Breast milk jaundice

What is breast milk jaundice?

Breast milk jaundice is a type of newborn jaundice which is associated with breastfeeding. It is characterised by a raised level of unconjugated bilirubin (also called the indirect bilirubin) in blood. It develops after the first 4 to 7 days, lasts for about 3 to 12 weeks and has no other identifiable cause. The cause of breast milk jaundice is not found but is supposed to be due to following reasons,

presence of pregnane 3 -beta 20- alpha diol and free fatty acids in breast milk that interferes with normal metabolism of bilirubin.
the delay in appearance of normal gut bacteria in baby's gut, due to ingestion of breast milk- which interferes with excretion of bilirubin.
Breast milk jaundice is important because

the presence of jaundice beyond 2 weeks in term babies and 3 weeks in premature babies, should alert the doctor to look for and rule out other causes of jaundice by examining the baby, testing for a split bilirubin test and if necessary performing other tests.
when other conditions are ruled out, it is important to reassure the parents about the harmless nature of breast milk jaundice and prepare them for the lengthy period that the baby could remain jaundiced (up to 3 months).

What is bilirubin?

A newborn is born with an excess of red blood cells that has to be broken up and removed from his blood.These red blood cells have a shorter life span that those of adult's. Bilirubin is one such waste product of broken up red blood cells. The bilirubin that reaches liver is called unconjugated bilirubin. In the liver, bilirubin is conjugated with a sugar to form conjugated bilirubin. Conjugated bilirubin is soluble and it is secreted in to the gut. Here it is further broken down and excreted.

The importance of understanding the metabolism of bilirubin is that the split bilirubin test which measures the levels of conjugated and unconjugated bilirubin helps us to diagnose the cause of Jaundice. For example, jaundice due to liver disease usually causes a leakage of conjugated bilirubin in to blood which is detected by the split bilirubin test.

Also, such presence of water soluble conjugated bilirubin will turn the urine yellow, as kidneys try to excrete the metabolite. In cases of obstruction of bile flow due to liver disease or obstruction of bile ducts, the stools changes from the normal yellow color to white or putty color. This is very important to differentiate breast milk jaundice ( where babies pass plenty of colorless urine and golden yellow poo) from other serious causes of long standing jaundice (for example a liver disease where babies may pass dark yellow urine and pale poo).

Jaundice in newborn:

Jaundice is the yellow appearance of eyes and skin . Jaundice is very common in newborn babies. About 90% of babies become jaundiced two or three days after birth.(Jaundice occuring in the first 24 hours after birth is abnormal and must be evaluated by a doctor)

Physiological Jaundice:

When baby is in the mother's womb, his waste products are removed by the placenta. Once baby is born, baby's liver is responsible for metabolism and excretion. But, baby's liver is immature at birth and takes a few days to catch up. A newborn has an excess of short lived red blood cells which have to be removed. Such an increased work load and decreased functioning of immature baby liver can lead on to a surge in the level of bilirubin. This is called physiological jaundice. Physiological jaundice appears after the first 24 hours, reaches peak in 3 to 4 days and gradually disappears in 2 weeks. (Breast milk jaundice, on the other hand appears after 2 weeks and may last until 3 months).

Breastfeeding jaundice:

Breast feeding jaundice (otherwise called 'Not-enough-breast milk-jaundice') is different from breast milk jaundice. This occurs in the first few days of life and is due to infrequent feeding sessions, poor latching and other reasons that causes delay in establishment of breast feeding. The babies may appear dehydrated, passes scanty urine and poo. This type of jaundice can get severe if there is no intervention. The treatment is by encouraging frequent feeding (10 to 15 times per day ), helping the baby to latch properly and breast compression. A lactation consultant can help and support the mother in establishing breast feeding.

Other causes of Jaundice:

Apart from physiological jaundice, breast feeding jaundice and breast milk jaundice described above, babies can also get jaundiced in many other conditions like

Conditions that cause an increased break down of red blood cells : Examples- spherocytosis, sickle cell anaemia, G6PD, Blood group incompatibility etc.
Prematurity :Delayed clearance of physiological jaundice.
Under active thyroid gland: Delayed clearance of physiological jaundice.
Infections: A hidden urinary tract infection or sepsis in blood
Liver diseases- which are rare, but could be serious.
Symptoms of breast milk jaundice:

Breast milk jaundice occurs after 4 to 7 days of life, usually when physiological jaundice has resolved. Interestingly many infants with breast milk jaundice also had an exaggerated physiological jaundice. A second peak by the age of 14 days. After lingering on for a few weeks to months, it resolves by the age of 12 weeks.

Breast milk jaundice is often picked up by the yellowish appearance of skin and eyes during a routine examination of a new born baby during the first week. In dark skinned babies, gentle pressure can reveal the presence of jaundice. A rough correlation between the blood levels of bilirubin and the extent of jaundice is often noted (face- approximately 5mg/dl, mid abdomen-15mg/dl, feet- 20 mg/dl). However the doctor often performs a blood test to diagnose the presence or the extent of jaundice, because visual determination is often very inaccurate. Babies with high level of bilirubin tend to be sleepy.

Breast milk jaundice often runs in families. If a sibling has already had breast milk jaundice, there is greater chance for a baby to have breast milk jaundice. Babies with breast milk jaundice are thriving well, regained birth weight and gaining weight steadily, passing plenty of colorless urine (at least 6 to 8 wet diapers) and golden yellow or daffodil yellow poo.

How is breast milk jaundice diagnosed?

Breast milk jaundice is a diagnosis of exclusion- that is a diagnosis made when other conditions are ruled out.

So if a baby is still jaundiced after 2 weeks, the physician gives a thorough examination of the baby to see if the baby has any congenital abnormality, anaemia, dehydration,bleeding, any enlargement of liver or spleen etc. He enquires about the weight of the baby, number of wet diapers, color of urine and stool and if there were similar complaints with other siblings in their newborn period. He will do a split bilirubin blood test . Other tests, including blood grouping and tests to detect infection may be necessary depending on the clinical presentation. Similarly, with a prolonged course of jaundice, it may be necessary to repeat the blood test to look for a decreasing trend in the levels. Blood levels can also be measured by non invasive techniques like transcutaneous bilirubinometry.

Split bilirubin test determines if the elevated bilirubin is predominantly conjugated or unconjugated (if the conjugated fraction is greater than 20 % of the total bilirubin it indicates liver disease ).

Treatment of breast milk jaundice:

When a diagnosis of breast milk jaundice is made, it is important to allay the fear and anxiety of parents by explaining them the benign nature of breast milk jaundice. There has been claims that breast milk jaundice can be protective for the babies, citing the antioxidant role of bilirubin. Parents should also be counselled for a long period of resolution, as long as 3 months.

Mothers are instructed to breast feed the babies frequently - 12 to 15 times for the first several days. Jaundiced babies tend to be sleepy and may need to be gently waken up for a feed. Lactation consultant can help in establishing and supporting breast feeding. Frequent feeding increases the number of bowel movements that help in excretion of bilirubin.

Although studies have shown that breast milk jaundice can rapidly be brought down by stopping breast feeding (and resuming breast feeding strangely does not cause an increase in blood level to the previous level) interruption of breast feeding is not generally recommended.

If the bilirubin levels gets too high , the baby is treated with phototherapy. Phototherapy can be administered with standard phototherapy units (where the baby is made to lie ,with only diapers and eye pad, on a cot under special blue lights) or wrapped in a bili blanket. The light breaks down the bilirubin and lowers its level. Although sunlight also has the sufficient wavelength to provide phototherapy, the risk of getting a 'sun burn' while exposing the baby to sun prevent some doctors from advising so. Fibre optic phototherapy can often be safely administered at home. Mothers are instructed to feed the baby frequently despite phototherapy.

Complications:

There is no documented case of high bilirubin level led brain damage (kernicterus) due to breast milk jaundice. Babies are often put on phototherapy well before such levels could be reached.

You must call the doctor immediately if

baby is too sleepy to wake, nurses poorly, is floppy , develops a high pitched cry, arches the back or neck or throws a seizures- these signs indicate that the blood level of bilirubin is dangerously high.
if the baby's poo or urine is not in the right color, irrespective of the age , baby should be investigated.

Remember:

Breast milk jaundice is very common.
It has an excellent prognosis although it can last for up to 12 weeks.
Interruption of breast feeding is generally not recommended in breast milk jaundice.