Jaundice in breast-fed babies

Jaundice is a fairly common condition in newborn babies. You may know it as the condition that causes babies to turn yellow. It’s caused by a yellow pigment (bilirubin) accumulating in the body, which turns the skin and the whites of the eyes a yellow colour. More on that in a minute.

Jaundice can have serious consequences if you don’t treat it, but fortunately it is very easy to treat. The one challenge, though, is breastfeeding – because there is a lot of misunderstanding and outdated information in the medical professions, mothers are often told to stop breastfeeding or to supplement with water or formula while their babies have jaundice. As I will explain in this post, that is simply not necessary.

I always believe that the best way to understand how to treat an illness is to understand what causes it. So we’ll start by looking at how jaundice develops, and then we’ll look at what can be done to prevent jaundice and how it is treated. Most importantly, we’ll look at how to preserve your breastfeeding relationship through it all.

How jaundice develops

Before we get into the medical side of things, let’s just dispel one myth that I must have heard a million times: jaundice is not caused by the mother eating orange coloured foods. It just doesn’t work that way. So go ahead and eat all the oranges, butternut and carrots that you like.

There are a few different kinds of jaundice that may be seen in babies. They all have one thing in common: baby’s skin and eyes are tinged yellow by the build-up of a pigment called bilirubin. Every human alive has some bilirubin in their blood; it actually has a few important functions in the body. The difference is that babies can’t always get rid of the excess bilirubin quickly enough, so they accumulate too much of it in their bodies.

It helps if you know where bilirubin comes from and where it’s supposed to go, so let’s start there. Bilirubin is formed when the body breaks down old red blood cells. At birth, there’s a lot of half-formed red blood cells that get broken down, so baby will have a lot of bilirubin in his blood. This bilirubin is supposed to go to the liver where it is processed (the fancy word is “conjugated”). The processing makes the bilirubin water-soluble so that it can be excreted. The liver stores the bilirubin in the gallbladder, and from there it flows into the intestines and leaves the body with the stools. (Fun fact: bilirubin is the stuff that makes your poop brown). If the baby doesn’t have regular bowel movements, and the stools stay in the intestines for a long time, the bilirubin can be re-absorbed back into the blood.

Different types of jaundice interrupt this process of excreting bilirubin at different places. By far the most common is normal newborn jaundice (formally known as neonatal jaundice). This simply happens because the liver can’t process bilirubin fast enough. Since there’s more bilirubin floating around that the liver can get to, it gets stored everywhere else in the body. We can see the bilirubin in the skin and eyes, because it has that yellow colour.

Newborn jaundice can also happen when there’s an abnormally large amount of red blood cells being broken down. This can happen, for instance, if mom has a negative blood group and baby has a positive blood group. Again, there’s simply more bilirubin that the liver can handle.

A second kind of jaundice used to be called breastfeeding jaundice, which is a silly name – I prefer the new name, starvation jaundice. It happens when baby is not breastfeeding well (so perhaps it should be called breast non-feeding jaundice?!). If baby does not take in any milk, he will not pass stools. That means that the bilirubin in the gut gets re-absorbed into the blood, and the blood levels of bilirubin get higher and higher.

These first two types of jaundice – neonatal jaundice and starvation jaundice – usually require medical treatment because the bilirubin levels are so high. If the levels of bilirubin get very high, bilirubin crystals can be deposited in the brain, causing lasting brain damage. For that reason, it’s very important to monitor bili levels closely with proper blood tests.

There is also a third kind of jaundice called breast milk jaundice. Yes, this kind is actually caused by breast milk; there seems to be some unknown factor in breast milk that causes more bilirubin to be absorbed from the gut, so less of it leaves the body in the stool. However, it is not a reason to avoid breastfeeding – a baby with breast milk jaundice usually doesn’t have high enough bili levels that it requires treatment, and certainly not high enough to pose any danger to the baby. These babies often have a yellow tinge for several weeks, and it eventually goes away on its own, no interruption of breastfeeding needed.

Preventing jaundice

We know that bilirubin leaves the body through the stools, so that suggests an important strategy for preventing jaundice: make sure baby poops! Breastfeeding is ideal for this: colostrum, the first breast milk, acts as a laxative to help baby move his bowels as soon as possible. Feeding early and often is one of the best ways to prevent newborn jaundice.

Sunlight can also help to break down bilirubin in baby’s skin. This is a great therapy for babies who have a slight tinge of jaundice, but whose blood bili levels are still in the normal range; often it’s enough to resolve the jaundice completely. Simply place baby naked in the sunlight for 5-10 minutes (depending on the time of year), front and back. Do this in the early morning or late afternoon when the sun is not too strong; you don’t want baby to get sunburn!

 

Treatment of jaundice

If the blood bili levels are above a certain limit, baby will need to be treated to bring the levels down. The cut-off level for starting treatment differs depending on the weight and age of the baby, so we’ll leave it to the doctors to make that decision.

Jaundice is usually treated with phototherapy, which is just a fancy name for light. Baby’s skin is exposed to a special blue light, either through an overhead lamp or by wrapping baby in a blanket with little LEDs embedded in it (called a bili-blanket). The light does one simple thing: it changes the chemical structure of the bilirubin to make it water soluble, so that it can be excreted. So basically, it’s doing the same thing as the liver. This helps the bilirubin move out of the body more quickly, and you can actually see it: when babies are under phototherapy, their stools and urine tend to have a darker colour.

If the bilirubin levels are dangerously high, baby may need to get a blood transfusion. This literally removes the “dirty” blood and replaces it with clean blood.

What about breastfeeding?

Breastfeeding should continue uninterrupted while baby is being treated for jaundice. In fact: breastfeeding is an important part of the treatment: the more you breastfeed, the more stools baby will pass, and the quicker the bilirubin will be cleared from the body. There are still doctors and nurses out there that will insist babies with jaundice must receive formula to help clear up the jaundice, but trust me, it’s not necessary. Yes, the jaundice may clear up a bit faster, but the risks to your baby’s health, your milk supply and your breastfeeding relationship are just not worth it. I’ve seen dozens of babies who were successfully treated for jaundice while drinking nothing but breast milk.

Some doctors also still like to recommend water in-between feeds, in the belief that it helps to flush out bilirubin from the body. But since only a tiny amount of bilirubin is excreted in the urine (about 10%), it makes far more sense to give baby breast milk. In any case, breast milk is mostly water, so if you give breast milk you are giving water. Only if baby starts to show signs of dehydration do you need to worry.

You may worry that breastfeeding can decrease the effectiveness of the phototherapy, because baby is spending so much time out from under the lights. Rest assured, studies have shown that feeds of 30 minutes or less, every 2-3 hours, do not make any significant difference to how well babies respond to phototherapy.

Of course, all this assumes that baby is breastfeeding well. Unfortunately, some babies get very sleepy when they have jaundice, and then they do not feed as effectively. This creates a vicious cycle, since less milk intake = less stools = more bilirubin build-up. Getting enough milk is very, very important, so if baby is not suckling well and not passing stools at least three times a day, you should express some milk and give that as a top-up. As always with newborns, avoid using a bottle – feed baby the milk with a syringe or a cup.

Does formula ever need to enter the picture? Well, the reality is, yes. Especially in cases of starvation jaundice, there may simply not be enough breast milk available, and formula may be needed for nutrition as much as for anything else. Many doctors also use formula to treat stubborn cases of jaundice where the bili levels simply do not want to come down despite optimal treatment. If you find yourself in this situation, keep in mind that giving a small top-up of hydrolysed infant formula is usually enough; there’s no need to switch completely to formula even for a single day.

Info for your doctor

If your doctor is giving you grief, demanding that you give water or formula for no good reason, I have some ammunition for you: download the Academy of Breastfeeding Medicine’s protocol for the management of jaundice in the breastfeeding infant (You can find it here). It is a well-researched, evidence based article that will provide your doctor with much the same information as I have shared above. It’s always good to make sure you and your doctor are on the same page, and that he/she knows how strongly you feel about breastfeeding.

Summing it up

Before I wrap this one up, let’s just put together a short list of the most important things to remember:

• Jaundice is pretty common – it’s not your fault, you didn’t do anything wrong.
• The best way to prevent jaundice is to breastfeed early and often
• If baby has jaundice, breastfeeding should continue uninterrupted. More breastfeeding = more stools = faster recovery.
• Water is not necessary.
• Formula is very, very rarely necessary. When it is necessary, small top-ups for a short time should be all that is needed to bring the bili levels down.
• Jaundice may make baby too sleepy to breastfeed effectively. If this is the case, express some milk and feed it to baby with a syringe or cup, not a bottle.

If you are one of the unlucky moms who had to deal with jaundice, I hope that this information has helped you to understand what’s going on, given you some peace of mind and – of course! – helped to preserve your breastfeeding relationship. Let me know in the comments if you managed to breastfeed a baby with jaundice and what your experience was.