Jaundice, breastfeeding both normal for newborns

ABM’s newly released Clinical Protocol #22: Guidelines for the Management of Jaundice in Breastfeeding Infants 35 Weeks’ Gestation or More concludes with the reminder that “(j)aundice and some degree of hyperbilirubinemia are normal and expected aspects of newborn development. Breastfeeding is also a normal and expected aspect of infancy and childhood.”

I personally loved this part, because I will never forget reading  Larry Gartner’s  work on bilirubin metabolism during a family medicine rotation in medical school.  That was what finally  pulled me into the growing, developing subjects of pediatrics and neonatology – and it was even before Dr Gartner went on to become a founding member of ABM and the lead author of this protocol.

The way I explain newborn jaundice to non-medical parents goes something like this:

“Jaundice” means a yellowish color of the skin.  It’s caused by bilirubin, which is a normal breakdown product that comes from the body’s recycling of red blood cells.  Our livers help get rid of the bilirubin.  Newborns have more red blood cells, they recycle them faster, and so they make more bilirubin.  But their livers aren’t ready to get rid of all that bilirubin at first — it builds up in their bloodstream.  And that’s why newborns tend to look a little yellow, or jaundiced, after the first day or two of life.

ABM’s guidelines begin with this perspective:  the physiologic basis of most newborn jaundice.   The first section differentiates among physiologic jaundice, breastmilk jaundice (prolonged physiologic jaundice related to an as-yet-unidentified component of human milk), and starvation jaundice (or its colloquial name, “breast-NON-feeding jaundice” ).   The less common, pathologic causes of hyperbilirubinemia are not included in the discussion but should always be kept in mind by care providers.  The concern for bilirubin encephal0pathy and the American Academy of Pediatrics’ clinical practice guideline are both emphasized.

The next section offers an extensive overview of ways to prevent excessive levels of hyperbilirubinemia in breastfeeding newborns (early initiation of exclusive, cue-based breastfeeding; avoiding routine supplementation; support by health care providers trained in breastfeeding management; and recognition of patients at higher risk who may need more intervention).

The section on treatment emphasizes phototherapy as the first line for babies with exaggerated hyperbilirubinemia, with careful evaluation and support of breastfeeding.  Phototherapy may be suspended for up to 30-minute eyeshield-free feeding sessions without lessening its effectiveness.  IV fluids are not routinely indicated, nor is home phototherapy.  Supplementation with small amounts of formula (hydrolyzed/elemental formulas being more effective) may be of use in reducing bilirubin levels for patients who are not yet in need of phototherapy.  Temporary cessation of breastfeeding (while maintaining mom’s milk expression) may be useful in avoiding phototherapy, as well as establishing the diagnosis, in older newborns with breastmilk jaundice.

The guidelines’ reminders to use care in speaking to parents about the relationship between breastfeeding and jaundice, as well as to avoid artificial nipples and excessive amounts of formula supplementation, may seem obvious to some of us –  but are important to note.

Finally, the thoughtful list of potential research directions at the end should be welcomed by anyone looking for a way to make a difference to babies and families who are affected by this common, but potentially life-altering, situation.

Kimberly Lee, MD, MS, IBCLC, is an Associate Professor of Pediatrics (Neonatology) at the Medical University of South Carolina.