September 14th, 2011 by Hasham

What is Newborn Jaundice

Breastfeeding and Jaundice

After the birth of a baby, it is common for care providers to watch a newborn closely. One of the things that your care provider will be monitoring is jaundice. Jaundice is normal in most all newborns, however if the jaundice appears out of the normal range then steps will be taken to get it back under control.

Jaundice is more common in a breastfed baby and tends to last a bit longer. Unfortunately, there is conflicting information about how jaundice should be handled in the breastfed baby and the treatment of jaundice can greatly impact the breastfeeding relationship long term.
What is Newborn Jaundice?

Jaundice is a condition that can occur in newborns, within 2-3 days of birth. Jaundice is a yellowing of the skin or whites of the eyes’. This is caused by elevated bilirubin levels in the newborns blood. Jaundice normally appears first on the face and then will move down the body to the chest, abdomen, arms and legs. Jaundice is best seen in natural light and can be harder to detect in dark skinned babies. If jaundice is suspected, your health care provider will run blood tests to measure the amount of bilirubin in the blood.
What causes Jaundice in the Breastfed baby?

Physiologic Jaundice- This is most common type of jaundice in all babies. This is the normal type of jaundice that can affect up to 60% of full term babies in the first week of life and is caused by elevated bilirubin levels. Bilirubin is a substance created by the normal breakdown of red blood cells. Bilirubin is processed and removed by the liver. Jaundice will develop when a baby’s liver is not efficient enough to remove the bilirubin from the bloodstream. Once the baby begins to mature and the red blood cell amounts diminish, the jaundice will subside with no lasting effects on the baby. This usually happens about 1-2 weeks after birth.

Breastmilk Jaundice- This is jaundice that persists after physiologic jaundice subsides and is seen in the otherwise healthy, full term breastfed baby. There is no known cause for this type of jaundice although speculation is that it may be linked to something in the breast milk that is blocking the breakdown of bilirubin. (Breastmilk jaundice tends to be genetic and run in families.) Breastmilk jaundice does not mean that something is wrong with the mother’s milk and that breastfeeding should be stopped. Most babies who present true breastmilk jaundice (only 0.5% to 2.4% of all newborns), may see another rise in bilirubin levels at about 14 days, but they will level out and eventually decrease. Breastmilk jaundice can last for 3-12 weeks after birth, but as long as baby is feeding well and bilirubin levels are monitored, it rarely leads to serious complications. Breastmilk Jaundice must also be differentiated from breastfeeding jaundice, which is a lack of milk that results in jaundice, or from any other underlying health conditions.

Breastfeeding Jaundice- Breastfeeding jaundice is caused by the baby not getting enough milk and is not related to breastmilk jaundice. Adequate amounts of breastmilk increase a baby’s bowel movements, which help secrete the buildup of bilirubin. Breasfeeding jaundice can occur when a newborn does not get a good start to breastfeeding, has an improper latch or is supplemented with other substitutes which interfere with breastfeeding. Breastfeeding jaundice often will resolve itself with increased feedings and help from a lactation consultant to make sure the baby is indeed taking in adequate amounts. Rarely does a breastfed baby need any other type of treatment besides these for breastfeeding jaundice.
What is the Treatment for Jaundice in the Breastfed baby?

If bilirubin levels are below 20 milligrams, the following treatments are often used for breastmilk jaundice and breastfeeding jaundice in the full term, healthy infant:

* Increase feedings to 8-12 times a day. The best way to decrease bilirubin levels it to help remove it—increased feedings will increase bowel movements, which will excrete the bilirubin.
* Work with a lactation professional to make sure that the baby is latched on the breast well, so that he/she can take in as much milk as needed. Improper latch can directly affect how much milk a baby is receiving.
* If a supplementation is recommended to increase baby’s calories and intake, work with a lactation professional to use a lactation aid. The mom would also want to pump during this time, to not interrupt the production of her milk. Using a lactation aid to deliver expressed breastmilk or a mixture of breastmilk and formula is the best way to not interrupt the breastfeeding relationship.
* Rarely is the interruption of breastfeeding an effective treatment for jaundice in a breastfed baby. If a baby’s bilirubin levels reach 20 milligrams or above, a recommendation to cease breastfeeding for 24 hours may be used in conjunction with phototherapy. This can usually drop bilirubin levels dramatically and the mom can then resume breastfeeding as normal after the 24 hour period. Using a lactation aid to deliver supplementation and pumping during this 24 hour period would be the best way to avoid any problems in the breastfeeding relationship.
* If phototherapy is recommended (usually only if bilirubin levels reach over 15-20 milligrams), talk with your health care provider about using fiber optic blankets. These can be taken home and allow mom to continue the breastfeeding relationship, with no interruptions. Increased feedings and the use of the bilirubin lights should effectively lower the bilirubin levels.

Jaundice

The diagnosis of jaundice in their newborn baby is often very frightening to new parents. They immediately begin to think that something is very wrong with their infant, and may not be fully informed about the facts, which are actually very reassuring. Because jaundice is such a common condition, some medical professionals don’t take the time to explain all the details, because they deal with jaundiced babies every day. However, when the baby in question is your own precious newborn, you need to get as much information as possible to put your mind at ease.

Nearly all infants are jaundiced to some degree. In the vast majority of cases, newborn jaundice is a normal process, which many researchers feel may even serve protective functions, such as guarding the infant from the effects of oxygen free radicals. It makes sense that something that occurs in the majority of babies so routinely may be part of nature’s plan for the human infant.

Jaundice occurs when a yellow pigment called ” bilirubin” accumulates in the tissue, especially the skin, where you can see it as a yellowish or orangish tint. In adults or older children, jaundice is considered a pathological condition, but this is rarely the case with newborns. The very common type of jaundice that most babies experience is called normal, or ” physiologic” jaundice. Physiologic jaundice is not a disease – it is nearly always a harmless condition with no adverse after effects, as long as the bilirubin count doesn’t reach dangerous levels.

Before babies are born, they need high levels of red blood cells in order to get oxygen from their mother’s blood. Immediately after birth, when they begin breathing high-oxygen blood outside the womb, they no longer need their fetal hemoglobin. The red blood cells containing fetal hemoglobin now need to be broken down and eliminated from their bodies. Bilirubin is a by-product of the breakdown of these extra blood cells, and is removed from the bloodstream by the liver and excreted in the stool. It accumulates in the meconium (fetal stool-the black, tarry stuff that the baby excretes the first couple of days after birth) and if not excreted, can be re-absorbed into the baby’s system. The newborn’s immature liver may not be able to process and excrete the bilirubin fast enough in the first days after birth, so jaundice often develops. This is especially common in premature infants.

Bilirubin is measured in milligrams per deciliter of blood, or mg/dl. The average level for an adult is 1mg/dl. The average full-term newborn will have a peak level of 6mg/dl on the third or fourth day of life. Levels usually go down to about 2-3mg/dl by the end of the first week, gradually reaching the adult value of 1mg/dl by the end of the second week. It usually takes the newborn’s liver a week or two to mature enough to handle the build-up of bilirubin in the blood. It is important to know that there is no evidence that bilirubin levels of less than 20mg/dl during the first week of life, and less than 25mg/sl after that have any harmful effects of healthy, full-term babies.

So, if jaundice is such a normal condition, why all the concern? Because there are rare medical conditions which cause bilirubin to rise to dangerous levels, and can cause brain damage. Years ago, before we had the diagnostic tools and treatment options that we have today, some babies with very high bilirubin levels suffered from a condition called bilirubin encephalopathy, or kernicterus. This is rarely seen today, and then usually only in very premature or sick babies. Doctors today monitor bilirubin levels very carefully, and initiate treatment well before levels get high enough to cause problems.

There are three types of jaundice: Normal, or physiologic jaundice, affecting the majority of newborns; pathologic jaundice, caused by medical conditions such as blood type incompatibilities (the most common cause), as well as prematurity, infection, liver damage from rubella, syphllis, or toxoplasmosis, and metabolic problems such as hypothyroidism; and late-onset, or breastmilk jaundice (probably caused by a factor in some mother’s milk that seems to delay or prolong the excretion of excess bilirubin).

It is important to understand the different types of jaundice, because each has different causes, consequences, and treatments.

Physiologic jaundice affects nearly all newborns to some degree. It is more prevalent in certain ethnic groups, such as Chinese, Japanese, Korean, Hispanic, and Native Americans. If you define jaundice as bilirubin levels of greater than 10mg/dl, one study found that Japanese newborns were more than three times as likely to be jaundiced as white newborns. Babies who are premature or are low birth weight are more likely to become jaundiced. Babies who don’t feed often enough during the early days, and who don’t stool often, are also more likely to become jaundiced. This underscores the importance of early, frequent feedings. Colostrum (the sticky yellow fluid produced before the milk comes in) acts as a laxative. Bilirubin accumulates in the baby’s stools, and if it isn’t excreted, it re-circulates in his system. Frequent stooling helps lower bilirubin levels.

In the baby with physiologic jaundice, bilirubin levels will usually peak between the third and fifth days of life and are usually less than 12mg/dl. Occasionally they will go higher than 15mg/dl. Most doctors will monitor levels closely during this time, checking the baby’s levels with a blood test, pricking his heel, toe, or finger. If the levels are rapidly rising, or are 20mg/dl or higher (lower levels are used with premature infants), phototherapy is often suggested. This is a treatment which involves exposing skin to blue range light which breaks down the bilirubin and makes it more easily excreted. Years ago, nurses found that babies who were in beds near sunny windows had lower bilirubin levels. Researchers then found that phototherapy can make bilirubin levels drop quickly. Untill the past few years, babies with high bilirubin levels had to be in the hospital for phototherapy treatments – now, with new technology, babies can receive phototherapy at home using bili-blankets, provided by home health care providers. In most cases, bilirubin levels drop rapidly after phototherapy is initiated, and once the levels begin to go down, they almost always continue to decline. Usually only a day or two or therapy is needed.

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.