The yellowing of the skin and whites of the eyes caused by an accumulation of the brownish yellow pigment bilirubin in a newborn baby is known as jaundice. For an explanation of what causes newborn jaundice and symptoms to look out for see Causes and Symptoms of Jaundice.
Newborn jaundice is a normal process, however, if bilirubin levels continue to rise past a certain threshold they could be harmful to your baby and may require treatment. There are many risk factors that can create bilirubin levels that are higher than normal. You may have heard that one of the risk factors is breastfeeding which can seem very confusing when breastfeeding is biologically normal. This article discusses the different types of jaundice in breastfeeding babies and risk factors for jaundice. Breastfeeding can almost always continue without interruption.
Types of jaundice in breastfeeding babies
Types of jaundice include:
- Normal newborn jaundice—happens naturally after birth
- Breast milk jaundice—a factor in breast milk is thought to raise jaundice levels
- Starvation jaundice—insufficient calories increase the bilirubin pool
- Pathological jaundice—specific medical conditions cause or increase jaundice
Different sorts of jaundice may occur at the same time.
#1 Normal newborn jaundice
Also known as physiological (normal functioning) jaundice, physiologic hyperbilirubinemia or icterus.
It is normal for a newborn baby’s bilirubin levels to rise after birth and then drop again during the first two weeks of life. In the first five days the levels of bilirubin in formula fed babies are the same as optimally fed breastfed babies 1. Author Nancy Mohrbacher explains:
In most newborns, jaundice is temporary, resolves on its own, and does not require treatment. Bilirubin levels in the full-term, healthy baby usually peak between the 3rd and 5th days of life at less than 12mg/dl (204 µmol/L), and rarely go higher than 15mg/dl (255 µmol/L)
#2 Breast milk or late-onset jaundice
Also known as prolonged physiological jaundice.
In many breastfed babies jaundice can last longer than the two weeks mentioned above. A diagnosis of breast milk jaundice is made when jaundice appears between days four and seven, and peaks around days 10-15. It may take four to eight weeks to fall to normal levels 2. Other estimates quote two to three months for levels to fall 3. This compares with full term formula fed babies whose newborn jaundice tends to last seven to ten days. This exaggerated form of normal newborn jaundice in a breastfed baby is called breast milk jaundice. The exact reason for this not clear but may be caused by factors in mature breast milk (not colostrum) that promote the reabsorption of bilirubin in the intestine. Although there is the typical yellowing of the skin, the baby is well, gaining weight and has no underlying disorders.
Your health professionals will keep an eye on bilirubin levels while breastfeeding continues and may carry out tests to rule out more serious causes of raised levels. They will advise if any treatment is needed should levels rise towards a certain threshold. Contacting an IBCLC lactation consultant if there are any problems with breastfeeding or milk supply will help avoid the possibility of getting starvation jaundice (see below) and breast milk jaundice at the same time. The following paper from Gartner discusses the levels of bilirubin found in breast milk jaundice.
The full-term infant with breastmilk jaundice of less than 340 µM/L (20 mg/dl ) requires no intervention, and breastfeeding should be continued without interruption. For those full-term, healthy infants with breastmilk jaundice and serum bilirubin levels between 340 and 425 µM/L (20 and 25 mg/dl ), closer observation of bilirubin concentrations is indicated. Some clinicians may wish to observe, whereas others may choose to complement breastfeeding with formula for 24 to 48 hours, which will reduce intestinal bilirubin absorption, or initiation of phototherapy. When serum bilirubin concentrations rise toward 425 µM/L (25 mg/dl), the use of phototherapy while continuing breastfeeding, or the interruption of breastfeeding for 24 hours, substituting formula, may be indicated.
If a baby is poorly or premature the safe level for bilirubin may be lower and will require closer monitoring.
Carefully monitored breast milk jaundice is unlikely to cause harm and the jaundice will gradually fade without treatment. However, prolonged jaundice can be an indication of serious liver disease or involve some other cause (Gartner, 2001).
Is there a test for liver disease?
The Children’s Liver Disease Foundation (CLDF) describes a test called the split bilirubin blood test which can identify liver disease:
Parents are frequently reassured that the cause of their baby’s jaundice is breastfeeding and, as it is harmless, it will go away with time. The vast majority of babies will have breast milk jaundice but very few will have liver disease jaundice, or even both. It is therefore extremely important that this diagnosis is made by testing. Your baby should have a blood test called a split bilirubin blood test. This test measures the ratio of the conjugated and unconjugated bilirubin levels in your baby’s blood.
There is more information in a useful leaflet Jaundice in the Newborn Baby that can be downloaded as a pdf from the CLDF’s Yellow Alert Prolonged Jaundice Campaign.
#3 Starvation jaundice or breastfeeding jaundice
Also known as breast nonfeeding jaundice, suboptimal intake jaundice, or not enough breast milk jaundice.
Breastfeeding or starvation jaundice can happen in the first few days of life or it can occur later in the newborn period, this is not “normal”. It is caused by not enough milk and it is the baby equivalent of adult starvation jaundice. Large amounts of bilirubin in meconium coupled with infrequent stools increase the serum bilirubin levels (levels in the blood) and further increase reabsorption of bilirubin in the intestines. A baby may have a combination of breast milk jaundice and starvation jaundice at the same time (Gartner 2001). This indicates the importance of getting breastfeeding off to a good start from birth with help from your IBCLC lactation consultant. When a baby gets plenty of colostrum and breast milk he will have plenty of poops (stools) and frequent poops help to lower the bilirubin levels.
#4 Abnormal or pathologic jaundice
A number of medical conditions can cause abnormal jaundice (see risk factors below). This type of jaundice usually appears within the first 24 hours after birth. It can also be combined with breast milk jaundice and/or starvation jaundice so, as above, it is still important to get feeding off to a good start with help from your IBCLC (and see ABM Clinical Protocol #22, 2017).
Blood Incompatibility Jaundice
One of the risk factors for abnormal jaundice is if there are certain incompatible blood types between mother and baby. Derby National Health Service (NHS) in the United Kingdom have a handout explaining more:
If the mother’s blood group is negative and the baby’s blood group is positive, antibodies may be made by the mother to protect her against what the body recognises as different cells. These antibodies invade the baby’s blood stream and surround his/her red blood cells causing them to break down. This is called ‘Haemolytic Disease of the Newborn’. It is usually prevented by screening during pregnancy and by the mother having an ‘Anti D’ injection to prevent the antibodies being produced.
Different blood groups already have antibodies present. This means that if the mother’s and the baby’s blood group are different and they become mixed for some reason, the mother’s antibodies will break down the baby’s red blood cells, as happens with Rh incompatibility. Both of the above conditions are usually diagnosed quickly, as your baby will become jaundiced within 24 hours of birth.
Some babies are more at risk of jaundice than others. A list of some of the risk factors includes:
- Babies not feeding well and not pooping often, babies losing more than 10% of their bodyweight, or if mother’s milk supply is late to come in
- Babies born too early (premature babies) or those with a low birthweight
- Babies who have infections, liver disease, anaemia, galactosemia, metabolic disorders, family history of Gilbert’s Syndrome and more
- Babies receiving certain medications
- Babies with a blood group incompatibility, most commonly Rhesus or ABO incompatibility, DAT positive (direct antiglobulin test or Coombs test)
- Babies with bruising e.g. from forceps or ventouse delivery, or with cephalohematoma
- Babies with glucose-6-phosphate-dehydrogenase (G6PD) deficiency (a hereditary enzyme deficiency more common in certain ethnic groups)
- Babies with a red cell enzyme deficiency
- Babies of East Asian ethnicity
- Babies whose mothers have diabetes
Can I breastfeed when my baby has jaundice?
A baby with newborn jaundice can usually continue to breastfeed alongside any medical treatments except in rare cases 4 5 6. Plenty of colostrum and breast milk is a great way to speed up clearance of bilirubin via the bowel so it is important to get successful breastfeeding established early (see below). More poops mean more bilirubin excreted and less reabsorbed.
Get breastfeeding off to a good start
Comprehensive ideas to minimise jaundice are listed in the Jaundice protocol from the Academy of Breastfeeding Medicine. They include; starting breastfeeding as soon as possible (within the first hour), exclusive and frequent breastfeeding, knowing when to spot early feeding cues, getting positioning and latch as good as possible, being vigilant for poor milk transfer, signs of dehydration, high weight loss, and identifying babies at risk. Other tips include avoiding mother-baby separation, using both breasts per feed, breast compression, skin-to-skin and avoiding using a dummy (pacifier). Contact your IBCLC lactation consultant for help and support and see our articles A Good Start to Breastfeeding and Breastfeeding Tips for Newborns.
If baby isn’t feeding well
A poorly baby, low weight baby, premature baby or one with a poor suck/latch may be unable to breastfeed effectively at first. Jaundice can cause babies to become sleepy and to want to feed less often. In these situations hand expressing colostrum and then pumping will help a mother protect her milk supply and provide plenty of supplements to feed her baby if he is unable to latch properly and get the milk directly. The supplements can be fed by cup (baby must be alert and awake), syringe, or bottle to ensure the baby is getting plenty of calories. If a mother can’t express enough milk then banked donor milk or formula milk may be necessary for a time. How to Make More Breast Milk has information on increasing your milk supply with links to other useful articles including How Can I Pump More Breast Milk and Do I Need a Breast Pump?
For information about treatment for jaundice and links to clinical protocols see Treatment for Jaundice.
There are several different types of jaundice; normal newborn jaundice, breast milk jaundice, starvation jaundice, and pathological jaundice. More than one type of jaundice could be present at the same time. Breastfeeding doesn’t cause jaundice but poor feeding and not getting enough breast milk is a risk factor for high levels of bilirubin.