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2.6 Jaundice and Breastfeeding

Key Points - Case Study B

Joanne asks you what she can do before the baby is born to help her successfully breastfeed.

The Ten Steps to Successful Breastfeeding, designed by the ExternalWHO and ExternalUNICEF summarise the maternity practices needed to support and encourage breastfeeding.
Topic 2.1: Preparation Before Birth
Inform all pregnant women about the benefits and management of breastfeeding
Joanne's baby Rosie is born by spontaneous vaginal delivery at 37 weeks following a 15-hour labour. She had been given pethidine (meperidine) and an epidural for pain relief during labour. Are there any features of her birthing experience that may affect breastfeeding?
Topic 2.2: Birthing Factors that Affect Breastfeeding
Labour analgesia and near-term birth
Topic 2.3: Management After Birth
Place Rosie in skin-to-skin contact; Encourage breastfeeding on demand; Practice rooming-in, allow Joanne and Rosie to remain together 24 hours a day; Give Rosie no food or drink other than breastmilk, unless medically indicated; Give Rosie no artificial teats or dummies; Show Joanne how to breastfeed and how to maintain lactation even if she should be separated from Rosie.
Rosie is now 24 hours old. Although she seems interested in the breast, she is not attaching well and tends to slip off the breast easily. What is the most appropriate management to suggest at this time?
Topic 2.4: Poor Attachment
Investigate whether there an underlying reason; Maximize breastfeeding opportunities; Protect the milk supply; Feed the baby; Nipple shields may be useful.
Because Rosie has not been feeding well, the hospital staff are concerned that she may develop hypoglycaemia. Is hypoglycaemia likely to occur in a healthy term breastfed neonate?
Topic 2.5: Hypoglycaemia
Healthy full-term infants do not develop symptomatic hypoglycaemia simply as a result of underfeeding.
On day three, just before Rosie and Joanne are to go home, the midwife or nurse mentions that Rosie looks jaundiced and says it is due to the breastfeeding. What is the relationship between jaundice and breastfeeding?
Topic 2.6: Jaundice and Breastfeeding
In the early days jaundice in a breastfed infant may be due to inadequate breastfeeding. Breast milk jaundice usually begins after day five, is associated with increasing milk volumes and is thought to be due to as yet unidentified substance in breast milk. It rarely requires investigation or treatment.
On day three, just before Rosie and Joanne are to go home, the midwife or nurse mentions that Rosie looks jaundiced and says it is due to the breastfeeding. What is the relationship between jaundice and breastfeeding?

Jaundice and the newborn

Unconjugated or indirect bilirubin, derived from the breakdown of haem (mainly red blood cells), is normally bound to albumin and transported to the liver where it is metabolised to conjugated (or direct) bilirubin. Direct bilirubin is excreted via the biliary tree into the small intestine, where it is broken down by bacteria to form urobilinogen. However, urobilinogen and conjugated bilirubin may be converted back to unconjugated bilirubin and resorbed into the portal circulation.

Unconjugated bilirubin is fat soluble and can enter the skin and brain if not bound to albumin causing the yellow colouration of skin and sclera (jaundice) and bilirubin encephalopathy (kernicterus). Jaundice usually appears on the head and progresses caudally with increasing levels of bilirubin. 1

Infants are at risk for increased bilirubin levels postpartum because of an imbalance in bilirubin production and bilirubin elimination due to:

  • an increase in red cell destruction
  • an increase in enterohepatic circulation of bilirubin because of:
    • an increased load in the intestine (meconium)
    • a lack of bacteria to breakdown conjugated bilirubin
    • higher levels of B-glucuronidase - the enzyme that converts urobilinogen and conjugated bilirubin to unconjugated bilirubin
  • immaturity of the enzyme systems in the liver to transport bilirubin into the liver and metabolise it to conjugated bilirubin
  • lower levels of albumin to transport unconjugated bilirubin and less tight binding. 2 3
Bilirubin levels in most infants begin to rise after birth usually peaking around 95 umol/l (5.5mg/dl) around day 4 (physiological jaundice). 1 These levels drop rapidly by Day 5 and then more slowly, so that by Day 11 bilirubin levels in formula-fed infants reach the adult range of less than 25.5umom/L (1.5mg/dL). 1 Jaundice is more pronounced in infants with Asian origins as well as those born before term. 1

Early jaundice

Early onset jaundice (within the first 24-48 hours) or raised levels of conjugated bilirubin are nearly always due to a pathologic process and needs investigation and appropriate treatment regardless of the feeding method.

Feeding and jaundice

Compared with formula-fed infants, bilirubin levels in breastfed infants are reported to be higher during the first week and continue to be elevated for at least three and up to 12 weeks. Although these higher levels arise from increased enterohepatic circulation of bilirubin, there appear to be different causes for elevated levels within the first week and later.

  • Before day five, higher bilirubin levels are usually the result of inadequate breastfeeding - enterohepatic circulation is increased because of the delayed passage of meconium, few bacteria are present to break down conjugated bilirubin, and there is a starvation effect.

  • Breastfed infants who feed frequently, have little weight loss and experience early, frequent passage of stools have similar bilirubin levels to formula-fed infants.

  • Conversely, when breastfeeding is less than optimal, infants are at increased risk of developing jaundice and reaching bilirubin levels requiring active treatment.

Discharge monitoring

  • How effectively the infant is breastfeeding,
  • the presence (or absence) of jaundice, and
  • the age of the infant and the gestational age
need to be considered when arranging appropriate follow-up following discharge from hospital. 2

Breastmilk Jaundice

Increases in bilirubin levels after Day 5, termed breastmilk jaundice, appears with increasing volumes of transitional and mature breastmilk. An as yet unidentified substance in human milk is thought to increase bilirubin enterohepatic circulation. Bilirubin levels will often plateau around 170-200 umol/l (10-12mg/dl) and rarely rise above 300 umol/l (17-18mg/dl).

Prolonged mild jaundice in a well and thriving breastfed infant is most likely due to breastmilk jaundice.

However, rare pathological conditions may also present with prolonged jaundice. Appropriate investigations should be undertaken especially if:

  • the level of jaundice is maintained or increases,
  • the bilirubin level is unusually high (>300 umol/l),
  • the infant is unwell in any way, or
  • the stools are pale.
Treatment

These is no need to withhold breast milk from the infant to confirm the diagnosis of breastmilk jaundice. In the rare situation where bilirubin levels due to breastmilk jaundice are at a level requiring treatment, supplementing the infant with an elemental formula or substituting elemental formula for breastfeeds for a 24-hour period is usually sufficient to reduce it to a satisfactory level. 4

Are you concerned about Rosie developing jaundice?

As Rosie was born late preterm and did not feed well for at least the first 24 hours she is at increased risk of developing clinically apparent jaundice and may require further monitoring.

Case Study Activity

Think about what your response would be to the scenario presented, write it into the exercise, then submit it and read the suggestions given.

Notes

  1. # Gartner LM et al. (2001) Jaundice and breastfeeding
  2. # Academy of Breastfeeding Medicine (2010) Guidelines for management of jaundice in the breastfeeding infant equal to or greater than 35 weeks gestation.
  3. # Preer GL et al. (2011) Understanding and managing breast milk jaundice.
  4. # Gartner LM (2007) Hyperbilirubinemia and breastfeeding