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Back-to-the-basics care

Medical resident Ashley Balsam, M.D., got to know the children in Jalapa. (Photo: Courtesy of Ashley Balsam)

A medical resident uses an improvised light box to prevent jaundice-related disabilities in newborns

After finishing a 30-hour hospital shift, Ashley Balsam, M.D., a third-year internal medicine and pediatrics resident, doesn’t go straight to bed. “I’m going to play soccer,” she says.

That energy is typical of Balsam. Her normal routine includes doing rotations at University of Minnesota Medical Center, Fairview, playing soccer on a team with other residents, and caring for her new puppy, Chopper. She also finds the time and passion to volunteer with local outreach programs and travel to Nicaragua, where she’s studying the long-term effects of neonatal jaundice.

Spotting the problem

As part of an international rotation, Balsam spent two weeks last February working at a hospital in the city of Jalapa, Nicaragua, providing health care for “los pipitos”—children with disabilities.

“It’s very bare bones. You’re forced to rely on your clinical knowledge,” Balsam says, noting that the hospital had no x-ray or ultrasound machines and just one oxygen tank for the entire facility.

Balsam and her colleague, fellow resident Janielle Nordell, M.D., accompanied by faculty member Teri Reid, M.D., treated a number of children with cerebral palsy, hearing problems, and developmental disabilities. They learned that the children had had uneventful births but developed disabilities later. Balsam’s group suspected that untreated jaundice at birth may have been the underlying cause.

Jaundice is a yellowing of the skin that occurs when the body is waiting for the liver to process bilirubin—a byproduct of the normal breakdown of red blood cells. If the bilirubin level gets too high, it can cause developmental problems.

In the United States, neonatal jaundice is easily treated and often diagnosed in the first few days after birth, while babies are still in the hospital. But in Nicaragua, most mothers and babies stay in the hospital for only about eight hours after birth, so the chance to diagnose and treat jaundice is often missed.

The medical team checked bilirubin levels in the 10 newborns who were delivered in the hospital during Balsam’s stay in Jalapa. Of these 10, two had bilirubin levels that were in the range that required treatment with phototherapy.

A mother keeps a close watch as her baby is treated for jaundice in one of the phototherapy boxes Balsam and her colleagues built. (Photo: Courtesy of Ashley Balsam)

DIY treatment approach

Phototherapy is the use of bright blue light to treat jaundice. “The UV rays in the light allow the bilirubin to be processed without the liver,” Balsam says. On its own, a newborn’s liver can take three to four days to remove excess bilirubin.

To administer the treatment, Balsam and her colleagues built a wooden phototherapy box. “We brought with us a simple design for how to build a phototherapy treatment box with fluorescent lights and wood,” she says. “We fancied it up with wheels.”

Balsam borrowed the design from Tina Slusher, M.D., a physician at Hennepin County Medical Center who used the same type of box to treat jaundiced newborns in Africa. Staff in Jalapa helped build it, learning the technique so they could make more boxes later.

The jaundiced babies are placed in the light box and exposed to UV rays. The treatment time depends on their bilirubin levels. “We treated 10 babies and none have [developed] problems from jaundice,” Balsam says. Since she left Jalapa, more than 10 babies have received phototherapy treatment, and her group has sent funds for constructing a second phototherapy box.

A big challenge in the process has been to build nurses’ confidence in administering the treatment. “The nursing staff was nervous [about the box],” Balsam says. “We had to do a teaching session, and after that they were really supportive.”

Another challenge was convincing the newborns’ parents that the treatment would help. “It took three to four hours of talking with them first,” says Balsam, who speaks Spanish.

Continuous learning

Working directly with families changed her view of what it means to deliver care. “We had this excitement over helping these babies, but it took sitting down and having a relationship with the families to make it happen,” Balsam says. “If the family doesn’t trust you, you’re not going to be effective.”

Balsam has since traveled back to Nicaragua and is planning another trip in February. “On our return trip in July, we made very basic handouts about jaundice and went out into the community to talk with pregnant women about recognizing [it] in their own babies.”

Now Balsam is awaiting approval from the Institutional Review Board—the group that monitors medical research involving human subjects—to begin a formal study on jaundice treatments and outcomes in babies in Nicaragua.

“If phototherapy treatment works, I think it will make a big difference,” she says.

By Robyn White

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