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Breast Milk Jaundice: Differential Diagnoses & Workup

Author: Prashant G Deshpande, MD, Attending Pediatrician, Department of Pediatrics, Christ Hospital Medical Center and Hope Children's Hospital, Oak Lawn, Illinois; Chairman, Department of Pediatrics, Palos Community Hospital, Palos Heights, Illinois; Assistant Clinical Professor Of Pediatrics, University Of Illinois at Chicago
Contributor Information and Disclosures

Updated: Oct 23, 2009

Differential Diagnoses

Anemia, Acute
Jaundice, Neonatal
Biliary Atresia
Neonatal Sepsis
Cholestasis
Polycythemia
Galactose-1-Phosphate Uridyltransferase Deficiency (Galactosemia)
Polycythemia of the Newborn
Hemolytic Disease of Newborn
Hypothyroidism

Other Problems to Be Considered

Hemolytic anemia (RBC membrane defects: spherocytosis, acanthocytosis, ovalocytosis; RBC enzyme defects, hemoglobinopathies)
Blood type incompatibility (ABO and minor group antigens)
Large cephalhematoma
Hypothyroidism
Urinary tract infections
Sepsis
Gilbert syndrome
Early galactosemia

Workup

Laboratory Studies

  • Breast milk jaundice (BMJ) is a diagnosis of exclusion. Detailed history and physical examination showing that the infant is thriving and that lactation is well established are key elements to diagnosis. Breastfed babies should have 3-4 transitional stools and 6-7 wet diapers per day and should have regained birth weight by the end of the second week of life or demonstrate a weight gain of 1 oz/d.
  • Measure total serum bilirubin concentration in neonates who have jaundice that has progressed from the face to the chest and in neonates at risk for hemolytic disease of the newborn.
  • The following tests are to be considered if serum bilirubin levels are greater than 12 mg/dL (170 µmol/L). A total serum bilirubin concentration that rises faster than 5 mg/dL/d (85 µmol/L/d) or jaundice before 24 hours of life suggests pathologic jaundice.
  • A level of conjugated bilirubin greater than 2 mg/dL (34 µmol/L) suggests cholestasis, biliary atresia, or sepsis (see Jaundice, Neonatal).
  • CBC count with reticulocyte count findings are as follows:
    • Polycythemia (hematocrit level, >65%)
    • Anemia (hematocrit level, <40%)
    • Sepsis (WBC count, <5 K/mL or >20 K/mL) with immature to total neutrophil ratio greater than 0.2
  • Urine specific gravity can be useful in the assessment of hydration status.
  • If hemolysis is suspected, consider the following tests:
    • Blood type to evaluate for ABO, Rh or other blood group incompatibility
    • Coombs test, as well as an elution test for antibodies against A or B, to evaluate for immune mediated hemolysis
    • Peripheral smear to look for abnormally shaped RBCs (ovalocytes, acanthocytes, spherocytes, schistocytes)
    • Glucose-6-phosphate dehydrogenase (G-6-PD) screen, especially if ethnicity consistent
  • Factors that suggest possibility of hemolytic disease include the following:
    • Family history of hemolytic disease
    • Onset of jaundice before 24 hours of life
    • Rise in serum bilirubin levels of more than 0.5 mg/dL/h
    • Pallor, hepatosplenomegaly
    • Rapid increase in serum bilirubin level after 24-48 hours (G-6-PD deficiency)
    • Ethnicity suggestive of G-6-PD deficiency
    • Failure of phototherapy to lower bilirubin level
  • If sepsis is suspected, consider the following tests:
    • Blood culture
    • WBC differential
    • Platelet count
    • Urine analysis and culture
  • Factors that suggest the possibility of sepsis include the following:
    • Poor feeding
    • Vomiting
    • Lethargy
    • Temperature instability
    • Apnea
    • Tachypnea
  • Signs of cholestatic jaundice that suggest the need to rule out biliary atresia or other causes of cholestasis include the following:
    • Dark urine or urine positive for bilirubin
    • Light-colored stools
    • Persistent jaundice for more than 3 weeks
  • The follow-up includes the state newborn screen for galactosemia and hypothyroidism.

More on Breast Milk Jaundice

Overview: Breast Milk Jaundice
Differential Diagnoses & Workup: Breast Milk Jaundice
Treatment & Medication: Breast Milk Jaundice
Follow-up: Breast Milk Jaundice
Multimedia: Breast Milk Jaundice
References
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References

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  3. Maruo Y, Nishizawa K, Sato H, Sawa H, Shimada M. Prolonged unconjugated hyperbilirubinemia associated with breast milk and mutations of the bilirubin uridine diphosphate- glucuronosyltransferase gene. Pediatrics. Nov 2000;106(5):E59. [Medline]. [Full Text].

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Further Reading

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Keywords

breast milk jaundice, jaundice, neonatal jaundice, indirect bilirubin, bilirubin, breastfeeding, physiologic jaundice, uridine diphosphoglucuronic acid, UDPGA, UDPGA glucuronyl transferase, unconjugated bilirubin pigment, conjugated bilirubin, hyperbilirubinemia, clinical jaundice, cholestatic jaundice, bilirubin level, pathologic jaundice, phototherapy, breast milk, breastfeeding-associated jaundice, Gilbert syndrome, kernicterus

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Contributor Information and Disclosures

Author

Prashant G Deshpande, MD, Attending Pediatrician, Department of Pediatrics, Christ Hospital Medical Center and Hope Children's Hospital, Oak Lawn, Illinois; Chairman, Department of Pediatrics, Palos Community Hospital, Palos Heights, Illinois; Assistant Clinical Professor Of Pediatrics, University Of Illinois at Chicago
Prashant G Deshpande, MD is a member of the following medical societies: American Academy of Pediatrics and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Oussama Itani, MD, FAAP, FACN, Clinical Associate Professor of Pediatrics and Human Development, Michigan State University; Medical Director, Department of Neonatology, Borgess Medical Center
Oussama Itani, MD, FAAP, FACN is a member of the following medical societies: American Academy of Pediatrics, American College of Nutrition, American College of Physician Executives, and American Heart Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Brian S Carter, MD, FAAP, Professor of Pediatrics (Neonatology), Vanderbilt University School of Medicine; Co-director, Pediatric Advance Comfort Team, Monroe Carell Jr Children's Hospital at Vanderbilt
Brian S Carter, MD, FAAP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Hospice and Palliative Medicine, American Academy of Pediatrics, American Society for Bioethics and Humanities, American Society of Law Medicine and Ethics, National Hospice and Palliative Care Organization, and Southern Society for Pediatric Research
Disclosure: Nothing to disclose.

CME Editor

Carol L Wagner, MD, Professor of Pediatrics, Medical University of South Carolina
Carol L Wagner, MD is a member of the following medical societies: American Academy of Pediatrics, American Chemical Society, American Medical Women's Association, American Public Health Association, American Society for Bone and Mineral Research, American Society for Clinical Nutrition, Massachusetts Medical Society, National Perinatal Association, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Chief Editor

Ted Rosenkrantz, MD, Professor, Departments of Pediatrics and Obstetrics/Gynecology, Division of Neonatal-Perinatal Medicine, University of Connecticut School of Medicine
Ted Rosenkrantz, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Pediatric Society, Connecticut State Medical Society, Eastern Society for Pediatric Research, and Society for Pediatric Research
Disclosure: Nothing to disclose.

 
 
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