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What You Need to Know About Jaundice, Breastfeeding, and Your Newborn Baby

by Linda Zager, RN, IBCLC
This post made possible by the generous support of Ameda, inc.

 

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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?

 

guest post, jaundice article

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.

guest post, jaundice article

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, IBCLC2 smaller
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.

Dear Kathleen- Nursing strikes, biting, low weight gain, and painful breastfeeding in pregnancy

We receive hundreds of emails and messages daily from Leakies looking for help and information in their breastfeeding journey.  As so many seek support from us, we are so honored to have the support of Kathleen Huggins, IBCLC and author of The Nursing Mothers’ Companion.  Kathleen is jumping on board with The Leaky Boob to have a regular article answering Leaky questions every month.  The questions will be selected from the huge pool we get in every day to try and help cover the wide range of topics about which Leakies are asking.  These questions are from real moms and represent hundreds of requests for more information in the past few weeks.  Please understand that this is simply the professional opinion of one International Board Certified Lactation Consultant in an informal setting and is not intended to replace the care of a health care provider.  Kathleen is offering support and information, not diagnosing or prescribing treatment.  For your health and safety, please seek the care of a qualified physician and/or IBCLC.  Kathleen does have limited availability for phone or online consultations, see her website  for more information.

Bfing tip low supply sleep on it

Dear Kathleen,

I need help!! I struggled to breastfeed my now 10 month old. After 3 months of struggle we made it and he has been breastfeeding beautifully. I work long hours and pump at work but have had a great supply. I just returned from a 5 day trip where I pumped and dumped and during that time my milk supply went from 24 oz a day to less then 15. Now my baby latches but cries after about 5 min on each side. He calms with expressed milk in a bottle. What do I do now to increase my supply back? I wanted to make it to a year and am heartbroken that I may have to stop sooner!! Help!!

Desperately yours,

Heartbroken for Milk

 

Hi there Heartbroken for Milk,

So sorry about your difficulty.  There are several things you can do.  First of all, I would make sure that you are using the best possible pump, like a Hygeia. If you don’t have a strong pump, you might consider either getting one or renting a clinical grade pump, like a Symphony, or an Ameda Platinum.  I would be sure that between pumpings and nursings that your breasts are being drained at least 7 times each 24 hours.  Having your breasts emptied less than this will keep your supply at the level it is at now.  The other thing I would suggest is More Milk Plus from Motherlove Herbals.  If you go to their website, you may be able to find a local distributor or order it directly from Motherlove.  This herbal product contains fenugreek and three other milk stimulating herbs.  Keep in mind that teas are a weak form of any herb and may not help much.  For a a short while you may also want to nurse before offering solids and once your supply increases, you can offer solids first, but again try to keep the number of nursings remain at a minimum of seven per 24 hours.  If your baby wakes in the night, welcome those nursings for now.

Best wishes too you!

Kathleen

 

Dear Kathleen,

My 10 month old bit me and I yelped, which made her cry. That was 6 days ago and since then she’s completely refused to nurse. She was exclusively breastfed before introducing solids and has never had formula. She won’t take a bottle and will only drink water from a sippy cup. I tried offering expressed breastmilk in an open cup but she wouldn’t have it. I’ve been mixing express breastmilk into her food but that’s all she’s been having. My supply is going and I can only pump a few oz a day. I’ve tried nursing her asleep, warm baths, skin-to-skin, everything, but she still refuses. Everything I’ve read says 10 months is too early to wean and that nursing strikes are temporary, but every day I feel more hopeless. I offer every couple of hours. She has three meals a day. I’m worried she’s missing out on essential nutrition, and even if I had to give formula I don’t know how I’d get it into her. I miss breastfeeding so much, I just want it back. 

Thank you for your help,

Not Ready to Wean

 

Dear Not Ready to Wean,

Tough situation!  At this point, be sure that you are expressing milk at least 7 times each 24 hours with an excellent pump to keep your production high.  You are certainly been doing the right things with co-bathing and lots of skin to skin.  I would offer your milk with an ordinary cup rather than a sippy cup with your guidance and see if she prefers that over the sippy cup.  I would also suggests seeing if she will nurse while asleep or very sleepy maybe while you lie down together in a darkened room.  Final words, hang in there.  Nursing strikes usually end as suddenly as they begin!

Good luck!

Kathleen

 

Dear Kathleen,

My son is 8 1/2 months and exclusively breast fed, and the last couple months has a side preference when he wants to relax or fall asleep. He has 6 teeth and is still in the teething process. My problem is, he bit his preferred nipple 3 times in 24 hours, drawing blood the first couple times. Now, I am trying to give it some time to heal, but he has a total meltdown when I don’t let him nurse on that side! 

Any suggestions to help him through this while I attempt to heal would be much appreciated! 

Sincerely,

Wounded Nipple

 

Dear Wounded,

I hope that you are expressing your milk very often with an excellent pump, at least 7 times each 24 hours.  I would also suggest feeding on that side using other positions that irritate the wounded nipple less, like “football” hold or having him straddle your thigh and then come onto the breast.  If the nipple is open after 5 days, it may then be time for an antibiotic as bites can easily become infected and then not only are they slow to heal, but you can also develop mastitis.  There are other healing remedies like Motherlove’s Nipple Cream which you may be able to find if you visist Motherlove’s website.  It contains several healing herbs and can work quickly unless there is already bacteria in the wound.  Also, you may want to learn more about biting.  If you visit my website, Kathlenhggins.com, I have a blog about “biting”.  This needs to stop!

Kathleen

 

Dear Kathleen,

I still breastfeed my just 2 year old and am 15 weeks pregnant. Breastfeeding is now VERY painful contributed by a very poor latch I think (there are teeth marks left behind on my nipples). It is no longer pleasant for me and I find myself feeling anger and resentment during feeding. The problem is my toddler is not ready to stop, she feeds on waking and before sleeps so it in entrenched in those routines. No amount of distraction, food or drink offerings or cuddles can stop endless sobbing and clawing at me. I’m at a loss.  

Thank you, 

Unpleasant Breastfeeding

 

Hi Unpleasant Breastfeeding,

There are a few things you can try.  First of all it is very common for nipples to be tender during pregnancy.  They may improve as your pregnancy continues.  With that and the marks from your toddlers teeth, it is no surprise that you are suffering through nursings!  There is nothing that can be done about your pregnancy nipple soreness, but you can help the problem with your toddler’s latch. Because the baby’s mouth tends to drag down the breast tissue, it may be important to lift her upwards by using a pillow and lifting your breast upward.    Experiment with other nursing positions to see which positions are more comfortable and which  avoid letting her chin rest on her chest, trying to get her head tilted back a little more.  Try and offer your breast with the nipple pointing downward and wait for a wide open mouth before latching. Feel free to use lanolin after nursings.

With all that being said, if you are still wanting to stop nursing, you can do that too! If you are only nursing in the morning and just before sleep, you and your partner can both help out.  She really is mostly weaned at this point!

For now, I would suggest tackling just one nursing at a time.  When she wakes, start of new routine of an early breakfast and some sort of play or other activity. Without telling her  “No”, let her know you are “saving the milk” until nap time, using whatever words she understands. Think of all the things she loves to do and substitute any of those things, Once you have that morning one gone, pick another, maybe the nighttime or nap time nursing. One the week-end, or in the evening, let your partner work his magic, with you out of sight.  Go take a walk. Perhaps Dad can help her off to sleep at night by making a new routine, like reading a book and rocking him for awhile.   A bath, a story and more rocking can certainly be a new way to distract her and soon you will have weaned. On the other hand, maybe one nursing a day is pleasant for the both of you.

See how changing the latch works. Move slowly on this, taking the nursings out just one at a time over a period of time until you are feeling better and she is adjusting.

Best wishes!

Kathleen

Dear Kathleen,

I have a soon to be 5 months old infant who is breastfed since birth and the biggest challenge is his weight, he only weighs less than 13 lbs and his birth weight was 6 lbs 12 oz. I’ve fed him every 2 hours and now sometimes 3 hrs to 4. When I pump I only produced 2 oz total from both breasts which the pediatrician isn’t happy and is very concerned that he’s probably not getting enough milk.  He spit up a lot, lots of urinations and some common bowel movements but his doctor isn’t satisfied and we keep having to go back for a weekly or biweekly weight check and now the doctor wants me to start giving him rice cereal now which I’d rather wait til he is 6 months old so I dont know what to do.  I don’t want to do formula. This is my 4th child and my 3rd child to breastfeed.  With my last 2 children I breastfed and did produced good amount of milk but this time I’m not sure if I’m producing enough milk which is very discouraging for me.  I took fenugreek for 3 months but I wished I had known I should have taken blessed thistle along with fenugreek.  Any suggestion on how I can increase my milk supply? Could it be his latch?  It still hurts when he latches on and sucks on my nipples.  I’m trying to stay positive but I feet like a failure that my baby is probably not getting enough milk from me because of his very low weight for his age.  With my other two nurslings I had a wonderful lactation consultant but that was 7 years ago and we have moved, I don’t even know how to find a good consultant.  Please help!

Yours truly,

Worried but hopeful

 

Hi Worried,

It’s understandable that you are worried, when I plot out your baby on the World Health Organizations Breastfed Infant Growth Charts, which you can find on line, I see that we was born on the 15th %tile and he seems to now be on the 3rd %tile.  I think you can offer him more calories without having to resort to formula.  I don’t know when you are pumping in relation to a nursing, so that doesn’t help me much.  Your baby needs more milk which has more calories, so I agree that cereal is not the answer.

I would suggest a few things.  First of all, you need to aim for 7-8 nursings each 24 hours. I would not allow the baby to go without nursing for 3-4 hours.  Watch for early hunger cues, like finger sucking and offer your breast whenever you notice this.  If your baby uses a pacifier, I would put it away.  Welcome night time feedings as mothers produce more milk in the night time.  If he sleeps through the night, I would wake him before you go to bed, or even wake him after five hours of sleep.  During the day and evening, I would try and double pump after most of these nursings for 5-10 minutes and offer him that milk after the next nursing.  This milk will be very high in calories and help him gain more weight.  While not knowing what pump you have, be sure that it is a good one, like a Medela or Hygeia or you could even rent a clinical grade pump for awhile if you have doubts about the pump you are using.  If your nipples are larger than a penny, be sure to use a larger sized flange, like a size 27mm.

Next, I would add a strong herbal galactagogue, like More Milk Plus from Motherlove Herbals.  If you go to their website, you may be able to find a local distributor or order it directly from Motherlove.  It contains, fenugreek, Blessed Thistle, and two other milk stimulating herbs.  It usually takes 48-72 hours to kick in.  A second herb you can add is GoLacta.  Go to their website for ordering information, Using both of these together can really boost your supply.  At this point, I would like to see a daily weight gain of 1/2 ounce per day.  That is normal for this age.

If your periods have already resumed, you may see that your supply lessens between the time you ovulate and when your period resumes.  If that is the case, you can take 1000 mgms of Calcium and 500 mgms of magnesium every day until your period starts.  I am assuming that you are not on any estrogen containing birth control which definitely lessens milk supply,

If your baby is spitting up, that suggests reflux to me which can cause some babies to limit their nursings.  I would avoid any of the following the following foods and beverages; these include chocolate, all citrus fruits and their juices (including strawberry, pineapple and kiwi), the gassy veggies like onion (onion powder), garlic (garlic powder), peppers, cucumbers, cauliflower, cabbage, broccoli, and Brussels sprouts.  It may be your baby is reacting to the foods you’re eating, eliminating the most likely culprits first and then testing them by adding them back one at a time could help you figure out if one of these are the cause.  If this baby has the same Daddy as the others, and they had colic symptoms, you might also consider a trial off of all cow milk products for a short while to see if that helps with the spitting up.  Cow milk products can be an allergen which runs in certain families.

Lastly, if you want to find a lactation consultant, go to ILCA.org and scroll down to “Find a Lactation Consultant”, enter your info and some name should pop up.  If you have private insurance, they should cover the cost.

Best wishes to you and your baby!

Kathleen

Kathleen-HigginsKathleen Huggins RN IBCLC, has a Master’s Degree in Perinatal Nursing from U.C. San  Francisco, founded the Breastfeeding Warmline, opened one of the first breastfeeding clinics in  the United States, and has been helping breastfeeding mothers professionally for 33 years.  Kathleen  authored The Nursing Mother’s Companion in 1986 followed by The Nursing Mother’s Guide to Weaning.  Kathleen has also co-authored Nursing Mother, Working Mother with Gale Pryor, Twenty Five Things Every Breastfeeding Mother Should Know and The Nursing Mothers’ Breastfeeding Diary with best-friend, Jan Ellen Brown.  The Nursing Mothers’ Companion has also been translated into Spanish.  Mother of two now grown children, Kathleen retired from hospital work in 2004 and after beating breast cancer opened and currently runs Simply MaMa, her own maternity and breastfeeding boutique.  She continues to support breastfeeding mothers through her store’s “breastaurant,” online at The Leaky Boob, and in private consultations.