Failure To The Metabolize Bilirubin Philosophy
If mothers would really know what is going on with their babies when they are just born, then many things could be prevented because most of the diseases children and babies present here in Nicaragua, is due to the lack of information, ignorance of treatments and lack of prevention.
Through information obtained from doctors, pediatricians and a neonatologist as well as surveys and information acquired from other sources, this essay is designed to serve as a simple guide that every mother could manage to read and understand for the benefit of her baby. The approach is to make the community, which in this case are the mothers, and the experts, which are the doctors, interact with each other for the better understanding and improvement of diseases.
Bilirubin, can be considered the main character in this research paper, bilirubin is a product that results from the breakdown of red blood cells, is a liposoluble molecule and the excretion through urine is practically impossible, that is when bilirubin accumulates and causes hyperbilirubinemia and in the most extreme cases Kernicterus which occurs whenever bilirubin goes through the barriers of the brain. Fortunately, phototherapy, which is the use of light to treat jaundice includes the emission of UV rays to the skin and converts bilirubin molecules into water soluble isomers so that these can be excreted to the bile without the normal conjugation in the liver. As time passes the baby system is mature enough to sustain his metabolic needs.
Have you ever wonder why most of the newborns have a yellowish color during their first days of life? It was back in the 19th-20th century when many pediatricians discovered about the hemolytic disease of newborns, due to Rh incompatibility among parents. Around 1960s, a nurse noticed that a baby who was suffering from jaundice was getting rid of the yellowish pigmentation in his skin; she then noticed that the baby was the one being exposed to sunlight through a window during the previous days this of course contributed and enhanced researchers.
With research made, it was found that there were causes beyond Rh group incompatibilities. They found that either the baby was producing too much bilirubin or that the patient was not able to conjugate it and get rid of it properly and this had nothing to do with the Rhesus factor. They got to the conclusion that there were other kinds of jaundice also known as Icterus.
After this, researchers kept on doing their job and found out that UV rays aids with this issue, and that this is how we now know that during the baby´s first days of life, the organs are immature and so is the ability to metabolize certain particles such as bilirubin.
The inability of the liver to metabolize bilirubin is the main cause for physiological jaundice, how sunlight helps with the excretion of bilirubin and an analysis about the methods used by mothers in Managua to deal with this issue, the knowledge and responsibility they have towards their babies will be the focus of this essay.
The Liver and bile
The liver and the bile are the main organs involved with Icterus. The liver is the organ responsible for many important functions such as homeostasis  , modification of substances absorbed by the intestines, removal of toxins and bacteria picked up from the intestines and one of the most important is examining the normal composition of the blood so as to prevent blood disorders that may lead to a severe kind of jaundice among other hepatic diseases.
Last but not least, the liver is also important because blood leaving the hepatic vein may also cause problems with the heart since later on it enters to the inferior vena cava and brain. The relationship that the liver has with the rest of the body, being the vital organ it is, must really be taken into consideration. Blood containing bilirubin is totally harmful for such organs and tissues, it is therefore important to keep every process working as it is supposed to.
The bile is formed in the liver; it facilitates lipid absorption thanks to biliary salts and is also the medium of elimination of waste products, biological substances and bilirubin. The formation of the bile is the most complex one of the liver and is therefore vulnerable to any alteration; such alteration is again, characterized by a yellowish color which indicates the retention of such. 
The structure of blood plays an important role in our body. Blood has so many functions and without an appropriate pathway and/or metabolism, our bodies would definitely not work. Human blood has many components and each one of them performs different functions. Plasma, platelets, leukocytes (white blood cells) and erythrocytes (red blood cells) are the blood components.
Plasma proteins play a role in blood clotting while others transport large organic molecules in the blood. Platelets´ main function is to prevent bleeding, while the main function of leukocytes is to fight infections and contribute to the immune system. Red blood and plasma are the components that relate the most to physiological jaundice. Erythrocytes are in charge of carrying oxygen throughout the body and taking or carrying away carbon dioxide. These cells contain hemoglobin inside, once the cell is broken down by the reticuloendothelial system  there is a series of processes that result into bilirubin. Erythrocytes break down, hemoglobin is released, and then it is broken down into heme and globin, now, once again heme is broken down and an oxidation process occurs until the formation of biliverdin; iron is produced as a broken down product. Biliverdin is the closest product to bilirubin since the final transformation consists in the conversion of biliverdin into bilirubin  with the aid of biliverdin reductase. Bilirubin is a lipophilic  molecule; once it is achieved it must undergo a certain pathway. Such pathway will help the baby get rid of icterus. At first, bilirubin is unconjugated due to its original structure as a lipophilic molecule; the physiological pH is the reason why bilirubin is lipophilic or non-water soluble; therefore it is not possible for it to be excreted through urine. That is when the presence of albumin and glucuronyl transferase is needed. The transport of unconjugated bilirubin is achieved by the binding of Albumin serum, which is a plasma protein that will carry this unconjugated bilirubin into the liver.
Once bilirubin is situated in the liver, membranes of hepatic cells transport it to the hepatocytes where conjugation occurs. Now, liver enzymes are ready to perform their job: catalyze reactions. Glucuronyl transferase, the enzyme in charge of the conjugation of bilirubin, will convert this indirect bilirubin into a water soluble state, once this happens the liver excretes this conjugated molecules to the bile and is wasted via intestine so that it is efficiently removed through urine and feces.
Failure to metabolize Bilirubin
Bilirubin is always going to be present in our bodies but at the same time we should always be getting rid of it. Failure to do so makes us turn to jaundice. As we know many factors may cause physiological jaundice such as infections and incompatibility of blood groups, but one of the major causes comes with the pathophysiology of this symptom. It has been believed that this issue is mainly due to the lack of glucuronyl transferase. Glucuronyl transferase belongs to a group of enzymes (UGT) in charge of mediating the conjugation process yet this specific enzyme is the only one in charge of such process.
Failure to metabolize bilirubin will be mainly due to the deficiency of this enzyme. This will result in too much unconjugated bilirubin in the baby´s blood, tissues and fluids, consequently this will be noticeable mainly through their skin, eyes and mucus membranes. This issue not only bases itself in the lack of such enzyme but the actual problem is the conjugation of the product and the ability of the system to get rid of it.
Physiological jaundice is one of the major causes of hyperbilirubinemia and even though it is not severe at first, like any other disease that is not detected on time, will eventually harm our body. For instance, large amounts of bilirubin can get through the brain barrier and may cause brain damage which is known as Kernicterus.
Neonatal Jaundice is the sign of a possible disease which is characterized by the yellowish pigmentation present in the baby´s skin and eyes. Since the baby cannot reach full maturity until two weeks of age, most babies present neonatal jaundice, which is also known as the physiological jaundice of the newborn or, but jaundice actually comes from the word jaune in French, specifically meaning yellow.
There are many kinds of jaundice such as the pre-hepatic, hepatic and post-hepatic yet two of the most common types are due to incompatibility among the parents´ Rhesus factor and due to liver immaturity.
Hepatic tells us that the pathology is occurring at the liver, this kind of jaundice could be produced by acute hepatitis and alcoholic liver disease which is only present in adults. It could also be caused by different syndromes such as Gilberts´ and Crigler- Najjar. Pre-hepatic jaundice tells us that the pathology is happening prior to the liver. It is closely associated to Kernicterus. Post-hepatic jaundice happens once the conjugation of bilirubin is achieved in the liver. It is also known as obstructive jaundice due to the obstruction in the drainage of bile in the biliary system.  Icterus and Cholestasis are the most common consequences of the hepatic disease.
Rh incompatibility, on the other hand consists on the Rh factor of blood. Blood groups include A, B, O or AB, besides that, it contains a Rhesus factor which is helpful for the recognition of certain characteristics about the person, this Rh factor can be positive or negative. If the baby and the mother have different Rhesus factors, whenever the baby is born, the mother creates antibodies to protect her immune system and ends up destroying the baby´s red blood cells because they are not recognized as something from her body. This can result mainly into anemia and jaundice. This is called the hemolytic disease of the newborn or fetal erythroblastosis and it includes pathology, after it is diagnosed, the baby must go through phototherapy, in case phototherapy did not work, the baby´s blood would have to be completely replaced which could be extremely dangerous. On the other hand physiological jaundice tells us that there is a little high amount of bilirubin than normal in the newborn, yet it is not something as malignant as long as there is no pathology involved.
The yellowish/orange color of bilirubin makes it a pigment really easy to identify, such coloration usually appears between 24-30 hours of life. It is quite normal that babies present a certain amount of bilirubin in their bodies due to immaturity. The problem arises whenever those molecules surpass remarkably the regular values. Hospitals and/or laboratories have a table of values in case a bilirubin test needs to be performed, such table of values will vary at a small degree from lab to lab. The treatment for Jaundice might vary depending on the level and severity of each case. Some treatments for icterus include phototherapy, bili blankets and breastfeeding although it is also said that breastfeeding might contribute to jaundice due to the enzymatic presence in the milk. 
According to an interview to Dr. Nancy Aguilera from Hospital Roberto Calderon, Managua, Nic. a doctor can determine if the causes are pathological or physiological based on a table of values and also depending on how many days of life the baby has. Values of bilirubin will depend on the age in hours and the condition of the newborn, whether he is a pre mature or a full term baby. 
Therefore it can be said that as Icterus is at some point normal, it is imperative to determine if the baby has any other problem that would contribute to a more severe kind of jaundice. The factors that affect one way or another should be informed to the mothers. Sometimes mothers alarm themselves whenever they see their pre mature babies with a protruding yellowish color and that is when communication between the mothers and doctors should happen. They should be informed that such things are expected because of the baby´s condition.
Misconceptions of Sunlight
Everyone has heard about the harmful effects of sunlight but we barely listen to its benefits. Economic factors such as the desire of firms to make more profit with their production e.g sun-block, lip-stick, among other cosmetics have been responsible along with media for the misconception we have of it.
Based on research and studies many scientists have made, we know for a fact that UV rays which are emitted from light are harmful to humans but as Mike Garey, nutrition specialist and personal trainer said: "The Sun is the provider of all life on Earth, without the Sun, everything on Earth would die". It is true that every living process requires sunlight, after all the sun is not as bad as it is portrayed.
There is an ambiguity about UV rays. Everything in excess is harmful; these same things could also be beneficial for us. The lack of information is what makes most people inclined to one side of the balance. For example, I know due to my education that exposing myself to sunlight at noon will harm me more than what it would benefit me. This also happens with the babies, when doctors recommend the mother to expose the baby to the sun, it is important that they fulfill the requirements and accomplish the directions as they were given in order to prevent any sunburn on the baby.
UV rays or Ultra Violet rays are emitted from sources of light such as computer, lamps, televisions and the most powerful and natural source, sunlight. There are over 10 types of UV rays, yet, three of the most important and the ones that usually affect us are: UVA, UVB and UVC. UVA emits long wave rays from sunlight of approximately 320-400nm. It represents most of the sun´s natural light, they penetrate deep into the skin until they reach the dermis, UVA rays are the ones that harm the most, and they can cause pre mature aging and skin cancer. On the other hand there are UVB rays with shorter wavelengths of approximately 290-320nm and it slightly reaches the epidermis after passing through the skin surface; this is what helps us acquire the famous sunburn or tan. UVC rays have even shorter wavelengths that go from 200-290nm.These rays hardly get to the ground; they are absorbed whenever they are entering the ozone layer  . Knowing UV rays characteristics is important since some methods are based on the replacement of natural sunlight into that of artificial light such as curing, mercury vapor, fluorescent and incandescent lamps along with natural photo therapy.
The use of visible light for the treatment of hyperbilirubinemia in the newborn is called phototherapy. Visible light emits wavelengths that are stronger than UVA. This is used in hospitals to treat jaundice that include pathology.
According to an interview made to Dr. Fajardo, resident of pediatrics in Hospital Fernando Vélez Paíz, Managua, Nic. Natural phototherapy and lamp phototherapy´s principles are the same, but lamp phototherapy is used only when pathologies in order to keep resources available for those who will actually need such treatment. He also mentioned that lamp phototherapy does not necessarily means that wavelengths are stronger, they are actually less intense but more controlled. 
Many people and most importantly mothers will see lamp phototherapy not as good as it can be. The fact that their babies have to go through a treatment that is far from being natural makes them worried. They should be informed about the characteristics, differences and similarities between natural light and phototherapy.
Sunlight for many people is the best cure, yet they don´t know that UV rays in big amounts can harm the cellular DNA while others benefit. It is imperative to know about this. For instance, you want your baby to receive UVA rays because they are the ones in charge of the metabolism of bilirubin yet your baby will also receive UVB rays which will probably cause sunburn. Therefore the fact that it is used as a home treatment to cure icterus makes mothers and babies more vulnerable to alter the treatment and acquire side effects. Babies should be carefully and adequately exposed to it or else the damage will be worse off. Dawn and afternoon sun would be the most adequate time to expose babies, at this time the sun is not as harmful as it would be at noon, so this way it will suit the baby´s need of sunlight.
"When the baby is born it is very common that his or her skin will appear to be yellow and we usually recommend the mother to expose her baby to the sun early in the morning for about 10 minutes every day for a week or two; however if the baby does not improve, a bilirubin test should be performed to check his or her levels and apply another kind of treatment for if it is not cured with sunlight and the baby is left off that way, he or she might suffer from brain damage" Said Dr. Rodrigo Alvarez from Hospital Lenin Fonseca, Managua, Nic. 
Not only the mothers have the responsibility to accomplish the treatment but they also have the responsibility of fulfill it as it is supposed to.
UV rays and the isomerization
Phototherapy is used as the method that mediates the conversion of molecules by rearranging their structure, such method is called Isomerization. There is a relationship between UV rays and jaundice. Sunlight aids with icterus by isomerizing the molecules and making them more soluble without undergoing the liver conjugation.
Configurationally Isomerization is: "the process that changes some of the predominant 4Z, 15Z bilirubin isomers to water-soluble isomers in which one or both of the intermolecular bonds are opened"  . Meaning that the 4Z, 15 bilirubin changes to 4Z, 15E bilirubin and lumi rubin.
Structural isomerization in the other hand consists on the formation of lumi bilirubin. Bilirubin undergoes a photocyclization process which is the process that enhances the formation of a new single bond. It greatly depends on the intensity of light, the more intense the light is the faster photocyclization and excretion will occur. Once the structure is changed it is easier to be excreted and is mostly responsible for the decrease of bilirubin levels. Photo bilirubin on the other hand goes through a slower process; it is more difficult for it to be excreted.
Hemolysis is the main cause from which all these products derive. Such products have a physiological or natural way of being wasted, yet we can also use other sources which will also be beneficial and will contribute to improve jaundiced babies. According to Dr. Fajardo; pediatricians always recommend sun bathing but that does not necessarily mean that the baby is going through jaundice, some babies keep their pinky/reddish color. This is probably why some mothers do not realize that their babies suffer from physiological jaundice. Since this is always recommend it, there is actually nothing but the yellowish color that can tell you that you baby is or is not suffering from jaundice.
Mother's role and knowledge
The importance of having the appropriate knowledge to fight a disease is of extreme importance. Many times, ignorance is what makes us unaware of possible chances we have for curing a disease. Ignorance at some point is due to the lack of communication.
Based on a survey it was found that only 40% of the mothers had some kind of knowledge about jaundice  .It is important to mention that these mothers were the ones that had a higher level of education. Mothers were asked if their babies presented jaundice, most of them said no, but whenever they were talked about the characteristic of such and sun exposure they realized that their babies did suffer from jaundice, only that since it was physiological the doctors never mentioned it probably because they believe it is not necessary yet it is.
They were asked if the doctors had recommended their babies to have a sun bathing and they said yes. 98% of them fulfill the treatment in some way, 60% of them did exactly as the doctor said. 38% exposed their babies to sunlight yet they altered the amount of days and time of exposure because they saw an improvement and did not consider it necessary any longer  . The time at which the babies were recommended by pediatricians to be exposed to sunlight went from 6:00 to 8:30 AM for approximately 10 days for about 30 minutes. The mothers that were able to fulfill the treatment strongly recommend sun exposure; they said it was very effective and easy to follow. Overall they said that it was not hard for them to attain the treatment, since it really did not require that much time and that their babies were their priority and would do anything for them to be fine. On the other hand around 5% of them said that it was hard for them to fulfill the treatment mostly because they did not have time due to their jobs and other responsibilities. These are probably the cases that Dr. Alvarez mentioned. Some babies as he said were left off that way and their condition got worse. Only a very little percent of the mothers showed concern about this issue but this might be due to the fact that they had very little information about the topic and ignore the consequences that it might bring.
The common issue of neonatal or physiological icterus is found to be the most common treatable issue with newborns. It can be concluded that sunlight aids with the metabolism of bilirubin by the isomerization process and/or transformation of this molecule into water-soluble molecules that can be excreted. Besides that there many processes happening at once, those contribute to a faster disposal of bilirubin. However if the mothers do not follow the home treatment doctors usually recommend, they might experience a severe problem, since the baby´s metabolism is not enough to deal with this issue by itself.
According to several mothers in Managua jaundice is nothing to worry about, the majority of them have exposed their kids to sunlight for around 10 days and the yellowish color had disappeared. They do not seem to understand why it is helpful yet they follow the treatment.
The importance of education must be present in any kind of disorder a mother experiences with her baby, sometimes ignorance has been the main cause for this pathology. The lack of information and communication between mothers and doctors lead to ignorance about the importance of this sing. Since mothers are not informed they might decide not to accomplish the treatment since supposedly there is really nothing to worry about.
The fact that physiological jaundice cannot be prevented, and we can´t really do nothing about it, doesn´t mean that the same thing applies to all different kinds of Icterus. I would say that a blood compatibility test and an amniocentesis study would be of much help to prepare for it and detect any kind of disorder on time. I also recommend the fact that doctors should inform the mothers if their babies suffer from physiological jaundice because this will contribute to a decrease in the cases of hyperbilirubinemia, failure of blood transfusions and prevention. I believe that if the mother is not informed she might fall into the mistake of not following the treatment, yet we know that if we let this continue, bilirubin production might continue increasing and the chances of acquiring any other disease such as Kernicterus will increase as well.
Article name: Failure To The Metabolize Bilirubin Philosophy essay, research paper, dissertation