Corner Clinic: Our Experts Answer Your Health Questions
UC San Diego Health System Experts
This month we talk about post-holiday depression, congestion, and yellow babies with the following questions:
- The holidays are over, and I’m depressed. What do I do?
- When should I take an antihistamine versus a decongestant?
- Why is my baby turning yellow?
Question: The holidays are over, and I’m depressed. What do I do?
Daniel D. Sewell, MD, director, Senior Behavioral Health Program:
For many, the winter holiday season can be challenging. Although many of the holiday traditions, tasks, decisions and events are rewarding and enjoyable, finding the time and energy for all of these “extra” activities is not always easy. The holidays may also be a time when budgets are stretched and financial stress increases.
In addition, the winter holidays are often a time when family members, including some whom are seen infrequently, spend time together. It seems as if almost every family may have one or two members who are somewhat difficult to be around and with whom there may be unfinished business.
Experts in the field of mental health do not recommend that unfinished business between family members be dealt with over the holidays but, in reality, avoiding unresolved controversies or conflicts is not always possible.
Consumption of alcohol-containing beverages, especially when consumed regularly or in excess, is another potential behavior during the holidays that may impact mood and energy. Alcohol’s physical effects on the body include reducing the quality of one’s sleep and, in some individuals, triggering both short-term and/or more enduring changes in mood.
By the time the holidays are over, it is not uncommon to feel a mix of joy, satisfaction, relief, sadness and exhaustion.
If you find yourself feeling down, tired or lacking motivation after the winter holiday season has passed, this may be perfectly normal or it could be a sign of depression illness.
There are different types of depression illness and, just like with other illnesses, depression illness does not necessarily look the same in each individual nor reach the same level of severity.
In May 2013, after literally years of review and discussion among mental health experts, the American Psychiatric Association published a new edition of the Diagnostic and Statistical Manuel of Mental Disorders, Fifth Edition (DSM-5). This text provides clearly written and easy to understand criteria for diagnosis all of the important psychiatric illnesses and conditions, including the various forms of depression illness such as seasonal affective disorder (SAD), which is a form of depression illness that occurs during the time of year when the length of the daylight period becomes shortest.
If the holidays are over and you are feeling “depressed,” the most important thing to do is to determine whether what you are experiencing is a normal or expected response to the additional demands, events and expectations of the winter holiday season or, possibly, the emergence of a form of depression illness that will need to be diagnosed accurately and treated by a mental health professional.
Some of the factors that help determine whether a person is experiencing an expected letdown or a more serious problem with depression illness include the duration and severity of a person’s symptoms.
To be diagnosed with the most severe type of depression illness, Major Depressive Disorder, symptoms must have been present for the same two-week period and represent a change from how a person usually feels.
Symptoms that are so severe that they interfere with a person’s ability to complete usual daily tasks and responsibilities or include thoughts of death or suicidal thoughts are strongly correlated with depression illness and, if present, indicate that it is highly unlikely that the person is experiencing a normal period of after-the-holidays letdown.
If you believe, based on the information shared in this article, that you are experiencing something beyond a normal period of letdown after the holidays or if you are uncertain whether you may be experiencing something normal versus something requiring evaluation and treatment by a mental health professional, then you should consult with your primary care physician or with a mental health professional.
If you are certain that what you are experiencing is normal and expected, then one or more of the following may help you recover and feel like yourself again:
- Get plenty of rest.
- Get back to a healthy diet that does not include excessive amounts of alcohol or sweets.
- Resume (or start) exercising on a regular basis.
- Spend time with trusted and supportive family members or friends and use this time not just to share some form of entertainment, but also to speak about the important thoughts and feelings you are experiencing.
- Monitor your thoughts and avoid overly negative or distorted thoughts or speech that lower your mood or trigger anxiety. For example, “My holidays were a disaster.”
Question: When should I take an antihistamine versus a decongestant?
Taylor Doherty, MD, Allergy & Immunology:
Antihistamines are usually at least partially helpful for allergic reactions including sneezing, itchy, watery eyes and hives. This is because histamine is released by allergy cells in sensitized people after interaction with allergens such as pollens, molds, animals, or dust mites.
Decongestants can be helpful for people with nasal congestion or sinus symptoms and may work better than antihistamines for people without allergies, though some caution should be used.
Decongestant nasal sprays should only be used for a maximum of three days in a row because of worsening symptoms when stopping after a long period of use. Decongestant pills may also raise blood pressure and lead to some jittery feelings or anxiety in some people.
Thus, it’s important to have an allergy evaluation to help direct which medicines to take. Although decongestants and antihistamines may help with some symptoms, other measures including nasal corticosteroids and allergen avoidance are often needed for maximum relief.
Question: Why is my baby turning yellow?
Lisa M. Stellwagen, MD, clinical professor, Department of Pediatrics:
The tendency for newborns to turn yellow in the days after birth has been observed for centuries. In Korea, the days after birth are called “Huang Dal” or “yellow-time” and accepted as a normal phase of newborn life.
Bilirubin is the chemical that makes baby’s skin turn yellow. The body recycles iron when red cells are broken down; the left over hemoglobin pigment is converted into bilirubin. The bilirubin is then excreted by the kidneys and liver, which is why urine is yellow and stool is brown.
The liver step involves enzymes, which allow the bilirubin to get into bile and then to the intestinal tract. The first stools of newborns – called meconium – are tarry and black because they’re mostly composed of fetal bile. Adults produce bilirubin, but are more adept at excreting it.
Newborn liver function is immature in the days after birth, leading to elevation in bilirubin and jaundice in most newborns. Premature babies are not only more immature in their handling of bilirubin they are also more sensitive to its toxic effects.
Additionally, genetic variants that impair bilirubin metabolism are common. Five to 10 percent of babies have an enzyme mutation called Gilbert’s disease that often leads to jaundice. More than 40 percent of Asian babies have mutations in these enzymes, and interestingly, many African-American infants have the opposite: a supercharged enzyme that leads to much lower bilirubin values in infancy.
In addition to liver immaturity, newborns are in a semi-starvation mode at birth; breast milk is not abundant for the first few days after birth. Babies all lose weight and are a little on the dry side as they await mother’s plentiful milk on day 2 to 4 of life.
The bile-laden meconium sits in their GI tract and the bilirubin is reabsorbed from the gut. The hydration that comes after the newborn starts to take in larger amounts of milk results in the elimination of meconium, and rapid maturation of liver enzymes leads most newborns to quickly clear their bilirubin load and jaundice within a week or so after birth.
Birth is a difficult process and many babies have bruising or hematomas on their scalp. This leads to red blood cell breakdown that adds to baby’s bilirubin burden. Other infants have blood group differences from their mother that can lead to break down of blood cells – called hemolysis – and overwhelm their capacity to eliminate bilirubin.
The most severe hemolysis is that from Rh incompatibility, when the fetus becomes severely anemic from maternal antibodies to baby’s blood. After birth, the baby can become terribly jaundiced.
Fortunately, these days mothers receive an injection to prevent the antibodies from being produced and the incidence of Rh-sensitized mothers is much lower than in the past.
A milder form of hemolysis can happen when mother is blood type O and baby is A or B (like dad). This hemolysis is less severe and leads to jaundice needing treatment in only 15 percent of these babies.
Lastly, other genes that can cause hemolysis in newborns are common. G6PD is present in 13 percent of African American boys (the gene is on the X chromosome so males are most frequently affected), 5 percent of Asian and 10 percent of Mediterranean male infants. These babies can have mild to severe hemolysis and may require therapy. We frequently see breast-fed babies with a combination of increased levels of bilirubin and poor bilirubin excretion that need some observation or treatment before they are safe to go home from the hospital.
Many cultures practice daily sun bathing for babies in the first weeks of life as a form of treatment. It wasn’t until 1956 when a British nurse noted that babies in the nursery near the windows were less jaundiced than those in the interior of the nursery. Soon babies in South America and Europe were getting phototherapy to treat jaundice, but skeptical American physicians did not adopt the practice until 1968 when it was introduced by Dr. Jerold Lucey.
We now know that specific wavelengths of blue light make a molecular change in the bilirubin molecule that allows it to bypass the liver enzyme step and be easily excreted. Today, many types of lights are available and are used in hospitals or at home to treat jaundiced babies.
Sunlight is a very potent form of phototherapy, but may put baby at risk for sunburn or hypothermia and so is not widely used in the United States.
Bilirubin is a potent antioxidant and serves a protective role in the body, but extremely high levels in newborns can have a catastrophic side effect. Certain parts of the newborn brain are sensitive to toxic effects of bilirubin, especially if baby is sick or premature. If this occurs, the brain may be stained yellow in the central areas, called kernicterus. Babies that develop kernicterus may have permanent neurologic injury. They are cognitively normal, but have a form of spastic cerebral palsy, deafness and lifelong disability.
Doctors and nurses who care for newborns are very careful to assess each newborn for jaundice, feeding abilities, hydration and other risk factors for high bilirubin before babies are sent home.
At UC San Diego Health System, medical professionals carefully record a medical and family history for all newborns. All babies have a blood test for bilirubin at 24 hours of age. The value of bilirubin is plotted on a graph for a risk assessment before baby is discharged.
About 8 percent of healthy, full-term newborns stay an extra day or two in the hospital for phototherapy to be sure that the baby has a safe experience with jaundice. Parents are taught to watch for jaundice in their baby in the week after birth and are encouraged to take their baby in for a doctor check up in one to three days following discharge from the hospital.
Most visible jaundice starts on the head and moves down the body as the bilirubin level rises. If the baby looks really yellow, jaundice is visible on the arms and legs or baby isn’t eating well, parents need to call the physician for an examination or take the baby to the emergency room.
It’s important to remember that most jaundice is a normal part of babyhood. Babies with mild jaundice who are feeding well, making plenty of wet and dirty diapers and with good pediatric follow-up are sent home after just a day or two in the hospital and do just fine with no special treatment.
The “yellow-time” after birth is usually a normal phase of infancy, but watching for the outliers and educating parents on the basics of newborn jaundice, can serve to avoid the rare complications of severe jaundice.
Pregnancy and Childbirth