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Gartner Breastfeeding and Jaundice
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Total Serum Bilirubin (uM/L)
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100
60
80
40 60
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20
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
Days of Life
Days of Life
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DIAGNOSIS OF BREASTMILK JAUNDICE
10 Recognition that at least two thirds of all breastfed infants will have
5 serum bilirubin concentrations in the third week of life that are
0
significantly higher than the adult normal value is an important
0 - 25 26 - 50 51 - 100 101 - 150 151 - 200 201- 300
Total Serum Bilirubin (uM/L) foundation for diagnosis. Breastmilk jaundice is a normal, regularly
Figure 2. Typical pattern of total serum bilirubin concentrations in a occurring prolongation of physiologic jaundice of the newborn. For
healthy, full - term, optimally breastfed infant during the first 22 days of life. the healthy, full-term infant, elevations of serum unconjugated
bilirubin to 340 or 425 M/l (20 or 25 mg/dl), the highest levels growth and development in the preterm infant.18,19 Human milk
seen with breastmilk jaundice, are not a cause for alarm, although feeding increases serum bilirubin concentrations in premature
they indicate a need for investigation to rule out pathologic causes of infants by about 3 mg/dl over at least the first 50 days of life
exaggerated hyperbilirubinemia. Elevations to this level are rare, compared with formula-fed infants.20 Whether this degree of increase
occurring in fewer than 1% of all thriving breastfed infants. The great places the breastfed premature infant at greater risk of kernicterus is
majority of infants with breastmilk jaundice will have much lower unknown. There may be compensation or protection against
levels (Figure 3).4 Only one third has levels greater than 100 M/l kernicterus by prevention of infection, a factor known to increase risk
(6 mg/dl) and the great majority of breastfed infants with elevated for kernicterus.21
bilirubin concentrations have less than 150 M/l (9 mg/dl).4 The
recent report by Maruo et al.15 from Japan provides strong evidence
that most of the breastfed infants with these very high levels have a BREASTFEEDING (NONFEEDING) JAUNDICE
genetic factor which contributes to their extreme hyperbilirubinemia Although the optimally breastfed infant has serum bilirubin
by restricting the hepatic conjugation of bilirubin. The diagnosis of concentrations which are identical with that of the artificially fed
breastmilk jaundice can usually be made in the healthy, thriving infant during the first 5 days of life, many breastfed infants develop
breastfed infant with good weight gain in whom hemolysis and other higher bilirubin levels during this early period of physiologic
pathologic causes of jaundice have been ruled out by clinical or jaundice. While some authors have considered this higher level of
laboratory study. bilirubin in the breastfed infant to be normal and expected, there is
ample evidence that these elevations are, in fact, abnormal.22,23
Terminology is often the cause of confusion among both authors and
CLINICAL MANAGEMENT OF BREASTMILK JAUNDICE readers. The term ‘‘breastmilk jaundice’’ should be reserved for the
Clinical management of the infant with breastmilk jaundice is of normally occurring prolonged unconjugated bilirubin, which has its
considerable interest and importance. The full-term infant with onset after the fifth day of life. The increase in serum unconjugated
breastmilk jaundice of less than 340 M/l (20 mg/dl) requires no bilirubin concentration seen in the first 5 days of life in some
intervention, and breastfeeding should be continued without breastfed infants should be called ‘‘breastfeeding jaundice’’ or, more
interruption.16 For those full-term, healthy infants with breastmilk precisely, ‘‘breast-nonfeeding jaundice.’’
jaundice and serum bilirubin levels between 340 and 425 M/l (20 In addition to confusion in the terminology describing the
and 25 mg/dl), closer observation of bilirubin concentrations is relationship between human milk feeding and jaundice, there is also
indicated. Some clinicians may wish to observe, whereas others may confusion in the literature regarding the precise definition of
choose to complement breastfeeding with formula for 24 to 48 hours, breastfeeding. Many papers, particularly in the earlier literature,
which will reduce intestinal bilirubin absorption, or initiation of failed to include descriptions of the breastfeeding techniques used in
phototherapy. When serum bilirubin concentrations rise toward the study population. It is now well recognized that the volume of
425 M/l (25 mg/dl), the use of phototherapy while continuing milk produced by the lactating mother is intimately linked to the
breastfeeding, or the interruption of breastfeeding for 24 hours, time of onset of breastfeeding, the frequency of the breastfeeding, the
substituting formula, may be indicated. Those infants with completeness of emptying of the breast at each feeding, the position
breastmilk jaundice who have developed kernicterus may have of the infant during nursing, and the ability of the infant to suckle
additional factors of hemolysis, infection, or a genetic alteration in effectively. Administration of water or other feeds prior to or in
bilirubin metabolism. The great majority of full-term breastfed addition to nursing will also adversely affect the volume of milk that
infants who developed kernicterus had excessive weight loss of more the breastfeeding mother will produce.24 – 27 This is especially critical
than 10%, suggesting a period of lethargy and poor feeding, possibly during the early days of life when lactation is being established.
secondary to the rising serum bilirubin.17 These infants may have Reduced volume of milk transfer to the infant will limit the caloric
both breastmilk jaundice and breast-nonfeeding jaundice (see intake of the infant, producing a state of partial starvation. I use the
below). Thus, breastmilk jaundice may be a contributor to term ‘‘starvation’’ because there is a well-described entity in the
kernicterus, but probably only in combination with other factors. adult human and other adult mammals known as starvation
Early recognition of the breastfed infant with poor intake is essential jaundice. This increase of 17 to 35 M/l (1 to 2 mg/dl) in
to insure preservation of breastfeeding and to avoid excessive rises in unconjugated serum bilirubin, which occurs in virtually all adults
bilirubin due to starvation. It is for this reason that breastfed infants after 24 hours of fasting despite adequate water intake, has been
should be examined by a well-trained clinician 2 to 3 days after shown to be due to an enhancement of the enterohepatic circulation
hospital discharge to assess nutritional adequacy, as well as jaundice. of bilirubin.11,28 Studies in newborn rhesus monkeys demonstrated a
Unlike the full-term infant, the premature infant poses an five-fold increase in intestinal bilirubin absorption even with normal
interesting dilemma. Breastmilk, whether given directly from the feeding regimens.29 Starvation — even partial starvation — can
breast or by cup, bottle, or tube, has been shown to provide significant be expected to further increase the intestinal absorption of bilirubin
protection against a variety of infections and to promote improved in the newborn.
The presence of large amounts of bilirubin in meconium and evaluation of the breastfeeding and correction of the problems to
delay in emptying of meconium have been shown to contribute insure adequate milk production and intake. Some may require
to an increase in serum bilirubin levels in the early days of life, temporary supplemental feeding by cup or bottle. In the full-term
further increasing intestinal bilirubin absorption.30,31 Neither healthy infant, phototherapy and complementary or substitution
breastfeeding nor reduced caloric intake increases bilirubin feedings with infant formula are not needed until serum levels exceed
synthesis as measured by expired carbon monoxide.32 Thus, the 300 to 340 M/l (18 to 20 mg/dl). Even when slightly greater than
most likely explanation for the observed excessive increase in 340 M/l (20 mg/dl), but not rising rapidly, further observation
serum bilirubin in the first 5 days of life in breastfed infants in and assurance of good breastmilk intake may be all that is required.
some studies is the inadequacy of milk intake due to poor Hemolysis and other pathologic causes of hyperbilirubinemia must
breastfeeding practices and hospital policies. Support for this is be ruled out, of course.
found in the studies demonstrating that lower serum bilirubin Whereas some degree of hyperbilirubinemia is normal and to be
concentrations in breastfed infants are associated with weight expected in the newborn period and even to be prolonged for weeks in
gains comparable to or better than those of artificially fed the breastfed infant, excessive levels that place the infant at risk for
infants.33,34 Elevated bilirubin concentrations have been observed bilirubin encephalopathy are certainly to be avoided, while also
with greater losses from birth weight.35 Breastfeeding frequencies making every effort to preserve the breastfeeding. This can often be
of at least 11 times per day, starting with the first day, have achieved by practicing good lactation techniques that assure an
been associated with the lowest serum bilirubin concentrations optimal milk volume and caloric intake. Thus, initiation of
on the third to sixth days of life.36,37 Delay in initiation of breastfeeding in the first hour, followed by at least 10 to 12
breastfeeding beyond the first hour of life, and administration of breastfeeds per day for the first week or two without any water or
water to infants either before initiation of breastfeeding or in other food supplementation, and using good positioning that assures
addition to breastfeeding significantly reduce the frequency of effective milk transfer to the infant will minimize weight loss to less
breastfeeding and increase serum bilirubin concentrations.38 While than 7% and maintain serum bilirubin levels well under those that
these negative effects on breastfeeding and increases in jaundice would cause concern about risk for kernicterus.
are seen primarily in the first 5 days of life, reduced caloric
intake later in the newborn period can also produce marked
increases in jaundice, often accompanied by dramatic weight FUTURE RESEARCH
loss, dehydration, and even kernicterus.17 Many clinicians have Future research is needed to identify the factor in mature human
observed the development of lethargy and poor feeding with high milk that promotes the enterohepatic circulation of bilirubin and
levels of bilirubin. This may further suppress caloric intake and to achieve an improved understanding of how bilirubin moves
continue a vicious cycle of increasing serum bilirubin from the intestinal lumen into the mucosa. This might lead to
concentration. therapeutic techniques that would allow continuation of
breastfeeding while minimizing bilirubin elevations in those
RELATIONSHIP OF BREAST-NONFEEDING JAUNDICE occasional infants whose bilirubin concentrations rise to threat-
AND BREASTMILK JAUNDICE ening levels.
8. Arias IM, Gartner LM. Production of unconjugated hyperbilirubinemia in 23. Gartner LM. On the question of the relationship between breastfeeding and
full - term, new - born infants following administration of pregnane - jaundice in the first 5 days of life. Semin Perinatol 1994;18:502 – 9.
3( alpha ),20( beta ) - diol. Nature 1964;203:1292 – 3. 24. American Academy of Pediatrics, Work Group on Breastfeeding. Breastfeeding
9. Cole AP, Hargreaves T. Conjugation inhibitors and early neonatal and the use of human milk. Pediatrics 1997;100:1035 – 9.
hyperbilirubinemia. Arch Dis Child 1972;47:415 – 8. 25. Shrago L. Glucose water supplementation of the breastfed infant during the
10. Luzeau R, Odievre M, Levillain P, et al. Lipoprotein lipase activity in human first three days of life. J Hum Lactation 1987;3:82 – 6.
milk; inhibition in vitro of the glucuronoconjugation of bilirubin. Clin Chim 26. Goldberg NM, Adams E. Supplementary water for breast - fed babies in a hot
Acta 1975;59:133 – 8. and dry climate — not really a necessity. Arch Dis Child 1983;58:73 – 4.
11. Demirkol M, Bohles H. Breast milk taurine and its possible influence on the 27. Righard L, Alade MO. Sucking technique and its effect on success of
development of breast milk induced jaundice of the neonate — a breastfeeding. Birth 1992;19:185 – 9.
hypothesis. In: Hixtable R, Michalk DV, editors. Taurine in Health and 28. Gärtner U, Goeser T, Wolkoff AW. Effect of fasting on the uptake of bilirubin
Disease. New York: Plenum; 1994: pp.405 – 10. and sulfobromophthalein by the isolated perfused rat liver. Gastroenterology
12. Gourley GR, Arend RA. - Glucuronidase and hyperbilirubinemia in breast - 1997;113:1707 – 13.
fed and formula - fed babies. Lancet 1986;I:644 – 6. 29. Gartner LM, Lee KS, Vaisman S, et al. Development of bilirubin
13. Ince Z, Coban A, Peker I, et al. Breast milk beta - glucuronidase and transport and metabolism in the newborn rhesus monkey. J Pediatr
prolonged jaundice in the neonate. Acta Pediatr 1995;84:237 – 9. 1977;90:513 – 31.
14. Gartner LM, Lee KS, Moscioni AD. Effect of milk feeding on intestinal 30. Weisman LE, Merenstein GB, Digirol M, et al. The effect of early meconium
bilirubin absorption in the rat. J Pediatr 1983;103:464 – 71. evacuation on early - onset hyperbilirubinemia. Am J Dis Child 1983;137:
15. Maruo Y, Hishizawa K, Sato H, et al. Prolonged unconjugated 666 – 8.
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bilirubin uridine diphosphate - glucuronyosyltransferase gene. Pediatrics possible contributing factor in neonatal jaundice. Lancet 1963;I:1242.
2000;106:E59. 32. Stevenson DK, Bartoletti AL, Ostrander CB, et al. Pulmonary excretion of
16. American Academy of Pediatrics, Provisional Committee for Quality carbon monoxide in human infant as an index of bilirubin production: IV.
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management of hyperbilirubinemia in the healthy term newborn. Pediatrics Pediatrics 1980;65:1170 – 2.
1994;94:558 – 65. 33. Rubaltelli FF. Unconjugated and conjugated bilirubin pigments during
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newborns. Pediatrics 1995;96:730 – 3. hyperbilirubinemia. Biol Neonat 1993;64:104 – 9.
18. Narayanan I, Parakash K, Gujral VV. The value of human milk in the 34. Nielsen HE, Haase P, Blaabjerg J, et al. Rick factors and sib correla-
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1981;99:496 – 8. 76:504 – 11.
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North Am 2001;48:207 – 19. effect of breast - feeding. Pediatrics 1986;78:837 – 43.
20. Lucas A, Baker BA. Breast milk jaundice in premature infants. Arch Dis Child 36. De Carvalho M, Klaus MH, Merkatz RB. Frequency of breast - feeding and
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