Understanding and managing breast milk jaundice

Abstract

The breastfed infant with prolonged unconjugated hyperbilirubinaemia can present a vexing clinical dilemma. Although it is a frequently observed and usually benign finding, prolonged jaundice in the breastfed newborn requires a thoughtful evaluation that excludes possible pathological aetiologies. While recommendations for the treatment of unconjugated hyperbilirubinaemia in the first 7 days of life are straightforward, the approach to the breastfeeding infant with jaundice that persists beyond the immediate neonatal period is less clearly delineated. A sound understanding of bilirubin physiology and familiarity with current literature must guide the management of the otherwise well breastfeeding infant with prolonged unconjugated hyperbilirubinaemia.

Inherited disorders of bilirubin clearance

“…Infants with breast milk jaundice are otherwise healthy, with normal weight gain, normal stool and urine output, and a normal physical examination. Total serum bilirubin levels usually do not exceed 12 mg/dL (69), though higher bilirubin levels and rare cases of kernicterus have been reported (70). …”

“…However, since breast milk jaundice is a benign and self-limiting condition, current recommendations do not support discontinuation of breastfeeding in these infants (69). …”

Strategies for Neonatal Hyperbilirubinemia

“…• "normal" breastfeeding jaundice (also called "human milk jaundice syndrome") • "not enough" breastfeeding jaundice Diffi culties with breastfeeding can cause common and usually transient hyperbilirubinemia (Bhutani et al, 2010;Maisels, 2006;Preer & Philipp, 2010;Watchko, 2009;Watson, 2009). "Normal" breastfeeding jaundice, called "breastfeeding jaundice" or "human milk jaundice syndrome," occurs due to as-yet-unexplained metabolic changes involving factors in breast milk (Maisels, 2006;Preer & Philipp, 2010).…”

“…"Normal" breastfeeding jaundice, called "breastfeeding jaundice" or "human milk jaundice syndrome," occurs due to as-yet-unexplained metabolic changes involving factors in breast milk (Maisels, 2006;Preer & Philipp, 2010). The jaundice begins in the fi rst or second week postpartum, can last up to 12 weeks, and usually resolves spontaneously (Preer & Philipp, 2010). The jaundice begins in the fi rst or second week postpartum, can last up to 12 weeks, and usually resolves spontaneously (Preer & Philipp, 2010).…”

Physiology and Development of the Term and Preterm Neonate

“…Although a similar pattern of inadequate oral intake can develop during feeding with formula, its association with breast-feeding requires careful assessment of maternal factors and techniques of feeding. To avoid dehydration and worsening of hyperbilirubinemia, adequate enteral feeding must be established or alternative hydration delivered (e.g., intravenous fl uid) until the cause of inadequate oral intake is identifi ed and eliminated [ 442 ]. Abnormalities in the enzymes of conjugation, anatomic malformations of the biliary system (e.g., biliary atresia), and obstructive processes (e.g., neonatal obstructive fi brosclerosing cholangiopathy) [ 443 , 444 ] impair biliary function, often leading to jaundice in the fi rst months of life.…”