Breastfeeding Jaundice

Jaundice is yellowing of babies’ skin that is caused by elevated bilirubin levels (hyperbilirubinemia).  Bilirubin is a substance that is produced when red blood cells are broken down. Jaundice usually starts to appear when babies’ bilirubin levels in their blood are greater than 5 mg/dL.

Hyperbilirubinemia is one of the most common newborn problems and 65% of newborn hospital readmissions are for treatment of jaundice. Newborns have higher bilirubin levels than adults. This is due to the interplay of three main factors:

1. Newborns’ red blood cells have shorter lifespans than adults, leading to increased bilirubin loads from frequent red blood cell breakdown.
2. Babies’ have lower levels of an enzyme called UGT. UGT plays an important role in the liver’s ability to change bilirubin into a form that can be excreted by the body.
3. Newborns reabsorb bilirubin across the intestinal wall and back into the bloodstream. This is called enterohepatic circulation. Meconium, babies’ earliest stool that is formed in utero, has a very high bilirubin load. Babies who have a significant delay in passing meconium have higher bilirubin loads than those who eliminate meconium quickly.

Why do newborns get jaundice? Bilirubin is a potent antioxidant and protects cells from damage. According to the American Academy of Pediatrics (AAP), “It has been hypothesized that moderate increases in bilirubin levels may be protective for the transition to extrauterine life.” Thus, low to moderate levels of bilirubin are not harmful, and might even be helpful. It is concerning, however, when newborns’ bilirubin levels get too high, as bilirubin can cross the blood-brain barrier and cause a type of brain damage called kernicterus.

Full-term, healthy infants’ bilirubin levels peak at day of life 3-4 and then slowly decrease, while preterm infants’ bilirubin levels peak later, closer to day of life 5-6.  Breastfed infants have a tendency to become jaundiced. They are 3-6x more likely to develop moderate (bilirubin level > 12 mg/dL) to severe jaundice (bilirubin level > 15 mg/dL) than formula fed infants. There are two discrete categories of jaundice associated with breastfeeding: breastfeeding jaundice and breastmilk jaundice.

Breastfeeding jaundice typically occurs during the first week of life and results from insufficient breast milk intake. Alternative names for breastfeeding jaundice include breastfeeding-associated jaundice, starvation jaundice, and suboptimal intake jaundice.

The Academy of Breastfeeding Medicine (ABM) prefers that this type of jaundice be called suboptimal intake jaundice.

Most babies with breastfeeding jaundice are exclusively breastfed, less than one week old, have excessive weight loss during the first few days of life (lose >7-10% of their birth weight), have decreased urine and/or stool output, and some degree of dehydration. Breastmilk jaundice, on the other hand, occurs in healthy and thriving infants, starts after breastfeeding has been well-established, and can last for weeks to months. Please see our recent review article for more information about breastmilk jaundice.  

Characteristics of Breastfeeding Jaundice/Suboptimal Intake Jaundice:

• Onset between the first 2-5 days of life
• Usually resolves by two weeks of age
• Associated with ongoing weight loss (>7-10% decrease from birth weight) and starts to improve once a newborn starts to gain weight
• Occurs in babies <40 weeks’ gestation, especially late preterm infants (those born at 34-36 weeks’ gestation). Rare in newborns born after their due date (40+ weeks’ gestation)
• Associated with delayed passage of meconium and transition to a normal stooling pattern (>4 yellow, seedy stools per day) taking longer than usual

Additionally, newborns with breastfeeding jaundice may be fussy and difficult to settle between feedings or excessively sleepy and difficult to wake up to feed.

Risk factors for breastfeeding jaundice include all of the following:  

• Preterm delivery
• First-time, exclusive breastfeeding mother
• Delivery by c-section
• Mother with risk factors for their milk “coming in” (lactogenesis II),  including hormonal problems, gestational diabetes, pre-eclampsia, and/or obesity
• Lack of breastfeeding and lactation support, both in the hospital and after discharge home
• Significant breastfeeding problems including poor latch, pain with feeding, insufficient milk supply, and/or engorgement.

The main way to prevent the development of breastfeeding jaundice is to optimize lactation and breastfeeding support for all mother-baby dyads. One of the first steps in doing this is to encourage skin-to-skin contact between mothers and babies during the first hour after birth. Early and frequent skin-to-skin contact increases levels of hormones that are essential for lactogenesis II. It is also important to refrain from putting newborns onto strict breastfeeding schedules or to attempt to “sleep train” them to sleep for long stretches of time - mothers need to have frequent emptying of their breasts to obtain a full milk supply and should aim to breastfeed their newborns 8-12 times per day, around the clock, during the first 3-4 weeks postpartum.

Teaching mothers who are at risk for breastfeeding problems how to hand express colostrum can help to prevent their babies from developing suboptimal intake jaundice. The colostrum obtained by hand expression can be used to supplement breastfeeding.  Medical supplementation with pasteurized donor human milk (pDHM) or infant formula can also be prescribed to babies who are struggling to breastfeed to prevent jaundice resulting from excessive weight loss and/or dehydration.

The AAP recommends that all newborns have screening for jaundice within the first 48 hours of age. Bilirubin testing can be done via the skin, using a device called a transcutaneous bilirubinometer, or by sending blood to a lab. Babies should have their bilirubin rechecked within 2-3 days of discharge home from the newborn nursery, especially if they are exclusively breastfeeding.  A bilirubin level > 25 mg/dL at any point is a medical emergency and requires admission to a neonatal intensive care unit (NICU).

The decision as to whether or not to treat breastfeeding jaundice depends on multiple factors, including a newborn’s bilirubin level, gestational age at birth, and whether or not they have any other risk factors for jaundice. Temporary disruption of breastfeeding is no longer recommended as a method of treating newborn jaundice.  Treatment options for suboptimal intake jaundice include all of the following:

1. Mothers are encouraged to continue to breastfeed their newborns, even if they need to be treated with phototherapy. This is because frequent breastfeeding leads to an increased milk supply, which improves caloric intake and hydration.  Breastfeeding also helps to promote stooling, which is important because newborns rid their bodies of bilirubin via the stool. Mother-baby dyads with breastfeeding jaundice require intensive lactation support and are often advised to increase breastfeeding sessions to at least 10 times per day.
2. Supplementation options for newborns who are jaundiced and have lost too much weight include expressed human milk, pDHM, and infant formula. The ABM recommends that small volume supplemental feedings of 10-15 ml be given after breastfeeding, instead of the larger feeds of 30-60 ml (1-2 oz.) that were customarily given in the past.
3. The decision to start phototherapy is based on a baby’s current age (in hours of life), bilirubin level, and the presence/absence of other risk factors for hyperbilirubinemia.  Phototherapy treatment, if indicated, can be done in either the hospital or home setting. Of note, most newborns can safely come out from phototherapy for up to 30 minutes at a time to breastfeed.
4. Intravenous (IV) fluid administration is discouraged unless a newborn who is re-admitted to the hospital for breastfeeding jaundice is also significantly dehydrated. This is because IV fluids can decrease babies’ appetites and lead to even worse breastfeeding outcomes.

The prognosis for breastfeeding jaundice is excellent. However, it’s important for all new parents to have awareness of the link between breastfeeding and jaundice, and to know that the best way to prevent breastfeeding jaundice is to make sure to have adequate and timely lactation support.  Breastfeeding jaundice can be prevented with early skin-to-skin contact after birth, breastfeeding frequently and on demand, getting timely help with breastfeeding problems, and supplementation, if medically indicated. Phototherapy treatment should not interfere with breastfeeding, especially if a product like NeoLight’s Skylife system is used.

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