Jaundice and Breastmilk Jaundice

The common worry most mothers will have to go though.

I am including this article as a guide to new parents especially the Chinese in their fight against neo-natal jaundice. Hopefully they will be more prepared than I was.

The following is my account on my battle with Jaundice and breastfeeding.

My son who was born premature developed jaundice on the 3rd day after birth. The level was about 248mmg/mol, which was quite high. He was placed in photo therapy for two days and was discharged on the third day but the level remained at 175mmg/mol.

This level was still considered high but the pediatrician felt that as long as we “sun” him and nurse enough, he would be all right. We were told to strip him and put him in the sun, with a cloth to protect his eyes for about 10mins before 10am each day.

Note: There is no need to put your baby in direct sunlight, just in a bright corner of the room will do. I have heard of friends who put their babies in direct sunlight and they ended with sunburn.

So we faithfully followed our doctor’s advice to “sun” our baby but the problem was the weather. It was cloudy and cold during that period.
How could I strip my yellowish coloured son and place him in the open when the weather is so chilly. I was really stressed out during that period of time. My mind was full of wild thoughts about how jaundice could affect his brains. It did not help when people commented that the baby’s yellow colour would disappear in two weeks and that babies with jaundice should discontinue breastfeeding and go on formula milk. This is the same advice that even some doctors gave.

I would have given up breastfeeding if not for the encouragement and reassurance from my husband and our pediatrician, Dr Belinda Muragusa.

My son was later diagnosed with breast milk jaundice. His jaundice disappeared at about six weeks but during this period he was happy, very alert and active. In fact, he gained about 400grams every week and by the end of his third month he was a whopping 6kg baby.

I hope that the following article will explain what is jaundice and dispel myths about jaundice and breastfeeding.

What is Jaundice?

Jaundice is a yellowish discolouration of the skin caused by excessive bilirubin in the body.

Jaundice is common and occurs in about nine out of ten newborn babies. It usually develops in the second or third day of life and reaches its peak around the fourth day. Although we can tell that a baby is jaundiced by looking at the skin, a blood test may be necessary to decide if treatment is necessary.

Jaundice can occur within the first 24 hours after birth, but this is rare. If this happens it is important that a Neonatologist or Paediatrician (Doctors who specialise in the care of babies and children) sees your baby. Normally this is not a problem as you will still be in hospital. If your baby is at home, if is important that your Midwife or Doctor is informed.

What causes jaundice?

When your baby is in the womb, the waste products are removed through the placenta. Once your baby is born, their own body has to do this. It can take some days, or even weeks, for a baby to be able to remove its waste products properly. Therefore, in the early days of your baby's life some waste products may build up in their body. One waste product is called bilirubin. Bilirubin is a substance, which is formed by the breakdown of red blood cells, and the liver gets rid of the bilirubin pigment in the stool. In newborn babies, there is more bilirubin being produced compared to the amount excreted, so there is accumulation of bilirubin in the blood. Excessive Bilirubin causes the yellow colour seen in the skin, a condition most mothers know as jaundice.

Does my baby have jaundice?

The symptoms of jaundice depend on the cause and severity, but may include:

  • Yellow tinge to the skin, usually appearing first on the skin of the face and scalp.
  • Yellow tinge to the white parts of the eyes (sclera).
  • In moderate jaundice, the yellow tinge will spread to the skin of the body.
  • In severe jaundice, the palms of the hands and soles of the feet will turn yellow.
  • Unusual drowsiness.
  • Feeding difficulties.
  • In some cases, light-coloured faeces and dark urine.
What are the treatments for jaundice?
Good fluid intake is essential for the baby. This helps flush the bilirubin out of the blood stream. Some doctors suggest giving water especially when the mother has not established her milk supply but it should not be in large quantities as it interferes with breastfeeding.

Moderate jaundice is treated by placing the baby naked (with a protective mask over the eyes) under a bright light or a bluish-coloured light. This light breaks down the bilirubin in the skin and makes the jaundice fade. 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 breast milk; expressed milk with sugar water or sugar water alone rather than formula.

In severe jaundice the baby may need to have a special blood transfusion in which baby's blood is replaced with fresh blood to wash the bilirubin out of the system.

Are there any long term problems from jaundice?

There are usually no long term problems following jaundice in babies. Babies who have had high levels of jaundice should have their hearing checked at regular intervals. This is best discussed with your doctor or baby health nurse. The brain damage mentioned above associated with very high levels of jaundice is now extremely rare because the levels are carefully checked in hospital.

What is physiologic jaundice?*

The liver changes bilirubin so that it can be eliminated from the body. If, however, the liver is functioning poorly, as it 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.

What is Breast milk Jaundice?*

There is a condition commonly called breast milk jaundice. No one knows what the cause of breast milk jaundice is. In order to make this diagnosis, the baby should be at least a week old, though interestingly, many of the babies with breast milk jaundice also have had physiologic jaundice, sometimes to levels higher than usual.

The baby should be gaining weight well, with breastfeeding alone, having lots of bowel movements, passing plenty of clear urine and be generally well . In such a case, the baby has what some call breast milk jaundice, though, on occasion, infections of the urine or an under functioning of the baby's thyroid gland may present the same picture.

Breast milk jaundice peaks at 10-21 days, but may last for 2-3 months. Breast milk jaundice is normal. Rarely, if ever, does breastfeeding need to be discontinued even for a short time.

There is evidence to suggest that this jaundice causes any problem at all for the baby. Breastfeeding should be continued "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 rather than taking the baby off the breastfeeding completely, since this may result in difficulties with breastfeeding later.

If the baby is truly doing well on breast milk only, there is no reason, 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 breast milk 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 whether this absence of jaundice is something we should worry about? Do not stop breastfeeding for jaundice.

What is Not-enough-breast milk 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.

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.

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. If latching and breast compression alone do not work, a lactation aid would be appropriate to supplement feedings.

*(Reproduced here with permission from Jack Newman, MD, FRCP)

For more articles read : Myth on breastfeeding

Compiled from the following sources:

  • Practical Hints on Breastfeeding by BMSG (Singapore)
  • Management of Hyperbilirubinemia (Jaundice) in the Healthy Term Newborn AMERICAN ACADEMY OF PEDIATRICS- "The AAP discourages the interruption of breast-feeding in healthy term newborns and encourages continued and frequent breast-feeding (at least eight to ten times every 24 hours). Supplementing nursing with water or dextrose water does not lower the bilirubin level in jaundiced, healthy, breast-feeding infants."
  • Jaundice by Anne Smith, IBCLC

Contributed by Jenny Wee, mother of James

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