Newborn jaundice (yellowing of the skin and whites of the eyes) is quite common in newborn babies as all babies are born with more red blood cells than they need for life outside the uterus, and these are broken down releasing the yellow pigment bilirubin. If levels of 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, see Breastfeeding Tips for Newborns for help to get breastfeeding off to a good start or contact your IBCLC lactation consultant for one-to-one help.
This article discusses the options for treatment for jaundice when it is needed. For further reading about symptoms of jaundice and what causes it see Causes and Symptoms of Jaundice. For 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 see Jaundice in Breastfeeding Babies.
When does jaundice require treatment?
Bilirubin levels can be measured and serve as a guide to treatment when they cross a certain threshold. The baby’s medical team will also take account of each baby’s medical situation. The baby’s age, whether premature, their weight, when the jaundice started, whether the baby is feeding well along with any maternal and infant health factors will all be considered before deciding when to start treatment. This can create some uncertainty about the exact levels of bilirubin that require treatment for an individual baby, particularly in babies with darker skin tones1.
If breastfeeding is going well, and the bilirubin levels are dropping naturally, treatment may not be needed. A 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.
Lower levels may be of concern in premature babies and/or babies with other health issues 2. If the need for treatment for jaundice is identified, this may involve phototherapy, supplementation with milk or exchange transfusion.
Official guidance on thresholds for treatment
Documents with treatment guidelines that are supportive of preserving breastfeeding include:
National Institute for Health and Care Excellence (NICE) recommendations can be found in Jaundice in Newborn Babies Under 28 Days (2016). Their information includes a threshold table and treatment threshold graphs to assess and treat jaundice based on bilirubin levels found in the blood.
Academy of Breastfeeding Medicine guidelines
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 document: Clinical Practice Guideline on Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation and the 2009 update to the guideline.
How is bilirubin measured?
Visually checking for jaundice—by noting the progression of yellow pigment from head towards the lower body—is not as accurate as measuring the levels in the following ways:
- Total serum bilirubin (TSB) is the amount of bilirubin in the blood and is measured by a blood test. Blood is usually collected 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.
- Transcutaneous bilirubin (TcB) is the level of yellow bilirubin in the skin measured with a transcutaneous bilirubinometer
NICE guidelines advise which of these tests to use in which circumstances and caution against using umbilical cord blood bilirubin level, 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
Phototherapy is a treatment that uses 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 (in poop!).
Phototherapy normally works well to drop the bilirubin levels quickly and a couple of days of treatment may be all that are needed. A baby may tend to lose more fluids while under the lights but as long as the quantity of breast milk 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, 2016).
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
Fibreoptic phototherapy – where your baby lies on a blanket that incorporates fibreoptic cables; light travels through the fibreoptic cables and shines on to your baby’s back
NICE guidelines, 2016; recommend which form of phototherapy to use in which situation.
Is phototherapy safe?
Phototherapy is reported to be very effective with few side effects. Babies will be carefully monitored for overheating, or dehydration by the health care team (NHS, 2015).
#2 Supplementation (extra feeds)
If one of the causes of a baby’s jaundice is not enough milk intake (starvation jaundice), a baby may need to be supplemented with pumped breast milk, donor breast milk, cows’ milk formula or hydrolysed formula in addition to the mother working with an IBCLC lactation consultant to increase her milk supply. Jaundice can also make a baby sleepy which can prevent them from feeding well 3 and a mother may need to pump her milk in these circumstances to maintain or increase her supply to provide sufficient milk for her baby.
Lawrence Gartner explains:
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.
The following protocol from the Academy of Breastfeeding Medicine explains why supplementing with formula can be suggested as an alternative to phototherapy to lower bilirubin levels in certain cases:
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.’’
Note: this paper suggests there is no evidence that hydrolysed formulas prevent allergy 4.
The ABM protocol advises giving the minimum amount of formula so as not to interfere with breastfeeding, but enough to ensure baby is well fed. The supplements can be fed by cup (baby must be alert and awake), syringe, supplemental nursing system, finger feed, or bottle to ensure the baby is getting plenty of calories.
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 and the harms will exceed the benefits 5 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 needed.
#3 Exchange transfusion
Exchange transfusions (blood transfusions) are rarely performed today as phototherapy is so effective. Guidelines and risks for exchange transfusion are clarified in:
Is stopping breastfeeding for a while ever necessary?
The NICE guidelines say continue breastfeeding during phototherapy, give the mother good breastfeeding support and that mothers’ expressed breast milk should be the first choice if additional feeds are indicated 9.
Occasionally a baby’s health professionals may advise interrupting breastfeeding for a short period (24 to 48 hours) in specific situations. The Academy of Breastfeeding Medicine jaundice protocol states that interrupting breastfeeding for 24–48 hours for formula feeding can lower serum bilirubin more quickly than supplementing in rare cases of extreme exaggeration of breast milk jaundice. However they 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.
Pump to maintain supply
In the event of a pause in breastfeeding, pumping frequently will maintain a good supply of breast milk ready for when breastfeeding resumes.
Should I put my baby in sunlight?
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.
It’s quite normal for newborn babies to have a little jaundice as they are born with extra blood cells that are no longer needed after birth. The breakdown of these blood cells releases a yellow pigment. If levels of the pigment get too high in certain circumstances, treatment will be needed to avoid complications 11. Treatment of newborn jaundice that is not associated with an underlying health problem usually involves phototherapy and/or supplementation. Rarely, a blood transfusion may be needed. In most cases breastfeeding can and should continue alongside any treatment.