JAUNDICE AND DEHYDRATION IN THE EARLY DISCHARGED HEALTHY TERM NEWBORN

What are the most serious consequences of discharging healthy term newborns within 24 to 48 hours of birth?

Early discharge has resulted in fewer opportunities to teach new mothers how to breastfeed or to detect medical conditions that don’t become evident until 24 to 72 hours after birth. This has resulted in a doubling of readmission to hospital within 1 to 2 weeks of birth, mainly due to jaundice and dehydration.

What risk factors are most commonly associated with jaundice?

Even though there is a well established association between breast feeding and an increased risk of neonatal hyperbilirubinemia in the first week of life, this should in no way inhibit, prevent or discourage mothers from breastfeeding. In babies who nurse poorly, the likelihood of becoming jaundiced is even greater. It must also be remembered that babies of 36 to 37 weeks’ gestation (or less) do not nurse as well as more mature babies. One study has shown that infants at 37 weeks were four times more likely to have a serum bilirubin > 230 mmol/L than those of 40 weeks’ gestation. Other risk factors for developing jaundice include: ABO incompatibility, maternal diabetes, use of oxytocin in labor, Asian male babies, presence of bruising and cephalhematoma, and a family history of neonatal jaundice.

What risk factors are most commonly associated with dehydration?

In the neonate, dehydration results primarily from an inadequate amount of fluid intake. Breast feeding, first-time mothers and an infant who does not latch properly are risk factors for developing dehydration. Other factors include the presence of inverted nipples, previous reduction surgery, cesarean section, use of analgesics and an immature infant with a weak sucking ability.

What screening investigations should be done in a jaundiced infant?

Initially a total bilirubin will suffice. If there is a suspicion of hemolytic disease or anemia (e.g. clinical jaundice at < 24 hours or a MBR > 230 mmol/L in the first 48 hours), then a blood type and Coombs test should be done. In addition a CBC, smear and reticulocyte count should be ordered. If the neonate is a male Asian or Mediterranean infant with late onset jaundice and a MBR> 260 mmol/L, a G6PD screen should be done.

What are the current guidelines for phototherapy?

(1) Refers to infants born at 37 weeks or more gestation
(2) Phototherapy at these levels is a clinical option, meaning that the intervention may be used on the basis of individual clinical judgement.
(3) If hemolysis is likely or present phototherapy should begin at lower MBR levels (220-250).
(4) Intensive phototherapy refers to double or triple phototherapy with lights placed above and below the infant.
(5) Term infants who are clinically jaundiced at < 24 hours old are not considered healthy and require further evaluation (See text)

How can jaundice and the dehydration be anticipated?

Infants who are clinically jaundiced < 24 hours of age, or breastfeeding infants < 37 weeks gestation with a primigravida mother should not be discharged from hospital in less than 48 hours. Any infant discharged home within 48 hours of delivery needs timely follow-up with a competent healthcare professional within 2 to 3 days of discharge. By the third day of life the healthy term infant should stop losing weight, have lost no more than 10% of birth weight, be passing milk stools (non-meconium) at least 2 to 3 times per day, wet at least 5 to 6 diapers per day and latch well on to the breast. The mother should experience some engorgement and expect to feed the infant a minimum of 6 to 8 times per day. For mothers experiencing difficulty with breast feeding, early contact by telephone or in person with a lactation aid consultant should be very strongly encouraged.

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