eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Neonatology

Breast Milk Jaundice: Follow-up

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

Follow-up

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.9

Further Outpatient Care

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

Transfer

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

Deterrence/Prevention

  • 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.10
  • 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.8 .
  • 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.11 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.12 The factors most predictive included predischarge TSB or TcB levels above 75th percentile, lower gestational age, and exclusive breastfeeding.13
  • 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.14

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 (35-37 weeks' gestation) are more likely to manifest breastfeeding jaundice because of difficulty achieving adequate nursing, greater weight loss, and hepatic immaturity.

Prognosis

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

Patient Education

  • Provide excellent breastfeeding education. Refer to a lactation consultant or La Leche League.
  • For excellent patient education resources, visit eMedicine's Pregnancy and Reproduction Center. Also, see eMedicine's patient education article Breastfeeding.

Miscellaneous

Medicolegal Pitfalls

  • Failure to differentiate breast milk jaundice (BMJ) from pathologic jaundice
  • Failure to appropriately treat elevated bilirubin levels in a timely manner
  • Failure to identify and treat inadequate breastfeeding, with resultant dehydration

Special Concerns

  • Treat preterm infants (estimated gestational age <37 wk at birth) with phototherapy at lower bilirubin levels (see Jaundice, Neonatal).
 
Acknowledgments

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



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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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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