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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
B: 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 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.
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