Jaundice in the Breastfed Baby

Mary Francell, Georgia, USA

La Leche League Leaders are sometimes contacted with questions about breastfeeding and newborn jaundice. Parents may even have been told to wean their infants and give artificial baby milk instead. Leaders can assure them that this is rarely necessary and help support continued breastfeeding. Parents can also be encouraged to share with their healthcare provider the newly revised protocol on jaundice (#22) from the Academy of Breastfeeding Medicine (ABM), available in several languages (http://www.bfmed.org/protocols, scroll down to #22).

Jaundice refers to the yellowing of the skin due to bilirubin^[1] in the blood. While jaundice in adults is almost always a symptom of an underlying disease, virtually all newborn babies experience some rise in serum bilirubin levels (bilirubin in the blood). In fact, more than 80% of newborns appear jaundiced during the first week of life. Bilirubin is an antioxidant and may have some protective effects for newborns. However, since bilirubin levels that are very high can indicate a problem that could cause brain damage, physicians generally monitor levels carefully and treat infants with jaundice well before it approaches dangerous levels. The ABM recommends that all breastfed infants released from the hospital before 72 hours of age be seen by a healthcare provider within two days of discharge.

Maternal risk factors for infant jaundice include diabetes, Rh sensitization,^[2] previous births of infants who developed jaundice and those mothers at risk for delayed secretory activation (milk “coming in” late), such as birth by cesarean birth or high maternal body mass index. Preterm or early term newborns are also particularly at risk for jaundice, as are infants of east Asian heritage and those born with significant bruising or cephalohematomas.^[3]

Early onset jaundice which occurs within the first 24 to 48 hours after birth is usually unrelated to breastfeeding according to the ABM. It should be treated promptly without interrupting breastfeeding. However if the bilirubin is very high due to poor feeding, which is a common cause, mother and baby will need help to improve breastfeeding and make sure the baby is drinking well at the breast (see below).

Jaundice in breastfed babies associated with low intake of milk in the first week or two of life has been called “breastfeeding jaundice” or “starvation jaundice.” However, since it is due to low intake rather than breastfeeding itself, the ABM now calls it suboptimal intake jaundice. It is distinguished by an onset during the first five days of life, ongoing weight loss, less than five stools per day that are black, green or brown in an exclusively breastfed infant and scant urine output that may contain uric acid crystals (“brick dust”).

Breast milk jaundice also appears during the first two to five days of life, but persists past the first week despite robust weight gain. The baby wakes to feed regularly and has adequate urine/stool output. This type of jaundice generally resolves on its own with time. However, if it persists for longer than three weeks, the baby’s doctor may want to rule out underlying issues such as cholestasis^[4] or congenital hypothyroidism (underactive thyroid). When breast milk jaundice lasts longer than two months, physicians may want to evaluate for rare conditions or ongoing undiagnosed hemolysis (ongoing destruction of red blood cells).

The ABM recommends a number of strategies to prevent suboptimal intake jaundice. It is important to encourage breastfeeding in the first hour, even with a cesarean birth. Skin-to-skin contact and frequent nursing—at least 8-12 times or more in 24 hours—helps maximize intake and stimulate the milk supply. Small, frequent feeds of colostrum are normal for the first 24 hours of life, usually resulting in a total intake of 5-37 ml. It is recommended that new parents receive specialist breastfeeding support, including information on hunger cues.

Both breastfeeding difficulties and a delay in milk coming in increase the risk of suboptimal intake jaundice. In these cases, the ABM recommends hand expression of colostrum during the first few days of life, particularly for sleepy babies or those who don’t show signs of hunger. Colostrum can be expressed into a spoon or small cup and given to the baby frequently—parents can be reassured that 1-5 ml is a full feeding during the first 24 hours. Once the milk increases, mothers may find it easier to use a mechanical pump combined with breast massage and compression to express milk until the baby is nursing effectively at the breast. Informing parents how to tell whether their baby is drinking well at the breast and about adequate diaper (nappy) output (of wet and especially dirty nappies) can assure them that baby is getting enough during this time.

If treatment for jaundice does become necessary, parents can be reassured that most treatments are compatible with continued breastfeeding. Jaundiced infants are usually treated with phototherapy, either alone or combined with supplementation. The ABM recommends that infants are supplemented with their mother’s own expressed colostrum or breast milk. If this is not possible, donor human milk is the second choice, followed by infant formula. Water or glucose supplementation is not recommended for reducing serum bilirubin levels. Babies undergoing phototherapy do not routinely need intravenous fluids, but if baby is too sleepy or is not breastfeeding effectively, they may need to be supplemented by syringe, gavage (tube feeding) or bottle until direct breastfeeding improves.

Extremely high total serum bilirubin levels may require artificial baby milk supplementation for a short time.^[5] Small volumes of infant formula following breast milk feeds are preferred. Temporary interruption of breastfeeding and substitution of formula is very rarely needed, generally only if a quick reduction in bilirubin levels is necessary or phototherapy is not available. Mothers can be encouraged to pump frequently to keep up their milk supply during this time.

Infant jaundice is a common concern for breastfeeding parents. La Leche League Leaders can provide support and information about this issue. If more help is needed, contact the Professional Liaison Department in your Area.

Mary Francell, Georgia, USA

Further reading