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Introduction
Jaundice
is due to a buildup in the blood of bilirubin, a yellow pigment which comes from
the breakdown of old red blood cells. It is normal for red blood cells to break
down, but the bilirubin formed does not usually cause jaundice because the liver
metabolizes it and gets rid of it into the gut. The newborn baby, however, often
becomes jaundiced during the first few days because the liver enzyme which
metabolizes bilirubin is relatively immature. Furthermore, newborn babies have
more red blood cells than adults, and thus more are breaking down at any one
time. If the baby is premature, or stressed from a difficult birth, or the
infant of a diabetic mother, or more than the usual number of red blood cells
are breaking down (as happens in blood incompatibility), the level of bilirubin
in the blood may rise higher than what is usual.
Two
Types of Jaundice
The liver
changes bilirubin so that it can be eliminated from the body. If, however, the
liver is functioning poorly, as occurs during some infections, or the tubes
which transport the bilirubin to the gut are blocked, this changed bilirubin may
accumulate in the blood and also cause jaundice. When this occurs, the changed
bilirubin (called conjugated bilirubin), appears in the urine and turns the
urine brown. This brown urine is an important clue that the jaundice is not
"ordinary". Jaundice due to conjugated bilirubin is always abnormal,
frequently serious and needs to be investigated thoroughly and immediately.
Except in the case of a few extremely rare metabolic diseases,
breastfeeding can and should continue.
Accumulation of bilirubin before it has been changed by the enzyme of the liver
may be normal—"physiologic jaundice". Physiologic jaundice begins on the 2nd or
3rd day, peaks on the 3rd or 4th day and then begins to disappear. However,
there may be other conditions that cause an exaggeration of this type of
jaundice, such as a more rapid than normal breakdown of red blood cells. Because
these conditions have no association with breastfeeding, breastfeeding should
continue. If, for example, the baby has severe jaundice due to rapid
breakdown of red blood cells, this is not a reason to take the baby off the
breast. Breastfeeding should continue.
Breastmilk Jaundice
There is
a condition commonly called breastmilk jaundice. No one knows what the cause of
breastmilk jaundice is. In order to make this diagnosis, the baby should be at
least a week old, though interestingly, many of the babies with breastmilk
jaundice also have had exaggerated physiologic jaundice. The baby should be
gaining well, with breastfeeding alone, having lots of bowel movements, passing
plentiful, clear urine and be generally well (Is
my baby getting enough milk?). In such a setting, the baby has what
some call breastmilk jaundice, though, on occasion, infections of the urine or
an under functioning of the baby's thyroid gland, as well as a few other rare
illnesses may cause the same picture. Breastmilk jaundice peaks at 10-21 days,
but may last for 2-3 months. Breastmilk jaundice is normal. Rarely, if ever,
does breastfeeding need to be discontinued even for a short time. There is
not one bit of evidence that this jaundice causes any problem at all for the
baby. Breastfeeding should not be discontinued "in order to make a diagnosis".
If the baby is truly doing well on breast only, there is no reason, none,
to stop breastfeeding or supplement with a lactation aid, for that matter. The
notion that there is something wrong with the baby being jaundiced comes from
the assumption that the formula feeding baby is the standard by which we should
determine how the breastfed baby should be. This manner of thinking, almost
universal amongst health professionals, truly turns logic upside down. Thus, the
formula feeding baby is rarely jaundiced after the first week of life, and when
he is, there is usually something wrong. Therefore, the baby with breastmilk
jaundice is a concern and "something must be done". However, in our experience,
most exclusively breastfed babies who are perfectly healthy and
gaining weight well are still jaundiced at 5-6 weeks of life and even later. The
question, in fact, should be whether it is normal not to be jaundiced and is
this absence of jaundice something we should worry about? Do not stop
breastfeeding for “breastmilk” jaundice.
Not-enough-breastmilk Jaundice
Higher
than usual levels of bilirubin or longer than usual jaundice may occur because
the baby is not getting enough milk. This may be due to the fact that the
mother's milk takes a longer than average time to "come in", or because hospital
routines limit breastfeeding or because, most likely, the baby is poorly latched
on and thus not getting the milk which is available (Is my baby getting enough milk?). When the baby is getting little
milk, bowel movements tend to be scanty and infrequent so that the bilirubin
that was in the baby's gut gets reabsorbed into the blood instead of leaving the
body with the bowel movements. Obviously, the best way to avoid "not-enough-breastmilk
jaundice" is to get breastfeeding started properly (Breastfeeding
- Starting Out Right). Definitely, however, the answer to
not-enough-breastmilk jaundice, is not to take the baby off the breast or
to give bottles. If the baby is nursing well, more frequent feedings may be
enough to bring the bilirubin down more quickly, though, in fact, nothing needs
be done. If the baby is nursing poorly, helping the baby latch on better may
allow him to nurse more effectively and thus receive more milk. Compressing the
breast to get more milk into the baby may help (Breast Compression).
If latching and breast compression alone do not work, a lactation aid would be
appropriate to supplement feedings
(Using a Lactation Aid).
Phototherapy (Bilirubin Lights)
Phototherapy increases the fluid requirements of the baby. If the baby is
nursing well, more frequent feeding can usually make up this increased
requirement. However, if it is felt that the baby needs more fluids, use a
lactation aid to supplement, preferably expressed breastmilk, expressed milk
with sugar water or sugar water alone rather than formula.
About The Author: Dr. Jack Newman is a Toronto
pediatrician who has practiced medicine since 1970. In 1984 he established the
first hospital based breastfeeding clinic in Canada, at the Hospital for Sick
Children in Toronto. He now holds breastfeeding clinics in several Toronto area
hospitals. Jack has been a consultant with UNICEF's Baby Friendly Hospital
Initiative and has spoken at conferences around the world. He is the father of
three children, all breastfed.
Dr. Newman is the author of
"The Ultimate Breastfeeding Book of Answers"
NOTE: The article above titled "Breastfeeding
and Jaundice" was written by Dr. Jack Newman and is the opinion of its author. "The New Parents Guide" does not guarantee the information to
be factual. Always use the guidance of your personal
doctor or your child's doctor over information you read on this site or elsewhere; your doctors know what is
best for you and your baby.
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