Neonatal jaundice

What is jaundice that is related to breastfeeding?

I suppose everyone knows that infants who are breastfed tend to have jaundice. But why is this? There are two main reasons/two main types:
– Breastfeeding jaundice – this is the early-stage jaundice, and it is an ‘exaggeration’ of the process that I described that occurs in physiologic jaundice. This type of jaundice presents in the first week of life in infants that are breastfed. On average, infants that are breastfed have higher bilirubin levels that infants that are bottle-fed (formula). Breastfeeding jaundice occurs due to insufficient breastmilk intake that leads to insufficient weight gain as well as the milk itself (will explain more about this below).
– Breastmilk jaundice – this is the late-stage jaundice; jaundice that presents in a small percentage of breastfed infants after their first week of life and it leads to higher levels of bilirubin that last for longer, sometimes even several weeks. The reasoning behind this jaundice is confined to the characteristics of the breast milk which contains an enzyme that turns bilirubin in the intestines back into its indirect form and by doing so increases its absorption back into the blood.

So, should you not breastfeed? Should you stop breastfeeding because of the jaundice?

No, no and no!
Breastmilk is the best “formula” out there for most infants. Even in those with breastfeeding jaundice and breastmilk jaundice. Of course, the primary care physician should be consulted, and the infant should be weighed. In most cases, there will be no need to add formula to the baby’s diet just to bring down the bilirubin levels if it is not at a dangerous level. Doing this will probably only mess up the child’s breastfeeding routine and habits. See more below about the rare times when the mother might be advised to do this.
I’m going to just try and make this a little clearer because I do not want infants whose mother read these posts to see their doctor at the age of 3 weeks, with completely yellow babies and not having gained a gram of weight. It is important, especially in breastfeeding infants, to see the primary care physician in the first few days of life and have their baby weighed.
And do not worry, I will be getting to the issue of circumcision soon.

What does the workup for jaundice consist of?

The words “jaundice workup” are often heard at the hospital.
It is as simple as it sounds. The workup for jaundice is carried out when pathologic jaundice is suspected. It just means that your baby will undergo a series of tests so we can try and figure out the possible cause of the jaundice.
What does it include?
– A complete blood count that assesses whether the level of red blood cells in the blood is within or below normal limits. Because as I mentioned earlier, in jaundice there is an increased destruction of red blood cells.
– A test that checks whether the jaundice is direct or indirect. As I mentioned earlier, each one of these may have different causes.
– A test for blood type and crossmatch with maternal blood, which checks for any maternal antibodies that may have crossed the placenta and caused destruction of red blood cells in the baby. Remember how we learn about the maternal blood type and how it is related to jaundice?
– G6PD enzyme levels – a deficiency in G6PD causes increased destruction of red blood cells and a quick rise in bilirubin levels. See? You’ve got this!
– And sometimes a few other tests, depending on physician discretion, to try and rule out other differentials to the cause behind jaundice.

How is neonatal jaundice treated?

It is important to remember that the goal behind treatment is to identify those babies that are at higher risk of developing severe jaundice to prevent the rare cases of bilirubin accumulation at high levels that may cause neurological damage to the baby.
The truth is that the most important part of management is follow-up. By following up on the infants, you can be sure that no one “escapes” the office with high bilirubin levels, and if they do so then it is not for too long. That is the reason why prior to discharge from the nursery in most countries, all infants undergo jaundice screening test using the transcutaneous device. This is also the reason why parents are advised to see their pediatrician within two days after discharge. Please make sure you do so.
The pediatrician will ask lots of questions about the history of the pregnancy, the delivery, the birth weight, the maternal blood type (many mothers get tested for their blood type), the infant’s feeding habits, the infant’s stool colour (see the important image below) and the frequency of all the risk factors that we discussed earlier. Afterwards, he will examine the infant, assess the severity of jaundice, weigh the infant, and measure the bilirubin using the transcutaneous device, if needed. If the value on the device is high, the pediatrician will refer you to a heel-prick blood test or a venous blood test, depending on what is available at the time (the heel-prick method isn’t available everywhere). Depending on the results, the pediatrician will determine whether there is a need for further workup and the frequency of monitoring required to ensure that the bilirubin does not reach levels that require treatment.

For bilirubin values that do not require any special management other than monitoring, there are a number of things that you can try to decrease the chances of reaching high values:
– Make sure your child is feeding well – this is really the most important management. If your child is breastfeeding, make sure the breastmilk is sufficient and that he is gaining weight. If need be, see a lactation consultant to help improve your technique. If your child is bottle-fed, make sure he is receiving sufficient amounts of formula in adequate frequency. Read more about how much does a baby need to eat here. When needed, especially if your child is not gaining enough weight, consult with your nurse or pediatrician. Infants who are not feeding properly and gaining enough weight will have prolonged jaundice that is more. Take a look at this post here to read more about important issues with regards to the beginning of a baby’s life.
– Observe your baby’s stools – remember how we said that bilirubin undergoes changes when it is in the liver and gets excreted into the intestines? In the intestines, some of the bilirubin can turn back into the original bilirubin and get absorbed into the intestines and the blood. In babies who pass stools infrequently, their stool sits in their intestines for longer and this allows more bilirubin to be absorbed back into the bloodstream. An infant who is feeding well will usually pass stool more frequently and thus his/her bilirubin levels will decrease.

What should not be part of the treatment of jaundice?

Of-course, this question is also important.
– Do not expose an infant to the sun as an alternative to phototherapy – this is unhealthy and can be dangerous.
– Do not stop breastfeeding altogether – the jaundice that most breastfed infants will get will not lead to anything dangerous. Beyond missing out on all things that are good in breastmilk, the difficulties that cutting off breastfeeding could lead to in terms of feeding habits, slow weight gain and even dehydration, the severity of jaundice will only deteriorate. Therefore, encouraging breastfeeding and improvement of the technique, together with a follow-up of weight gain is all that needs to be done. The only time breastfeeding should be stopped is if the bilirubin reaches very high levels that continue to increase and reach values that require plasma exchange (see more about this below). Even then, the cessation of breastfeeding should be temporary, and the mother can continue pumping breastmilk in the meantime.
– Do not give the infant sugar water instead of food – why? There is absolutely no need for this. An infant needs food and calories and not sugar water and it only prevents them from eating and gaining weight and it worsens the jaundice.

Treatment of jaundice at the hospital

In addition to all the simple treatments suggested above, there are several other treatments that can be provided to the infant.

Phototherapy

I’m sure you’ve all seen babies with jaundice “tanning” under a purple light, with sunglasses (to protect their eyes) in the nursery. So, it’s not exactly a tanning bed. This therapy is referred to as phototherapy. It is a simple and common form of treatment for jaundice when it reaches a certain level, depending on the age of the infant. The therapy is based on the discovery that a certain wavelength of light can cause a chemical change in bilirubin that allows it to be excreted into the intestines and urine and by doing so decreases the level of bilirubin in the blood. Nice and simple.
How do you know when a baby needs phototherapy? So, similarly to the Bhutani curve that I mentioned earlier, we have other charts that guide us as to when an infant’s bilirubin levels require phototherapy, depending on their age. Phototherapy is administered for several hours during which the bilirubin levels in the blood of the baby are measured several times, until they are below the threshold required for treatment. After the baby has reached such a value, phototherapy is stopped but the bilirubin levels continue to be monitored because there is a concern for rebound.
Generally speaking, phototherapy does not have any big side effects. However, during the therapy the baby may develop a self-resolving rash, a change in temperature or slight dehydration (in an infant that isn’t feeding well) that can be treated with fluids etc. Phototherapy does not have any known long -term effects or complications.

Intravenous Immunoglobulins – antibody therapy

When the reason behind the jaundice is maternal antibodies that have crossed the placenta and have caused destruction of the baby’s red blood cells, and when the jaundice continues to increase despite maximal phototherapy, the baby is given a large intravenous load of antibodies that “block” the maternal antibodies and prevent the destruction of the baby’s red blood cells.

Plasma exchange

The last line of treatment for jaundice.
When the bilirubin levels continue to rise despite intensive phototherapy and they reach values that are very high, plasma exchange is carried out. Just like the name states, a certain volume of blood is exchanged with matched blood for the blood bank and by doing so bilirubin is simply removed from the blood. The procedure has possible complications, and we try to avoid it as much as possible with the help of the treatment options I mentioned before. Not done very often.

Should circumcision be delayed because of jaundice?

Medically speaking, if your pediatrician believes that your child’s jaundice is physiological and is not related to a liver disease, a significant destruction of red blood cells or any other significant medical problem that requires workup and treatment then there is no reason for you not to proceed with circumcision because of the infant’s jaundice (there may be reasons other than jaundice for why circumcision should be postponed, see more in this link here).
Furthermore, if the jaundice is indeed not dangerous, then the actual bilirubin value that was measured is not significant either. I know that many Rabbis want the baby’s bilirubin levels to be below 12 or 12.5 or even 15 (they each have their own cut-off) but this has no medical basis and medically speaking it does not matter whether the baby’s bilirubin is 10.7, 11.8, 12.9 or 13.4 when the jaundice is uncomplicated and not dangerous.
It is true that at higher values of bilirubin, pathological jaundice that requires meticulous monitoring and treatment should be considered, as I mentioned earlier.

What should we do with an infant who has jaundice and has been discharged from the hospital?

Now that we have learned all the material related to jaundice, let’s try and summarize what needs to be done practically.
Remember how before discharge the babies undergo screening tests for jaundice with the help of the transcutaneous device?
– If the device yields a high value, a blood test is done and the parents are told when they need to do a repeat test, depending on the results (according to the Bhutani curve):
o Low risk – clinical follow up within 48-72 hours at the pediatrician’s office who will then decide whether a repeat test is required (either transcutaneous or blood test).
o Low intermediate – clinical follow up within 48 hours at the pediatrician’s office, who will then decide if there is a need for a repeat test (transcutaneous or blood test).
o High intermediate – this risk level requires a repeat test within 24 hours and a workup for jaundice as we mentioned above.
o High risk – this requires an immediate laboratory workup as well as determining whether phototherapy and continuous monitoring of bilirubin levels several hours later at the hospital are needed.
– Some babies are treated with phototherapy during hospitalization. These babies also usually undergo a workup for jaundice and the parents receive a set of guidelines from the hospital regarding the next bilirubin test depending on the results of the workup that was done.
– If the values are not high, you will be told when you should see your pediatrician. The usual recommendation is within two days. At the pediatrician’s office the child will undergo his first checkup and the pediatrician will determine the need for either a transcutaneous test or blood test, depending on the intensity of jaundice and the chances of developing severe jaundice. After receiving the first results, the pediatrician will determine the need for follow up measurements according to the classification I mentioned above.
– An infant who has significant jaundice in their second week of life will need to undergo blood tests to measure the level of bilirubin and a complete blood count. At bilirubin levels below 13, there is no need for repeat tests. If the bilirubin values are between 13 and 15, the infant will be asked to return for follow up within 48-72 hours. Values above 15 require a full laboratory workup as I mentioned above.
– Prolonged jaundice – jaundice that lasts for longer than 2 weeks needs to be assessed. One should make sure that a jaundice workup, similar to the one I mentioned, was carried out and sometimes additional tests are also required to rule out the various causes of jaundice. And this is certainly also true for jaundice that lasts 3 weeks or 1 month.