Newborn urine turns reddish brown indicative of hemoglobinuria

What is hemoglobinuria? 
Our red blood cells (RBCs) are composed of hemoglobin (red pigment) that carries oxygen and carbon dioxide in our circulatory system. If there is excess of RBC lysis (or breakdown/turnover), then our blood will have excessive amount of hemoglobin. Hemoglobin will be filtered out from kidney along with urine and because of its colour, the urine will stain reddish to brown.

Why it is pertinent to us?
Our baby had reddish to brown urine during the first postnatal week. The nurse said that it was normal to see reddish diaper stain sometimes and that upon subsequent feeding and passing of water, the stain will go away.

However, that reddish stain later served as an indication of persistent jaundice that we experienced later on. I am blood group B+ while my wife is A+ and our baby is AB+. Fortunately, we requested that our baby's blood group be tested (it was not normal routine for our hospital to test baby's blood group and we had to explicitly ask for it), or else we wouldn't have gotten this important information that facilitated the medical staff to conclude that our baby was having ABO incompatibility (and persistent jaundice).

What is ABO incompatibility?
ABO incompatibility happens when mother's antibody recognizes and attacks baby's blood cells. It seemed that mother's antibody can traverse from the umbilical cord to the baby's blood circulation.

As an example, if mother had no antigen B in her blood cells (i.e. she is A+ or O+), she will have antibody against this antigen. If baby has antigen B on the blood cells (e.g. if baby is B+, AB+), then the maternal antibody will start attacking the baby's blood cells. This causes excessive blood cell loss and increases circulating hemoglobin and its broken-down product, bilirubin.

Update

It has been more than a month and our baby still has jaundice (indicated by higher bilirubin level). We had phototherapy for 3.5 days and it didn't help to reduce baby's jaundice. Liver function was tested normal (indicated by testing the ratio of conjugated vs unconjugated bilirubin; where normal conjugated bilirubin signifies a working liver). Regular visits to polyclinic depletes our wallet but not the jaundice problem. We got to know that some parents just stopped visiting the clinic after the repetitive tests and brief "consultations" informing them numbers ranging from 180 to 210 of bilirubin level. The consultation fee was very high as compared to the price of the test itself (almost10 fold difference!), e.g. SGD 6.00 per test as compared to SGD 45.00 per consultation. My opinion is that there shouldn't be a flat rate of SGD45 for consultation pertaining to reading to parents their babies' bilirubin test results and setting another appointment for further tests!

How I wished there was an over-the-counter test kit for measuring bilirubin at home. Alas, a spectrophotometer is required to test bilirubin and that machine is not cheap to be placed in homes.

Solution
Now, we are advised to mix formula with breast milk for our baby in order to hasten the clearing of his jaundice. Although we wanted to give complete breast milk, but under the current circumstances - breast milk alone had failed to reduce baby's jaundice and thus - we are obligated to get a tin of formula and start giving mixed milk to our baby. Hope this approach will help reduce our baby's jaundice.

2 hours intermitent feeding, diaper changes, and more

Mothers are really strong. They can endure lack of sleep by waking up every 2 hours to feed and change diaper (or rather change diaper first then feed). I have been helping out by taking three to four slots (total > 6 hours) in feeding our baby (starting from 9 pm, then 11 pm, 1 am, and finally 3 am). It was really challenging.

At the same time, my wife has to take care of our older child who is currently adapting to the presence of a new member of the family. Fortunately, she has grown used (or rather fond) to the baby.

Products needed for baby

• Breast pump

Thanks to Ameda pump Lactaline Personal (or purely yours), my wife could provide sufficient amount of milk to store and for daddy to feed the baby later. We keep freshly expressed milk at 4°C instead of in -20°C freezer (this prevents off-flavour of milk, our opinion). 

Our baby is drinking milk at increasing volume (gradually). In just 3 weeks, he is already taking in more than 2.5 oz (approx. 75 ml), sometimes at 3 oz.

• Sterilizer, bottles, warmers

In addition, we are using Philips Avent products, e.g. single electric pump (with manual pump available for outdoor expression if power outlet is not available), storage bottles, sterilizer, and Pigeon's bottle warmer. The models that we are using (bought three years ago) now are no longer available, and had been replaced by newer models.

• Portable or mini fridge

Nowadays, mothers are getting usb portable fridge for storing expressed milk (which is a good thing to have in the office if the common fridge is messy and moldy - or there is a chance that the milk might be mistakenly drank by someone). Just search for USB fridge and you will get returns for different types. An example is the following. Alternative, mothers can pool resources and get a mini-fridge for use in the office.

Coco Digital Portable USB Mini Fridge at £22.66 (Amazon). However, a much cheaper alternatives are available at Amazon, eBay, Alibaba etc. These mini-fridge runs using the Peltier cooling method.

MIDEA BAR FRIDGE~4 TICKS (minibar fridge) at SGD 119 at Gain City Singapore. This smaller less portable fridge can be installed at a corner of office area for mothers to share the cost and space. Several types at more affordable price is available and milk is stored at 4°C (good for up to 5 days).

For information about expressed milk storage, refer to this site, "Breast milk storage: Do's and don'ts" by MayoClinic.

• Preferred bottles (we prefer Playtex)

 We have tried Avent feeding bottles but our baby doesn't like it. After each feed, too much air is ingested. We haven't tried the latest version called "natural bottles" (Philips Avent). We have tried Nuk bottles and found that the nipple is a little quirky and unnatural for babies (nipple confusion). It is also difficult for us to feed our baby because of the nipple shape (see Nuk bottles here and try it on baby to see if he/she likes it). Most of the time, as parents, we wouldn't want to force any bottle on babies. We would try different bottles and maintain those that our baby loves (without nipple confusion).

Playtex VentAire bottles are our favourite. The nipple is not too confusing and the anti-colic mechanism works for us.

• Diapers

We used to give our first baby cloth diapers with liner to wear (in order to prevent nappy rashes). However, having two kids reduced our time and luxury to change frequently the soiled/wet diapers of our second baby. That prompted us to use commercial diapers (we are using Huggies).

To prevent nappy rashes, we used Vaseline Petroleum Jelly to produce a "waterproof coat" on the groin and back area. It worked better than applying Desitin Rapid Relief (Zinc oxide cream). In addition to the above measure, we try to wash off poo poo with warm bath at least twice daily (so that baby will feel fresh and any residual urine and dried stool is cleaned), and after the wash, we will apply a layer of Vaseline to baby. We have not tried this but some suggested using lightly salted water bath to clean and sooth baby's skin.

• Ambience

I believed that having silent surrounding for baby to sleep or rest is not healthy. This is considering that nature intended to enrich our hearing all the time, with at least some background noises, e.g. crickets, cicadas, lizards, wind, ruffling of leaves, etc. In order to emulate nature, I downloaded Android apps on my smart phone and would play the "background noise" to our baby. It soothed him to sleep and even at sudden noises, he wouldn't be jolted as when he was sleeping in silent. My favourite apps are Lullaby Relax and Sleep and Relax Night. There are others too, but I didn't try any other considering that Relax Night has plenty of cricket noise, croaking of frogs, and others.

As for temperature, Singapore is hot and humid. At night, it is humid and cold. For our baby, we try to use the air-con to reduce the humidity and maintain the temperature at 29°C. A fan will be blowing to move the air inside our room. To prevent our baby from catching a cold, we would cover him with a cozy blanket. Sometimes, leaving the window open to let in warm night breeze is fine (but the humidity at night can be a pain at some nights especially when we stay at lower floor of our HDB flat).

Lighting is maintained at low. We normally will switch on the bathroom light. Also, I will be holding a torchlight at night to peek in the diaper to see if it needs changing before feeding time.

• Activity

There will not be too much activity in the room. During feeding time, I will try to feed baby without waking him up. When he is done, I would normally pat or rub his back to allow him to let our air after feeding. Then I will place him on a slanted baby rocking chair. On it is layered with a folded cloth diaper to prop his head. I will adjust the baby so that he is faced sideways in order to prevent any chocking if he puke milk at night. If he soil his diaper then, I will let him rest until he complains about it (only then I will change the diaper). Having baby and parents to rest enough is crucial! If you change baby's diaper, you will surely wake him/her up (guaranteed).

• Cries

It is normal for baby to cry (it's the only work they do in order to get food and direct our attention to their any discomfort. It takes a lot out of them to cry, which is their means of communicating with adults. Normally, a healthy amount of cry will exhaust them afterwards and they will sleep better. However, some "experts" suggest that babies should not cry more than 5 min or else they will ingest a lot of air and that will cause tummy pain. If all else fail in understanding their cry, we can only let babies cry to sleep. However, a prolonged cry could indicate of problem requiring medical attention).

First thing I do when baby cries is to look at the time and see if it's feeding time. If it isn't, I will check the diaper and change it when needed. I will carry the baby and rub his back to see if there is any gas trapped in the stomach or throat. Any burp is an accomplishment. If the baby still cry, I will warm my palms by rubbing them together and then rest them on my baby's belly to sooth any discomfort there. I will apply medicated oil on the tummy as well. I will also massage the belly gently in a downward motion. If baby is still crying, I will carry him and walk around the room while rocking him gently on my arms. If all else fail, I will put him gently on the slanted baby rocking chair and let him cry for a while before carrying him again and rock him gently in my arm so that he will sleep after crying (a form of exercise for babies!). The reason babies cry inconsolably is due to discomfort (e.g. gas in the tummy, flatulence, or constipation due to formula milk or dehydration) BUT as parents, we have to be vigilant to ensure that inconsolable cries are not due to any discomforts that need medical attention.

That's all for now. It's a challenge being mothers. It would be nice if the dads can chip in once in a while to help. By feeding and changing my baby's diaper for two sessions, my wife gets to sleep for 4 hours  uninterrupted. That is a luxury to her!

Just to share.

ABO incompatibility between mother and child equals jaundice

I am B+ and my wife is A+. Our first child was not screened for her blood group, which was surprising, especially considering that this test is not too expensive and would be informative for parents and children. The hospital told us that such test is only applicable if we asked for it or if the baby is G6PD deficient.

Our first child had jaundice and it took us some time before her bilirubin level was reduced. At that time, we thought that her jaundice must have been a common case among Asians.

Then, when it was our second child, we explicitly asked for his blood group to be determined. Our boy was AB+. Similar to his older sister, our boy had jaundice and it was not manageable for us when we brought him home. As we opted for full breast feeding, my wife's milk supply was initially low (colostrum) and it did not provide sufficient fluid and material for baby to pass enough stool or urine to cleanse his system of bilirubin. We brought our baby out for the morning sun for the purpose of reducing his jaundice, but that effort was insufficient.

A visit to a polyclinic to have our boy tested showed that his bilirubin level was high (at 292 micromol/l). The doctor recommended admission for phototherapy. It took our baby 4 days for his jaundice to subside under the phototherapy!

Our insistence on testing for our baby blood type allowed the pediatrician to suggest that our baby's jaundice could have been due to ABO incompatibility. We wondered, if we didn't insist on the blood test, would the pediatrician have been able to form such diagnosis? If ABO incompatibility is a common problem that contribute to jaundice in baby, why doesn't the hospital provide compulsory blood group test, so that parents' can be informed of next course of action?

Just a thought

Note

• ABO incompatibility in mother and child is due to the traversing of mother's antibody to her baby's circulatory system. In our case, my wife is A+ (which means she has antibody against antigen B). When the antibody gets into baby's circulatory system, it will attack baby's red blood cells that have both antigen A and antigen B on them. This causes increased lysis/destruction of babies red blood cells and hence increase in bilirubin level (intermediate product of the cell turnover).
• Abnormal increase in bilirubin level in babies have been associated with mental retardation. That is why we are compelled to send our son to the hospital for phototherapy when the doctor told us his bilirubin level was high.
• How blue light reduces bilirubin is by solubilizing the chemical in the body so that it can be cleansed from the system via passing of water and motion. See Bilirubin by Wikipedia.

Penicillin administered during labour detriment to baby's gut microflora

For expectant mom who got her water broke for more than 12 hours (whereas CDC recommends > 18 hours!), Singapore General Hospital (SGH) will recommend administering penicillin-type of antibiotic to the mother. My wife was given this without choice.

Our main concern in intrapartum (or during delivery) administration of antibiotic was whether the administered antibiotic will kill mother's good bacteria and deprive the baby these bacteria, especially in natural vaginal delivery. If yes, then it would defeat the purpose of natural birth! It has been known that natural vaginal delivery provides babies with good gut flora and minimize allergy in later development (see subsection on "Acquisition of gut flora in human infants" by Wikipedia), whereas C-sections reduces the diversity of baby's gut flora.

Sometimes, I think hospitals are being too overzealous in their effort to beat infection (or prescription of antibiotics). This effort can be more harmful than helpful, considering that depriving babies of good gut flora weakens their gut health and not to mention, babies abilities to acquire immunity against these bacteria. FYI, we can use gut bacteria because we are immune to them and able to rein in any "rebellious" bacteria by an immune response. To deprive babies of early exposure to gut bacteria will deprive them of this immunity.

If hospitals strive to encourage more "bubble babies" (babies in sterilized condition), then they are not doing any good to patients (or mankind). I was let down that SGH went down-the-road of trying to sterilize mothers' womb by prescribing antibiotics when there was no indication/suggestion that babies were immunocompromised/immunodeficient. Why would SGH want to prevent good "infections". Note that there was no indication that my wife was having any infection (i.e. the vaginal bacteria was at "normal" titer/amount rather than overran by them during infection).

Since when did "infection" (exposure to mild titer of bacteria or microbes) become a bad thing? We are constantly fighting (or balancing) "infection". That is how we grow stronger (rather than weak and dependent on antibiotics).

Fortunately, a study showed that intrapartum administration of antibiotic (specifically penicillin) has minimal effect on microfloral transmission of babies undergone vaginal delivery. Read "effects of intrapartum penicillin prophylaxis on intestinal bacterial colonization in infants".

However, in contrast, another study showed that regardless of antibiotic-type, intrapartum administration of antibiotic due to rupture of membrane (or water broke) caused significant drop in transmission rate of good bacteria (e.g. Lactobacillus) in infants. Note that good bacteria is responsible in preventing the development of allergic diseases later in life, so... it's no wonder that in developed countries, many people are having one or several kind of auto-immune diseases. We are just too darn clean!

Now, my question is that, do we have a choice when it comes to "medical intervention" that do not require our consent? As patients, are we well represented by doctors and the medical team? I mean, did these doctors judged correctly the risk-over-benefit criteria before prescribing treatments to us?

Another example is that during my wife vaginal swap to test for presence of Group B Streptococcus, which seemed to be a contributing factor in infection in newborn babies (or in worst scenario, septicemia or infection in blood), the test tested negative but there was presence of fungi. The doctor gave the good news, and then shocked us to the news that my wife has fungal infection! FYI, our body is constantly covered with Strep and Fungi, and as long as we are healthy and strong, we are not at risk. Also, Strep presence in our body do come-and-go and today's test is negative doesn't mean that it will be negative tomorrow. How the hospital earned from us for this test is funny because it did not help us a bit during expected delivery date (EDD) where by then, Strep tested earlier is nullified by time!

What was alarming was the suggestion by this doctor that she could help my wife administer medication to rid of the Fungi. Oh my goodness, what is wrong with doctors these days? We might as well be living in a bubble from now on, no?

According to CDC Prevention of Perinatal Group B Streptococcal Disease: Revised Guidelines from CDC, 2010, one thing that is lacking in this report is the mention of harmful effect of the measures taken to fight Strep on babies (i.e. post-treatment effects). There are always benefit-over-risk and vice versa and giving the right information to patients is always appreciated.

As a parent, what I can hope for now is to allow my kids to be exposed to as much of environmental microbes as possible (naturally), so that their immune system will be an efficient machine that manages host-microbe interactions to their favours.

As for the TV commercials frightening the populace with overblown picture of infections so that more of us will buy their antiseptic cream, spray, soap, mouth rinse etc., these companies are not helping one bit in protecting us from infections. Best protection is to overcome the infection rather than "hiding" from it.

Being too clean has been shown to pose health problems (see Hygiene hypothesis by Wikipedia). However, in practice, it's not possible to be completely clean from microbes, fortunately.

Just a thought.

Anti-itch remedy for polymorphic eruption of pregnancy (aka PUPPP)

Pruritic urticarial papules and plaques of pregnancy (PUPPP) cause is not known, but the effect on patients are unpleasant. Pruritic means itchy and urticarial means nettle-like sensation, whereas papules and plaques are just description of the appearance of the "bumps" or rashes.

Although the cause of PUPPP is not known, it can be speculated to be contributed by abdominal stretch due to baby size. Overly stretching the skin might have exposed tissues (not normally found in circulation) to the immune system and that caused an allergic reaction. There is no medication to stop the rogue immune reaction. However, anti-histamine can be given to reduce the symptoms, e.g. itchiness and eruptions.

Some mothers had to go through the itchiness from 2 weeks to several weeks.

Things that exacerbate the rashes are

• Bathing in hot/warm water
• Seated for too long (heat seemed to increase more rashes)
• Scratching increases severity

Doctor would normally prescribe

• Anti-histamine to relieve itchiness, but it doesn't seem to mask the itchiness completely. However, a mild relieve is better than none.
• Calamine, which is composed of zinc oxide and ferric oxide (see Wikipedia). Its anti-itch property has been debated, and doctors seemed to discourage its use because the solution can dry up the skin and could potentially worsen the recovery. My wife seemed to prefer this solution rather than the steroid based medication as she is worried about the harm of steroid on baby during breast-feeding (although doctors said it's not harmful).
• Steroid based cream for topical (skin) application, e.g. Elomet (R) Mometasone furoate by Merck.

Home based remedies are as follows

• 2.1% (v/v) sodium bicarbonate (or baking soda) in bath water. E,g, 2 ml in 100 ml or 2 cup in 100 cups (or 1 cup in 50 cups [3.125 gallon]) of water.
• Oatmeal bath, and how to prepare the bath is described "How to make an oatmeal bath" (by WikiHow). Taking a dip in oat bath provides the minerals and nutrients needed to rejuvenate the skin, especially one that is "sad".
• Epsom salt (or Magnesium sulfate) bath. The concentration in the bath is not fixed and some just guess the right concentration to use. Although the bath is normally at higher temperature, it is not advisable to take a dip in warm bath especially considering that rashes tend to get worst with higher temperature! Here is an instruction on how to prepare Epsom bath (Scdlifestyle)
• For Chinese, there is a necessity to increase body heat by consuming herbs that will increase body temperature. Although it helps in the postpartum (after delivery) recovery process, there should also be a need to balance it to help alleviate the rashes. A nurse suggested that drinking buttermilk or plain yogurt could help (See buttermilk as cooling drink by MediManage). I am giving my wife coconut drink to cool her body but drink moderately as breast-fed baby might have runny stool if too much of this drink.
• Other suggestions are Aloe Vera gel  and cucumber puree. I wrote down these two because there has not been report of anyone being allergic to these health food.
• There are those suggestions that should be used with care as some might be allergic to the ingredient, e.g. lemon juice might exacerbate the skin condition and banana peels might be harmful to some people. Those interested to experiment (with own risk) can refer to this site, "Home Remedies for Rash" (by HomemadeMedicine).

Tips
To apply calamine solution is quite tricky, we initially used cotton balls to apply the medication on the skin but most of the solution is soaked up to the cotton. I tried to squeeze the solution out and re-apply it on my wife's skin numerous time to avoid wastage. Today, I got a small spray bottle (from Daiso Singapore) to try to apply the solution on her skin by aerosol. I filled a small volume of the calamine to the spray bottle and dispense the aerosol enough to cover her affected skin. It worked, but the aerosol caused the whole room to be smelly. Also, care should be taken to prevent inhaling too much of calamine! For your information, read about zinc poisoning, (MerckManuals) and iron poisoning (CDC).

 

For now, I just hope my wife will recover next week. Seeing her in this state makes me feel helpless...