by Linda Zager, RN, IBCLC

This post made possible by the generous support of Ameda, inc.

You just went through this transformative experience. You created life! And then, as you bask in the glow, you are told the newest member of your family has jaundice.

What does it mean? How concerned should you be?

Jaundice is a very common condition in newborn babies. Newborn jaundice is caused by a pigment substance, known as bilirubin, and when it increases in the baby’s blood it makes him/her appear yellow. More than half of all newborns become jaundiced within the first week of life. This situation is usually temporary and resolves on its own within a few days without treatment. This is termed physiological jaundice. Physiological means what happens normally in the body. Physiological jaundice is not a disease but a temporary condition.

So what exactly is bilirubin? Bilirubin is formed in our bodies when red blood cells die off. This is a normal process. Red blood cells contain the substance bilirubin. Newborns are born with a surplus of red blood cells. When greater numbers of red blood cells break down, this yellow pigment, bilirubin, accumulates in the newborn’s blood and is deposited in the skin, muscles and mucous membranes, causing the skin to appear yellow. Bilirubin is fat soluble, meaning it mixes easily with fats and oils. For the body to get rid of bilirubin, it needs to be water soluble. So how is it possible for the body to get rid of bilirubin if this is the case? That’s the job of the liver. The liver processes the bilirubin, changing it from fat soluble to water soluble and is then passed into the intestines. From the intestines, the bilirubin leaves the body through the newborn’s bowel movements. Some bilirubin, however, is reabsorbed back into the body after becoming fat soluble again. This occurs if the baby is having very few or no bowel movements. The less bowel movements, the more bilirubin gets reabsorbed, resulting in higher bilirubin levels. The most common cause of increased reabsorption of bilirubin is insufficient intake of breast milk. Bilirubin levels on the third day is directly linked to the number of EFFECTIVE breastfeeds per day in the first few days of the baby’s life.

Some mothers are informed by their health care provider that they need to stop breastfeeding and start feeding their little one formula in order to lower the bilirubin levels in the blood but options are available to treat jaundice without interrupting breastfeeding. For the healthy, full term baby, breastfeeding should continue so it does not become more of a challenge for mother and baby. The solution is not to stop breastfeeding but to resolve the breastfeeding issue so the baby gets the breast milk needed to have regular bowel movements.

Colostrum, the first milk available to the newborn, is actually a laxative which causes bilirubin to pass into the meconium stools. However, when a newborn does not receive enough colostrum as a result of inadequate feeding; either too few feedings, ineffective feedings, or both during the first few days, the bilirubin levels are exaggerated by day three. All mothers and babies should be assessed for effective breastfeeding while in the hospital by the nursing staff every shift and by a Lactation Consultant if a problem has already been identified. A newborn can be at the breast frequently but not breastfeeding. They do not become jaundiced from the breast milk but from a lack of breast milk. That is why it is necessary to have the nursing staff and/or a lactation specialist evaluate baby for effective latch and nutritive breastfeeding. Milk transfer is critical. Mothers may need to be taught how to latch their baby correctly to the breast and to recognize effective breastfeeding. This action assures mothers of comfortable, efficient breastfeeding and prevention of newborn jaundice.

As the liver is responsible for converting fat soluble bilirubin to water soluble bilirubin problems can arise because a newborn’s liver is relatively immature and may be unable to convert all the bilirubin in the first few days. Premature newborns’ livers are even less mature so therefore have higher levels of bilirubin than full term babies.

There are other reasons for excessive red blood cell breakdown resulting in high bilirubin levels and jaundice. ABO blood type incompatibility can result when mother has type O blood and her baby is one of the other blood types, A, B or AB. During pregnancy, red blood cells can leak across the placenta from the baby to the mother. The mother’s immune system reacts to the baby’s cells by forming antibodies against the baby’s blood resulting in increased red blood cell breakdown after birth and jaundice. With appropriate treatment, jaundice resolves. If a baby has a difficult birth and this results in bruising or a hematoma, there will be more red cells broken down resulting in higher bilirubin levels and jaundice. These are all normal causes of newborn or physiological jaundice with some babies requiring treatment and others not. But all these babies have one thing in common; they can and should continue to breastfed a minimum of 10 times or more per day every 24 hours for the baby’s first 2 days of life. Frequent nursing should be considered the norm; rooming-in with your baby promotes more breastfeeding than if baby were kept in a separate nursery.

Some babies are often sleepy as the bilirubin levels increase, sometimes resulting in baby falling asleep soon after feeding begins or he/she won’t even wake up to feed at the breast. Try skin to skin, holding you baby between your breasts, keep baby in close proximity to enable you to observe feeding or waking cues and never watch the clock for when you should nurse next. Remember a minimum of 10 or more feeds in 24 hours is norm. If baby does not respond to various stimuli to breastfeed more effectively, then an alternative method should be used to supplement baby with expressed colostrum/breast milk, if necessary. Hand expression of the breast is a very effective means of collecting colostrum. It can be expressed into very small cups or spoons for feeding. Mom should receive instructions for using a Hospital Grade breast pump for milk expression and to breast stimulation for adequate milk production. Breast milk can be given by cup, syringe, eyedropper or small spoon. Formula supplementation, on a short term basis, may be needed if fewer effective breastfeeds in the first days has contributed to a lower milk supply. Mother can continue pumping and nursing during treatment.

Most cases of jaundice require no treatment or little more than exposure to direct sunlight each day, but if the bilirubin levels continue to rise, more action is needed. The child’s physicians will observe and monitor the baby’s jaundice and bilirubin levels which are obtained through a simple blood draw from the baby’s heel. Phototherapy is a common treatment for all types of exaggerated jaundice. Phototherapy uses fluorescent light to break down bilirubin through the skin. The bilirubin absorbs the light, changing the bilirubin to the water soluble form, which then is eliminated through the baby’s stools. The baby is placed in an Isolette or self-contained incubator unit that provides for controlled heat and humidity. The light source, called bili-lights, is placed over and/or on the side of the Isolette. The baby is naked but for his diaper. His eyes will be covered to protect his retinas and corneas from damage.

If breastfeeding is a priority talk to your doctor and nurses about options. Often, babies are taken to the nursery for this treatment but most hospitals give mothers the option of treatment in their room. Baby’s eye patches should be removed during feeding to make eye contact with his parents. The Wallaby phototherapy unit is a fiber optic blanket that is wrapped around the baby’s trunk and provides continuous treatment that does not require eye patching or separation. The blanket can be used both in the hospital and in the home after hospital discharge.

If your baby has jaundice, it doesn’t have to interrupt breastfeeding. You are your child’s number one advocate and if breastfeeding is important to you, communicating that with your child’s care providers is an important part of your child’s care. Breastmilk may be exactly what is required to help your new baby get well. 

More information:

AAP Management of Hyperbilirubinemia in the Newborn Infant 35 weeks or More

AAP Clinical Practice Guidelines for Hyperbilirubinemia in the 35 week or more newborn infant

Bilirubin Screening and Management of Hyperbilirubinemia, Stanford Medicine

The Academy of Breastfeeding Medicine protocol for management of jaundice in the breastfed newborn of 35 weeks or more

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Did your baby have jaundice as a newborn? How were they treated? Were you supported in continuing to breastfeed?

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Linda Zager, RN, IBCLC

I’ve been an RN for 37 years, working in various hospital positions from Intensive Care to Hemodialysis/Plasmapheresis, Maternal Child Care and finally Lactation Consulting, my true calling in life. I have been an IBCLC for 23 years working with moms/babies in their homes and in the hospital. I left hospital work and now work as Ameda, Inc.’s Nurse Clinician/Lactation Consultant in the ParentCare division. I speak with mothers all over the country when they require resolution to breastfeeding/pumping issues.