Jaundice is due to a buildup in the blood of bilirubin, a yellow
pigment which comes from the breakdown of old red blood cells. It
is normal for 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
which 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 happens in blood incompatibility), the level of bilirubin in
the blood may rise higher than what is usual.
Two Types of Jaundice
The liver changes bilirubin so that it can be eliminated from
the body. If, however, the liver is functioning poorly, as occurs
during some infections, or the tubes which 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 (called conjugated 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". Physiologic jaundice
begins on the 2nd or 3rd day, peaks on the 3rd or 4th day and then
begins to disappear. However, there may be other conditions which
cause an exaggeration of this type of jaundice, such as a more rapid
than normal breakdown of red blood cells. 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.
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 physiologic
jaundice, sometimes to levels higher than usual. The baby should
be gaining well, with breastfeeding alone, having lots of bowel
movements, passing plentiful, clear urine and be generally well
(see 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 may cause the same picture.
Breastmilk jaundice peaks at 10-21 days, but may last for 2-3 months.
Breastmilk jaundice is normal. Rarely, if ever, does breastfeeding
need to be discontinued even for a short time. 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, however, your doctor feels that discontinuing
breastfeeding is appropriate, it would be worth trying a lactation
aid with formula (see handout #5, Using a Lactation Device) rather
than taking the baby off the breast altogether, since this may result
in difficulties with breastfeeding afterwards. 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 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 5-6 weeks
of life and even later. The question, in fact, should be whether
it is normal not to be jaundiced and is this absence of jaundice
something we should worry about? Do not stop breastfeeding for 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 a longer than average
time to "come in", or because hospital routines limit breastfeeding
or because, most importantly, the baby is poorly latched on and
thus not getting the milk which is available (see 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 (see handout #1, Breastfeeding—Starting
Out Right). However, the answer to not-enough-breastmilk jaundice,
is not to take the baby off the breast or to give bottles. 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 (see handout #15, Breast Compression). If latching and
breast compression alone do not work, a lactation aid would be appropriate
to supplement feedings (see handout #5, Using a Lactation Aid).
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.
Handout #7. Jaundice. Revised January 1998
Breastfeeding and Jaundice
Written by Jack Newman, MD, FRCPC
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