Jaundice in breastfed babies (part 2)
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Anne Smith, IBCLC
Prevention and treatment
Here are some suggestions for preventing and/or treating normal, physiologic jaundice:
- Feed your baby early and often. Remember that colostrum acts as a laxative, and frequent stooling lowers bilirubin levels. Keep track of urine and stool output.
- Avoid water supplements. Only 2 percent of the bilirubin is excreted in the urine, and 98 percent in the stools. Colostrum and milk contain fat, which stimulates bowel movements, and water can fill your baby up so that he is less interested in nursing.
- Encourage your baby to stay awake and to feed at least every two hours. One of the things jaundice does is make your baby sleepy, especially is he is "under the lights."
- Supplement with your expressed milk. If your baby is sleepy at the breast, and is having fewer than three large bowel movements in 24 hours, consider expressing your milk after feedings and giving it to him (preferably not with a bottle at this stage -- he may become confused by rubber nipples if he is only a few days old). Use a dropper, syringe, cup or tube-feeding device if possible. If your only option is hand expression or manual pumping, you may want to consider renting an electric pump for a few days until the bilirubin levels go down.
Babies are often sleepy and lazy nursers as long as their levels are elevated, and the pump can provide extra stimulation to ensure an adequate supply.
- Expose him to indirect sunlight. Undress him down to his diaper and put him in a room that gets a lot of light. His skin is very sensitive, so never put him in direct sunlight.
- Avoid medications such as aspirin and sulfa drugs. Make sure your doctor knows which drugs you are taking, so that you can discontinue or find substitutes for drugs which might cause problems.
Pathologic, or abnormal jaundice is caused by medical conditions, and usually shows up at birth or within the first 24 hours after birth. The levels often rise quickly (0.5 mg/dl or more per hour). The baby may need immediate treatment, but breastfeeding can and should be initiated and continued. The colostrum and milk he receives will help him move his bowels, speeding up the elimination of bilirubin from his system A sick baby needs the benefits of breastmilk even more than a healthy baby.
In some extreme cases babies may be given exchange blood transfusions. This is the fastest way to bring down the bilirubin level, but is seldom needed these days since phototherapy is usually effective. If you are separated from your baby during his treatment, ask for information about where to obtain a hospital-grade breast pump to use while in the hospital and after you go home. A sick baby with elevated bilirubin levels will often be too sleepy and weak to nurse effectively for a while, and you may need the extra stimulation from the pump to ensure an adequate supply of breastmilk for him.
There is a third type of jaundice called late-onset, or breastmilk jaundice. This type of jaundice shows up during the second week of life, and peaks around the 10th day or later. It affects a very small percentage of infants (between 2 and 33 percent, depending on how you define "jaundiced" -- usually a level of 5-10mg/dl). The bilirubin count can remain elevated for weeks or even months, but will eventually level out at adult levels of 1mg/dl.
The diagnosis is usually made in a healthy, thriving infant, and only after all the pathologic causes of jaundice have been ruled out. Often, this type of jaundice runs in families, and breastfed siblings are likely to be jaundiced as well.
No one is sure why this type of jaundice occurs, but there seems to be something in some mother's milk that increases the reasbsorption of bilirubin, or decreases the liver processing of bilirubin. When the baby is temporarily given formula, either as a substitute for, or along with mother's milk, the levels drop quickly, rising again as the baby returns to total breastfeeding. Even though we are not sure of the cause, what is important to remember in cases of late-onset jaundice is that the baby is not harmed in any way by continued breastfeeding. There has never been a case of kernicterus associated with this type of jaundice, or any detrimental after effects.
Because we know the well-documented benefits of breastfeeding, the baby should not be denied the advantages of breastfeeding, given the fact that the slightly elevated bilirubin levels will soon return to normal levels without any intervention. Once pathologic causes are ruled out, nursing should continue. Sometimes babies are taken off the breast for 24 to 48 hours just to make the diagnosis of breast-milk jaundice, though this is seldom necessary. If your healthcare provider wants to go this route, and the levels drop significantly, then breastfeeding should be resumed.
In most cases, jaundice is a normal, possibly even beneficial process that can be managed without interrupting breastfeeding. The treatment for physiologic jaundice is more breastfeeding rather than less, and sick babies with pathologic jaundice need breastmilk even more than healthy babies. Even in rare cases where the jaundice is caused by the breastfeeding, there is no reason to wean and every reason to continue giving your baby the best possible nourishment -- mother's milk.
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