Jaundice and its relationship to Breastfeeding - by Dr Jack Newman (with kind permission to the babes for publication here!)

Myth: A baby who is jaundiced should be taken off the breast until his bilirubin goes down.

Fact: It is almost never necessary to stop breastfeeding because of jaundice. Not only is it not necessary, but it is not good, because the baby is deprived of breastfeeding. Furthermore, stopping breastfeeding even for a day or two may make breastfeeding more difficult, and even impossible for the mother.

            Well, then why is jaundice such a big problem? Why are so many mothers being told to stop breastfeeding so that the baby’s bilirubin will come down? What harm does it do the baby to be jaundiced?

Physiology of Bilirubin

            Bilirubin is the pigment in the blood that makes the baby with jaundice look yellow. Bilirubin comes from the breakdown of the iron containing protein (haemoglobin) found in red cells when these cells die. An average adult red cell lives about 120 days, and since there are millions dying every day, there is a lot of iron which needs to be recycled for other red cells or for other iron containing enzymes in the body. And a lot of haeme which needs to be disposed of. The part of the hemoglobin molecule which holds the iron is called the haeme portion and it is from the breakdown of this haeme portion that bilirubin is derived.

<diagram here to illustrate metabolism of haeme and bilirubin>

            Bilirubin which is derived from haeme is fat soluble and therefore is not soluble in water. In order to get rid of it from the body, it needs to be made water soluble. This is one of the jobs of the liver which takes the fat soluble bilirubin, and adds a biochemical piece to it to make it water soluble. Now that the bilirubin is water soluble, it can pass into the bile ducts in the liver which lead it to a large bile duct, which goes from the liver to the small intestine. The bilirubin thus passes into the intestine. Most leaves the body with bowel movements, but some is reabsorbed into the body after made fat soluble again by removal of that biochemical piece. The circuit starting with the formation of water soluble bilirubin from fat soluble bilirubin, excretion of water soluble bilirubin into the bile ducts and then into the intestine, and then reabsorption of some of the bilirubin back into the baby’s body is called the “enterohepatic circulation of bilirubin” (“entero” refers to intestine, and “hepato” to the liver). Water soluble bilirubin is also called direct bilirubin (from the test that’s done to measure it, where the amount is measured directly) and conjugated bilirubin (the process that makes it water soluble is called conjugation). The fat soluble bilirubin is called indirect bilirubin and unconjugated bilirubin.  All three names (fat soluble, indirect, unconjugated) and (water soluble, direct and unconjugated) refer to the same thing and are not different. The variety of names can be confusing.

            It is interesting that the body does not have to make bilirubin in order to dispose of the haeme portion of the haemoglobin molecule. In fact it takes more energy to make bilirubin than to go through alternative pathways which do not make bilirubin. This finding has led to some scientists postulating that bilirubin actually performs a useful function in the body. In fact, it is believed that bilirubin protects the baby against the effects of oxygen free radicals, formed during other metabolic processes, which can injure normal tissue. This will be brought up again when I discuss “breastmilk jaundice”.

            Why do newborn babies develop a visible “yellowness”, or jaundice? If you look at the scheme explaining how bilirubin is metabolized, you can actually figure it out, especially for abnormal situations.

1. Too much bilirubin being formed:

            In the normal situation, a newborn baby has more red cells in a single millitre of blood than an adult. Furthermore, the cells of the newborn are less long living, so at any given moment, a baby is breaking down considerably more red cells for his size than an adult. This is part of the explanation of “physiologic” jaundice.

            In an abnormal situation, if more than the average number of red cells are dying, then more haeme will need to be disposed of. If more than the average amount of haeme is to be disposed of, then more bilirubin will be formed. How does this happen?

            The classic situation occurs with Rh incompatibility. During pregnancy, a mother with Rh -ve blood may develop antibodies against her baby’s blood cells if the baby’s blood cells are Rh +ve. This occurs because red cells can leak across the placenta from the baby to the mother. The mother’s immune system recognizes the antigen on the red cells (and antigen is a molecule, usually a protein, which provokes production of an antibody) as foreign and starts producing antibodies against the antigen. These antibodies will pass back across the placenta and start destroying the baby’s red cells (a process called “haemolysis”). In severe cases, these babies can be jaundiced from birth, because cells were being destroyed even before they are born. So many red cells can be destroyed so quickly that the baby develops severe anemia and may even go into congestive heart failure. Many of these babies developed severe problems of mental retardation, spasticity, deafness and some even died. It is for this reason that so many physicians are so frightened of jaundice.

            The reason that Rh incompatibility often caused such serious problems is not only because of the high bilirubin, but also because of the fact that babies who were suffering from this problem also had severe metabolic problems, heart failure and severe anaemia. We are now aware that it was these factors which had more to do with the damage done to the baby than the high bilirubin alone. There is actually no evidence that a high bilirubin, unless extremely high, has any bad effect on the baby at all.

            There is much less reason for this fear now in any case, since most physicians who graduated after 1980 have never seen a case of Rh incompatibility. The virtual disappearance of this problem, at least in affluent countries, is one of the great triumphs of modern medicine. A pregnant woman who is Rh -ve now receives an injection of antibodies, usually around 28 weeks of pregnancy. If there is leakage of Rh +ve cells from the baby, these antibodies will coat these cells and prevent the production of antibodies by the mother. But the memory of the old days has left many many physicians “gun shy” about jaundice. This is unfortunate, because it impacts negatively, and unnecessarily, on breastfeeding.

            There are other reasons why more cells than usual will break down.  There are other situations which are similar to the Rh situation. There are other antigens on red blood cells which can provoke the mother’s immune system to produce antibodies against the baby’s red blood cells and cause increased destruction of the cells. The most common of these is ABO incompatibility, and though it is generally less severe for the baby than Rh incompatibility, it can still be quite serious in rare instances. Usually these babies do alright with phototherapy alone, whereas the baby with Rh incompatibility often had to have his blood completely removed and replaced by other blood (exchange transfusion).

            There may be more cells breaking down if the baby has a large bruise. Sometimes these bruises are obvious, on the baby’s face, but sometimes they can be hidden, around the kidney. The red cells in the bruise are dead, and their breakdown products, are absorbed into the blood over a period of time.

2. The liver is not able to handle the bilirubin:

            This may occur in the normal situation. The newborn’s liver is relatively immature, and unable to handle all the bilirubin that comes to it for the first few days. This is another reason for babies getting normal “physiologic” jaundice. Once the conjugation enzymes of the liver develop a little more, the physiologic jaundice decreases, after about the third day. It is for this reason that premature babies often have higher levels of bilirubin than full term babies.

            Infants of diabetic mothers also may have higher than average levels of bilirubin because even if born at term, physiologically, the infant of the diabetic mother is relatively immature. This may be part of the cause of higher than average levels of jaundice in the baby who is born with an underactive thyroid. If the baby suffers from lack of oxygen during the birth, this lack of oxygen may result in his liver not being able to process as much bilirubin. Sometimes infections of the blood or urine are associated with jaundice in the newborn. The exact way infection causes higher than average bilirubins is not known, perhaps because of poor feeding (see enterohepatic circulation of bilirubin, below). There are some very rare genetic diseases where the enzyme necessary for conjugation is absent or decreased. One which is not rare, but not a big problem is called Gilbert’s Syndrome. It is not usually noticed in the first days of life, and is not dangerous.

3. Increased enterohepatic circulation of bilirubin:

            Remember that once the bilirubin gets to the gut, some of it is reabsorbed, after being unconjugated in the intestinal wall. If the baby is not having many bowel movements, then the percentage of bilirubin which gets absorbed is increased, and this may also result in higher than average bilirubins.

            An increased enterohepatic circulation of bilirubin may occur in babies who have an underactive thyroid, since typically, they have few bowel movements, though this would not be the only explanation. Babies who have blockages in their bowels, so that they are unable to have bowel movements, also may have an increased enterohepatic circulation of bilirubin, though this is hardly their most dramatic symptom.

            By far the commonest cause of an increased enterohepatic circulation of bilirubin is insufficient intake of breastmilk. Or “not enough breastmilk” jaundice. The fact of the matter is that some “breastfed” babies are more jaundiced than average, in the first few days, not because of the breastmilk they are receiving, as many physicians believe, but because they are not receiving breastmilk (see Chapter on “Not Enough Milk”). Note “breastfed” in quotes, because these babies are not really breastfed. They are nothing fed, and the fact that they are at the breast frequently does not change that. A baby can be at the breast and not breastfeeding.

4. Conjugated (direct) hyperbilirubinemia (jaundice):

            But wait, there is one more thing here. If the liver is diseased, or the ducts leading from the liver to the gut are blocked, conjugated bilirubin cannot get to the gut, and spills back into the blood. This also will cause jaundice. But this is a completely different situation. This is always abnormal, and quite often very serious. The tipoff that this might be a problem is that the baby’s urine will likely be brownish, not clear, like the typical urine of the well feeding baby. The brownish colour is due to the water soluble bilirubin’s finding a way out of the body, and that is in the urine. Fat soluble bilirubin cannot get into the urine.

            Babies with jaundice due to high levels of conjugated (direct, water soluble) bilirubin need to be investigated as soon as possible, since successful treatments are available for some of the causes, especially if begun early.

What has all this to do with breastfeeding?

            Well, as you see, there is actually only one reason that babies are having higher than average bilirubins during the first few days that has anything to do with breastfeeding, and that is actually due not to the fact that the babies are breastfeeding, but to the fact that they are not breastfeeding well or even not breastfeeding at all.

            It is my strong belief that babies should not be taken off the breast ever, for the early type of exaggerated jaundice that we are frequently seeing in the first few days. On the contrary, a skilled lactation expert should observe the mother and baby breastfeeding and actually decide if the baby is breastfeeding well or not. If the baby is, in fact, breastfeeding well, there is no need for concern. The jaundice will decrease. If the baby is not breastfeeding well, it makes no sense to take the baby off the breast, because the baby is not breastfeeding in any case. What needs to be done is to fix the breastfeeding!!! The latch needs to be fixed as well as possible. The mother should be shown how to know the baby is getting milk. Compression should be used to keep flow of milk continuing to the baby. The mother should switch sides when the baby is no longer drinking at the breast and repeat the process. Baby off the breast for early jaundice? No, no, no!

            If it is not possible to fix the latch or get the baby breastfeeding well, it would be important to start expressing the mother’s milk so that the baby can have it. Colostrum is actually a purgative, it makes the baby poop, so it is good for jaundiced babies. If it is not possible to get much, as is frequently the case in the first days (remember, many mothers can get more in the first few days by hand expression, than by using a pump, which only discourages them), then techniques to help the baby get on the breast (see chapter on Breast Refusal) should be instituted, and the baby given the colostrum (plus sugar water, used as a tool to help the baby get going with breastfeeding). Only rarely is it necessary to give formula, though it is difficult to convince many paediatricians of that.

            If the high bilirubin is due to ABO incompatibility, or a large bruise, there is also no reason to stop breastfeeding. The approach is the same as for any breastfeeding baby with jaundice. If the baby is breastfeeding well. Good. If not, fix the breastfeeding.

            It is often said that jaundiced babies do not feed well because they are sleepy. I do not agree. I think they are sleepy because they are not feeding well, not the other way around. You start getting food into these babies and it is apparent how quickly they wake up. Only when the bilirubin gets quite high do the babies become sleepy because of the jaundice. And overly sleepy baby needs to feed, and alternative methods should be used to get the baby feeding well, if the baby does not feed well on the breast. Of course, the first approach is to get the baby breastfeeding well on the breast.

            Recently studies have come out purporting to show that babies who are jaundiced become less jaundiced more quickly if they are supplemented with formula. These studies are terribly flawed, because no one assured that the babies were actually breastfeeding in the first few days. Many of them were not, as shown by the greater weight loss of the exclusively “breastfed” infants.

             The point is, however, that it is not the breastfeeding that is causing the problem, but the lack of breastfeeding. The point is not to stop breastfeeding, but to fix the breastfeeding.

“Breastmilk Jaundice”

            This “diagnosis” cannot be made until we are sure the baby is getting substantial and sufficient amounts of breastmilk, usually only by the end of the first week of life. Again, this is to emphasize that the higher bilirubins in the first few days have nothing to do with some sort of effect of breastmilk on keeping the bilirubins higher than in formula fed babies.

            However, I don’t believe there is such a diagnosis as “breastmilk jaundice”. After 15 years of seeing young breastfeeding babies, I would say that the majority of exclusively breastfed, well gaining babies are a little bit jaundiced, not just for a week or two, but often for three months or more. Usually, it is hardly noticeable, but if you look carefully it is there. Sometimes there is no jaundice no matter how carefully you look, and sometimes there are babies that are quite yellow. The baby who is quite yellow and the baby who is not yellow at all, represent the extremes of the normal, which is slight yellowness. There is a tendency for those who have had exaggerated physiologic jaundice during the first few days, to have more obvious jaundice later, it is true, but this is not a reason to suppose that jaundice later on is somehow more worrisome.

            There is no evidence that what is called “breastmilk jaundice” is bad for the baby. Not one stitch. On the contrary, bilirubin may be good for the baby, in order to protect the baby from oxygen free radicals which can cause damage to tissues. What we have here is a problem of understanding. That is, understanding that breastfeeding is the normal physiologic method of feeding infants and young children. If it is true that most exclusively breastfed well gaining babies are jaundiced, then this is normal, not a concern. On the contrary, we should be concerned about babies fed with “close to breastmilk” substitutes who are not jaundiced. What’s wrong with them that they are not jaundiced? It is the breastfed baby who should be the model of what we expect, not the artificially fed baby. It is true that jaundice past the first week of life in artificially fed babies may indicate that something is wrong, but the same conclusion cannot be drawn about breastfed babies.

            Because of the above, there is no call to take the baby off the breast for 24 or 48 hours “to be sure that it is breastmilk jaundice”, to bring the baby’s bilirubin levels down to those of the artificially fed baby. In fact, if people were logical (which they obviously are not a lot of the time), we would not be worrying the breastfeeding mother at all about her jaundiced baby. We would be saying to the formula feeding mother “Your baby’s bilirubin is too low. This is probably not dangerous, but just to make sure that it is the formula that is keeping his bilirubin too low, I would like you to put the baby to the breast for a few days, so that his bilirubin moves up into the normal range”. That’s logical. It will never happen.

            By the way, jaundice of this type tends to be more obvious and lasts a longer time in Chinese, Vietnamese, Black, Native Canadians and Americans... In any baby whose parents are not Caucasian. But let’s face it. It is Western Medicine which rules the roost now. And so jaundice is bad.

Is it possible that jaundice at three weeks is actually a problem?

            Yes, of course. The direct (conjugated) jaundice is always a problem and needs to be investigated. But only rarely does breastfeeding need to be stopped. A few very rare metabolic disorders (galactosemia, for example) may present as direct (conjugated) jaundice. Galactosemia occurs in about 1:60,000 live births (I personally have seen only one case in 25 years as a paediatrician). It is one of the few true reasons for not breastfeeding.

            There are some medical problems which may prolong jaundice. Haemolysis can occur even late, though it is unusual. One cause is glucose-6-phosphatase deficiency, an enzyme deficiency, occurring almost exclusively in boys, may result in breakdown of the red blood cells when the babies are exposed to certain drugs or toxins. Considering how common this deficiency is (very common in Asia, Africa and Mediterranean Europe), this problem hardly ever seems to arise. It is important, though, to know if your baby has this if the mother could be a carrier and the baby needs to take certain medications. If this is a cause of the jaundice it would not require the mother to stop breastfeeding.

            An underactive thyroid could result in prolonged high levels of jaundice. The baby needs to be treated with thyroid hormone, not stop breastfeeding. A urine infection occasionally can cause jaundice, apparently. The infection needs treating, not stopping breastfeeding.

            The baby also can have more obvious jaundice for the same reason as the baby on day three may have higher than average bilirubin levels. Because he is not feeding well, though interestingly, babies who are not gaining well on breast along usually do not have the typical jaundice of well gaining exclusively breastfeeding babies. But some do. This is an extension of jaundice due to “not enough breastmilk”. Again, the approach is not to stop breastfeeding. On the contrary, the approach is to get the baby breastfeeding better (see chapter “Not Enough Milk”).

            Sometimes a physician will suggest interruption of breastfeeding “to make the diagnosis”. I feel this is completely unjustified. These exclusively breastfeeding babies are usually bouncing with health. If there is no reason to suspect an underactive thyroid (fairly rare in any case, and usually caught by the newborn screening programmes), a urinary tract infection, or a liver problem, or these problems have been ruled out, the baby should just be left alone and further tests, including the bilirubins, need not be done. And breastfeeding should not be stopped just “to make the diagnosis”.