Hyperbilirubinemia, commonly known as jaundice, is a frequent concern in newborns, especially in the early days after birth. It occurs when there is an excess of bilirubin in the blood, leading to the characteristic yellowing of the skin and eyes. For breastfeeding infants, managing jaundice requires careful consideration to ensure that both the baby’s health and breastfeeding are protected. In this post, we’ll explore the different types of hyperbilirubinemia, how they are managed, and strategies to support breastfeeding throughout treatment.
Understanding the Different Types of Hyperbilirubinemia
Physiologic Jaundice
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- Cause: Physiologic jaundice is a normal occurrence in newborns, typically appearing on the second or third day of life. It results from the newborn’s immature liver, which is not yet fully capable of processing bilirubin.
- Management: Most cases of physiologic jaundice resolve on their own as the baby’s liver matures. Frequent breastfeeding (8-12 times per 24 hours) is crucial to promote bilirubin excretion through the stool. Monitoring bilirubin levels is essential, but in most cases, no additional treatment is necessary.
Breastfeeding Jaundice
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- Cause: Breastfeeding jaundice often occurs when a baby is not getting enough milk, leading to dehydration and reduced stool output, which can cause bilirubin to accumulate.
- Management: Ensuring adequate milk intake is the primary goal. This includes evaluating the baby’s latch and positioning, increasing the frequency of breastfeeding, and, if necessary, using breast compression to boost milk flow. If there are concerns about the baby’s intake, a lactation consultant should be involved to assess breastfeeding and recommend interventions.
Breast Milk Jaundice
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- Cause: Breast milk jaundice typically appears after the first week of life and can persist for several weeks. It is believed to be related to substances in the mother’s milk that inhibit bilirubin metabolism.
- Management: Unlike breastfeeding jaundice, breast milk jaundice is not caused by insufficient milk intake. In most cases, it is not harmful and does not require treatment beyond continued breastfeeding. However, it is important to differentiate it from other types of jaundice to avoid unnecessary interventions.
Pathologic Jaundice
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- Cause: Pathologic jaundice is more concerning and can appear within the first 24 hours of life. It may be due to underlying conditions such as ABO incompatibility, hemolytic disease, infections, or liver dysfunction.
- Management: Immediate evaluation and treatment are necessary. Management may include phototherapy, and in severe cases, exchange transfusion. During treatment, it’s crucial to support breastfeeding by offering expressed breast milk when direct breastfeeding is not possible. Once the baby’s condition stabilizes, breastfeeding should resume as soon as possible.
Managing Hyperbilirubinemia in Different Settings
Hospital Setting
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- In the hospital, newborns with significant hyperbilirubinemia may require phototherapy, which involves placing the baby under special lights that help break down bilirubin in the skin.
- Breastfeeding Support: During phototherapy, mothers should be encouraged to breastfeed frequently. If the baby is too sleepy or unwell to nurse effectively, expressed breast milk should be given. According to the Academy of Breastfeeding Medicine (ABM), supplementation should be done with expressed breast milk whenever possible. If supplementation with formula is necessary, it should be done in a way that supports breastfeeding, such as using a spoon, syringe, or supplemental nursing system (SNS) to avoid nipple confusion.
Home Setting
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- If jaundice is mild and the baby is otherwise healthy, it can often be managed at home with frequent breastfeeding and regular monitoring of bilirubin levels. Sunlight exposure (indirect and through a window) can also help lower bilirubin levels naturally, but this should be done cautiously to avoid overexposure.
- Breastfeeding Support: At home, mothers should be supported with techniques to ensure effective breastfeeding. Lactation consultants can be a valuable resource for assessing and addressing any issues. If supplementation is needed, the ABM recommends using methods that support breastfeeding, such as an SNS or cup feeding.
Supplementation: When and How to Do It
In cases where supplementation is indicated due to insufficient milk intake or severe jaundice, the goal should be to support breastfeeding while addressing the baby’s nutritional needs.
- When to Supplement: Supplementation may be necessary if the baby’s bilirubin levels are rising rapidly, if there are signs of dehydration, or if the baby is not gaining weight as expected.
- How to Supplement: The ABM advises that supplementation should be done in a way that supports breastfeeding. Options include:
- Supplemental Nursing System (SNS): Allows the baby to receive additional milk while nursing at the breast, helping to maintain the breastfeeding relationship.
- Cup Feeding or Syringe Feeding: These methods avoid the use of artificial nipples, reducing the risk of nipple confusion.
- Expressed Breast Milk: Whenever possible, use the mother’s expressed milk for supplementation.
Protecting Breastfeeding During Hyperbilirubinemia Treatment
The key to managing hyperbilirubinemia in breastfeeding infants is to protect the breastfeeding relationship while effectively treating the condition. Here are some tips:
- Frequent Monitoring: Regular monitoring of bilirubin levels is essential to ensure timely intervention if needed.
- Lactation Support: Engage with a lactation consultant early to assess and support breastfeeding.
- Avoiding Unnecessary Supplementation: Not all jaundiced infants need supplementation; reserve it for cases where it’s clearly indicated.
- Promoting Breastfeeding: Encourage frequent breastfeeding sessions, skin-to-skin contact, and other practices that support milk production and effective feeding.
Conclusion
Managing hyperbilirubinemia in breastfeeding infants requires a balanced approach that treats the jaundice while protecting the breastfeeding relationship. By understanding the different types of jaundice and using evidence-based strategies, healthcare providers and parents can work together to ensure that infants receive the care they need without compromising breastfeeding.
For further reading and guidance, the Academy of Breastfeeding Medicine provides detailed protocols on managing jaundice and other breastfeeding challenges.
References
Academy of Breastfeeding Medicine. “ABM Clinical Protocol #22: Guidelines for Management of Hyperbilirubinemia in the Breastfeeding Infant Equal to or Greater than 35 Weeks’ Gestation.” Breastfeeding Medicine, vol. 5, no. 2, 2010, pp. 87-93. doi:10.1089/bfm.2010.9982.
American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. “Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation.” Pediatrics, vol. 114, no. 1, 2004, pp. 297-316. doi:10.1542/peds.114.1.297.
Maisels, M.J., and McDonagh, A.F. “Phototherapy for Neonatal Jaundice.” New England Journal of Medicine, vol. 358, no. 9, 2008, pp. 920-928. doi:10.1056/NEJMra0800889.
Gartner, L.M., et al. “Breastfeeding and Jaundice.” Pediatrics, vol. 106, no. 2, 2000, pp. 297-303. doi:10.1542/peds.106.2.297.
Moyer, V.A., et al. “What are the Clinical Signs of Severe Neonatal Hyperbilirubinemia?” Pediatrics, vol. 110, no. 4, 2002, pp. e41. doi:10.1542/peds.110.4.e41.
