Parentpedia

What Experts Say^*

You may be surprised when your doctor tells you that your new baby has jaundice, but it's more common that you probably thought. Jaundice occurs in most newborns and is more common in breastfed babies. The American Academy of Pediatrics (AAP) Policy Statement, July 2004, recommends that "mothers nurse their infants at least 8 to 12 times per day for the first several days ... Poor caloric intake and/or dehydration associated with inadequate breastfeeding may contribute to the development of hyperbilirubinemia (exaggerated jaundice.)"

What You Need to Know about Jaundice

Jaundice, which causes the yellow-tinged skin and whites of the eyes in newborns, is caused by a rise in bilirubin levels. Physiologic (normal) jaundice generally begins between the second and fifth day, peaks the third to fifth day (rarely going higher than 15 mg/dl) and resolves within a week or two as your baby's system matures. It is not a disease, and in most cases does not require treatment. Some researchers theorize that the antioxidant properties of bilirubin help protect the newborn.

• Frequent feeds lower bilirubin levels. Frequent nursing, beginning at birth, is the first line of defense against exaggerated jaundice. It stimulates your milk supply, providing a higher volume of milk sooner, along with more calories. This aids in the quick passage of meconium stools, which clear the bilirubin from your baby's body. A study of 140 babies found that significant jaundice on day six occurred in 15 percent of babies nursing only 5 to 6 times day, while no babies nursing between 9 and 11 times a day experienced exaggerated jaundice (Yamauchi and Yamanouchi, 1990.)
• Proper positioning and attachment helps your baby access your milk. This is very important in preventing exaggerated jaundice. You can be sure your baby is effectively accessing your milk if you feel your baby?s strong suck and hear swallowing after every couple of sucks, you feel your milk eject and/or notice your baby starts to swallow more frequently, you see a few drops of milk at the corners of your baby's mouth, and your baby comes off the breast looking relaxed and satisfied. Breastfeeding should be comfortable. If you have difficulties nursing, get hands-on help from a lactation consultant (IBCLC) and express your milk with an automatic electric double breast pump to feed your baby with a cup, spoon, syringe, or supplementer.
• More frequent, early stooling equals reduced bilirubin levels. Ninety-eight percent of bilirubin is eliminated through bowel movements. If your baby has less than three or four bowel movements a day by the third day or still has black, tarry stools, rather than green transitional stools, your baby needs to breastfeed more frequently or more effectively.
• Jaundiced babies are often sleepy. Allowing your baby to sleep through feeds will make her even sleepier. The more you nurse, the more your baby stools and the less jaundiced and the more eager to nurse she will be. To encourage your sleepy baby, watch for hunger cues such as sucking sounds and/or lip movements, rapid eye movement, and changes in facial expression; use skin-to-skin contact; wear your baby in a sling; and try breast massage/compression when nursing to keep your milk flowing. If sleepiness keeps your baby from nursing effectively, offer your expressed milk by cup, spoon, syringe, or supplementer.
• Water supplements can cause elevated bilirubin levels. Glucose water, sometimes recommended to flush out bilirubin, can actually make the problem worse. It fills your baby so she nurses less frequently and delays stooling. Only 2 percent of bilirubin is eliminated through urine.
• Newborns should be closely monitored for jaundice. Your baby should be checked for jaundice in the hospital and then seen by the pediatrician between 3 and 5 days of age, when bilirubin levels may be highest. A baby born between 35 and 38 weeks gestation should be checked within one to two days after hospital discharge. Visual inspection alone has been found to be inadequate in assessing jaundice (Moyer, Ahn, and Sheed, 2000.) Your baby will be tested for jaundice with a blood test (heel stick) or one of the newer, noninvasive methods. Breastfeeding acts as a potent painkiller for your baby during a painful procedure.
• Late-onset jaundice is a normal variation of physiologic jaundice. Sometimes called breast-milk jaundice, this occurs in one-third of breastfed babies. It may not be diagnosed until the baby is a week old and generally peaks between 10 and 21 days, sometimes lasting even longer. It is rare for a baby with breast-milk jaundice to have high bilirubin levels (over 20 mg/dl) or rapidly rising levels.
• Breastfeeding rarely needs to be interrupted. Some doctors routinely recommend temporary (24- or 48-hour) weaning to see if bilirubin levels fall. The AAP "discourages the interruption of breastfeeding in healthy term newborns and encourages continued and frequent breastfeeding."
• Phototherapy is on the front line of treatment for exaggerated jaundice. If your baby's bilirubin levels are high or rapidly rising, phototherapy may be recommended. Many experts do not recommend intervention until bilirubin levels reach 20 to 25 mg/dl in a normal, healthy, full-term baby. Phototherapy uses light to quickly reduce bilirubin levels. Depending on the situation, you may be able to use bili lights or a bili blanket, where you can hold and nurse your baby, even at home, rather than keeping your baby in the nursery under phototherapy lights. Frequent nursing is especially important while a baby is receiving phototherapy, because it can cause dehydration.
• Are formula supplements ever recommended? Formula supplementation is rarely needed, but does have a place in treatment to bring down high or rapidly rising bilirubin levels. Let your health care providers know how important breastfeeding is to you and work out a plan. Formula supplements can be given by cup, spoon, or syringe to avoid sucking problems when your baby returns to the breast. If you are taking a short break from nursing, express your milk every two to three hours with an automatic electric double breast pump to protect your milk supply.

Safety Notes

• Call the pediatrician if your baby's skin appears more yellow; your baby's abdomen, arms, or legs are yellow; the whites of your baby's eyes are yellow; or if your baby is jaundiced and hard to wake, fussy, or not nursing well; or if your baby's jaundice lasts more than three weeks.
• Keep a close eye on your near-term baby. Though babies born between 35 to 37 weeks of gestation are usually treated as full-term, they have 5 to 10 times the risk for hospital readmission due to poor feeding, weight loss, and/or jaundice.
• Aspirin and other salicylates, as well as some sulfa drugs, should not be used if your baby is jaundiced. These medications can increase the risk of brain damage in a jaundiced baby (Drew and Kitchen, 1976.)
• Several conditions put a baby at risk for higher than normal levels of bilirubin: jaundice in the first 24 hours, a high bilirubin level before leaving the hospital, difficulties with breastfeeding, difficult labor and birth, a lot of bruising or bleeding under the scalp related to birth, a parent or sibling who had high bilirubin and received phototherapy, premature birth, multiples, being a member of certain ethnic groups (Chinese, Japanese, Korean, Native American, and South American), maternal diabetes, and blood incompatibility.
• Pathologic (abnormal) jaundice, with high or rapidly rising bilirubin levels, generally begins the first or second day after birth. It is rare, usually associated with infection or blood incompatibility, and can cause serious problems, such as brain damage, when left untreated. Breastfeeding should continue while your baby receives treatment.
• Breastfeeding is contraindicated in babies whose jaundice is caused by the inherited metabolic disorder, galactosemia.