Jaundice

During the first week of life, more than half of all newborns have jaundice. Usually, jaundice is a normal part of adjusting to life outside the womb, but occasionally it may be a sign of serious health problems. Sometimes, the treatment of jaundice is challenging for mothers and babies.

What causes jaundice?

After birth, the infant no longer needs the extra red blood cells that transport oxygen in utero.  During the first days after birth, the excess red blood cells break down producing the yellow pigment bilirubin. The liver processes (conjugates) bilirubin into a form transported to the intestines and from there, carried out of the body in the stool. However, a newborn baby’s liver may not be able to process bilirubin efficiently and the newborn’s gut easily absorbs unconjugated bilirubin, so bilirubin levels increase in blood circulation. The excess is deposited in the skin, muscles, and mucous membranes of the body.

What does jaundice look like in the newborn?

The baby’s skin usually appears yellow, first in the face and then, as bilirubin levels rise, moving to the chest and downwards to the abdomen, arms and legs. Eye whites may also appear yellow. Following discharge, if jaundice is visible in the abdomen, extremities or eye whites, a medical assessment is necessary. It is easiest to observe changes in skin tone in good light. However, the changes may be less visible in darker skinned babies.

Because of the difficulty of accurately assessing bilirubin levels based on the baby’s appearance, most experts recommend screening all infants prior to discharge and follow-up with a health care provider at 3-5 days after birth, the period in which the baby’s bilirubin is usually the highest. Screening may include performing skin tests with a special instrument or blood tests.

Why be concerned about jaundice?

When blood levels are exceptionally high (exceeding 25 mg/dL- 30 mg/dL), bilirubin may enter the brain and damage the nervous system and brain.  Such complications are very rare, but extremely serious and thus recommended treatment thresholds are much lower, especially for babies considered as “high risk”.  Risk factors include gestational age – premature and early term (35-37 weeks), illness, blood group incompatibility, significant bleeding or bruising related to labor and delivery, exclusive breastfeeding with feeding problems or above normal weight loss and East Asian race.

High levels in the first 24-48 hours after birth are termed pathological jaundice and likely to indicate an underlying medical problem. Levels that are rising quickly and high levels in premature or sick infants are also of special concern. Monitoring newborns’ bilirubin levels can help identify the underlying cause and enable early treatment.  Breastfeeding generally can and should continue throughout treatment.

Physiological hyperbilirubinemia, also called normal newborn jaundice has low levels that rise slowly and peak over the first three to five days. It is generally short-lived and harmless and does not usually require treatment. However, early breastfeeding challenges may result in sub-optimal intake and bilirubin levels above treatment thresholds.

Breastfeeding and Jaundice

Physiologic jaundice occurs more frequently in breastfed than formula fed babies. It occurs, in particular, among babies who do not nurse frequently in the first days of life or are not breastfeeding well and who continue to lose weight. Frequent and effective breastfeeding in the early days helps baby’s body eliminate bilirubin. Colostrum stimulates early passage of meconium stools that are rich in bilirubin and reduces the possibility that bilirubin will be reabsorbed into the bloodstream and cause higher blood levels. Newborns who nurse every hour or two have frequent stools, and this eliminates bilirubin from the intestines more efficiently. Babies whose intake is sub-optimal accumulate bilirubin due to reduced number of stools.

Additionally, jaundice seems to last longer in breastfed babies. Researchers are not sure why. A substance in mother’s milk may affect the way the body eliminates bilirubin. As a result, healthy breastfed babies (thriving infants) may still show signs of harmless jaundice (with low bilirubin levels) at two or three months of age.  Prolonged jaundice, once considered as a separate type of jaundice, is now defined as a continuation of normal newborn jaundice. In most healthy term babies who are gaining adequately, prolonged jaundice will eventually clear without treatment. However, it is recommended to consult with your doctor to rule out any medical causes for prolonged jaundice.

Treating Jaundice

The first step is to encourage the jaundiced baby to nurse more often (at least 10 to 12 times in 24 hours) and more effectively (check to see if baby is latched-on and sucking well) to reduce bilirubin levels as soon as possible. Skin-to-skin contact and use of breast compression during feeds can help encourage the baby who is slow to feed actively. Seek skilled breastfeeding help early if you encounter difficulty. If the baby’s stools are not turning yellow by day 4 and/or weight loss continues after day 4 or is more than 10%, further help is indicated.

Check out this web page for more information on how to breastfeed effectively https://llli.org/breastfeeding-info/positioning/

If the baby is not breastfeeding actively despite this help, milk expression may be needed to initiate adequate milk production and possibly to supplement breastfeeding. Feeding methods such as a spoon, cup, eyedropper, syringe or an at-breast supplementer, in preference to the bottle, can facilitate transition to full breastfeeding.

Phototherapy is the most frequently used treatment when bilirubin exceeds thresholds. Phototherapy uses special lights to break down the bilirubin stored in baby’s skin so that it can be eliminated more easily. The baby is placed under the “bili-lights” wearing just a diaper, with eyes covered to protect them. The baby remains under the lights continuously for a day or two, although parents may remove the baby from the lights for feedings. Once the baby’s bilirubin levels begin to fall, the lights are no longer needed.

One of the problems with phototherapy is that it interferes with mother and baby being together and interacting freely in the first days of life. In hospital, it may be possible for the phototherapy unit to be set up in your room, so that you can talk to, touch and breastfeed your baby frequently. If the baby is hospitalized but you are not, you can stay with your baby in the nursery. If treatment is needed after release from hospital, your doctor might order a home phototherapy unit. In some cases, it may be possible for your baby to receive phototherapy using a fiberoptic blanket that wraps around the baby’s trunk and provides continuous light treatment. The baby’s eyes do not have to be covered, and you can hold and breastfeed your baby without interrupting the treatment.

Putting the baby in indirect or direct sunlight as an alternative to phototherapy is no longer recommended to treat jaundice. Indirect sunlight is not reliable and direct sunlight can cause a dangerous increase in body temperature and sunburn.

Physicians used to suggest routinely substituting formula for 12-48 hours or supplementing breastfeeding to bring down bilirubin levels. This course of action is no longer routine but may be suggested when phototherapy is not readily available or deemed unduly expensive. It may be used, often in conjunction with phototherapy, when high bilirubin levels must be reduced urgently.  Interrupting breastfeeding can lead to early weaning and deprive the baby of the many benefits of breastfeeding.  If supplementation is necessary, pumping is critical for the mother to build up and maintain her milk supply.

Giving baby bottles of water or glucose water to “flush out” the jaundice is no longer recommended. Bilirubin is eliminated in baby’s stools. A baby whose tummy is filled with water or sugar water will nurse less often and thus is more likely to have problems with jaundice.

Working With Your Doctor

There is no one “right” way to treat jaundice in a breastfed baby. The American Academy of Pediatrics suggests that pediatricians discuss several treatment options with parents. Here are some questions to consider:

• Is it necessary to treat the jaundice at this stage? Could we continue to monitor the baby’s bilirubin levels, encourage the baby to breastfeed more frequently or supplement with human milk (either expressed or banked human milk), and re-evaluate the situation in 24 hours?
• If phototherapy is needed, what can be done to keep mother and baby together and breastfeeding?

If a doctor suggests that you stop breastfeeding and give your baby formula, ask about using phototherapy to treat the jaundice while you continue to breastfeed. In most babies, jaundice is short-lived and harmless. For sure, there may be times when it is necessary to treat the jaundice, but in these situations, parents and health professionals should remember that frequent breastfeeding in the first days of life helps ensure successful breastfeeding in the weeks and months to come. The goal is a healthy baby who continues to breastfeed.

Helping Your Baby Breastfeed More Effectively

Check baby’s latch-on. Babies who are latched-on well get more milk from the breast. Baby should be facing mother and pulled in close to her body. The baby opens her mouth wide as she goes onto the breast and takes a large mouthful of breast tissue. The baby’s chin is pressed into the breast and the lower jaw is as far back from the nipple as possible. Baby’s lips are flanged out, not tucked or pulled in. If baby is not latched-on well, take the baby off the breast and try again.

Check for effective sucking. The baby moves her jaw, not just her lips, as she sucks. After the initial let-down, baby will swallow after every one or two sucks. This active swallowing should continue for ten to twenty minutes per breast.

Keep baby interested. Encourage baby to breastfeed longer by using breast compression when her sucking slows or stops. Hold the breast between your thumb and your other four fingers, close to the chest wall. Bring the thumb and fingers together, firmly compressing the breast, but not so hard that it hurts. This will start the milk flowing again, and the baby will respond with more sucking and swallowing. Keep up the pressure on the breast until baby’s sucking slows. Then release the breast compression. Baby may start to suck again. If not, shift your hand around the breast to a new position and compress the breast again. Repeat this technique until the baby gets sleepy or fussy, and then repeat on the other breast.

Is the baby getting enough milk at the breast? Beginning on the third or fourth day after birth, babies should have at least six to eight wet cloth diapers (six disposables) and at least three to four bowel movements in twenty-four hours.

Get help. A La Leche League Leader can assist you as you evaluate your baby’s latch-on and sucking and find ways to encourage your baby to breastfeed better.

How to Wake a Sleepy Baby

• It’s easier to wake a baby in the stage of light sleep: eyes are moving under the eyelids, baby is making sucking motions or moving his arms and legs.
• Dim the lights so that baby will open his eyes.
• Undress baby down to just a diaper.
• Hold baby in an upright position. Talk to the baby. Gently rub his back, hands, and feet. Walk your fingers up and down baby’s spine.
• Wipe baby’s forehead and cheeks with a cool, damp cloth.

References

Academy for Breastfeeding Medicine:
https://abm.memberclicks.net/assets/DOCUMENTS/PROTOCOLS/22-jaundice-protocol-english.pdf

American Academy of Pediatrics:
https://www.healthychildren.org/English/ages-stages/baby/Pages/Jaundice.aspx

CDC:
https://www.cdc.gov/breastfeeding/disease/jaundice.htm

Nancy Mohrbacher, Breastfeeding Answers Made Simple, A Pocket Guide, Hale Publishing, 2012, pp.152-160