Breastfeeding and Jaundice

(1.) Breast Milk Jaudice

• Breast milk jaundice has been traditionally defined as the persistence of “physiologic jaundice” beyond the first week of age.
• It typically presents after the first three to five days of life, peaking within two weeks after birth, and progressively declined to normal levels over 3 to 12 weeks
• infants commonly have TB levels >5 mg/dL (86 micromol/L) for several weeks after delivery

Cause

• appears to be due to a factor, which has not yet been identified, in human milk that promotes an increase in intestinal absorption of bilirubin.
• Approximately 20 to 40 percent of women have high levels of beta-glucuronidase (increasing bilirubin absorption)  

Treatment

• Although the hyperbilirubinemia is generally mild and may not require intervention, it should be monitored to ensure that it remains unconjugated and does not increase.
• If levels begin to increase or there is a significant component of conjugated bilirubin, evaluation for other causes of hyperbilirubinemia should be performed including neonatal cholestasis.
• If after evaluation, breast milk intake is the only remaining viable factor, breastfeeding can continue with the expectation of resolution by 12 weeks of age and that the hyperbilirubinemia is in the safe zone 
• Temporary interruption of breastfeeding is rarely needed and is not recommended unless serum bilirubin levels reach 20 mg/dL (340 µmol/L)
• The most rapid way to reduce the bilirubin level is to interrupt breastfeeding for 24 hours, feed with formula, and use phototherapy; however, in most infants, interrupting breastfeeding is not necessary or advisable.
• Phototherapy can be administered with standard phototherapy units and fiberoptic blankets

(2.) Breasfeeding Failure Jaundice

•  Suboptimal breastfeeding compared with formula feeding is associated with an increased risk of jaundice and kernicterus

Main Cause

• failure to successfully initiate breastfeeding rather than a direct effect of breast milk itself, as is seen in breast milk jaundice.
• level was only marginally higher in successfully breastfed compared with formula-fed infants
• typically occurs within the first week of life, as lactation failure leads to inadequate intake with significant weight and fluid loss resulting in hypovolemia.
• This causes hyperbilirubinemia (jaundice) and in some cases, hypernatremia defined as a serum sodium >150 mEq/L.
• Decreased intake also causes slower bilirubin elimination and increased enterohepatic circulation that contribute to elevated TB.

Prevention

• initiation of successful breastfeeding, one of the mainstays of preventing hyperbilirubinemia, has become an increasing problem due to shortened postpartum length of stay for newborn infants and their mothers
• During the first postpartum week while breastfeeding is being established, mothers should nurse whenever the infant shows signs of hunger or when four hours have elapsed since the last feeding.
• This will usually result in 8 to 12 feedings in 24 hours, which is usually sufficient to prevent significant hyperbilirubinemia that requires intervention

References:

1. www.uptodate.com