Breast Milk Jaundice Workup

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

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.
Proceed to Treatment & Management
 
 
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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