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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 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 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? (416) 813-5757
(option 3) or drjacknewman@sympatico.ca
or 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
1. Breastfeeding:
Starting out right
a) The
importance of Skin-to-Skin contact
2. Colic in the Breastfed Baby
3. a) Sore Nipples
b) Treatments
for Sore Nipple and Sore Breasts
4. Is my baby getting enough?
5. Using a Lactation Aid
6. Using Gentian Violet
7. Breastfeeding and Jaundice
8. Finger Feeding
9. a) You should continue breastfeeding
(Medications and breastfeeding)
b) You
should continue breastfeeding (Illness in the mother or baby)
10. Breastfeeding and other foods
11. Some breastfeeding myths
12. More breastfeeding myths
13. Still more breastfeeding
myths
14. More and more breastfeeding
myths
15. Breast compression
16. Starting solid foods
17. What to feed the baby when
the mother is working outside the home
18. How to know a health professional
is not supportive of breastfeeding
19. a) Domperidone 1
b) Domperidone
2
20. Fluconazole
21. Breastfeed a toddler –
Why on earth?
22. Blocked ducts and
mastitis
23. Breastfeeding your adopted baby
24. Miscellaneous treatments for problems
25. Slow weight gain after
the first few months
26. When the Baby refuses to
latch on
27. Expressing Milk
28. Toxins and Infant Feeding
How breastmilk protects Newborns
Risks of formula feeding
Breastfeeding and guilt
Candida protocol
Protocol to increase the intake
of Breastmilk by the Baby ("Not enough milk")
When latching
Protocols for Induced Lactation
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