Medscape is available in 5 Language Editions – Choose your Edition here.


Breast Milk Jaundice Workup

  • Author: Prashant G Deshpande, MD; Chief Editor: Ted Rosenkrantz, MD  more...
Updated: Dec 31, 2015

Laboratory Studies

Breast milk jaundice (BMJ) is a diagnosis of exclusion. Note the following:

  • 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.

Consider obtaining the tests discussed below 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 Neonatal Jaundice).

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:

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.

Contributor Information and Disclosures

Prashant G Deshpande, MD Attending Pediatrician, Department of Pediatrics, Christ Hospital Medical Center and Hope Children's Hospital; Assistant Clinical Professor of Pediatrics, Midwestern University

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

Disclosure: Nothing to disclose.

Specialty Editor Board

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, University of Missouri-Kansas City School of Medicine; Attending Physician, Division of Neonatology, Children's Mercy Hospital and Clinics; Faculty, Children's Mercy Bioethics Center

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 Pediatric Society, American Society for Bioethics and Humanities, American Society of Law, Medicine & Ethics, Society for Pediatric Research, National Hospice and Palliative Care Organization

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 Pediatric Society, Eastern Society for Pediatric Research, American Medical Association, Connecticut State Medical Society, Society for Pediatric Research

Disclosure: Nothing to disclose.

Additional Contributors

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 Association for Physician Leadership, American Heart Association, American College of Nutrition

Disclosure: Nothing to disclose.


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

  1. Gotze T, Blessing H, Grillhosl C, Gerner P, Hoerning A. Neonatal cholestasis - differential diagnoses, current diagnostic procedures, and treatment. Front Pediatr. 2015. 3:43. [Medline].

  2. Fujiwara R, Maruo Y, Chen S, Tukey RH. Role of extrahepatic UDP-glucuronosyltransferase 1A1: Advances in understanding breast milk-induced neonatal hyperbilirubinemia. Toxicol Appl Pharmacol. 2015 Nov 15. 289 (1):124-32. [Medline].

  3. Zanardo V, Golin R, Amato M, et al. Cytokines in human colostrum and neonatal jaundice. Pediatr Res. 2007 Aug. 62(2):191-4. [Medline].

  4. Kumral A, Ozkan H, Duman N, Yesilirmak DC, Islekel H, Ozalp Y. Breast milk jaundice correlates with high levels of epidermal growth factor. Pediatr Res. 2009 Aug. 66(2):218-21. [Medline].

  5. Rosa Manganaro, Lucia Marseglia, Carmelo Mami, Giuseppe Saitta, Romana Gargano, Marina Gernellie. Serum alpha-fetoprotein (AFP) levels in breastfed infants with prolonged indirect hyperbilirubinemia. Early Human Development. 2008. 84:487-490.

  6. Tuzun F, Kumral A, Duman N, Ozkan H. Breast milk jaundice: effect of bacteria present in breast milk and infant feces. J Pediatr Gastroenterol Nutr. 2013 Mar. 56(3):328-32. [Medline].

  7. Alonso EM, Whitington PF, Whitington SH, Rivard WA, Given G. Enterohepatic circulation of nonconjugated bilirubin in rats fed with human milk. J Pediatr. 1991 Mar. 118(3):425-30. [Medline].

  8. 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. 2000 Nov. 106(5):E59. [Medline]. [Full Text].

  9. Monaghan G, McLellan A, McGeehan A, Li Volti S, Mollica F, Salemi I. Gilbert's syndrome is a contributory factor in prolonged unconjugated hyperbilirubinemia of the newborn. J Pediatr. 1999 Apr. 134(4):441-6. [Medline].

  10. Huang CS, Chang PF, Huang MJ, Chen ES, Hung KL, Tsou KI. Relationship between bilirubin UDP-glucuronosyl transferase 1A1 gene and neonatal hyperbilirubinemia. Pediatr Res. 2002 Oct. 52(4):601-5. [Medline].

  11. Lin Z, Fontaine J, Watchko JF. Coexpression of gene polymorphisms involved in bilirubin production and metabolism. Pediatrics. 2008 Jul. 122(1):e156-62. [Medline].

  12. Chou HC, Chen MH, Yang HI, et al. 211 G to a variation of UDP-glucuronosyl transferase 1A1 gene and neonatal breastfeeding jaundice. Pediatr Res. 2011 Feb. 69(2):170-4. [Medline].

  13. Huang MJ, Kua KE, Teng HC, Tang KS, Weng HW, Huang CS. Risk factors for severe hyperbilirubinemia in neonates. Pediatr Res. 2004 Nov. 56(5):682-9. [Medline].

  14. Watchko JF. Genetics and the risk of neonatal hyperbilirubinemia: commentary on the article by Huang et al. on page 682. Pediatr Res. 2004 Nov. 56(5):677-8. [Medline].

  15. Uras N, Tonbul A, Karadag A, Dogan DG, Erel O, Tatli MM. Prolonged jaundice in newborns is associated with low antioxidant capacity in breast milk. Scand J Clin Lab Invest. 2010 Oct. 70(6):433-7. [Medline].

  16. [Guideline] American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics. 2004 Jul. 114(1):297-316. [Medline].

  17. Stark AR, Lannon CM. Systems changes to prevent severe hyperbilirubinemia and promote breastfeeding: pilot approaches. J Perinatol. 2009 Feb. 29 Suppl 1:S53-7. [Medline].

  18. van Dommelen P, van Wouwe JP, Breuning-Boers JM, van Buuren S, Verkerk PH. Reference chart for relative weight change to detect hypernatraemic dehydration. Arch Dis Child. 2007 Jun. 92(6):490-4. [Medline].

  19. Gourley GR, Li Z, Kreamer BL. A Controlled, Randomized, Double-Blind Trial of Prophylaxis Against Jaundice Among Breastfed Newborns. Pediatrics. 116:385 - 391. [Medline].

  20. Maisels MJ. Transcutaneous bilirubinometry. Neoreviews. 2006. 7(5):e217-e225.

  21. Keren R, Luan X, Friedman S, Saddlemire S, Cnaan A, Bhutani VK. A comparison of alternative risk-assessment strategies for predicting significant neonatal hyperbilirubinemia in term and near-term infants. Pediatrics. 2008 Jan. 121(1):e170-9. [Medline].

  22. Maisels MJ, Deridder JM, Kring EA, Balasubramaniam M. Routine transcutaneous bilirubin measurements combined with clinical risk factors improve the prediction of subsequent hyperbilirubinemia. J Perinatol. 2009 Sep. 29(9):612-7. [Medline].

  23. Maisels MJ, Bhutani VK, Bogen D, Newman TB, Stark AR, Watchko JF. Hyperbilirubinemia in the newborn infant > or =35 weeks' gestation: an update with clarifications. Pediatrics. 2009 Oct. 124(4):1193-8. [Medline].

  24. Bhutani VK, Johnson L, Sivieri EM. Predictive ability of a predischarge hour-specific serum bilirubin for subsequent significant hyperbilirubinemia in healthy term and near-term newborns. Pediatrics. 1999 Jan. 103(1):6-14. [Medline].

  25. Fontaine P. The first month of life. Handbook of Pregnancy and Perinatal Care in Family Practice. Hanley & Belfus; 1995. 396-429.

  26. Gartner LM, Herschel M. Jaundice and breastfeeding. Pediatr Clin North Am. 2001 Apr. 48(2):389-99. [Medline].

  27. Grunebaum E, Amir J, Merlob P, et al. Breast mild jaundice: natural history, familial incidence and late neurodevelopmental outcome of the infant. Eur J Pediatr. 1991 Feb. 150(4):267-70. [Medline].

  28. Hamosh M, Bitman J. Human milk in disease: lipid composition. Lipids. 1992 Nov. 27(11):848-57. [Medline].

  29. Huang MJ, Kua KE, Teng HC, Tang KS, Weng HW, Huang CS. Risk factors for severe hyperbilirubinemia in neonates. Pediatr Res. 2004 Nov. 56(5):682-9. [Medline].

  30. Johnson LH, Bhutani VK, Brown AK. System-based approach to management of neonatal jaundice and prevention of kernicterus. J Pediatr. 2002 Apr. 140(4):396-403. [Medline].

  31. Lovejoy FH Jr, Robertson WO, Woolf AD. Poison centers, poison prevention, and the pediatrician. Pediatrics. 1994 Aug. 94(2 Pt 1):220-4. [Medline].

  32. Maisels MJ, Newman TB. Kernicterus in otherwise healthy, breast-fed term newborns. Pediatrics. 1995 Oct. 96(4 Pt 1):730-3. [Medline].

  33. Martinez JC, Maisels MJ, Otheguy L, et al. Hyperbilirubinemia in the breast-fed newborn: a controlled trial of four interventions. Pediatrics. 1993 Feb. 91(2):470-3. [Medline].

  34. Schneider AP 2nd. Breast milk jaundice in the newborn. A real entity. JAMA. 1986 Jun 20. 255(23):3270-4. [Medline].

  35. Yamauchi Y, Yamanouchi I. Breast-feeding frequency during the first 24 hours after birth in full-term neonates. Pediatrics. 1990 Aug. 86(2):171-5. [Medline].

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.
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.