Jaundice is due to a build-up in the blood of bilirubin, a yellow
pigment that comes from the breakdown of old red blood cells. It is normal for
old 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 that 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 can happen in blood
incompatibility), the level of bilirubin in the blood may rise higher than usual
Two Types of Jaundice
The liver changes bilirubin so that it can be eliminated from the body (the
changed bilirubin is now called conjugated, direct reacting, or water soluble
bilirubin--all three terms mean essentially the same thing). If, however, the
liver is functioning poorly, as occurs during some infections, or the tubes that
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 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" (this bilirubin is called
unconjugated, indirect reacting or fat soluble bilirubin). Physiologic jaundice
begins about the second day of the baby's life, peaks on the third or fourth day
and then begins to disappear. However, there may be other conditions that may
require treatment that can cause an exaggeration of this type of jaundice.
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 in such a circumstance.
So called 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. 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 even rarer illnesses may cause the same picture. Breastmilk
jaundice peaks at 10-21 days, but may last for two or three months. Breastmilk
jaundice is normal. Rarely, if ever, does breastfeeding need to be discontinued
even for a short time. Only very occasionally is any treatment, such as
phototherapy, necessary. 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 so
called 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 five to six weeks of life and
even later. The question, in fact, should be whether or not 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.
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 longer than average to "come in" (but if the baby feeds
well in the first few days this should not be a problem), 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. 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.
Definitely, however, the first approach 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. If latching and breast compression alone do not work, a lactation aid
would be appropriate to supplement feedings.