In recent years the "panic value" for serum bilirubin rose from 12 mg/dL to 15 mg/dL to 18 mg/dL.   Parental panic values have not declined.  Aggressive management styles and parent-to parent information have caused most parents to believe that jaundice is a terrible illness.   Parents are very fearful when they are told that their baby is jaundiced. They may feel that the infant is generally unhealthy or in grave danger.  "Clearly, the diagnosis and treatment of jaundice are associated with persistent maternal perceptions of infant vulnerability.  .  . (Brown, L, et al 109)" or what has been called "vulnerable child syndrome." (Riordan  and Auerbach 381-382)  In the vast majority of cases, parents can be assured that the infant is healthy and that the jaundice is a transitional event.

In a recent study of 155 term breastfed infants Linda Brown,  et al, found that recommendations for treatment were not consistent.  Some mother were told to stop breastfeeding while others were told to continue nursing and all of the mothers were encouraged to offer water supplements (109).  Health care professionals need to familiarize themselves with neonatal jaundice and current treatment recommendations.

Pathological Processes
Erythroblastosis Fetalis is a disease of the newborn that occurs when the mother's body has produced antibodies against the Rh factor of the fetus.  The maternal antibodies cross the placenta and destroy the baby's red blood cells.  The resulting hemolytic anemia and its sequela are life threatening for the baby.  Since the introduction of RhoGamÆ, erythroblastosis fetalis is rarely seen (Dunn 382).

Kernicterus or bilirubin encephalopathy is the term used when there is damage to the brain from deposits of bilirubin.  Excessive unbound bilirubin in the infant's system can be deposited in various tissues.  Bilirubin is toxic to the tissues and cell necrosis results.  Damage can also occur in the kidneys, intestines and pancreas.  Premature infants are particularly susceptible to bilirubin related brain damage (Lawrence and Lawrence 480).  Kernicterus rarely occurs with serum bilirubin concentrations less than 20 mg/dL, yet controversy over what potential neurological deficits can occur with levels below 20 mg/dL persists (Lawrence and Lawrence 446-454).

However, there seems to be a correlation between high bilirubin levels and hearing loss in infants with other risk factors. (AAP 3 1, Lawrence and Lawrence 480, Thilio 251)   "There is a strong correlation between decreasing gestation age and risk for hyperbilirubinemia.  Infants born at 37 weeks gestation are much more likely to develop a serum bilirubin level of 13 mg/dL or higher than are those born at 40 weeks (AAP3 2). For the sick, compromised, or premature infant; elevations in serum bilirubin can be pathological and result in brain damage if not treated quickly.

ABO incompatibility.  Common when the mother's is blood type is O.  A Coombs test taken from the infant's cord blood will check  for the presence of antibodies and hemolytic processes.

Other causes of prolonged jaundice (Lawrence and Lawrence 481):

• Hemolytic disease.
• Hypothyroidism.
• G6PD deficiency.
• Inherited hepatic glucuronyltranferase deficiency
• Intestinal obstruction.
• Hepatitis.

Neonatal Jaundice Not a Pathological Process
An elevation in serum bilirubin above 5.0 mg/dL occurs in approximately 75% of all term newborns.  Of that number, 70% will have physiologic jaundice.  Infants of American Indian, Hispanic, Chinese, Japanese, Korean and Eskimo descent appear to have exaggerated physiologic jaundice: independent of feeding method.

In addition, ABO incompatibility accounts for 2% of neonatal jaundice.  Rh incompatibility accounts for 1%.  Other pathological causes account for l%.  Human Milk Jaundice occurs in approximately 1% of term, healthy newborns (Wilkerson 360-364).
 

Review of Physiologic Jaundice [Table: Comparison of Types of Jaundice]

Physiologic jaundice appears within the first 48 hours of life, and accounts for the greatest numbers of jaundiced babies.

1.  Five common medical interventions have been associated with a higher incidence of neonatal jaundice: oxytocin and prostaglandin induction of labor, intravenous fluids containing 5% dextrose in labor, epidural  labor anesthesia, glucose water supplementation of the infant and delayed or limited infant feedings in the first 24 hours of life (Wilkerson 1988: 362).
2. Infants are born with elevated levels of fetal hemoglobin.  Hematocrits as high as 80% have been reported.  The infant with a high hematocrit will be cherry red in appearance and can be expected to have exaggerated newborn jaundice. One gram of hemoglobin produces approximately 34 mg of bilirubin (Lawrence and Lawrence 481).
3. Increased oxygen levels outside the uterus result in rapid destruction of unneeded hemoglobin.
4. A by-product of hemoglobin destruction is bilirubin.  The infant with sequestered blood (e.g., cephalhematoma, bruising) will have a greater amount of hemolysis.
5. Metabolism of bilirubin is a function of the liver.
6. Bilirubin molecules, are insoluble in water, and bind to serum albumin.  The bilirubin is then circulated through the neonatal blood stream.  At serum levels of greater than 5.0 mg/dl bilirubin is deposited in the fatty subcutaneous tissue, giving the infant a yellow appearance.
7. Bilirubin is conjugated in the liver, through the action of liver enzymes (glucuronide).
8. Conjugated bilirubin is then made water soluble, and can be excreted from the liver; most often as bile, to the intestines where it is eliminated through the feces.
9. The immaturity of the infant's liver inhibits the normal adult physiology of bilirubin transport.
10. Meconium is loaded with bilirubin, therefore its deep green-black color.  The newborn's bowel contains 450 mg of Bilirubin at birth (Lawrence and Lawrence 484)
11. Because the newborn's bowel is sterile he lacks some of the normal bacterial enzymes that assist with bilirubin conversion and excretion.
12. Delayed passage of meconium can result in reabsorption of bilirubin into the infant's system.  Intestinal reabsorption of bilirubin is a major cause of physiologic jaundice, regardless of feeding method.  ì As stooling frequency and volume increases bilirubin levels decrease" (Auerbach and Gartner 93).
13. Although bilirubin is eliminated from other organ systems; increasing infant water intake will not increase the clearance of bilirubin through the urine.  The kidneys will only begin to excrete bilirubin when the bowel is overloaded.

Review of Jaundice While Breastfeeding

The jaundice, associated with breastfeeding in the neonatal period, has been called: Breastfeeding Jaundice or more correctly: "Improper Breastfeeding Jaundice." Besides the mechanisms of physiologic jaundice:

1. Lack of caloric intake, increases reabsorption of bilirubin from the infant gut. The infant is poorly latched-on or fed at infrequent intervals. The more jaundiced the infant becomes the more poorly he feeds.
2. Colostrum has a laxative effect and assists in emptying the bowel of meconium. Swallowing initiates peristaltic movement that will aid in emptying the bowel (Klaus 631).

Review of Breastmilk Jaundice

1. Breastmilk jaundice is not seen in the neonatal period.  It is unlikely that hospital nurses will see breastmilk jaundice because its onset occurs late in the newborn period.
2. The infant remains healthy and gains weight adequately (Auerbach and Gartner 96)
3. Late onset occurs between 5-10 days of age in the newborn period. Breastmilk jaundice peaks at day 14.
4. A baby may have physiologic jaundice followed immediately by breast  milk jaundice.
5. Actual cause remains under debate, has been associated, occasionally, with enzymes hormones, or antibodies found in the mother's milk.  However, these studies have not been duplicated.
6. Breastmilk jaundice has not been shown to cause any serious after effects such as kernicterus.
7. Usually effects all siblings (Rate 70% Lawrence and Lawrence 486).
8. Recommendations for diagnosis of true breastmilk jaundice (Lawrence and Lawrence 487): first obtain a bilirubin level after at least 24 hours of unsupplemented breastfeeding.  The infant is then formula fed for 24 hours, and the bilirubin level is retested.  Phototherapy is not used during this period.  If the level has dropped, the infant is put back to the breast for 24 hours.  A diagnosis of true breastmilk jaundice is made when the bilirubin level again rises after returning to breastmilk feedings.  No further examination of levels is needed.
9. The major problem is that breastmilk jaundice can be confused with other pathological conditions.  Breastfeeding is all too often blamed for persistent jaundice.  Further testing of the infant for other causes of jaundice must not be delayed simply because the only presenting symptom is prolonged jaundice in the breastfed infant.  Differential diagnosis is important in all cases of prolonged jaundice.  Indirect serum bilirubin will rise breastmilk jaundice.  In conditions such as biliary atresia, direct bilirubin will rise.  Pathologic jaundice is suspected if direct serum bilirubin is greater than 1 mg/dl at any time.

Reducing the Effects of Newborn Jaundice
Nurses can assist in the prevention of physiologic jaundice severe enough to require treatment.

Mothers need to be encouraged to nurse the baby 10-12 times per 24 hours.  Feedings do not need to be lengthy to be effective.

A. Colostrum has a laxative effect and assists in emptying the bowel of meconium.B. Human milk coats the gut and prevents the reabsorption of intestinal bilirubin.C. Human milk furnishes the natural intestinal flora and its enzymes that enhance bilirubin transport.D. Starvation, that is lack of caloric intake, will increase reabsorption.

Observe the baby for proper latch-on and suckling when put to breast.  Swallowing initiates peristaltic movement that will aid in emptying the bowel.Has the baby begun voiding and stooling and if so, how frequently? Since stool and urine output are the measure of breastfeeding effectiveness, expect the infant to have a stool after most feedings if he is nursing well.Avoid the use of complementary formula feeds and water supplementation.  Both contribute to neonatal flow preference and maternal engorgement.  Supplements will reduce the infant's suckling urge thus decreasing colostrum and breastmilk intake.  Researchers have consistently noted an increase in bilirubin levels with the routine use of glucose water after nursings (De Carvello, Hall and Harvy 568; Auerbach and Gartner 91-92).  There is also evidence that milk-based formula solids coat the gut differently  than human milk and can interfere with the normal processes of excretion and hydration.Encourage the mother to nurse her infant at night.  Prolactin levels rise with sleep, stimulation of the breasts causes the prolactin to rise further (Lawrence and Lawrence 67).  Repeated elevations in prolactin level will encourage the early onset of an ample milk supply.  As the milk matures, bilirubin levels drop.  Night nursing is also important in prevention of engorgement, which often leads to cracked nipples inhibited milk flow and/or improper breastfeeding jaundice.

These simple steps should reduce the incidence of infants requiring phototherapy.

Phototherapy
The AAP has published a practice parameter for jaundice (AAP 3). For term, healthy newborns, without evidence of hemolysis, most authorities now recommend that phototherapy should be considered when indirect serum bilirubin rises above 12-15 mg/dl by the second day of life and from 15-18 mg/dl thereafter.  Phototherapy should be considered a treatment for jaundice, not a preventive measure.
When an infant does require treatment, breastfeeding should be continued. The mother should be encouraged to continue nursing and the appropriate support offered.  The mother should have access to the infant for frequent feedings. Phototherapy and jaundice often make the baby sleepy and not interested in feeding. Mother may need additional help getting the baby awake for feedings.  In no way should a mother ever be made to feel that it is her milk that is "bad" or it is her milk causing the jaundice.

Copyright Marie Davis, RN, IBCLC 1999 

Last reviewed: Wed, Nov 8, 2006

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