Signs of fatty liver on face and skin

343 Hyperbilirubinemia In A National Cohort Of Extremely Premature Infants

Background and aims: Hyperbilirubinemia is a possible risk factor for adverse neurodevelopmental outcome in extremely premature infants. The study was undertaken to analyse the frequency, severity and treatment of hyperbilirubinemia in such infants.

Methods: Hyperbilirubinemia was studied retrospectively in a national cohort of 422 infants with gestational age (GA) of 220 to 276 completed weeks and/or birth weight (BW) of 500 to 999 g who survived beyond the 2nd day and had bilirubin measured. Group differences were analysed by t-test.

Results: Mean maximum bilirubin levels (TsB) were 176±43 µmol/L (range 72-391) and did not differ between GA. TsB ≥ 200 µmol/L and ≥ 250 µmol/L was seen in 24.2 % and 4.3 % of infants, respectively. Mean duration of TsB ≥ 200 µmol/L was 1.9±1.7 days (range 1-10) and did not differ between GA, but was more frequent in boys (p=0.048). 85.4 % of infants received phototherapy for 2.3±1.7 days (range 0-12). One infant received exchange transfusion, blood group immunization was diagnosed in only one infant (AB0). Prenatal steroids caused lower TsB (p=0.003) while initial acidosis increased TsB (p=0.015). Increased TsB was also associated with development of persistent ductus arteriosus (p=0.03), the degree of intraventricular hemorrhage (p=0.015), death (p=0.025), and possible neurologic sequelae at discharge (p=0.02).

Conclusions: Significant hyperbilirubinemia is common in extremely premature infants in spite of treatment. TsB seems to be associated with both prenatal and neonatal conditions as well as final outcome. Blood group immunization seems to be significantly underdiagnosed in these infants.

Delayed Cord Clamping And Jaundice – What You Need To Know

We now know that delayed cord clamping has a whole host of benefits – both immediate and long-term.

When we make birth decisions, we want to be sure we're making the best choices. Often that means weighing up the benefits and risks of each option.

In recent decades, immediate umbilical cord clamping was the norm. Recently there's been a shift towards routinely delaying cord clamping.

As a newer practice becomes more common, people start to look for connections with possible benefits or risks.

Some medical professionals had voiced their concern about an increased risk of neonatal jaundice (hyperbilirubinemia) among babies who had delayed cord clamping. In fact, this concern was sometimes used as a reason to deter patients from choosing delayed cord clamping, despite the many proven benefits.

Does Delayed Cord Clamping Increase The Risk Of Jaundice?

The World Health Organization (WHO) recommends routine delayed cord clamping for all babies, unless they need immediate medical attention that can't be accessed on or near their mother.

The WHO makes its recommendations after extensive research and data review. Before making this recommendation, it reviewed data that revealed several significant benefits. One benefit was that infants who had delayed cord clamping had much better iron stores. This significantly lowered their risk of iron deficient anaemia in the first six months.

Cord blood contains around one third of a baby's volume of blood. So the baby stands to lose a significant amount of iron (and blood in general) if the cord is clamped immediately.

The WHO also found the rate of jaundice was not higher among newborns who had delayed cord clamping. However, they found an increased need for phototherapy to treat jaundice among newborns who had delayed cord clamping.

Even with the increased risk of the need for phototherapy, there's little to no evidence to suggest that the risk outweighs the many known benefits of delayed cord clamping.

What Is Jaundice?

The body produces a substance called bilirubin, which breaks down old red blood cells. While baby is in utero, the placenta is responsible for removing bilirubin. After birth, baby's liver takes over the task of eliminating bilirubin from the blood.

In 60% of newborns, hyperbilirubinemia (elevated levels of bilirubin in the blood), or jaundice, occurs.

When baby has yellowing of the skin and whites of the eyes, or lethargy, then normal newborn jaundice is typically the culprit.

Is Jaundice Dangerous?

In short, jaundice is a descriptive symptom and not a disease.

When we first started testing babies for jaundice, we assumed that elevated bilirubin was automatically a health risk. We now know that bilirubin is a powerful antioxidant. It probably has an important role in the transition from womb to world.

If we take a moment to look at biological norms, it wouldn't make sense for 60% of healthy babies to have jaundice if it were a serious and abnormal complication. For healthy, full-term infants born after 37.5 weeks gestation, jaundice is rarely serious, and rarely requires treatment. Usually, it just needs to be monitored.

Preterm babies, those with low birthweight for gestational age, and infants not properly transferring milk (i.E. Dehydrated) are at risk of jaundice with potential complications. Blood group incompatibility, certain diseases and infections can also be associated with jaundice. However, there is treatment available to prevent or lower the risk of complications.

How Is Jaundice Treated?

It's important to remember that jaundice is simply a descriptive symptom, much like coughing. Like a cough, jaundice has different causes. The reason for the jaundice determines how it's treated.

There are three types of jaundice:

Physiological Jaundice is often called normal newborn jaundice. It occurs from around day 2-4 of life and is resolved by 1-2 weeks (or 3 weeks in premature babies). It is simply due to the transition that takes place after birth, when the immature liver must start to process the bilirubin that had been processed by the placenta before birth. There's no underlying disease or illness associated with this type of jaundice.

Babies with physiological jaundice are monitored, and might not require any treatment. If baby is lethargic, too sleepy to eat, or bilirubin levels are very elevated, phototherapy might be recommended. Additional IV fluids might be given to help the body flush bilirubin, if levels get too high.

Pathological Jaundice is jaundice caused by an underlying medical condition or concern. This possibility is always considered when baby shows signs of illness, or if jaundice levels are very high within 24 hours to 10 days of life.

Pathological jaundice might also be treated with phototherapy to help lower bilirubin levels. The underlying cause for the jaundice (infection, disease, etc) is treated at the same time.

Breast Milk Jaundice is a bit of a silly term, considering breast milk is our biological norm. Nonetheless, this term is used when an exclusively breastfed baby has jaundice that appears around 5-7 days of life, and persists for a few weeks, even a few months. This is physiologically normal, and nothing to be concerned about. Even so, the baby will probably be monitored, to make sure the higher bilirubin levels are not caused by low milk intake, or by pathological conditions.

Breast milk jaundice rarely requires treatment. It's important parents wake any sleepy babies to be sure they're transferring plenty of milk via frequent feeds. It's a good idea to work with an IBCLC lactation consultant if there are concerns about milk transfer.

If baby is overly lethargic, or less than 37.5 weeks gestation, phototherapy might be beneficial.

We used to treat breast milk jaundice with formula. Now, unless a baby is genuinely unable to get enough breast milk, we know there's no benefit in routinely supplementing jaundiced babies with formula.

Does Phototherapy Have Risks?

Phototherapy is a noninvasive treatment. It can be done via admission to hospital, where baby will be placed under a bilirubin light. It can also be done via home care (in some areas) with a portable bili blanket. This method is used for cases of borderline hyperbilirubinemia (levels less than 19).

The treatment and monitoring of jaundice often requires a heel prick for blood testing. It can be unpleasant, but it carries little risk.

Does The Benefit Of Delayed Cord Clamping Outweigh The Risk Of Jaundice And Phototherapy?

In short, in healthy full-term infants, delayed cord clamping has many known benefits. The benefits are very likely to outweigh the risk of jaundice, even when phototherapy is required.

This is often true for preterm and unwell infants, too. If you're at risk for a preterm birth, discuss delayed cord clamping with a neonatologist, so that you have a plan that everyone is confident about.

Delayed cord clamping decreases the risk of iron deficient anaemia for baby's first six months of life. It also has many other short and long term benefits.

You can read more about all of the benefits in BellyBelly's articles Delayed Cord Clamping – Why You Should Demand It and Delaying Cord Clamping May Offer Years Of Benefits, Study Finds.

Preterm Labor And Birth

Contractions and dilation (opening) of the cervix before 37 weeks of pregnancy are considered preterm, or premature, labor. A normal pregnancy lasts about 40 weeks after the first day of the last period (38 weeks after fertilization). The danger of preterm labor is that it will lead to the birth of a baby that has not fully developed, and therefore has a high risk of complications. About 10% of all pregnancies result in premature birth. About 60% of serious complications or infant deaths are due to consequences of premature birth.

Preterm labor can be extremely frightening, because mothers-to-be quite naturally fear that their baby will be born too early and suffer the problems of prematurity. If your baby is born too soon, there is a great chance that their lungs will be underdeveloped. If so, they'll need to be put onto a ventilator that can breathe for them. Receiving oxygen through a ventilator can lead to complications.

Your baby may also have trouble maintaining a normal body temperature, and may become hypothermic (too cold). They'll need to be kept warm. Your baby might be so early that they can't coordinate their muscles to suck and swallow. If this is the case, they'll have to be fed through a needle in the vein (intravenously), or through a tube passed into their nose, down their throat and into their stomach. A premature baby may also develop complications such as bleeding into the brain; an increased risk of infections, especially meningitis and sepsis; problems with kidney function; and jaundice. Premature babies are at higher risk for long-term complications, which may include vision impairment or blindness, hearing impairment, cerebral palsy and chronic lung problems. The earlier the baby is born, the more likely that they will have these complications.

You are more likely to experience preterm labor if:

You have had preterm labor or delivered a premature infant in the past.

You are carrying more than one baby (such as twins or triplets).

Your mother used the medication diethylstilbestrol (DES) while they were pregnant with you.

You have an abnormally shaped uterus or an abnormal cervix.

You have had a cone biopsy of your cervix in the past.

You are younger than 18 or older than 40 years.

You belong to a non-Caucasian race.

You are living in poverty.

You got pregnant while using an IUD, and it is left in place during the pregnancy.

You were seriously underweight when you became pregnant.

You smoke or use cocaine or other street drugs.

You have had second-trimester miscarriages during previous pregnancies, or you have had three or more elective abortions.

You are not receiving prenatal care from a qualified health-care provider.

You have a cervical infection, such as group B streptococci, gonorrhea, chlamydia, syphilis, trichomonas or gardnerella.

You are employed, doing extremely physical and strenuous work.

Symptoms

Contractions (tightening and hardening of the uterus), occurring more than four per hour (may be painless).

Low cramps, similar to menstrual cramps.

Low backache.

A feeling of pelvic pressure.

Abdominal cramps, gas or diarrhea.

A change in quality or quantity of vaginal discharge, especially any gush or leak of fluid.

Causes

Premature delivery may be preceded either by contractions or premature rupture of the fetal membranes (PROM), when the water breaks before labor begins. Although there have been many advances in caring for premature babies, there has been no improvement in solving the problem of preterm labor or PROM. We don't completely understand why some women go into labor or break their bag of water too early. We are often unable to accurately predict which women will do so, and we are limited in preventing these women from giving birth prematurely. In some cases, an infection may be involved; in others, it may be an abnormally short cervix or a combination of factors. In about half of all cases, no cause can be found. The number of babies born prematurely in the United States has actually risen in the last 10 years.

Diagnostic and Test Procedures

If you go to your health-care provider or a hospital because you think you may be in preterm labor, monitors will be placed on your abdomen to measure your baby's heart rate and record any uterine contractions that you have. The doctor will do a pelvic examination to check if your cervix is dilating. If you report that you think your water has broken or if the doctor sees any fluid coming from the cervix, they will take a small sample of fluid in order to determine whether it is truly amniotic fluid. If it is, a sample may be sent to a laboratory to determine how mature your baby's lungs are. Alternatively, your doctor may choose to perform an amniocentesis, which can provide information about your baby's lung development. Swabs of your cervix will be sent to a laboratory to test for infection, such as the presence of beta Strep. Your practitioner will want to test your urine for infection. You may be asked to provide a urine specimen, or your practitioner may put a tiny tube in your bladder (catheter) to remove a urine sample.

Treatment

If you get to the hospital early in labor, your practitioner can stop labor from progressing with hydration, bed rest, muscle relaxants or other drugs, possibly requiring hospitalization. The intent is to stave off labor to allow the baby's lungs and other organs more time to develop and reach maturity. Furthermore, if doctors can prevent delivery for even a little while, the mother can be given steroids to speed up the baby's lung development.

If your health-care provider determines that you are in preterm labor, you may be admitted to the hospital. You'll probably be given intravenous fluids (through a needle in your arm). The most common medications used to stop or slow labor contractions are magnesium sulfate, ritodrine (the only FDA approved medication for premature labor) and terbutaline. A number of other medications are still being investigated for this use, including prostaglandin synthetase inhibitors (indomethacin), calcium-channel blockers, aminophylline and progesterone. You are often given an antibiotic prophylactically, even if you have no obvious infection. Also, you'll usually be given steroid medications to speed up your baby's lung development.

If your contractions are successfully stopped, you may be sent home from the hospital, sometimes with an oral medication. You'll probably be asked to decrease your activity level, or even to stay on bedrest, until you get closer to your due date.

Sometimes when you are in premature labor, your doctor may choose to allow you to deliver the baby early, rather than trying to stop labor. This choice is usually made when the mother is suffering from an infection of the amniotic fluid and uterus, or has illnesses such as severe preeclampsia or eclampsia (forms of high blood pressure that occur during pregnancy). Delivering the baby prematurely may also be preferable if fetal evaluation shows that the fetus is not doing well, if there is placenta previa (placenta covering the cervix) that bleeds a lot, if there is abruptio placentae (detachment of the placenta) or if certain birth defects or malformations are identified.

Prevention

The most important thing you can do to try to have a healthy baby is to get early and adequate prenatal care. In fact, the best prenatal care begins even before you are pregnant. That way, you can be sure that you are in the best of health before pregnancy. Your practitioner will screen you for risk factors of premature delivery and discuss which precautions you could take. Measuring the length of the cervix using a special transvaginal ultrasound probe can predict a woman's risk of delivering prematurely. This is usually done in the doctor's office between 20 and 28 weeks of pregnancy. Researchers are studying vaginal secretions called cervicovaginal fetal fibronectin as a possible predictor of preterm labor. A woman at increased risk for premature delivery can be forewarned about what to do if symptoms occur, and may undergo further screening tests.

If you think that you broke your water, call your provider right away or go to the hospital. If you think that you are experiencing preterm contractions, you should stop what you are doing, go to the bathroom to empty your bladder, and then lie down on your left side. You should drink two glasses of water and juice, and try to relax. Many times, women are able to stop contractions by making sure that they are well hydrated and resting. If you continue to have four or more contractions per hour, call your health-care provider.

Call Your Doctor If:

You are having at least four contractions every hour, even if they're painless.

You have low, menstrual-like cramps.

You have a low, dull, constant backache.

You notice a change in your vaginal discharge, or a gush or slow leak of fluid from your vagina.

You notice a sensation of pelvic pressure.

You have abdominal cramping, gas or diarrhea.

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