigators could find no significant difference in their scores on a collection of cognitive tests. There also was no difference in either the proportion of children with neurologic findings or the documented diagnoses of neurologic findings.

So there you have it. Will the yellow tide begin to recede? Will physicians and nursery nurses begin to shift their focus away from jaundice onto more important issues, such as providing new mothers the technical and emotional support they often need to make breast-feeding succeed? It's time to give our jaundiced eyes a rest and begin to listen to what new mothers want.

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