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Clinical update: understanding jaundice in the breastfed infant

Author: Clark, Mary, RGN BA PGDip HV MA PGCertHe

ProQuest document link

Abstract: Breastfed infants are more likely to be jaundiced than infants who are formula fed.
Community practitioners need to understand the physiology of jaundice and the issues associated
with breastfeeding so that they can support parents. Visible jaundice is a result of
hyperbilirubinaemia and, in most cases, is harmless and caused by normal physiological
processes. It does, however, require detection monitoring and sometimes treatment to prevent
rare but serious health complications. Although some debate remains over the association
between breastfeeding and jaundice, the literature suggests that in the breastfed infant, early
onset jaundice may be a result of insufficient intake of breast milk and prolonged jaundice may be
related to a constituent of breast milk itself (breast milk jaundice). Early breastfeeding support to
promote good positioning, attachment and baby-led feeding may help prevent early onset
jaundice. Management of jaundice in the breastfed infant involves referral to local services to
determine bilirubin levels and exclude pathologies. [PUBLICATION ABSTRACT]

Full text: Headnote

Abstract

Breastfed infants are more likely to be jaundiced than infants who are formula fed. Community
practitioners need to understand the physiology of jaundice and the issues associated with
breastfeeding so that they can support parents. Visible jaundice is a result of hyperbilirubinaemia
and, in most cases, is harmless and caused by normal physiological processes. It does, however,
require detection monitoring and sometimes treatment to prevent rare but serious health
complications. Although some debate remains over the association between breastfeeding and
jaundice, the literature suggests that in the breastfed infant, early onset jaundice may be a result
of insufficient intake of breast milk and prolonged jaundice may be related to a constituent of
breast milk itself (breast milk jaundice). Early breastfeeding support to promote good positioning,
attachment and baby-led feeding may help prevent early onset jaundice. Management of jaundice
in the breastfed infant involves referral to local services to determine bilirubin levels and exclude
pathologies.

Key words

Breastfeeding, jaundice, breast milk, bilirubin, hyperbilirubinaemia

Community Practitioner, 2013; 86(6): 42-45.

No potential competing interests declared

Background

Jaundice is a common condition and the National Institute for Health and Clinical Excellence
(NICE) states that 60% of term and 80% of pre-term infants are jaundiced in the first week (NICE,
2010). Breastfed babies are more likely to be jaundiced than formula-fed babies. Breastfed babies
are also more likely to suffer from prolonged jaundice (see Box 1) with 10% experiencing jaundice

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at one month (NICE, 2010). These statistics indicate that staff working in health visiting teams
and children's centres (referred to in this article as community practitioners) may work with
families whose breastfed infant is jaundiced.

Alex and Gallant (2008) suggest that parents can perceive a contradiction when they are provided
with evidence of the overwhelming health benefits of breastfeeding, while at the same time being
informed that their infant's jaundice is as a result of breastfeeding. There is a risk that a mother's
decision to breastfeed may be undermined if professionals providing care and support for the
family are not confident in the physiology behind jaundice and breastfeeding, and are not aware
of current recommendations for management and support (Alex and Gallant, 2008). The inclusion
in the NICE guidelines (2010) of the 'mother's intention to breastfeed exclusively' as an increased
risk for jaundice needs to be understood so that it is not used as an argument for
supplementation or for replacing breastfeeding with formula.

The aim of this article is to enable community practitioners to confidently explain to parents what
jaundice is and its possible effects, the link between jaundice and breastfeeding and how this
relates to feeding their infant.

Jaundice: definition and physiology

NICE states: 'Jaundice refers to the yellow colouration of the skin and sclerae (whites of the eyes)
caused by the accumulation of bilirubin in the skin and mucous membranes' (NICE, 2010: 3). This
is also referred to as 'visible jaundice' (National Collaborating Centre for Women's and Children's
Health (NCC-WCH), 2010).

Raised levels of bilirubin (hyperbilirubmi- naemia) are the cause of the yellow discol- ouration
associated with jaundice (NICE, 2010). Mcintosh and Stenson (2008) explain that bilirubin is a
product of the breakdown of haemaglobin and when first produced is insoluble (also known as
unconjugated). For bilirubin to be excreted from the body it must be water soluble (conjugated),
as unconjugat- ed bilirubin is fat soluble and can potentially be deposited in the body's tissues
(Mcintosh and Stenson, 2008).

To prevent unconjugated bilirubin being deposited in tissues it is bound to albumin (a protein) and
then transported in the blood to the liver where it is converted to its conjugated form by an
enzyme called glucuronyltransferase (England, 2010; Mcintosh and Stenson, 2008). Mcintosh and
Stenson (2008) outline that conjugated bilirubin is excreted into bile and then transported to the
small intestine where it is then broken down by bacteria in the intestine. A small amount is
reabsorbed, to be excreted by the kidneys in the urine and a larger proportion in the stools
(England, 2010; Mcintosh and Stenson, 2008).

Conjugated bilirubin is gold in colour and when mixed with bile is responsible for the colouration
of stools and urine (England, 2010). Preer and Phillip (2011) highlight that some conjugated
bilirubin can be turned back into unconjugated bilirubin by an enzyme called beta-glucuronidase
in the intestine and this unconjugated bilirubin is reabsorbed and returned to the liver via a
process called 'enterohepatic circulation'.

Over half of all infants are thought to be jaundiced in the first week. This can be a result of normal
physiological processes of the newborn and is termed 'physiological jaundice', which is usually
harmless (NCC- WCH, 2010). For example, a foetus requires more red blood cells than a newborn
to supplement oxygen delivery from the placenta (England 2010). The implication of this is that

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excess red cells need to be broken down in the newborn and, therefore, more bilirubin is produced
as a by-product.

Glucuronyltransferase, which converts unconjugated bilirubin to conjugated bilirubin, is thought to

be less active in the newborn while conversely the enzyme that converts conjugated bilirubin to
unconjugated bilirubin in the intestine (beta-glucuronidase) is thought to be more active (Preer
and Phillip, 2011). These processes, coupled with the immaturity of the newborn's liver, result in
higher levels of the fat-soluble unconjugated bilirubin (England, 2010; Preer and Phillip, 2011).
This can lead to 'visible jaundice' as unconjugated bilirubin is deposited in the skin and mucous
membranes.

Jaundice and the breastfed infant

Physiological jaundice occurs in exclusively breastfed and formula-fed infants; however, NICE
gives'intention to breastfeed exclusively' as one of the factors contributing to an infant developing
significant hyperbilirubinaemia (NICE, 2010: 11). So why are exclusively breastfed infants
particularly at risk of raised levels of bilirubin?

The first reason is often referred to as 'breastfed jaundice'. Alex and Gallant (2008) suggest that
this might more accurately be termed 'not-enough-breast-milk jaundice'. UNICEF (2010) cites
jaundice as one of the indications that a baby is receiving insufficient breast milk. Early onset
jaundice caused by insufficient intake of breast milk usually occurs on day two or three of life
(Alex and Gallant, 2008).

Preer and Phillip (2011) explain that when a newborn infant does not receive enough breast milk
their meconium/stool output is decreased, which increases the reabsorption of bilirubin, resulting
in higher levels of unconjugated bilirubin. In addition, an infant who is not feeding effectively may
experience lethargy and this may make the baby less likely to feed, thereby perpetuating the
cycle (Preer and Phillip, 2011). Preer and Phillip (2011) go on to suggest that if this process were
to go unchecked there would be a risk of the levels of unconjugated bilirubin posing a severe risk
to health and potentially bilirubin encephalopathy. This cycle, however, would occur in any infant
who is deprived of calories in the first few days of life irrespective of the mode of feeding.

UNICEF (2010) states that there should be trained individuals available to the mother in the first
few hours and days to promote skin-to-skin contact, good positioning and attachment and baby-
led feeding. These are factors known to promote a good milk supply and an efficient transfer of
milk from the breast to the baby, and in the early days this will help provide the baby with much-
needed colostrum (UNICEF, 2010). Hockenberry and Wilson (2007) reinforce the fact that
colostrum is a natural laxative, and maximising the baby's colostrum intake is the most efficient
method of helping to expel meconium from the gut, preventing a build up of bilirubin (Medforth et
al, 2006). If a baby is reluctant or too sleepy to feed then expressed breast milk could provide this
colostrum until efficient breastfeeding is established (UNICEF, 2010).

The second reason for hyperbilirubinaemia occurring in the breastfed infant is thought to be
related to the constituents of breast milk itself and is termed 'breast milk jaundice' (Paul et al,
2012). Paul et al (2012) indicate that breast milk jaundice usually reaches its peak between 14
and 21 days and is resolved by three months of age. The key aspect of this type of jaundice is
that the baby is well and has a healthy weight gain (Alex and Gallant, 2008). Preer and Phillip
(2011) warn that there have been many unsuccessful attempts to identify exactly the specific

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properties of breast milk that increase the likelihood of jaundice and NICE (2010) states that
associative factors have not been fully clarified.

There have been some suggestions in the literature of what may be contributing factors. Alex and
Gallant (2008) cite studies, which suggest that breastmilk is rich in beta-glucuronidase (increases
uptake of unconjugated bilirubin). Preer and Phillip (2011) highlight a study suggesting that higher
levels of epidermal growth factors (EGF) were present in jaundiced breastfed infants and their
mother's breast milk. EGF increases intestinal absorption in the newborn infant (Preer and Phillip,
2011). Alex and Gallant (2008) reinforce that as long as the baby is thriving and other pathologies
have been ruled out, breast milk jaundice is not known to result in bilirubin encephalopathy. NICE
(2010) has specifically recommended research on the link between breastfeeding and jaundice so
there may be developments in the evidence available in the near future.

Pathological jaundice

The physiological processes outlined above are normal and, for most infants, jaundice is harmless
(NCC-WCH, 2010). England (2010) even suggests that low levels of fat-soluble bilirubin may be
beneficial as it can have an antioxidant effect. However, jaundice can also occur as a result of
underlying conditions - this is known as 'pathological jaundice'. These conditions are rare but they
can exist at the same time as physiological jaundice and need to be detected as the levels of
hyperbilinaemia they can create may pose a serious risk to the infant (NCC-WCH, 2010). Please
see NICE (2010: 3) and NCC-WCH, (2010: 34) for details of these conditions.

Pathological jaundice may significantly increase the amount of unconjugated bilirubin in the
blood. Unconjugated bilirubin is potentially toxic to the brain and spinal chord and can cause
neurological damage (NCC-WCH, 2010). England (2010) highlights that unbound unconjugated
bilirubin (not attached to albumin) coupled with other risk factors, such as pre-term birth and low
levels or lack of oxygen, may open up the blood-brain barrier, enabling the unconjugated bilirubin
to enter the brain resulting in bilirubin encephalopathy.

The term 'kernicticus' is often used interchangeably with 'bilirubin encephalopathy', but
Hockenberry and Wilson (2007) suggest that this refers to the yellow staining of the brain caused
by bilirubin encephalopathy. In its acute phase bilirubin encephalopathy may result in symptoms
such as lethargy, increased tone rigidity and convulsions (England, 2010). England (2010)
explains that if an infant survives into the chronic phase of the condition then effects can include
partial or complete deafness and intellectual impairment.

A further condition that community practitioners need to be particularly aware of is biliary atresia
as it may manifest itself a few weeks after birth when the infant is in the care of the community
team (Hockenberry and Wilson, 2007). Hockenberry and Wilson (2007) describe this as a rare
inflammatory condition, which results in fibrosis (hardening) of the biliary system. A child
experiencing biliary atresia may display prolonged jaundice, raised conjugated bilirubin levels,
dark urine and pale stools as a result of loss of bile pigment (Hockenberry and Wilson, 2007). The
NCC-WCH (2010) suggests that biliary atresia requires surgical treatment preferably in the first
eight weeks of life and Hockenberry and Wilson (2007) state that if untreated the condition leads
to liver failure and death by the age of two.

It is not within the scope of this article to discuss the treatment of jaundice in depth - full details
of this are provided by NICE (2010: 10) and NCC-WCH (2010). However, it is appropriate to
highlight when an infant should be referred for further investigation and tests.

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NICE (2010) recommends that any infant showing jaundice in the first 24 hours should receive an
urgent medical review to exclude pathological causes of jaundice. Any infant with factors
increasing the likelihood of hyperbilirubinaemia (see Box 2) should receive a visual inspection for
jaundice by a health professional in the first 48 hours of life. A visual inspection is best done in
bright sunlight and the professional should be aware that visual jaundice may be difficult to detect
in darker skin tones (NICE, 2010).

NICE (2010: 12) states that 'examination of the sclera, gums and blanched skin is useful across all
skin tones'. Visibly jaundiced infants more than 24 hours old should have bilirubin levels
measured and recorded within hours of the jaundice being detected (NICE, 2010). For those
infants whose bilirubin levels reach the appropriate threshold outlined by NICE (2010),
phototherapy (lamp light on the blue spectrum) is the first line of treatment. This type of light
converts the bilirubin in the skin to a harmless form that can be excreted by the urine (NCC-WCH,
2010). It is worth noting that natural sunlight is not recommended as a treatment for
hyperbilirubinaemia (NICE, 2010). An exchange transfusion may be required for those infants
exceeding the threshold for phototherapy (NICE, 2010).

In infants demonstrating prolonged jaundice the colour of their stools and urine should be
ascertained, as pale stools and dark urine may suggest biliary atresia (NICE, 2010). Infants should
be referred to the relevant local service/clinic for a range of tests to exclude any underlying
pathological conditions and to determine bilirubin levels (NICE, 2010). Paul et al (2012) argue that
these tests could be seen as intrusive for healthy breastfed infants who have breast milk jaundice
but concede that, at present, there is no other 'validated' way of determining whether there is any
underlying pathology behind the prolonged jaundice.

Support and reassurance

What support and reassurance can the community practitioner give to a parent who has been told
that their child's jaundice is either a result of insufficient intake of breast milk or breast milk
jaundice? The answer can be based on the NICE (2010) guidelines on neonatal jaundice. These
state that mothers of a visibly jaundiced baby should be encouraged to breastfeed their infant
'frequently' and lactation and breastfeeding support should be provided. Additional fluids, even for
infants receiving phototherapy, are not recommended routinely and, where they are specified,
expressed breast milk is the additional food of choice (NICE, 2010). The NCC-WCH (2010)
reinforces that this recommendation emphasises the benefits of breastfeeding for the mother and
child.

Once bilirubin levels indicate that treatment is not required, pathologies excluded and providing
the infant remains well, the parent can be reassured that the jaundice will not harm their child
and that it usually resolves on its own by three months {Paul et al, 2012). Parents should also be
informed of who to contact immediately should their child's condition change.

Conclusion

Explaining to parents the association between breastfeeding and jaundice while stressing the
overwhelming benefits of breastfeeding can be a delicate exercise in communication for the
community practitioner. Linking insufficient breast milk intake with early onset jaundice and
discussing the term 'breast milk jaundice' may help this explanation.

Although the community practitioner needs to be mindful of the current debate on the specific
cause of jaundice in the breastfed infant, once pathologies have been ruled out and any required
16 June 2015 Page 7 of 11 ProQuest
treatment given, they can confidently advise parents that the benefits of breastfeeding outweigh
any effects of jaundice.

Sidebar

Box 1. Key terms

*Prolonged jaundice. Term infant - jaundice lasting longer than 14 days. Pre-term infant - lasting
longer than 21 days (NCC-WCH, 2010)

*Visible jaundice. Yellow discolouration of skin and whites of the eye (sclera)

Conjugated Bilirubin. Water soluble (needs to be in this state for excretion)

Pathological jaundice. Jaundice caused by an underlying disease and condition

Sidebar

Box 2. Management and support (NICE, 2010)

Infants more likely to develop significant hyperbilirubinaemia are:

* Neontates under 38 weeks gestation

* Infants with a sibling who required phototherapy for neonatal jaundice

* Infants whose mothers intend to breastfeed exclusively

* Visible jaundice in the first 24 hours of life

Sidebar

CPD questions (please visit www.communitypractitioner.com/CPD to submit your answers)

1. Which of the following correctly represents the incidence of jaundice in infants?

A. 30% term, 70% pre-term

B. 80% term, 60% pre-term

C. 60% term, 80% pre-term

D. 50% term, 50% pre-term

2. For the term infant, which of the following is the correct definition of prolonged jaundice?

A. Jaundice lasting longer than 7 days

B. Jaundice lasting longer than 14 days

C. Jaundice lasting longer than 18 days

D. Jaundice lasting longer than 21 days

3. Jaundice is caused by ...

A. Raised levels of bilirubin

B. Decreased levels of bilirubin

C. Nothing related to bilirubin

D. None of the above

4. Which of the following definition of unconjugated bilirubin is correct?

A. It is water soluble and can be excreted

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B. It is fat soluble and cannot be excreted

C. It is fat soluble and can be excreted

D. It is water soluble and cannot be excreted

5. What is the term for jaundice caused by normal healthy processes in the body?

A. Physiological jaundice

B. Kernicticus

C. Pathological jaundice

D. None of the above

6. Which of the following processes is associated with physiological jaundice?

A. Crossing of unconjugated bilirubin across the blood brain barrier

B. Production of red blood cells

C. Stenosis of the biliary tract

D. Breakdown of excess red blood cells in the newborn

7. When does breast milk jaundice peak?

A. 7-14 days

B. 14-21 days

C. 28-42 days

D. 56-84 days

8. Breast milk jaundice is usually resolved by what age?

A. 3 months

B. 4 months

C. 5 months

D. 6 months

9. What is the correct treatment for hyperbilirubinaemia?

A. Acupuncture

B. Natural sunlight

C. Phototherapy

D. None of the above

10. A mother sees you in clinic. She has a healthy 2 month old who is gaining weight well and is
being exclusively breastfed. The infant has been diagnosed by the specialist clinic as having
breast milk jaundice. Which is the correct management?

A. Advise supplementing breastfeeding with formula

B. Advise giving formula for 24 hours and then resuming breastfeeding

C. Advise to continue with on-demand breastfeeding

D. None of the above

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References

References

Alex M, Gallant DP. (2008) Toward understanding the connections between infant jaundice and
infant, feeding. / Pediatr Nurs 23(6): 429-38.

England C. (2010) Care of the jaundiced baby. In: Lumsden H, Holmes D (eds). Care of the
Newborn by Ten Teachers. London: Hodder Arnold.

Hockenberry MJ, Wilson D. (2007) Wong's Nursing Care of Infants and Children, 8th edn. St. Louis:
Mosby Elsevier.

Medforth J, Battersby S, Evans M, Marsh B, Walker A (eds). (2006) Oxford Handbook of Midwifery.
Oxford: Oxford University Press.

Mcintosh N, Helms PJ, Smyth RL, Logan S. (2008) Forfar and Arneil's Textbook of Paediatrics, 7th
edn. London: Elsevier.

National Collaborating Centre for Women's and Children's Health (NCC-WCH) (2010). CG98
Neonatal Jaundice: Full guideline. London: Royal College of Obstetricians and Gynaecologists,

National Institute for Health and Clinical Excellence (NICE). (2010) CG98: Neonatal Jaundice.
London: NICE.

Paul SP, Hall V, Taylor TM. (2012) Prolonged jaundice in neonates. Pract Midwife 15(6): 14-17.

Preer GL, Phillipp BL. (2011 ) Understanding and managing breast milk jaundice. Arch Dis Child
Fetal Neonatal Ed96(6): 461-6.

UNICEF. (2010) Baby Friendly Care Pathways: Breastfeeding. Available from: www.unicef.org.uk/
BabyFriendly/Health-Professionals/Care-Pathways/ Breastfeeding/ [Accessed May 2013).

AuthorAffiliation

Mary Clark RGN BA(Hons) PGDip HV MA PGCertHe

Senior Lecturer Child Health

Middlesex University

Subject: Breastfeeding & lactation; Babies; Milk; Children & youth;

MeSH: Female, Great Britain, Humans, Infant, Infant, Newborn, Jaundice, Neonatal -- etiology,
Milk, Human -- chemistry, Practice Guidelines as Topic, Social Support, Terminology as Topic,
Breast Feeding -- adverse effects (major), Jaundice, Neonatal -- nursing (major), Jaundice,
Neonatal -- physiopathology (major), Patient Education as Topic (major)

Location: England

Publication title: Community Practitioner

Volume: 86

Issue: 6

Pages: 42-4; quiz 45

Number of pages: 4

16 June 2015 Page 10 of 11 ProQuest

Publication year: 2013

Publication date: Jun 2013

Year: 2013

Section: PRACTICE: CPD

Publisher: TG Scott & Son Ltd.

Place of publication: London

Country of publication: United Kingdom

Publication subject: Medical Sciences--Nurses And Nursing

ISSN: 14622815

Source type: Scholarly Journals

Language of publication: English

Document type: Feature, Journal Article

Document feature: References

Accession number: 23821885

ProQuest document ID: 1371824937

Document URL: http://search.proquest.com/docview/1371824937?accountid=50673

Copyright: Copyright TG Scott & Son Ltd. Jun 2013

Last updated: 2014-03-10

Database: ProQuest Medical Library

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