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Breastfeeding and Jaundice
Handout #7. Jaundice. Revised January
2005
Written by Jack Newman, MD, FRCPC. © 2005
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Introduction
Jaundice is due to a buildup in the blood of bilirubin,
a yellow pigment that comes from the breakdown of old red blood
cells. It is normal for old red blood cells to break down, but the
bilirubin formed does not usually cause jaundice because the liver
metabolizes it and gets rid of it into the gut. The newborn baby,
however, often becomes jaundiced during the first few days because
the liver enzyme that metabolizes bilirubin is relatively immature.
Furthermore, newborn babies have more red blood cells than adults,
and thus more are breaking down at any one time. If the baby is
premature, or stressed from a difficult birth, or the infant of
a diabetic mother, or more than the usual number of red blood cells
are breaking down (as can happen in blood incompatibility), the
level of bilirubin in the blood may rise higher than usual levels.
Two Types of Jaundice
The liver changes bilirubin so that it can be eliminated
from the body (the changed bilirubin is now called conjugated,
direct reacting, or water soluble bilirubin--all
three terms mean essentially the same thing). If, however, the liver
is functioning poorly, as occurs during some infections, or the
tubes that transport the bilirubin to the gut are blocked, this
changed bilirubin may accumulate in the blood and also cause jaundice.
When this occurs, the changed bilirubin appears in the urine and
turns the urine brown. This brown urine is an important
clue that the jaundice is not "ordinary". Jaundice due
to conjugated bilirubin is always abnormal, frequently
serious and needs to be investigated thoroughly and immediately.
Except in the case of a few extremely rare metabolic diseases,
breastfeeding can and should continue.
Accumulation of bilirubin before it has been changed
by the enzyme of the liver may be normal—"physiologic
jaundice" (this bilirubin is called unconjugated,
indirect reacting or fat soluble bilirubin). Physiologic
jaundice begins about the second day of the baby's life, peaks on
the third or fourth day and then begins to disappear. However, there
may be other conditions that may require treatment that can cause
an exaggeration of this type of jaundice. Because these conditions
have no association with breastfeeding, breastfeeding should continue.
If, for example, the baby has severe jaundice due to
rapid breakdown of red blood cells, this is not a reason to take
the baby off the breast. Breastfeeding should continue in such
a circumstance.
So-called Breastmilk Jaundice
There is a condition commonly called breastmilk jaundice.
No one knows what the cause of breastmilk jaundice is. In order
to make this diagnosis, the baby should be at least a week old,
though interestingly, many of the babies with breastmilk jaundice
also have had exaggerated physiologic jaundice. The baby should
be gaining well, with breastfeeding alone, having lots of bowel
movements, passing plentiful, clear urine and be generally well
(handout #4 Is
My Baby Getting Enough Milk?). In such a setting, the baby
has what some call breastmilk jaundice, though, on occasion, infections
of the urine or an under functioning of the baby's thyroid gland,
as well as a few other even rarer illnesses may cause the same picture.
Breastmilk jaundice peaks at 10-21 days, but may last for two or
three months. Breastmilk jaundice is normal. Rarely, if
ever, does breastfeeding need to be discontinued even for a short
time. Only very occasionally is any treatment, such as
phototherapy, necessary. There is not one bit of evidence that this
jaundice causes any problem at all for the baby. Breastfeeding should
not be discontinued "in order to make a diagnosis". If
the baby is truly doing well on breast only, there is no
reason, none, to stop breastfeeding
or supplement with a lactation aid, for that matter. The notion
that there is something wrong with the baby being jaundiced comes
from the assumption that the formula feeding baby is the standard
by which we should determine how the breastfed baby should be. This
manner of thinking, almost universal amongst health professionals,
truly turns logic upside down. Thus, the formula feeding baby is
rarely jaundiced after the first week of life, and when he is, there
is usually something wrong. Therefore, the baby with so-called breastmilk
jaundice is a concern and "something must be done". However,
in our experience, most exclusively breastfed
babies who are perfectly healthy and gaining weight well are still
jaundiced at five to six weeks of life and even later. The question,
in fact, should be whether or not it is normal not to be jaundiced
and is this absence of jaundice something we should worry about?
Do not stop breastfeeding for “breastmilk”
jaundice.
Not-enough-breastmilk Jaundice
Higher than usual levels of bilirubin or longer than
usual jaundice may occur because the baby is not getting enough
milk. This may be due to the fact that the mother's milk takes
longer than average to "come in" (but if the baby feeds
well in the first few days this should not be a problem), or because
hospital routines limit breastfeeding or because, most likely, the
baby is poorly latched on and thus not getting the milk which is
available (handout #4 Is
My Baby Getting Enough Milk?). When the baby is getting
little milk, bowel movements tend to be scanty and infrequent so
that the bilirubin that was in the baby's gut gets reabsorbed into
the blood instead of leaving the body with the bowel movements.
Obviously, the best way to avoid "not-enough-breastmilk jaundice"
is to get breastfeeding started properly (handout #1 Breastfeeding—Starting
Out Right). Definitely, however, the first approach to
not-enough-breastmilk jaundice is not to take the
baby off the breast or to give bottles (see Handout B: Protocol
to Increase Breastmilk Intake by the Baby). If the baby
is nursing well, more frequent feedings may be enough to bring the
bilirubin down more quickly, though, in fact, nothing needs be done.
If the baby is nursing poorly, helping the baby latch
on better may allow him to nurse more effectively and thus receive
more milk. Compressing the breast to get more milk into the baby
may help (handout #15 Breast
Compression). If latching and breast compression alone
do not work, a lactation aid would be appropriate to supplement
feedings (handout #5 Using
a Lactation Aid). See also the handout: Protocol
to Increase Breastmilk Intake by the Baby. See also the
website www.thebirthden.com/Newman.html
for videos to help use the Protocol by showing how to latch a baby
on, how to know the baby is getting milk, how to use compression,
as well as other information on breastfeeding.
Phototherapy (Bilirubin Lights)
Phototherapy increases the fluid requirements of the
baby. If the baby is nursing well, more frequent feeding can usually
make up this increased requirement. However, if it is felt that
the baby needs more fluids, use a lactation aid to supplement,
preferably expressed breastmilk, expressed milk with sugar water
or sugar water alone rather than formula.
Questions?
see
my book Dr. Jack Newman's Guide to Breastfeeding (called
The
Ultimate Breastfeeding Book of Answers in the USA)
Handout #7. Jaundice. Revised January
2005
Written by Jack Newman, MD, FRCPC. © 2005
This
handout may be copied and distributed without further permission,
on
the condition that it is not used in any context in which
the WHO code on the marketing of breastmilk substitutes is violated
