#include "headerA.incl"

Newborn Jaundice

#include "headerB1.incl"

See also:

Subsections on this page:



About Newborn Jaundice



Neonatal Hyperbilirubinemia: Study Identifies Risk Profile [11/9/15] - A set of maternal and obstetric risk factors readily available at birth predicts a greater than 100-fold variation in the incidence of nonhemolytic neonatal hyperbilirubinemia, according to a large population-based study published online November 9 in Pediatrics.


Predicting Nonhemolytic Neonatal Hyperbilirubinemia.
Norman M1, Åberg K2, Holmsten K3, Weibel V4, Ekéus C2.
Pediatrics. 2015 Nov 9. pii: peds.2015-2001. [Epub ahead of print]

CONCLUSIONS: Collection of a few easily available maternal and obstetric risk factors predicts >100-fold variation in the incidence of neonatal hyperbilirubinemia. The information provided herein enables individualized risk prediction with interactions between different risk factors taken into account.



Jaundice: Friend or Foe? by Holly Scholles - You thought you knew all about jaundice. Whether you are a new midwife or a seasoned expert, we promise you will be surprised by what you learn in this latest course from Holly Scholles, MA, CPM, LDM.

All it takes to avoid neonatal jaundice is a tender touch - Abdominal massage is found to hasten the passage of meconium to reduce the reabsorption of bilirubin and reduce resulting jaundice.  This assumes that you are already breastfeeding frequently, since the colostrum has a naturally laxative effect.

Preparation for Discharge, Maternal Satisfaction, and Newborn Readmission for Jaundice: Comparing Postpartum Models of Care

Lise Goulet MD, PhD, Aïssatou Fall MD, MSc, Danielle D’Amour RN, PhD, Raynald Pineault MD, PhD (2007)
Birth 34 (2), 131–139.

Results: Of the participating newborns, 45.5 percent presented with signs of jaundice, and 3.2 percent were readmitted for jaundice during the first week of life. The follow-up procedures used in regions operating under a community-based model most closely followed the recommendations of health authorities and featured a high level of mothers’ satisfaction. In the region operating under a mixed hospital model, mothers reported signs of jaundice significantly more often, and postdischarge services received by mothers were less effective at allaying their fears compared with other models. Phototherapy was offered in the home only in the region operating under a mixed ambulatory model, and no readmissions for jaundice were recorded in this region.

Conclusions: An effective coordination between community-based perinatal services and hospital-linked home phototherapy in the form of an integrated network appears to be an essential condition for improved monitoring of newborns’ health since it fosters a follow-up that is focused not only on jaundice but also on mothers’ and newborns’ needs while reducing the costs generated by newborn readmissions. (BIRTH 34:2 June 2007)



Jaundice in the Healthy Term Newborn
from Perinatal Services BC - formerly the British Columbia Reproductive Care -This has a nice section on Management of Newborn Jaundice at Home Program - they recommend getting a total bilirubin test with the Newborn Screen if concerned.

There's a great jaundice article is one from 1995 by consultant paed E N Hey.  "Neonatal jaundice how much do we really know?" Midirs Vol 5 No 1 March 1995 pp 4-8.

Basically he is saying that the statistics and research evidence do not support current protocols (1995 remember) and that there is no need for any action to be taken until bilirubin level is at 500.   He says "jaundice probably only calls for medical intervention in the absence of haemolytic disease in one term baby in a thousand".   I love this line:  "It is a sad indictment of the medical approach to normality that we now define 'normality' by the performance of the average bottle fed baby".


Changing Outcomes: Managing Neonatal Hyperbilirubinemia and the Special Needs of the Near-Term Infant - "The most common reason for readmission of a newborn to the hospital in the first 2 weeks of life is jaundice."


Availability of Revised Guidelines for Identifying and Managing Jaundice in Newborns

Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation - AAP Guidelines - [PEDIATRICS Vol. 114 No. 1 July 2004, pp. 297-316]


Home Phototherapy - Facts, Fads & Fables in the Real World by: Rob Rose, MD - look on p. 11. - includes a description of basic tenets of home phototherapy and a cost comparison of various techniques.  [Fall 2003 AAP Newsletter]


Pediatrics, July 01 2002 by William D. Engle, Gregory L. Jackson, Dorothy Sendelbach, Denise Manning, William H. Frawley

Noninvasive Measurement of Total Serum Bilirubin in a Multiracial Predischarge Newborn Population to Assess the Risk of Severe Hyperbilirubinemia.  [Full paper]
Vinod K. Bhutani, Glenn R. Gourley, Saul Adler, Bill Kreamer, Chris Dalin, Lois H. Johnson
Pediatrics, August 01 2000


The Art and Science of Caring: Focus on the Family - Early recognition of neonatal jaundice and kernicterus
Laura A. Stokowski, RN, MS


Early recognition of neonatal jaundice and kernicterus.
Stokowski LA.
Adv Neonatal Care. 2002 Apr;2(2):101-14; quiz 117-9.  Related Articles, Links

Transcutaneous Bilirubin Measurement is as Effective as Laboratory Serum Bilirubin Measruement at Detecting Hyperbilirubinemia
Date appraised: January 18, 2002


Transcutaneous bilirubin measurement: a multicenter evaluation of a new device.
Rubaltelli FF, Gourley GR, Loskamp N, Modi N, Roth-Kleiner M, Sender A, Vert P.
Pediatrics. 2002 Aug;110(2 Pt 1):407-8.

CONCLUSIONS: BC could be used not only as a screening device but also as a reliable substitute of TSB determination. At higher levels of TSB, in which phototherapy and/or exchange transfusion might be considered, BC performed slightly better than the laboratory. The accuracy and precision of the TcB measurement in this study was observed to be comparable to the standard of care laboratory test.


Assessment of a transcutaneous device in the evaluation of neonatal hyperbilirubinemia in a primarily Hispanic population.
Engle WD, Jackson GL, Sendelbach D, Manning D, Frawley WH.
Pediatrics. 2002 Jul;110(1 Pt 1):61-7.

CONCLUSIONS: The tendency of BC to underestimate TSB limits its usefulness in neonates with relatively high TSB.


Transcutaneous Bilirubinometry and Diagnostic Tests: "The Right job for the Tool"


Cost-Effectiveness of Strategies That Are Intended to Prevent Kernicterus in Newborn Infants
Gautham K. Suresh, MD, DM, MS* and Robin E. Clark, PhD
PEDIATRICS Vol. 114 No. 4 October 2004, pp. 917-924 (doi:10.1542/peds.2004-0899)

Conclusions. Widespread implementation of these strategies is likely to increase health care costs significantly with uncertain benefits. It is premature to implement routine predischarge serum or transcutaneous bilirubin screening on a large scale. However, universal follow-up may have benefits beyond kernicterus prevention, which we did not include in our model. Research is required to determine the epidemiology, risk factors, and causes of kernicterus; to evaluate the effectiveness of strategies intended to prevent kernicterus; and to determine the cost per quality-adjusted life year with any proposed preventive strategy.

Management of Hyperbilirubinemia: Quality of Evidence and Cost
Holtzman, N. A.
PEDIATRICS Vol. 114 No. 4 October 2004, pp. 1086-1088 (doi:10.1542/peds.2004-1753)


Slight Yellow Tint May Be Protective for Newborns - 11/25/02

Biliverdin reductase: a major physiologic cytoprotectant.
Baranano DE, Rao M, Ferris CD, Snyder SH.
Proc Natl Acad Sci U S A. 2002 Dec 10;99(25):15837-9.


Chinese tea 'may cure jaundice' - (1/3/04) A herbal tea used widely in China to treat jaundice could soon be used by doctors in the West.  - Scientists in the United States have found that Yin Zhi Huang (YZH) can stop the build-up of a type of bile that causes the condition.


Early Discharge Not Linked to Jaundice


Management of Hyperbilirubinemia in the Healthy Term Newborn from the AAP


It seems that a good reason to help a baby get over his jaundice would be primarily so that he will feel better and feed well. One problem with advancing jaundice is lethargy and dehydration in the infant.


I haven't noticed this in any of my babies, and most of them have jaundice...anyone else notice these signs?


This is the difference between normal physiologic jaundice (which we all see at times) and true hyperbilirubinemia. This is my algorithm for jaundice, taught to me by a pediatrician who I respected a great deal. See the jaundice, ask these questions; is there a positive coombs? (or is mother Rh neg, or is there an ABO incompatibility setup?) if yes, do a bili, if no leave it alone. is the baby alert and nursing well? (if yes, leave it alone, if no, do a bili) Is there are septic setup, eg. spiked a temp, or mum did, etc. (if yes, do a bili, if no leave it alone) Is the baby term? (if yes, leave it alone, if preterm do a bili) In this way, we at home will do very few bilirubin levels, as you can see. We will save the babies getting poked, and will have accurate readings on babies at risk.


The babies I see with bad jaundice are usually those who have had a rough birth with a lot of molding of the head, and often just can't get the knack of nursing well. My personal belief is that they have a headache and sucking hurts. Most frequently with primips, who don't know how to nurse yet, and see this sleeping baby as a "good" baby.

So the baby sleeps, and only nurses or tries to nurse every 4-5 hrs. Starts getting jaundiced. High bili causes lethargy. Baby sleeps even more, or is weak nurser.

My thing is to make SURE the baby is nursing before leaves the hospital, and if that means she stays an extra day, so be it. If baby not nursing well, I make sure mom knows how to cup feed water. I see baby back on 3rd day for wt and to watch him nurse. If big drop (more than 10%) I see baby daily. I don't check bili, no matter how yellow, unless baby still not nursing well. I put them in the window from the beginning if baby not nursing well, because I know he will get jaundiced.

I have heard of severely dehydrated, jaundiced, full term babies getting kernicterus. It does happen, tho extremely rare. The big thing is the poor nursing, and if the baby isn't nursing well, it is a spiral down - poor nsg, dehydration, jaundice, even poorer nsg and lethargy, more jaundice, etc, etc, etc.

IMO, it is the caregivers fault if he/she isn't checking the actual latch and suck to see this baby is getting on the way she should. Just because nsg is the normal way to feed a baby doesn't mean it always works. Vigilance is the word!


Why are we worried about jaundice? Jack Newman suggests that the idea that jaundice is bad is a standard based on formula-fed babies (who tend less often to be jaundiced). He suggests that rather than looking at the breast-fed baby and saying "why is that baby jaundiced?", we should look at the formula-fed baby and say "why isn't that baby jaundiced?"

There are sound physiological reasons to argue for the benefits of elevated bilirubin, as it is an antioxidant, something thought to be fairly important as a baby moves from a relatively low O2 to a high O2 environment (but w/ functioning fetal hemoglobin). Blackburn and Loper give a good explanation of this, I believe.

I find it hard to get too excited about jaundice in a baby that's doing all the "right" things...nursing well, peeing and pooping and gaining. I think it's just a part of the normal physiological process of adjustment to extrauterine life (barring, of course, pathological exceptions like jaundice in the first 24 hours, lethargy, etc).


I agree with you in the statement that jaundice is very normal. I too have "jaundiced" babies all the time. But their jaundice is physiologic and the only "treatment" they require is to keep nursing. Yes, pathological jaundice must be treated, but it is our job to determine which is which, and help parents not to panic about it.



Jaundice Criteria Lowered for Liability rather than Medical Reasons



Okay ladies, here is one case where I have PROOF that the criteria for diagnosis of a disease or complication has been lowered. My ped...my sweet, sensible, kind, caring, father of 5 breastfed babies, and his partners, two old timers short on bedside manner but still very competent and good with the little ones,(also Fathers of large breastfed families) DON'T TAKE CORRECTIVE ACTION unless the count is above 25!!!!!!!!! According to them, this was the way jaundice was handled when they were starting out, but the -and I quote! "Current trend is toward more aggressive action on lesser levels for liability reasons". Nowadays I hear of babies with a bili count as low as 12 being subjected to repeated heel sticks and bili lights:(

This is how my peds handle this.
Above 25: they rent out bili light units and recommend times based upon severity of jaundice.
Below 25 but above 20: heel sticks for count everyday along with UNRESTRICTED ACCESS TO THE BREAST and possibly additional fluids -water-via bottle. Undress the baby and put it in a sunny window several times a day.
above 15 but below 20: nurse more frequently, keep the little hats off and get them into sunlight as often as possible. Heel sticks only if color does not improve in 24-48 hours.
below 15: nurse more. That's it:)

They never recommend artificial baby milk over breastfeeding and are among the rare MDs who know how to support breastfeeding. They refer out! LOL! They don't take the "easy way" and say "bottle" at the first sign of a problem. AND, now this is important, they think formula CONTRIBUTES to the problem instead of alleviating it. More toxins to flush out which challenges the baby's liver even more!!

A lot of this depends upon the TIMING of the jaundice as there is jaundice that is pathological and must be treated more aggressively. This jaundice is usually apparent at birth where as the physiological jaundice appears around day 3 PP.

They also believe that jaundice can be indicative of dehydration and send in the "old timer nurse" who is unbelievably good at getting babies on the breast and feeding well. Or ,hi-ho hi-ho, it's off to call the lactation consultant they go....and sometimes..ME [GRIN]

"Least amount of action necessary to correct the problem keeping in mind one must treat the WHOLE child, not just the body....repeated heel sticks are cruel and may do harm to the child's sense of well being."



Assessing Jaundice



Improved Transcutaneous Bilirubinometry: Comparison of SpectRx BiliCheck and Minolta Jaundice Meter JM-102 for Estimating Total Serum Bilirubin in a Normal Newborn Population by Robertson, Kazmierczak, and Vos.


The Minolta/Hill-Rom Air-Shields® JM-103 Jaundice Meter is an accurate, instantaneous, non-invasive device that provides an estimate of serum bilirubin levels.


BiliCheck - Non-Invasive Bilirubin Analyzer Hand-Held Device for Measuring Bilirubin in Infants The handheld BiliCheck (SpectRx, Norcross, GA) for measuring bilirubin in newborns. The device is held against the infant’s forehead and completes the test in 15 seconds.  The measurement is conducted through the skin; no blood is drawn.  - Yes!  You can really check the baby's bilirubin levels without breaking the skin!  (Actually, you've been able to do this for a long time using an icterometer, but this is presumably more accurate.)

BiliChek - not sure if the same device


Someone posted some information awhile back on "eyeballing" bilirubin levels. I have found a citation for that and wanted to share it with you.

Visual estimates of serum bilirubin levels use the phenomenon of cephalocaudal progression of jaundice. Kramer (34) correlated the presence of dermal icterus with a serum bilirubin levels and found a cephalocaudal progression that continues as the concentration of serum bilirubin is increasing and remains the same when the level becomes stabilized. Jaundice to the level of the shoulders correlates to 5-7 mg/dL, to the level of the umbilicus to 7-10 mg/dL, below the umbilicus to 10-12 mg/dL, and below the knees to >15 mg/dL. The cephalocaudal progression is only seen when the bilirubin is rising. When the bilirubin begins to fall, the dermal icterus fades gradually in all affected skin areas at the same time.
De Steuben, C. 1992. Breastfeeding and jaundice: a review. Journal of Nurse-Midwifery, 37, (2), March/April, 59s-66s.

Kramer, LI. 1969. Advancement of dermal icterus in the jaundiced newborn. Am J Dis Child, 118, 454-8.


References for Recent Icterometer Research

First manufactured in 1954, icterometers were developed as a means to monitor the daily progression of newborn jaundice. Since that time, many attempts have been made to create a more accurate, modern and high-tech screening tool for newborn serum bilirubin (SB). To date, however, electronic transcutaneous bilirubinometers have not proven that they can meet the goal of increased accuracy. From the mid-1980s (when the electronic technology was first in development) through today, researchers have tested the effectiveness of both methods and found that they are rather on par with each other. Both are adequate for screening purposes, yet the icterometer can be used by parents as well as professionals, is more affordable, and is more portable. Electronic SB monitors might provide the illusion of greater accuracy, but study after study shows that the good, old icterometer does just as good a job of estimating.
Transcutaneous bilirubinometry: a comparison of old and new methods." July, 1985
Evaluation of Minolta jaundicemeter and icterometer for assessment of neonatal jaundice." February, 1989.
Recognition of the Presence and Severity of Newborn Jaundice by Parents, Nurses, Physicians and Icterometer." September, 1997.
Home health nurse clinical assessment of neonatal jaundice: comparison of 3 methods." 2001.
Maternal assessment of neonatal jaundice after hospital discharge." May, 2002.
AHRQ report on neonatal jaundice." June, 2003

-by Tara M. Bloom
 (c) 2004 Cascade HealthCare Products, Inc

You can purchase an icterometer from Cascade HealthCare Products, Inc.



Home Treatment for Jaundice with Sunlight




Some sources say that sunlight is not effective for treatment of physiological newborn jaundice.  However, midwives have often recommended this free treatment that doesn't interfere with breastfeeding.


 In my training, I had been taught to line a laundry hamper with a blanket to create a draft-proof environment where a nude baby could be sunbathed; hot water bottles or hot rice socks could be used to provide additional heat while the baby's nude body was exposed to the sun.  The baby's eyes were always supposed to be in shade, and you were supposed to use good common sense to limit the length of exposure so baby wouldn't be sunburned.  (This was generally 5-10 minutes near the summer solstice, and 15-30 minutes in autumn and winter.  It seems like you want to get about 20 minutes of moderate exposure, no more than 5 minutes in extreme exposure.)

Necessity is the mother of invention, indeed. One of my clients didn't have a suitable laundry hamper or similar container.  We thought about it and realized that a car could be used as a nice sort of mobile outdoor windscreen.  And, as a nice side effect, cars sitting in the sun are often much warmer than the ambient temperature.  First, we repositioned the car so that we could open the rear door and have the back seat exposed to light without any shadows from the car or door frame.  Then we brought the baby outside and positioned him in a Moses basket on the back seat of the car.  The really cool thing was that the roof of the car provided a sharp shadow, and it was easy to move the baby so that this line fell on the baby's face below the eyes.  It was a very satisfying solution!


The UV Awareness web pages has a page on UV Strength and another on the UV Index.  They have a really cool UV calculator where you can enter your location, and it will tell you the UV intensity hour by hour.  [NOTE - It's actually the light in the blue-green spectrum that helps to break down the bilirubin, but one would expect that varies in the same way as ultraviolet light varies with the season, time of day, daylight-savings adjustment, altitude, ozone layer, etc.]


There is some recent research that supports sun baths to treat newborn jaundice:

Importance of UDP-Glucuronosyltransferase 1A1 Expression in Skin and Its Induction by UVB in Neonatal Hyperbilirubinemia.
Sumida K, Kawana M, Kouno E, Itoh T, Takano S, Narawa T, Tukey RH, Fujiwara R.
Mol Pharmacol. 2013 Nov;84(5):679-86. doi: 10.1124/mol.113.088112. Epub 2013 Aug 15.

 . . . Sunlight, a natural and free source of light, makes it possible to treat neonatal jaundice while allowing mothers to breast-feed neonates.



Can sunlight replace phototherapy units in the treatment of neonatal jaundice? An in vitro study.
Salih FM.
Photodermatol Photoimmunol Photomed. 2001 Dec;17(6):272-7.

METHODS:  The efficiency of sunlight was quantified by a comparison with a phototherapy unit. Aqueous bilirubin solutions were exposed to periodic sunlight over the entire year and the reduction of bilirubin concentration was monitored spectrophotometrically. Bilirubin solutions were also exposed to a phototherapy unit intensity comparable to that of sunlight (17 cm away from the source).

RESULTS: The data indicated that at this comparable light intensity, the phototherapy unit was as effective as sunlight. However, for the treatment of neonatal jaundice, phototherapy units are usually operated at a distance of 50 cm (where the light intensity is six times less than that of sunlight). When this distance was tested, only 16% of bilirubin was isomerized in the first 5 min of exposure. In contrast, about 65% of bilirubin was isomerized when the phototherapy unit was placed at a distance of 17 cm and when the bilirubin solutions were exposed to sunlight for the same time period. The hourly and seasonal changes in sunlight intensity affected the reduction in bilirubin concentration significantly.

CONCLUSION: Data revealed that sunlight is almost 6.5 times more effective than a phototherapy unit when operating at the ward geometry after taking isomerization efficiency and area of exposure into consideration. Moreover, sunlight is still more effective during the winter season, when its intensity is lower. Thus, sunlight may be considered an alternative phototherapy source for the treatment of neonatal jaundice, particularly in areas where conventional phototherapy units are unavailable.



Home Treatment for Jaundice with BiliLights




Bright Embrace, A Single-Use Bright Light Therapy for Babies from Physician Engineered Products (PEP)

PEP’s new and very-affordable Bright Embrace is a hospital-grade single-use baby phototherapy device that delivers intensive phototherapy for jaundiced babies at home or in the hospital. Designed to wrap your jaundiced baby in bright blue light provided by low-cost, but reliable, high-intensity LED bulbs, the Bright Embrace will treat most jaundiced babies within 1 to 2 days. Then, the Bright Embrace can be sent back to PEP for component recycling – so your Bright Embrace becomes “green.”

This device can be dispensed from the pediatrician's office for faster initiation of treatment.  The cost is about $350.

The great benefit of this device is the efficiency; treatment may take just 1-2 days instead of the many more days required by weaker devices.  This is said to be about 7 times stronger than the Wallaby because of the updated technology.  In my eyes as a midwife, the biggest benefit is that it's so much quieter, so it won't interfere with mom's or baby's sleep!



Protocols for Using Home Bili Lights - AAP recommendations, as published in Pediatrics, Vol. 94 No. 4, October 1994:

The PEP Ultra BiliLight is another portable phototherapy device, which is supposed to be significantly more effective than the BiliBed.  However, it is not as "user friendly" and does require eye protection.  It might be a better choice for a severe case that would otherwise require hospitalization, but it may be more than is needed for most borderline cases.


The Medela BiliBed is the latest innovation in the treatment of hyperbilirubinemia. The BiliBed provides more intensive therapeutic light than fiberoptic and conventional phototherapy units.  Precisely directed light and minimum distance to the baby provide higher irradiance levels with superb therapeutic performance.  Since the baby is treated in a bassinet or crib, mother and baby can be together while rooming-in at the hospital and also at home.  Other phototherapy units are described at http://www.msdistributors.com/biomed/meh/PHOTOTHE.HTM


My son was fairly jaundiced and was treated at home with a portable "bili blanket."  This was a soft, flexible paddle-type thing that glowed bluish-green.  It was attached by a long tube to the light generator.  We put the paddle under his shirt against the skin on his back.  He was hooked up to it all day and night except for diaper changes and baths for three days and then slowly taken off of it.  We took him in for heel sticks (which made me cry every time :( ) daily but otherwise he was home with us; nursing, sleeping in our bed and cradled in our arms.  It was minimally disruptive to our life.  It was delivered to our house by a home-health agency and they picked it up when we were done.  It appeared to be very effective as his bili levels did drop off rapidly during treatment and leveled off when treatment was discontinued.  From my personal experience, I recommend it highly.


For jaundiced babies who aren't moving out the meconium as quickly as expected, it helps to use glycerin suppositories to induce bowel movements; this reduces the re-absorption of the bilirubin from the meconium in the bowels.



Charcoal for Jaundice



the midwife that i assist at homebirths has had very little trouble with jaundice. but on those occasional stubborn cases she has had great success with activated charcoal. she dissolves a little in water and administers by mouth. i was wondering, since it had not been mentioned, if anyone else has achieved similar results with charcoal.


In our Jehovahs Witnesses community, we have come up with some ideas to help in this area as if it was a witness baby and “16” they would be threatening blood transfusion and taking of baby so this is what we do in the home situation.  You get deactivated charcoal, it comes in capsules or loose, you put ½ teaspoon of it in 4 ozs of water and get the baby to drink all they will 'til it resolves, hardly ever do we do more then one bottle.  The charcoal grabs the bilirubin as it goes thru the gut and lowers the #s.  I have seen it work many times.  On doc said he knew about it but it was easier to keep the baby in and under the lights and it was messy.  Well, it isn't messy and to ask a new mom with other kids to run back and forth to the hospital isn't “easy”.


I learned the activated charcoal trick from a Jehovah's Witness midwife I used to do births with. Boy does it work well. The peds don't like the idea one bit, does a number on the babes stools. Worst case of jaundice I ever worked with was a peak at 35, no lethargy or any other signs of distress in the 10 lb. baby. One year old and was walking at 10 months. Healthy toddler. We are very happy about that!


I have used activated charcoal before for jaundice and didn't get very immediate results. The results were very slow in coming. I think it depends on the degree and type of jaundice possibly.


have you done it right? I have seen dramatic results. 1/2 teaspoon of deactivated charcoal in a 4 oz bottle of water. Aconite also can be dramatic.


I did use this same amount in one of my own babies and with no dramatic results. They were threatening to put her in the hosp and I needed to do something NOW. I used the activated charcoal so her bili count wouldn't be so high. Alas they still put her in.

 

#include "trailer.incl"