ABO Blood Incompatibility

[FarmgrrlRN]

Can anyone tell me how common this? Does it occur in all Moms that are O blood type with babies that are A or B blood type?

The reason I ask is that one of my bestfriends gave birth on Mon PM and baby has developed jaundice ('discovered' @ approx. 32 hrs old;Weds AM), with a bili level of 16.9, and is now receiving phototherapy. I guess you could say I'm looking for the scoop on this and how serious it is. I have read my nsg textbooks and done research online, my friend was told that it would be 'really serious' when his bili level reaches 20. (I'm guessing at the point they would consider an exchange transfusion?)

Also, she is receiving conflicting information, pediatrician vs. nursery RN. Baby has not really taken to breastfeeding and they had given him 15cc of Enfamil with finger feeding to help him learn how to position his tongue on Tues PM (he did nurse early Tues AM, but then he refused). Then during the day Weds they did start giving him bottles and she is still trying to pump q3h but is getting very little colostrum. Basicially, pediatrician is telling her baby is fine, that she shouldn't be giving him bottles, the baby is not dehydrated, and she should continue to try to strictly nurse him and forget the bottle feedings. The nursery RN has told her he is dehydrated, he has crystals in his urine, mucous membranes are tacky, and that he needs to eat. I would think that the RN is on the right track with this as today is now Thurs and he still doesn't 'get it' with the breastfeeding. To this point when she pumps, only the nipple shields (don't know if thats the right word) get wet with colostrum and nothing gets in the bottle, so she has been wiping what she can with her finger and giving it to baby that way.

Any thoughts would be appreciated!

[memphispanda, RN]

My first two children had ABO incompatability...it was much more severe with my second than with my first.

I do think that there are two issues here--the jaundice and the breastfeeding. They may not be related at all.

First the jaundice--I was the breastmilk nazi with my second--her bili level was 28 at the worst. We did small supplemental feeds thru an NG tube for the 2 days in the hospital before my milk came in, then we went home with bililights through home health, she nursed exclusively, and we had no further problems (did have to have bili level checked daily for 3 weeks).

Second, the breastfeeding. If there is a latch problem the LC should be able to help. My youngest (who did not have ABO problems because we have the same blood type) had a horrible latch. He became severely dehydrated by day 4--urinating a few brown drops every couple of hours. We went to an LC after the pediatrician (who was most unhelpful). LC took one look at the screaming baby and weepy mom, and said "I can tell you exactly what his problem is--look at his tongue". He was so severely tongue tied that his tongue was heart shaped--he couldn't move much at all, couldn't stick it out at all, couldn't reach the roof of his mouth with it. We did finger feeds for a couple of days while we hunted for a doc to do the frenulectomy. We had that done and he was able to nurse immediately.

ANyway, my point is there are things that can be wrong with a latch that can be easily fixed (teaching the baby proper latch, which is disrupted by the bottle attempts), and things that can require a bit more effort. But it is extremely rare that it is an unfixable problem, jaundice or not.

[FarmgrrlRN]

Well I just spoke to my friend this AM and baby's bili is down to 11.6. Pediatrician said if it continues to fall he will be discharged today. Then the sh*t hit the fan between mom and the MD. He told he that before he discharges the baby today, she must decide TODAY whether she will exclusively BF or bottle feed with formula (ie no supplemental feeds w/finger feeding). She is trying to stay away from bottles as much as possible but today is day 4 and her milk has not come in yet. The LC and nursery nurse told her that maybe once she gets back home, relaxes, and gets into a home routine, then it will come in. Basically, they told her to lie to the pediatrician and tell him that she will bottle feed. She has rented a Medula hospital-grade pump for a month and see what happens at home. She was in tears on the phone b/c she is exhausted b/c she really has tried hard to BF and pump, I'm sure her hormones are all over the place and she seems to feel like a failure now.

[fergus51]

What's the problem with finger feeding? I would rather have a mom finger feed while trying to establish breastfeeding than choose to not bottle while trying it and have the baby wind up dehydrated and back in the unit if breastfeeding is not working (seen that happen more than once). If she can't get him to latch in the hospital and has little knowledgeable support at home, it doesn't bode well for her establishing breastfeeding. Is she able to have a nurse or LC visit her at home?

[FarmgrrlRN]

fergus51,

From what she has said, either a nurse or LC will be visiting her at home. She said that she did have a good nursing session this morning and that he's not so sleepy anymore since his bili level has decreased.

[SmilingBluEyes]

One question: this is not the Ped she will follow up with after D/C, is it?

[BittyBabyGrower, MSN, RN]

I was thinking the same thing...if the ped is being a butthead now I really don't think I would want this person taking care of my baby in the future. Also, if there was an ABO problem he should have addressed it immediately...you want those kids to eat so that the poop moves thru...the longer the poop sits in the GI tract the more bili is reabsorbed, so we do supplement those kids and tend not to use IVF as much. The latest studies have shown that IVF aren't as effective in lowering bili and that feeding thru is much better.

IMHO...I'd be looking for a new doc.

[mitchsmom]

she must decide TODAY whether she will exclusively BF or bottle feed with formula (ie no supplemental feeds w/finger feeding).

that seems crazy... why would he care what method she choses as long as the baby is getting fed and showing improvement? I would probably ask around to the LC (and others whose word I trusted) to see which docs her clients seem to be happy with (I'm assuming she probably isn't allowed to out and out recommend anyone in particular).

[FarmgrrlRN]

Well the pediatrician is from the group of MDs, not the one that she chose. She really likes the one she picked and another doctor in the group, this guy is just a j*ck*ss.

Baby is staying in the hospital as they informed her today (at 4pm) that the baby is not nursing well (bottle or breast) and they want him to stay so they can 'fatten him up'. When she or her husband feeds him it takes about an hour for him to take in ~15-25cc and the nursery nurse was able to bottle feed him 30cc in a half hour. They want to see a nice wt gain over the weekend (he was 7lb6oz at birth, she told me he was down to 6lb12oz, but has gained 2oz). She told me he is having a BM after every feeding too. She left the hospital tonight to go home and sleep (was rooming in after she was discharged last night). She was completely floored that no one (MD or nurse) had mentioned this before this afternoon. Now she is distrustful of everyone there.

She has her rented pump and will continue to pump until he comes home.

[RNmommy]

I am totally UNIMPRESSED with the pediatrician. First of all, did the baby have a positive direct coombs? If so, it is totally unacceptable that the jaundice was not "discovered" until 32 hours of age. I find it unbelieveable that an infant with a 16.9 bilirubin at 32 hours of age was not clearly icteric prior to 24 hours of age and should have then had a bili drawn when the icterus was apparent. We do transcutaneous bili levels on ALL coombs positive babies at 18 and 36 hours of life as baseline and of course PRN. I have encountered VERY FEW infants who are coombs positive and do not become jaundiced enough to require phototherapy.

[FarmgrrlRN]

RNmommy,

I'm not sure exaclty happened with the direct Coombs test, I need to ask her for specific details about that. As far as the baby looking jaundiced, I have a hard time with that too. The baby was rooming with mom from Tues all day and evening long. PP nurses were in & out of the room all day and evening as well as the LC, but no one said anything. I feel bad b/c I was thinking to myself that he was looking jaundiced but I didn't say anything (thinking the lighting was bad, only 1 fluorescent light on at the sink) as well as the fact thatI am the lowly nsg student, what do I know? Who am I to tell the RNs how to do their jobs? (I was there from 1500-2100 Tuesday), and I didn't want to worry mom and freak her out. Now I'll consider that a lesson learned. She chose this hospital specifically for its wonderful reputation but she's incredibly disappointed.

The good news is that baby is home now and feeding much better, though they are still having a tough time rousing him to wake up and eat (she's BF and doing supplemental feeds...). He's going to the pediatrian's on Monday, hopefully he will have good wt gain and they can finally enjoy being parents!

[RNmommy]

Glad to hear that baby is home with mom. I know it is hard to point out possible problems to family and friends and I can surely understand how you felt as a nursing student not wanting to undermine the RN staff. However, it really was unacceptable for that baby to not have been thoroughly assessed for jaundice at least q4h during his first 24 hours of life. This responibility lies with the MD and nursing staff.

[Birdie RN]

Please tell your friend to take heart. It took a 10 days- yes really 10 days for my milk to come in. I too pumped every 3 hours and gave supplemental formula to my kiddo. The pediatrian was very supportive of me in my case I was so ready to give up, but she would not let me and I eventully breast fed exclusively.