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Dr Carol's Advice
   
How to Deal With Jaundice  
By: Carol Chamblin, DNP, APN, RN, IBCLC  
   
Physiologic jaundice of the newborn, also known as hyperbilirubinemia is the most common type of jaundice and can occur in newborns with breastfeeding problems. All newborns have some elevation of bilirubin in their first week of life compared to adult levels because newborns have an immature liver and gastrointestinal tract. There are both mother and infant-related health factors that can increase the likelihood of your infant developing jaundice. Another type of jaundice, “breastmilk jaundice” is less common, and extends into the second or third week of your baby’s life, and can continue up to 8-12 weeks of life. These infants can continue to breastfeed, and formula use is not recommended.
 
Breastfeeding is the healthiest choice for feeding your newborn. Newborns need to breastfeed 8-10 times in 24 hours. Breastfeeding does not cause jaundice, but newborns not getting enough to eat at breast can develop jaundice caused by dehydration. Not all breastfed infants feed properly to maintain normal weight gain and prevent jaundice. Indeed infant weight gain indicates your baby is getting enough by breast when strictly breastfeeding. It is very important to seek help from a health care professional knowledgeable in breastfeeding when your newborn is being treated for jaundice. Your health care professional should never discourage you from breastfeeding.
Common risk factors for developing jaundice are:
  • Bruising; a common cause is referred to as cephalohematoma. Your baby’s head may be misshaped from the birth process and bruising may have occurred
  • Infants with ABO incompatibility
  • Mothers with diabetes or Rh sensitization
  • Late preterm infants (born early between 36-38 weeks gestation)
  • Preterm infants less than 36 weeks gestation
  • Infections of mother or of newborn
  • Having had a prior newborn who received treatment with phototherapy
  • Delay in passing meconium stool
  • Poor feedings
  • Weight loss greater than 10% of birthweight
When any of these factors exist, and your infant is not breastfeeding well, there is a higher likelihood of your infant’s bilirubin levels to increase as a result of dehydration from feeding poorly. It is very important to seek assistance from clinicians in the early hours after delivery to get breastfeeding off to a good start. In some situations such as when your baby is too sleepy to latch onto the breast, or promptly falling asleep while at the breast, or born early (36-38 weeks gestation or younger), or separated from you, it is important that you begin to pump. The use of a double-electric hospital grade breast pump, such as the Medela Symphony pump will optimize your milk production. Pumping after breastfeeding your baby (7-8 times in 24 hours) will most effectively stimulate your breasts for achieving an adequate milk supply for your baby’s growth needs.

Often times the late preterm infants’ breastfeeding struggles are not properly managed because they are seen as if they are healthy term newborns. Their unique feeding needs can cause them to have an increased risk for jaundice. If your infant is born between 35-37 weeks gestation and is struggling with breastfeeding, your clinician may want you to provide a small amount of supplementation with expressed breastmilk, banked human milk, or formula (in that order of preference) until your infant gains weight so that dehydration is avoided. Again, when your baby needs supplementation, it is best to start pumping to initiate an adequate milk supply. Frequently mothers are told to supplement their infants, but not instructed on how and when to use a breast pump. Effective pumping can prevent a low milk supply problem, allowing you to be able to continue to breastfeed your infant.

All newborns are monitored by health care professionals for bilirubin levels using what is called a newborn jaundice record. This is a graph that measures your baby’s bilirubin level according to your baby’s age in hours since birth. There is a low risk zone, low intermediate risk zone, high intermediate risk zone, and high risk zone. If your baby’s bilirubin results are in the high or high intermediate zone, there will be another level taken in 6-8 hours. Here is an example: Your baby is 48 hours old and his bilirubin level is 10. This is in the low intermediate risk zone and a repeat bilirubin level will not be done unless other concerns arise. If your baby is 48 hours old with a bilirubin level of 18, this is considered in the high risk zone and a repeat bilirubin level will need to be done in 6-8 hours.
Treatment for jaundice often involves phototherapy. Breastfeeding can continue while your baby is receiving phototherapy. Breastfeeding more often, such as every two hours does not increase your baby’s intake from breast when your baby has had a 10% weight loss, and/or you are experiencing a low milk supply. There may be the need for extra supplementation besides only breastfeeding when bilirubin levels are rising rapidly. This is the time to start pumping to stimulate your milk supply using a double-electric hospital grade electric breastpump. Home phototherapy may be an option with the use of what is known as a bili-blanket. It is safe to interrupt phototherapy for up to 30 minutes during breastfeeding without causing any harm to your infant. Once your milk supply has increased with effective pumping and your baby is gaining weight with breastfeeding, it is important to understand that breastfeeding is the healthiest choice for your baby. Be reassured that continuing to breastfeed will not cause your baby’s bilirubin levels to rise again.
References:

Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks Of Gestation, Pediatrics, 2004; 114: 297-316.

ABM Clinical Protocol #22: Guidelines for Management of Jaundice in the Breastfeeding Infant Equal to or Greater Than 35 Weeks’ Gestation, Breastfeeding Medicine, 5 (2); 2010.

 
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