Breast Milk Jaundice Follow-up

  • Author: Prashant G Deshpande, MD; Chief Editor: Ted Rosenkrantz, MD   more...
 
Updated: May 18, 2012
 

Further Inpatient Care

If the patient has not been discharged with the parent, monitoring daily weights and serum bilirubin concentration for the need for phototherapy as well as assessment of caloric intake are important. Once serum bilirubin concentration is determined to be within a safe range (< 20 mg/dL) and is not rapidly rising, home phototherapy is an option to consider as long as thorough outpatient follow-up (home visiting nursing assessment or office check-up and bilirubin level monitoring) are feasible.

Weight monitoring is very important in breastfed infants to avoid prolonged and severe jaundice, as well as to avoid hypernatremic dehydration. The general standard states that loss of 10% of birth weight is considered to be significant.

A reference chart for relative weight change to detect hypernatremic dehydration has been proposed.[14]

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Further Outpatient Care

The American Academy of Pediatrics Safe and Healthy Begininngs Project has been established to facilitate implementation of the 2004 guidelines for management of hyperbilirubinemia using a systems-based approach. The 3 key aspects of this project include (1) assessment of risk for severe hyperbilirubinemia before hospital discharge, (2) breastfeeding support, and (3) care coordination between the nursery and primary care.[15]

If the infant is treated on an outpatient basis, measure serum bilirubin levels either daily in the clinic or in the home with home-health nurses until the bilirubin level is less than 15 mg/dL (260 µmol/L).

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Transfer

Transfer infants with pathologic jaundice or bilirubin levels greater than 20 mg/dL to a center capable of performing exchange transfusions.

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Deterrence/Prevention

Keys to deterrence and prevention include the following:

  • Poor caloric intake associated with insufficient breastfeeding contributes to the development of severe breast milk jaundice (BMJ). The first step toward successful breastfeeding is to make sure that mothers nurse their infants at least 8-12 times per day for the first several days starting from the first hour of life. The whey portion of human milk contains a feedback inhibitory peptide of lactogenesis; hence, effective emptying of the breast with each feeding results in successful lactation.
  • Infants who nursed more than 8 times during the first 24 hours had earlier meconium passage, reduced maximum weight loss, increased breast milk intake on days 3 and 5, and lower serum bilirubin levels and significantly lower incidence of severe hyperbilirubinemia (>15 mg/dL) on day 6.
  • In a recent double-blind controlled study, beta-glucuronidase inhibition with L-aspartic acid and enzymatically hydrolyzed casein in exclusively breastfed babies resulted in reduction in peak serum bilirubin level by 70% in first week of life.[16]
  • According to the latest clinical practice guidelines for the management of hyperbilirubinemia in the newborn aged 35 or more weeks' gestation, exclusive breastfeeding is a major risk factor for severe hyperbilirubinemia and all infants should be evaluated for the risk of subsequent hyperbilirubinemia by plotting their discharge serum bilirubin levels on an hour-specific nomogram.[13] .
  • Transcutaneous bilirubinometry is a measurement of yellow color of the blanched skin and subcutaneous tissue and can be used as a screening tool. It has been shown to be fairly reliable, with good correlation between total serum bilirubin (TSB) and transcutaneous bilirubin (TcB) levels obtained using instruments currently available in the United States (eg, Draeger Air-Shields Jaundice Meter JM-103, Respironics BiliChek meter by Philips). The TcB measurement tends to underestimate the TSB at higher levels.[17] Confirmation with TSB measurement is indicated in all patients with TcB levels above the 75th percentile and in those in whom therapeutic intervention is considered.
  • Recent studies suggest that combining clinical risk factors with predischarge measurement of TSB or TcB levels improves the accuracy of risk assessment for subsequent hyperbilirubinemia.[18] The factors most predictive included predischarge TSB or TcB levels above 75th percentile, lower gestational age, and exclusive breastfeeding.[19]
  • Newborns who are exclusively breastfed and who have elevated predischarge TcB or TSB levels do not qualify for discharge before 48 hours and should be evaluated for phototherapy in 24 hours. Newborns with TcB and TSB levels in the high-intermediate range and newborns who were born at less than 38 weeks' gestation should undergo repeat TSB and TcB measurement within 24 hours of discharge or should receive follow-up within 2 days.[20]
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Complications

Bilirubin encephalopathy (kernicterus) may occur in exclusively breastfed infants in the absence of hemolysis or other specific pathologic conditions. Distinguishing between breastfeeding jaundice and breast milk jaundice is important because bilirubin-induced encephalopathy occurs more commonly in breastfeeding jaundice. Near-term infants are more likely to manifest breastfeeding jaundice because of difficulty achieving adequate nursing, greater weight loss, and hepatic immaturity.

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Prognosis

Prognosis is excellent, although jaundice in breastfed infants may persist for as long as 12 weeks.

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Patient Education

Provide excellent breastfeeding education. Refer to a lactation consultant or La Leche League.

For patient education resources, see the Pregnancy and Reproduction Center, as well as Breastfeeding.

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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; Assistant Clinical Professor of Pediatrics, Midwestern University, Downers Grove, IL

Prashant G Deshpande, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, and American Telemedicine Association

Disclosure: Nothing to disclose.

Specialty Editor Board

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.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Brian S Carter, MD, FAAP  Professor of Pediatrics (Neonatology), Vanderbilt University School of Medicine; Director, Neonatal Follow-up Program, 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 & Ethics, National Hospice and Palliative Care Organization, Society for Pediatric Research, and Southern Society for Pediatric Research

Disclosure: Nothing to disclose.

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.

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Timothy Ramer, MD, to the development and writing of this article.

References

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The graph represents indications for phototherapy and exchange transfusion in infants (with a birthweight of 3500 g) in 108 neonatal ICUs. The left panel shows the range of indications for phototherapy, whereas the right panel shows the indications for exchange transfusion. Numbers on the vertical axes are serum bilirubin concentrations in mg/dL (lateral) and mmol/L (middle). In the left panel, the solid line refers to the current recommendation of the American Academy of Pediatrics (AAP) for low-risk infants, the line consisting of long dashes (- - - - -) represents the level at which the AAP recommends phototherapy for infants at intermediate risk, and the line with short dashes (-----) represents the suggested intervention level for infants at high risk. In the right panel, the dotted line (......) represents the AAP suggested intervention level for exchange transfusion in infants considered at low risk, the line consisting of dash-dot-dash (-.-.-.-.) represents the suggested intervention level for exchange transfusion in infants at intermediate risk, and the line consisting of dash-dot-dot-dash (-..-..-..-) represents the suggested intervention level for infants at high risk. Intensive phototherapy is always recommended while preparations for exchange transfusion are in progress. The box-and-whisker plots show the following values: lower error bar = 10th percentile; lower box margin = 25th percentile; line transecting box = median; upper box margin = 75th percentile; upper error bar = 90th percentile; and lower and upper diamonds = 5th and 95th percentiles, respectively.
 
 
 
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