Newborn jaundice (yellowing of the skin and whites of the eyes) is quite common and ‘normal’ in newborn babies as all babies are born with more red blood cells than they need and these are broken down releasing the yellow pigment bilirubin. If levels of the yellow pigment bilirubin climb too high however it could be dangerous for your baby. Getting breastfeeding established promptly can help reduce the risk of high levels of bilirubin.1
This article discusses the treatment for jaundice when treatment is needed. For further reading about symptoms of jaundice and what causes it see What are the Symptoms of Jaundice? A summary of the different types of jaundice, the risk factors for dangerous levels of bilirubin and more ideas to get breastfeeding off to a good start can be found in Jaundice in Breastfeeding Babies.
When does jaundice require treatment?
Although bilirubin levels can be measured and serve as a guide, a medical team will also take account of each baby’s unique situation. A baby’s age, weight, whether premature, when the jaundice started, whether the baby is feeding well along with any maternal and infant health factors will all be considered before deciding on a threshold for treatment. This can create some uncertainty about the exact levels of bilirubin that require treatment for a particular baby, particularly in babies with darker skin tones (Thomas, 2012; ABM,2 2010; NICE,3 2010; Mohrbacher, 2010).
NICE4 have addressed this uncertainty by setting out their own guidelines. Their information includes a threshold table and treatment threshold graphs to assess and treat jaundice based on bilirubin levels found in the blood:
The Academy of Breastfeeding Medicine (ABM) 2010 also has guidelines for managing jaundice over 35 weeks gestation which they advise reading in conjunction with the American Academy of Pediatrics (AAP) 2004 Clinical Practice Guideline on Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation and the 2009 update to the guideline. All these documents are supportive of preserving breastfeeding.
How is bilirubin measured?
Visually checking for jaundice is not as accurate as finding the total serum bilirubin (TSB) or transcutaneous bilirubin (TcB). The TSB is the amount of bilirubin in your baby’s blood. It is measured by a blood test, usually by a heel prick sometimes called an “SB” or a “bili” test. A split bilirubin test shows whether the cause of the jaundice is liver disease by measuring the ratios of the conjugated and unconjugated bilirubin levels in your baby’s blood. The TcB is a measure of the yellow bilirubin levels through the skin, found by using a bilirubinometer and serves as a screening tool. NICE guidelines advise which of these tests to use in which circumstances and caution against using other tests e.g. end-tidal carbon monoxide (ETCOc) measurement or umbilical cord blood direct antiglobulin test (DAT) (Coombs’ test) as ways to predict significant jaundice.
Treatment for Jaundice
If breastfeeding is going well and the bilirubin levels are dropping naturally treatment may not be needed. A useful paper from Lawrence Gartner, 2001 explains:
In the full-term healthy infant, phototherapy and complementary or substitution feedings with infant formula are not needed until serum levels exceed 300 to 340 µM/L (18 to 20 mg/dL). Even when slightly greater than 340 µM/L ( 20 mg/dL), but not rising rapidly, further observation and assurance of good breastmilk intake may be all that is required. Hemolysis and other pathologic causes of hyperbilirubinemia must be ruled out, of course.
However if the need for treatment for jaundice is identified, this may involve phototherapy, supplementation with milk or exchange transfusion.
Phototherapy is a treatment using blue spectrum light to lower bilirubin levels. The baby’s skin absorbs the light waves which break down bilirubin molecules in the body into a water soluble form that the body can get rid of more easily via the bowel. Phototherapy normally works well to drop the bilirubin levels quickly and a couple of days of treatment may be all that are needed. Your baby may tend to lose more fluids while under the lights but as long as the quantity of breastmilk can be increased they may not need any extra fluids (ABM, 2010). Short breaks for breastfeeding, changing nappies and contact with parents will be encouraged (NICE, 2010).
Types of phototherapy are described by the United Kingdom’s National Health Service (NHS) as:
Conventional phototherapy – where your baby is laid down under a halogen or fluorescent lamp with their eyes covered to prevent damage to eyes.
Fibre optic phototherapy – where your baby lies on a blanket5 that incorporates fibre optic cables. Light travels through the fibreoptic cables and shines onto your baby’s back.
NICE guidelines, 2010; recommend which form of phototherapy to use in which situation and are supportive of breastfeeding. They advise against giving additional fluids or feeds routinely and if additional feeds are indicated, maternal expressed milk is preferred.
Is phototherapy safe?
Phototherapy is generally very effective with few side effects (NHS, 2013). Potential complications such as diarrhoea, skin rash, bronzing of baby’s skin, parental anxiety and separation (which can affect establishing breastfeeding), overheating, water loss and retinal damage are described in Neonatal Jaundice and Phototherapy from Great Ormond Street Hospital for Children.
In Counseling the Nursing Mother: A Lactation Consultant’s Guide, Lauwers and Swisher (2010, p 535) explain that phototherapy can cause a baby to have sluggish responses and a weak sucking reflex. They advise any such changes in feeding behaviour be reported to the healthcare team. They suggest shorter more frequent feedings, and supplemental expressed breastmilk may help feeding.
Supplementation (extra feeds)
If one of the causes of a baby’s jaundice is not enough milk intake (starvation jaundice), he may need to be supplemented with pumped breastmilk, donor breastmilk, cows’ milk based or hydrolysed formula in addition to the mother working with an IBCLC to increase her milk supply.
The following protocol from the Academy of Breastfeeding Medicine explains why supplementing with formula can be used as an alternative to phototherapy to lower bilirubin levels.
Cow’s milk-based formulas have been shown to inhibit the intestinal absorption of bilirubin. Therefore, supplementation of breastfeeding with small amounts of infant formula can be used to lower serum bilirubin levels in breastfeeding infants. Hydrolysed protein formulas (elemental formulas) have been shown to be more effective than standard infant formulas in preventing intestinal absorption of bilirubin. Hydrolysed formulas are preferred because they are less likely to induce milk allergy or intolerance and may not be viewed by the parents as ‘‘switching to formula.’’
The protocol goes on to advise giving the minimum amount of formula so as not to interfere with breastfeeding, but enough to ensure baby is well fed.
Is stopping breastfeeding for a while ever necessary?
Breastfeeding can usually continue alongside other treatments (NICE, 2010). Occasionally your health professionals may advise stopping breastfeeding for a short period (24 to 48 hours) in specific situations and formula feeding for this time instead. Jack Newman (2009 and Lawrence Gartner (2001, 2010) say temporary weaning should rarely be necessary and Ask Dr Sears advocates parents asking their baby’s health professionals if phototherapy could be used first, rather than interrupting breastfeeding.
The ABM Clinical Protocol (2010) and Gartner, 2010 acknowledge that formula supplements can help lower bilirubin levels (see above). However the ABM advise starting phototherapy rather than relying on supplementation or temporary interruption of breastfeeding, because phototherapy works more quickly. They also point out that “In infants less than five days of age, interruption of breastfeeding and replacement feeding with formula may not be as effective as the use of phototherapy.”
In the full version of the NICE guidelines Neonatal Jaundice, 2010, there is a discussion of several studies that have compared the effects of supplemental feeds during phototherapy. They found the evidence was not very conclusive. One study found that “formula feeds were no more effective than breastfeeding in reducing serum bilirubin during phototherapy”. The NICE recommendation is “breastfed babies should not be routinely supplemented with formula, water or dextrose water for the treatment of jaundice”.
Pump to maintain supply
In the event of a pause in breastfeeding, pumping frequently will maintain a good supply of breastmilk ready for when breastfeeding resumes.
For neonates with jaundice and poor breastfeeding, the solution is not to stop the breastfeeding, but rather to correct the breastfeeding problem and to restore fluid and calorie intake. In some instances, expressed milk, banked human milk, or artificial milk supplementation may be required for a time. The main point is that the baby must be fed and the mother must be supported. Regardless of the aetiology of the jaundice, if breastfeeding is not going well, it must be improved, not abandoned.
Exchange transfusions are rarely performed today as phototherapy is so effective. Guidelines and risks for exchange transfusion are clarified in:
Should I put my baby in sunlight?
NICE Guidelines and The American Academy of Paediatrics do not advise treating a baby for jaundice by putting the baby in sunlight either directly or indirectly through a window:
Putting your baby in sunlight is not recommended as a safe way of treating jaundice. Exposing your baby to sunlight might help lower the bilirubin level, but this will only work if the baby is completely undressed. This cannot be done safely inside your home because your baby will get cold, and newborns should never be put in direct sunlight outside because they might get sunburned.
Supplementing with water?
Supplementing a baby with water or dextrose water will not prevent jaundice or lower the bilirubin levels because bilirubin is excreted in poop and not urine (AAP, 2004; NICE, 2010; Lauwers & Swisher, 2010). If a mother’s milk is delayed coming in or if she doesn’t have enough milk she may need to supplement with donor milk or baby formula alongside any treatments for jaundice needed.