Jaundice in the Breastfed baby

Jaundice in the Breastfed baby

There can sometimes be a misunderstanding of how jaundice can affect a breastfed baby. I will try to demystify how jaundice can affect a breastfed baby and what treatments are recommended.

So what is the treatment for jaundice in the breastfed baby? In the vast majority of cases, it is recommended to continue breastfeeding a jaundiced newborn. Jaundice is a symptom of increased levels of bilirubin, which is a by-product of red blood cells.  A continuous intake of breast milk will help increase the rate of bilirubin excretion in your baby’s stool and relieve jaundice. However, there are some rare cases where a jaundiced baby will need to stop breastfeeding or will require the supplementation of formula temporarily. This is needed in situations where bilirubin levels need to decrease rapidly or if your baby is not getting enough breastmilk.

Since jaundice can affect the breastfeeding relationship with your baby, I will describe the different types of jaundice that can occur in your baby, how long it lasts and how it is generally treated in the breastfed baby.

Types of Jaundice that Occur in a Breastfed Baby

As mentioned earlier, jaundice is a symptom that appears when there is too much bilirubin in the bloodstream. The accumulation of bilirubin may happen due to several reasons. Here are the different types of jaundice in breastfed babies:

Physiologic Jaundice

According to the American Pregnancy Association (source), physiologic jaundice is the most common and normal type of jaundice affecting up to 60% of full-term babies. Physiologic jaundice is named as such due to elevated bilirubin levels which is a normal bodily response in a newborn baby.  

While in the womb, the fetus contains a large number of red cells which are needed to oxygenate the fetus. These red blood cells will eventually break down. The by-product of this cell breakdown is bilirubin. Bilirubin is then processed by the mother’s liver for excretion.

After delivery when the placenta has been severed, the baby can no longer rely on her oxygen supply from her mother. The baby’s liver will also have the role of processing and excreting bilirubin. However, a newborn’s liver needs time to fully mature. This makes it harder for the baby to excrete large amounts of bilirubin in her bloodstream. Excess bilirubin will remain within the bloodstream where it will be deposited on the skin and mucous membranes. Areas most affected include the sclera or the white part of the eye. This leads to the yellowish discoloration called jaundice.

Physiologic jaundice begins with low levels of bilirubin that gradually increases over the first three to five days after the baby is born. Usually, this type of jaundice doesn’t need any medical treatment.

 Breast Milk Jaundice

This type of jaundice is observed among healthy, breastfed babies. For unknown reasons, some breastfed babies may continuously have high bilirubin levels after physiologic jaundice has resolved. Experts link this phenomenon to a particular component of their mother’s milk. This component is thought to block the breakdown of bilirubin. As a result, this type of jaundice is termed breast milk jaundice.

Breast milk jaundice is linked with familial genes. However, it doesn’t mean that the mother’s milk is not healthy.

Bilirubin levels will most likely rise again in babies with breast milk jaundice at around 2 weeks after birth. It will usually remain present from the third to the twelfth week of life. (source). Only a small percentage of newborns will experience this type of jaundice.

Breastfeeding jaundice

This is also known as “breast-nonfeeding jaundice” or “starvation jaundice of the newborn”. Breastfeeding jaundice occurs when the newborn is not receiving adequate amounts of breast milk. An insufficient caloric intake resulting from maternal and/or infant breastfeeding difficulties can increase serum bilirubin concentrations (source). 

This can happen when the baby is not correctly latched, excessively sleepy, premature, or has been given insufficient amounts of supplement to replace some breastfeeds. It can also occur if the mother’s milk comes in late or if she may have a low milk supply. High levels of bilirubin will remain to cause jaundice if the newborn is not receiving an adequate intake of breast milk.

Pathologic jaundice

This type of jaundice occurs within 24 hours after the baby is born. It is presented with a sudden and continuous rise in bilirubin levels. This type of jaundice occurs secondary to disease and requires immediate treatment.

How Long Does it Take for Jaundice to Subside in Breastfed Babies?

It will depend on what type of jaundice your baby has. Though it may vary on a case to case basis, here are the usual timeframes of when a particular type of jaundice subsides.

  • Physiologic jaundice

Physiological jaundice usually resolves in most infants by day 7 in a full-term formula fed baby and by days 10 to 21 in a preterm neonate. This can differ for breastfed babies as described below.

  • Breast milk jaundice

Breast milk jaundice may persist for up to 3 months and is considered an extension of physiological jaundice in breastfed babies. It usually first appears after the fifth day of life. At this time breast milk now consists of transitional and eventually mature milk.

  • Breastfeeding jaundice 

According to Wombach & Riordan (2016) in Breastfeeding and Human Lactation (fifth edition) breastfeeding jaundice may be seen in the first few days after birth, but not before 24 hours. In addition, other causes of jaundice must be considered and ruled out. Breastfeeding jaundice usually resolves once fluids and caloric intake have been restored.

The American Academy of Pediatrics (AAP) states that jaundice in breastfed babies typically goes away within a month. Rarely, it may last longer. 

Meanwhile, the Academy of Breastfeeding Medicine (source) says that parents can be reassured that almost all hyperbilirubinemia requiring treatment resolves within the first 5 days after birth. Even infants with prolonged breast milk jaundice who required and received treatment rarely require further intervention.

Why Does Jaundice Tend to Occur More Often in Breastfed Babies?

Jaundice is common among all newborn babies. This is due to a high count of red blood cells that need to be broken down within the immature liver of newborns. However, jaundice does appear more frequently among breastfed babies than formula-fed babies. The primary reason is due to the baby’s lower intake of milk intake during the first days of his life compared to a formula fed baby. 

During the first 24 hours, a breastfed baby only takes about a teaspoon of breastmilk or colostrum per feed. Due to this small quantity, a breastfeeding mother must feed 8 to 12 times per day during the first week after birth. Regular feeds will stimulate her milk to come in and maintain a good supply for her baby. With sufficient milk intake and regular bowel movements, the baby’s bilirubin levels will gradually subside.

Other Causes of Newborn Jaundice

Some babies are at a higher risk of jaundice. These include:

  • Premature babies – babies are born between 35th to 37th week of pregnancy 
  • Infants who are ill
  • Blood group incompatibility
  • Babies who are bruised or bleed while mom is giving birth
  • East-Asian race
  • Exclusively breastfed babies who have feeding difficulties
  • Newborns who exceed the normal weight loss 

Why Should You be Concerned about Jaundice?

Jaundice is a sign of high bilirubin levels in the blood. Bilirubin levels that are greater than 25 to 30 milligrams/dL are toxic to the brain and neurons. Although rare, this condition is serious and could cause irreversible damage. Doctors will, therefore, monitor and treating bilirubin at a much lower threshold.

How is breastfeeding jaundice treated?

The treatment for breastfeeding jaundice is generally similar for full-term healthy babies. For babies who have bilirubin levels of lower than 20 milligrams, here are the usual treatment recommendations:

Increase breastfeeding frequency

Mothers need to breastfeed their babies between 8 to 12 times in a 24 hour period. This will ensure that your baby will receive enough breast milk intake to produce regular bowel movements. Frequent stools will help expel excess bilirubin and prevent it from being reabsorbed into the intestines. It will also help stimulate the production of more milk and maintain a good supply.

Ensure a proper latch

Assistance from an experienced health professional or lactation consultant is advised to make sure that your baby is latching on well, correctly positioned, and getting a sufficient amount of breast milk.

Supplementation with formula as recommended by your doctor

The American Academy of Pediatrics suggests that supplementing breastmilk with formula can also help to lower the bilirubin level and prevent the need for phototherapy. (source) Supplementation with formula can be given in different ways to prevent your baby from getting used to a bottle. Using a lactation aid is frequently advised to deliver the supplement. This device has a fine tubing that can be attached next to your nipple so that your baby can take the supplement without interrupting breastfeeding.

Temporary cessation of breastfeeding

You may be advised to temporarily stop breastfeeding for 24 to 48 hours and use replacement feeding. This will determine whether your baby has breast milk jaundice. If you need to temporarily stop breastfeeding, it is critical to pump your breast milk to ensure a good milk supply is maintained. Consult a lactation consultant for advice and support.

Phototherapy 

Phototherapy uses artificial ultraviolet light to help reduce your baby’s bilirubin levels. Your baby will be undressed to his diaper to receive sufficient amounts of phototherapy. His skin will be exposed to the bili-light for the recommended amount of time each day. 

Where phototherapy is indicated, breastfeeding frequency must also be observed to effectively reduce bilirubin levels in a newborn with breast milk jaundice.

Phototherapy may temporarily interrupt your breastfeeding relationship with your baby. If this is indicated, you can request treatment in the same room where you are staying in the hospital. Quick and easy access to your baby means you can breastfeed him on demand when he is showing those hunger cues.

There have previously been other ways to treat jaundice in newborns. However, the latest research suggests that some are no longer recommended.

Treatment no Longer Recommended:

Direct sunlight

The natural UV rays from sunlight can help reduce bilirubin levels. This will only be effective however if most of your baby’s skin is exposed to the light. This really isn’t a practical way to treat jaundice as parents would also need to ensure the room is warm enough for your baby undressed. Exposing a newborn’s skin under direct sunlight is not recommended due to the risk of sunburn. 

Glucose water

Supplementing with water or glucose water is no longer recommended to treat jaundice in babies. It does not reduce serum bilirubin levels and could cause hyponatremia (source). Giving these fluids will also interfere with the recommended frequency of breastfeeding. Frequent breastfeeding means frequent stools where bilirubin is excreted from the body.

Do I Need to Stop Breastfeeding my Baby with Jaundice?

In the majority of cases, breastfeeding should be continued and even increased in frequency for jaundiced babies. Breastfeeding ensures your baby will have frequent bowel movements to help excrete the excess bilirubin in his bloodstream. Frequent breastfeeding will also ensure your baby will be well hydrated with sufficient caloric intake.

If serum bilirubin levels are very high or if for whatever reason your baby is not getting enough breastmilk, supplementation with formula may be required on a temporary basis. Infant formula is known to inhibit the intestinal reabsorption of bilirubin. To maintain breastfeeding frequency, it is best to give a small amount of formula first and end with a breastfeed rather than give a large amount of formula in one feed (source). 

In very limited cases, the pediatrician may require you to stop breastfeeding and replace it temporarily with a formula supplement. This usually lasts around 24 to 48 hours. This is done in cases where a rapid reduction is needed in bilirubin levels or if phototherapy is unavailable.  

Which is Best – Breast milk or Formula for Treating Jaundice?

Most health care experts recommend breast milk as the ideal source of nutrition for babies who have jaundice. Increasing breastfeeding frequency and maintaining a good latch must be achieved with the help of a lactation consultant. 

Breastfeeding experts suggest that breast milk is efficient in expelling the excess bilirubin at a faster rate. Colostrum, or the mother’s first milk, is designed to stimulate the excretion of meconium. Meconium is the baby’s first stool which contains high amounts of bilirubin. This will reduce the possibility that any excess bilirubin will be reabsorbed back into the baby’s bloodstream. Therefore, breast milk and frequent breastfeeding will reduce high levels of bilirubin and relieve jaundice.

However, in some rare cases, supplementation with formula may be advised by your doctor. It may be indicated in combination with phototherapy as a prompt treatment if bilirubin levels are too high. If this is indicated, mothers are still advised to pump their breast milk to ensure an adequate milk supply is maintained.

Does a Breastfeeding Mother Need to Adjust her Diet when her Baby is Jaundiced?

There is no recommendation that mothers need to adjust their diet while breastfeeding a jaundiced baby. Jaundice is not related to what a mother eats; rather, it is a response of the infant’s body due to the inability to effectively breakdown and eliminates bilirubin in the bloodstream.

Just like any other breastfeeding mom, you should eat a well-balanced diet to meet the increased caloric demands of breastfeeding. Keep yourself well-hydrated by drinking plenty of water and other fluids. This, in turn, will allow you to produce enough breast milk to ensure your baby can eliminate bilirubin from his body. 

The above are guidelines only and each child needs to be assessed on an individual basis. Consult with your pediatrician on all aspects of your baby’s health. 

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