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Thread: true breastmilk jaundice??

  1. #1
    Join Date
    Jun 2006
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    Default true breastmilk jaundice??

    Hey all--Thanks so much for the responses to my earlier post about my daughter's jaundice/lack of poop/pumping issues.

    Well, we saw the pedi again today and got some mixed news. The good news is that she is gaining weight. She was up to 6lbs 14 oz today(12 days old) just 3 oz from birth weight and up 5 oz. from Tuesday. Since Thursday I have hardly given her any formula(maybe 1-2 oz per day), just the EBM I am able to pump(about 20-30 cc). I only supplemented at 4-5 feedings per day. She was having 2 poops/day and at least 10 soaking wet diapers/day(sometimes more).

    Bad news is that her bilirubin has actually gone up(back to 16) since Tuesday. The pedi suspects that we have a true case of breastmilk jaundice. I had not even heard of this until a few days ago. He suspects it because both of the boys were jaundiced, slow to gain babies(both were slightly jaindiced until they were over 1 month old).

    The pedi gave me a couple of options about how to proceed but I am not sure what to do.
    Choice #1--stop BFing entirely for two days, only formula and see if her levels drop on Monday. I cried when he even mentioned this--not an option I am willing to consider
    Choice #2--Every third-fourth feeding give her 2 oz of formula first(in a bottle) and pump after. See if her levels drop at all by Monday
    Choice #3--Do nothing

    I am thinking of doing a combo of his options--supplement with the formula more often but continue to use the SNS(not a bottle) and continue to nurse on demand in addition--whether it is before or after the formula--and not limit her time at the breast at all.

    Any advice or insight? I have not found a whole lot of info about this issue, other than that it is not very common.
    TIA, Stacy

  2. #2
    Join Date
    Feb 2006
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    Default Re: true breastmilk jaundice??

    Hey Stacy,

    I'm looking at the _Breastfeeding Answer Book_ in its section about newborn jaundice, and I'm going to just type in some of the relevant passages from this book, pp. 263-264:

    "Jaundice rising or continuing past the first week -- previously called "late onset" or "breast milk jaundice" -- was once believed to be distinct from physiologic jaundice and to affect less than 4 percent of all breastfed newborns. However, recent research has found that prolonged jaundince and elevated bilirubin levels are more common than previously realized, with one-third of breastfed newborns two to three weeks old being clinically jaundiced (bilirubin levels above 5 mg/dl [85umol/L] -- with visual signs of jaundice present ...

    "Rather than being considered abnormal, this late-occurring elevated bilirubin is beginning to be recognized as a "normal extension of physiologic jaundice of the newborn" (Gartner 1994b). The high incidence of prolonged jaundice or elevated bilirubin in healthy breastfed babies is in the process of changing "the view of breast milk jaundice from one of a disease or syndrome to one of normal, expected developmental physiology" (Gartner 1994b)....

    "Prolonged jaundice or elevated bilirubin is thought to be caused by a combination of three factors: a substance in most mothers' milk that increases intestinal absorption of bilirubin, individual variations in the baby's ability to process bilirubin, and the inadequacy of feeding in the early days.

    "If a baby is growing well and the mother's milk supply is adequate, the doctor may want to do tests to rule out causes of pathological jaundice. Breastfeeding can and should continue unless the jaundice is found to be caused by a metabolic disease such as galactosemia.

    "Once pathologic causes have been ruled out, treatment is not usually necessary and the jaundice will eventually clear on its own without aftereffects, although in some cases it may take as long as three months.

    "...Some doctors recommend temporary weaning to determine whether or not a factor in the mother's milk is causing the jaundice, but this is neither beneficial nor necessary. According to Gartner and Lee (1999): "Breastfeeding should not be interrupted, even in the more severe cases of jaundice, either to make a diagnosis of breast milk jaundice or for fear of kernicterus ... unless the serum bilirubin concentration is 20 mg/dl or higher or rising rapidly. The proved benefits of breastfeeding far outweigh any theoretical advantage of reducing mild to moderate levels of jaundice."

    "In the healthy, full-term baby, bilirubin levels below 23 to 29 mg/dl (400 to 500 umol/L) have not been associated with short- or long-term health effects (Newman and Klebanoff 1993).


    And on p. 266, the _Breastfeeding Answer Book_ discusses specific treatments and when to do them:

    "The 1994 AAP guidelines recommend that treatment for the full-term healthy baby be considered based on the baby's age and total serum bilirubin level (in mg/dl [umol/L]). Babies who are clinically jaundiced within their first 24 hours are not considered healthy."

    Since your baby is about 10 days old now, I'll only type in the data that apply to babies older than 72 hours:

    Bili level of 17 or higher: Consider phototheraphy
    Bili level of 20 or higher: Phototherapy
    Bili level of 25 or higher: Exchange Transfusion if Intensive Phototherapy Fails
    Bili level of 30 or higher: Exchange Transfusion and Intensive Phototherapy

    It goes on after that to say:

    "In addition to the level itself, the rate at which the bilirubin level is rising is also of concern if it is rising more than 0.5 mg/dl (8.5 umol/L) per hour. Once a baby's bilirubin level has peaked, leveled off, and begun to go down, it is unlikely to increase again, except for a slight rebound effect that may occur after phototherapy (AAP 1994) or when the baby begins breastfeeding again after a temporary weaning, if this has been considered necessary. In these cases, the rise in serum bilirubin should be slight."

    The _BAB goes on to emphasize that for a premature baby, the safe levels of bilirubin are significantly lower and that jaundice is more dangerous for premies.

    And here are the references for the sources cited in the passages above -- so you can find them and show them to your doctor if you like:

    Gartner, L. Neonatal jaundice. _Ped Review_ 1994b; 15(11):422-32.

    Gartner, L. and Lee, K. Jaundice in the breastfed infant. _Clin Perinatol_ 1999; 26(2):431-45.

    Newman, T. and Klebanoff, M. Neonatal hyperbilirubinemia and long-term outcome: another look at the Collaborative Perinatal Project. _Pediatrics_ 1993; 92(5):651-57.

    American Academy of Pediatrics (AAP) Provisional Committee for Quality Improvement and Subcommittee on Hyperbilirubinemia. Practice parameter: management of hyperbilirubinemia in the healthy term newborn. _Pediatrics_ 1994; 94(4):558-65.

    --Rebecca

  3. #3
    Join Date
    Feb 2006
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    Default Re: true breastmilk jaundice??

    OK, now here are my very inexpert thoughts:

    It's good that she has gained weight, and it's also a good sign that you've been able to decrease the formula supplements while maintaining her diaper output.

    I think two poops a day is still on the low side, and I would encourage you to make sure your IBCLC is aware of this and helping you figure out why she is pooping infrequently and how to help her poop more often.

    According to the _BAB_ info in my previous post, a bili level of 16 does not seem to be cause for alarm. I'm wondering if this new increase to 16 is the "slight rebound effect" after her phototherapy in the hospital last week and/or after getting more breastmilk and less formula into her.

    Has her doctor done tests to rule out metabolic disorders and other causes of pathological (abnormal) jaundice?

    I encourage you to discuss your options with your baby's whole "team," and don't be afraid to ask your doctor to read something if he does not seem to be familiar with the AAPs latest guidelines or with the Gartner articles cited in my previous post.

    --Rebecca

  4. #4
    Join Date
    Jun 2006
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    7

    Default Re: true breastmilk jaundice??

    Thank you for the excellent info! It is my suspicion also that her levels went up because I cut back on the formula and was supplementing with 90% EBM. I guess my gut tells me to not be too worried because she is acting like a "normal" newborn. She is not overly sleepy, wakes on her own to feed, has several periods of alert/awake times during the day, etc...The pooping is still a concern, however. She had a huge blow-out last night so maybe this is going to become her pattern--one big one a day?

    Yesterday I did supplement with only formula and stored the EBM, but she still only took about 4 oz of formula from noon-midnight yesterday. I used the SNS, not a bottle. I think what bothers me the most is that the pedi wants to interupt BFing just to "know for sure" but all other causes have already been ruled out(she has had all of the blood tests done). In the end, knowing "for sure" won't change the treatment, so why take such a radical step?? At least the pedi is a pretty reasonible guy--I guess we'll just have to see where we are tomorrow!
    Thanks for the info!!
    Stacy

  5. #5
    Join Date
    Feb 2006
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    15

    Default Re: true breastmilk jaundice??

    I don't know how much it may help, but to help combat my DS mild jaundice I laid him in a sunbeam for a little while each day (inside the house, by a window), and also took him outside for some extra exposure to the sun. Each time I did that his skin tone looked less yellow and more pink. Of course, watch baby to make sure they don't get too warm or sunburnt. This also worked for a friend of mine.

  6. #6
    Join Date
    Jun 2006
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    7

    Default Re: true breastmilk jaundice??

    Thank you for the replies and advice!

    Well, we are at almost 3 weeks and she is *almost* at birthweight(6lbs 15 oz yesterday. Birthweight was 7lbs 1 oz.) I spent more time with the LC yesterday going over all of these issues(slow weight gain, slow to poop-once a day, continued jaundice, trouble pumping) and she seems to think that it may be a lack of hindmilk issue. For some reason, I am not "letting down" effectively for either the baby or the pump. Her suggestion was to try block nursing and only offer one side for every 3-4 hour block of time. I am willing to try just about anything at this point, but after only one day, this method is getting uncomfortable. The unused side is getting very sore and engorged by the 2 hour mark and it just gets worse as I try to wait until 3-4 hour mark to let her nurse on that side. Has anyone every used this method and seen it work to help with weight gain?? She seems pretty content with this method and is acting satisfied but she is still nursing on that one side for about 40 minutes per feeding. And she is still having lots of wet diapers(10-12 a day) with one bigger poopy diaper in the late evenings.
    TIA, Stacy

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