A Very Yellow Day at NICU

Written by Dr Gideon Yawson.

Jaundice affects about 60% of term babies and 80% of preterm babies.  In some babies, jaundice can be severe enough to progress to acute bilirubin encephalopathy and kernicterus, with a substantial risk of neonatal mortality and long-term neurodevelopmental dysfunction.  Complications of severe neonatal jaundice continue to place a high burden in low and middle-income countries. Globally over 100,000 late-preterm and term babies die each year from complications of neonatal jaundice. To achieve the targets of the SDG 3, widespread public education must be undertaken on neonatal jaundice (1).

The stifling heat of the NICU was exceptionally intense today.  Sweat poured down my face, my neck, and into my clothes.  My glasses kept slipping down my nose.  My vest was totally drenched in sweat and my yellow shirt was going to follow suit if I did not get the IV access urgently needed for this jaundiced baby.  I held my breath as I inserted the IV cannula into the baby’s arm.  Somehow, I was hoping holding my breath would increase my chances of getting access to the vein.  But, my hand shifted slightly and I missed the vein as a nurse blurted out my name that another baby with jaundice had arrived and was having seizures.  What? It was looking like a very yellow day for me.  “Apart from your yellow shirt, you must be wearing yellow boxer shorts and vest”, she said.  She and her colleague nurses burst into uncontrollable laughter.  I was not amused.  My long day duties were usually calm but this one had been jinxed.  Wearing a yellow shirt can’t harm you in any way but maybe putting on yellow boxer shorts and vest was a step too far. No wonder I already had five cases of jaundice to deal with.  I wondered how the nurse knew the colour of my boxer shorts.  But no time now.  Best left to decipher that mystery later.  

I rushed to the side of the baby having seizures and requested for phenobarbitone to abort the seizures, after instructing a nurse to first check the blood glucose levels.  To my relief, this baby already had an IV line.  I asked the mother a few questions to establish the cause of the jaundice and found out that she had impregnated most of her clothing with camphor, including clothing used for her baby too.  I tried to make a mental recall of my jaundiced cases so far.  The first two, most likely were due to sepsis.  The next two were probably

DO NOT STAY HOME!

due to blood group incompatibilities.  The other was an exaggerated physiological jaundice  The seizures seemed to have stopped.  My new headache now was getting a phototherapy unit for this new admission, being that all the machines were currently in usage.  Would the main paediatric ward adjacent to the NICU have a machine that is free?  What if they didn’t have one?  I hurried to find out.  The main ward had just an old phototherapy machine that looked like it was made in the sixties.  Just kidding.  But it did look quite old.  And I wondered how effective it would be.  But did I have much choice?  A life was waiting to be saved.  I snatched it and wheeled it back to the NICU. 

DO NOT PUT YOUR BABY IN THE SUN!

Back to the history of my current admission.  The mother was forty-one years old and this was her first child.  She kept wailing that the ‘witches’ in her family wanted her to be childless for life that is why they had inflicted the baby with jaundice.  It was evident that she needed in-depth education on jaundice, but I was too “hot” at that moment.  I had a precious baby to save first.  

And while still thinking of help for my unfinished IV line somewhere waiting, my MO just happened to walk in.  Before I even called.  There are days you just believe people are God-sent.  Today was one such day.  He got the IV line.  Somehow, your seniors always do.  He was also going to do the pending exchange transfusion needed for one of the babies.  So I had some time to attend to the ever-wailing mother.  

SEEK HEALTHCARE IMMEDIATELY!

She had noticed the yellowing of the baby’s eyes and skin three days earlier but had not reported immediately.  Instead, some ‘concerned’ neighbours had advised her to expose the baby to sunlight and she had thought it wise to follow that guidance, which she did religiously for two days.  The delay in reporting may have exacerbated the jaundice which was probably rapidly accelerating.  And if this baby boy turned out to also be G6PD deficient, then her liberal use of camphor balls on the baby’s clothing may have also inadvertently helped to tip this baby into acute bilirubin encephalopathy. And to make matters worse, the baby had also stopped breastfeeding as lethargy was setting in.  The acute bilirubin dysfunction is going to put this precious baby at a high risk of disability. 

PREVENT DISABILITIES AND DEATH!

She seemed calmer now, as I gave her time to narrate the history.  I listened.  I sensed she needed that.  She needed to talk about her family ‘witches’.  But I could only listen for so long I must confess.  Like fifteen minutes, which sadly seemed very long.  But I needed to move on.  I had to give my jaundice education, give her the plan of management and go assist my MO. 

“We actually do know that newborn jaundice is caused by infections, and blood group incompatibilities, and dehydration from poor feeding etc.  And from camphor usage in those who are G6PD deficient.  Please, it is life-saving to bring your baby to the hospital to be assessed especially in the early days of life.  Do not try pouring breast milk on the baby’s eyes or skin, or exposing to sunlight”.  She seemed as if she was only half-listening.  I think she wanted to get more of the family witchcraft drama off her chest.  I knew she needed a listening ear, but I just didn’t have the time.  I made a mental note to discuss further with my MO. 

I quickly gulped some water to hydrate myself, and braced myself for the long period of standing to assist with the on-going exchange transfusion.  Today was turning out to be a very long day.  The stress was numbing my legs.  But this needed to be done.  So here I come.  The nurse was also helping with the procedure.  So while at it, I better get the humour going.  Yes, so how did you know I was wearing yellow boxers?  She started laughing uncontrollably again. 

Dr Gideon Yawson is a house officer in Paediatrics at Cape Coast Teaching Hospital.

(1) Olusanya BO, Kaplan M, and Hansen TWR.  Neonatal hyperbilirubinaemia:  a global perspective. Lancet Child Adolesc Health 2018 8 http://dx.do i.org/10.1016/S2352-4642(18)30139-1