After your baby is born, the maternity staff or your homebirth care providers will keep an eye on your baby's wellbeing.
One thing they monitor for is neonatal (newborn) jaundice.
It can be concerning to have your baby tested for something and to recieve a positive diagnosis.
The good news though is most cases of jaundice are normal, short term and nothing to worry about.
However, if your baby’s jaundice appears to be excessive, a particular treatment will be recommended to help get things back under control. You might have heard from friends and relatives about their newborns' jaundice treatments. You might wonder if you should be worried or if treatment is really necessary.
Here is some information to help you understand more about jaundice and a breastfed baby.
What Is Jaundice?
Jaundice appears as yellow colouring of the skin and the white of the eyes.
The yellow colouring is due to bilirubin that is made when red blood cells are broken down.
Types of Jaundice
Normal Physiological Jaundice
Newborns get ‘physiological’ jaundice. When something is ‘physiological’ is means it is normal. This happens because newborns have more red blood cells that get broken down more rapidly than in adults, and newborns have less of the enzyme that converts bilirubin into the form that their body can get rid of via their poo.
This type of jaundice is normal and nothing to be worried about.
Normal Physiological Breastmilk Jaundice
Breastmilk jaundice is a common form of jaundice in breastfed babies and is also physiological. It is due to one or more (unidentified) factors in breastmilk (not colostrum) which increase the amount of bilirubin that gets back into the bloodstream rather than moving onto the liver and then coming out in the poo. This does not mean at all that there is something wrong with your milk or that breastfeeding should stop.
Breastmilk jaundice is only seen once a baby is drinking larger amounts of breastmilk. Hence it typically only occurs from about day 5 onwards.
Breastmilk jaundice is really just an extension of normal physiological jaundice and can last as long as a few months. A baby with breastmilk jaundice is otherwise well and healthy.
Temporary Interruption Of Breastfeeding – Justified?
Sometimes breastfeeding mothers are advised to temporarily stop breastfeeding and give their baby formula for 24 hours. This is done to confirm if the baby has breastmilk jaundice (which is harmless) as opposed to a medical condition which could also cause ongoing higher bilirubin levels. If, within the 24 hours, the baby’s bilirubin levels drop, the medical staff can relax as breastmilk jaundice will be confirmed. Doctor Jack Newman, paediatrician and IBCLC, says “Yes, the medical staff can relax, but it’s not their baby and it’s not their breastfeeding.”
Unfortunately, this procedure itself is not without risks. For example, it:
- Can jeopardise breastfeeding since early frequent and effective milk removal is important to help establish a milk supply and some mothers cannot replicate this as well with expressing
- Means the cessation of exclusive breastfeeding and exposes newborns to the risks associated with early formula use
Also, other signs are likely to be present if a baby has jaundice due to a medical condition (e.g. due to liver disease). For example, if a baby had liver disease the urine would be brownish.
Perhaps if a baby has normal newborn screening tests, normal poos and wees, no enlarged liver and the baby is otherwise well and feeding well, then this may be an unwarranted diagnostic test. Doctor Jack Newman says “Stopping breastfeeding is not a test. It’s bad practice.”
Not-Enough Breastmilk Jaundice
Not-enough-breastmilk jaundice is due to a baby not getting enough breastmilk.
One sign that a baby might not be getting enough is if they don’t poo enough. If they don’t poo enough, not as much bilirubin gets removed.
This type of jaundice may be a problem as early as the second or third day after birth, but never on day one.
A baby with not-enough breastmilk jaundice may:
- Not have been fed often enough
- Not be feeding well
- Be attaching to the breast sub-optimally
- Have tongue tie
This type of jaundice will often sort itself out once the baby starts getting more breastmilk. A lactation consultant can help you work out what might be going on and then help to work out a plan for helping your baby to get more breastmilk.
High Bilirubin Levels And Kernicterus
The main concern with babies who have high bilirubin levels is kernicterus (a condition that causes brain damage). If there is too much bilirubin, it can get across a newborn’s leaky blood-brain barrier and this could cause kernicterus.
High bilirubin levels alone do not necessarily cause kernicterus. Kernicterus is also associated with various medical conditions (e.g. severely low haemoglobin and metabolic abnormalities such as acidosis).
Doctor Jack Newman says “High bilirubin levels, say in an otherwise well baby (exclusively breastfeeding, drinking well at the breast, no evidence for haemolysis or infection etc) does not cause kernicterus.”
There is still more we need to learn about the causes of kernicterus and better tests need to be developed to figure out exactly what bilirubin levels may be dangerous.
Nonetheless, guidelines have been developed about bilirubin levels and which treatment is recommended.
Phototherapy Treatment For High Bilirubin Levels
Appropriate breastfeeding management (as guided by a lactation consultant) should be a main focus for a breastfed baby with high bilirubin levels.
In addition, phototherapy (light therapy) may be required for the treatment of high bilirubin levels. Phototherapy helps to get bilirubin out of the body.
Ideally, phototherapy would be done in the mother’s room so she is not separated from her baby. If the mother and baby have already been discharged, in some areas it is possible to arrange for home care with a semi-portable bili blanket. This allows for treatment to occur while mother and baby bond and settle at home.
It is important for breastfeeding to continue while the baby is receiving phototherapy. Regular interruptions for breastfeeding won’t alter the effectiveness of phototherapy.
For further information about the treatment of high bilirubin levels, refer to the Academy of Breastfeeding Medicine jaundice protocol linked above.
Prevention Of High Bilirubin Levels In Breastfed Babies
Prevention is always better than cure.
BellyBelly’s article Before The First Breastfeed – 12 Things You Need To Know provides you with key points to help get breastfeeding off to the best start possible. These points can also help prevent your baby’s bilirubin levels from getting too high.
For more information about how to prevent bilirubin levels from getting too high in exclusively breastfed babies, see the Academy of Breastfeeding Medicine jaundice protocol.
Jaundice Tends To Not Last Long Enough In Formula Fed Babies
Things that breastfed babies tend to do or not to do are physiologically and biologically normal, and should form the benchmark to how babies who are not breastfed are compared.
Hence, rather than saying that jaundice tends to last longer in breastfed babies (i.e. breastmilk jaundice), it should be said that jaundice doesn’t tend to last long in formula fed babies because formula lacks one or more factors that increases how much bilirubin gets back into the bloodstream.
Interestingly, bilirubin is actually thought to be antioxidant.
Bilirubin – An Antioxidant
In many instances, bilirubin production may actually be a good thing.
As Dr Jenny Thomas says, “Bilirubin production in most healthy, term newborns is more likely an expected and valued part of the transition to being born than a really dangerous brain toxin. The process of creating extra bilirubin serves as an elegant antioxidant, anti-inflammatory bridge from the womb to the outside world, and does not waste the product of the normal breakdown of unneeded red blood cells.”
For more information, see the chapter on jaundice in Dr Jack Newman’s Guide to Breastfeeding.