Chapter 1 Index

A. General Information about the well child examination
--Prenatal Visit
--Well Child Check-up
--Neonatal Jaundice

Breast Milk Jaundice

Introduction: One of the common problems presented to the pediatrician in practice is how to approach the baby that is jaundiced and is breastfeeding.  It is important to distinguish breastfeeding jaundice from breast milk jaundice. 

Breastfeeding jaundice: Jaundice that occurs in the first week of life in breast-fed babies.  There may be associated physiologic jaundice, but breastfeeding jaundice primarily results from decreased plasma volume, and, therefore, increased concentration of bilirubin.  The bilirubin should be indirect only.  Treatment for this condition is waiting for the mother’s milk to come in, thus increasing plasma volume and decreasing the concentration of bilirubin.  Extra administration of water does not help the jaundice disappear more quickly, and, in fact, may cause higher bilirubin levels.

Breast milk jaundice: Jaundice that develops between 4-7 days of age, and can persist for weeks. This type of jaundice tends to recur in breast-fed siblings, is caused by hormonal interaction (5-beta-pregnane-3-alpha-20 beta-diol) of breast milk with hepatic enzymes, and also will go away if left untreated.  This jaundice is also indirect; no kernicterus has ever been reported with this kind of jaundice. 

Evaluation and treatment of the 2-3 week old breast-fed infant with jaundice: How Rx?

Typical Case: Full term breast-fed baby who was noted to be jaundiced at the 4-day check-up.  Mother A+, Baby A+.  Initial bilirubin at that time was 13 - 12.8 indirect and 0.2 direct.  Reticulocyte count 3%.  Baby had lost 250 grams from birth weight.  Pediatrician tells parents that baby had breastfeeding jaundice- no treatment needed.

Baby returns for 2 week check-up and bilirubin is now 19.5 - 19.2 indirect and 0.3 direct.  The baby is nursing well and has gained 75 grams a day.  Mother states that she has just been able to establish a schedule in the last two days.  She has heard that some doctors stop breastfeeding for a few days - she gets teary at the prospect of that.

Options for approach to this baby: All have been used by pediatricians

1. Reassure the parents that baby now has breast milk jaundice and that you will see the child at routine visit at 1 month of age.
2. Reassure the parents that baby has breast milk jaundice, but that you need to see the baby     back in another week to check bilirubin.
3. Admit the baby for phototherapy and continue breastfeeding; check BR q12 hours.
4. Prescribe home phototherapy and continue breastfeeding.
5. Draw liver enzymes along with bilirubin, CBC, retic count to reassure yourself and parents that there is no underlying liver pathology.
6. Discontinue breastfeeding for 48-72 hours as a diagnostic test, and have parents bring child back in 2-3 days to repeat bilirubin.

The approach to the treatment of this baby will depend on the pediatrician’s concern about jaundice.  Historically, pediatricians were taught that bilirubins over 20% mg could produce kernicterus or at least brain damage, and at that level should receive an exchange transfusion.  The thinking now is that in otherwise well full-term babies bilirubins of 24-25 are acceptable. Most pediatricians in practice will choose option 2, but will vary.

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Department of Pediatrics  |  Medical College of Georgia
Please email comments, suggestions or questions to:
John T.  Benjamin M.D.,  jbenj@mcg.edu

February 27, 2004