by Amy Spangler
April 28, 2008

A recent article published in the February 2008 issue of the New England Journal of Medicine (NEJM), identified exclusive breastfeeding as one of two risk factors for neonatal jaundice. According to authors, Jeffrey Maisels and Antony McDonagh, “The largest group of otherwise healthy infants at increased risk for hyperbilirubinemia, are late-preterm infants and those who are exclusively breastfed [particularly if breastfeeding is not going well].”

The article includes a case report of a baby born at 37 weeks gestation following an uncomplicated pregnancy. Jaundice was first noted at 34 hours of age. The mother was described as needing “considerable help in establishing effective breastfeeding” and the baby as “exclusively breastfed.”

The baby was discharged 40 hours after birth and seen in the pediatrician’s office two days later. At that time, the baby was 11 percent below birth weight with extreme jaundice. The baby was readmitted to the hospital and treated with phototherapy—a fluorescent or fiber optic light source that reduces the concentration of bilirubin in the blood—intravenous fluids and formula supplementation. The authors acknowledged the need to “review the process of breastfeeding” and provide the mother with “knowledge and support so that effective breastfeeding can be established and continued.”

“Not” breastfeeding a risk factor for jaundice
To understand the role breastfeeding plays in the development of jaundice, you need to understand the physiology of jaundice. Jaundice is a term used to describe the yellow discoloration of the skin and the white of the eyes. Jaundice is common and affects 50 to 75 percent of newborns. When red blood cells break down, bilirubin is released into the blood; the higher the concentration of bilirubin, the more severe the jaundice. Jaundice is actually a symptom of a condition known as hyperbilirubinemia. If untreated, hyperbilirubinemia can cause permanent brain damage. So it is easy to see why efforts are made to keep the concentration of bilirubin low and the level of jaundice mild.

The liver plays an important role in removing bilirubin from the blood and excreting it into the stool. Babies are born with immature livers. This explains why the majority of babies exhibit mild jaundice during the first 5–10 days after birth. As the liver matures, the bilirubin level decreases, and the jaundice goes away.

Bilirubin is eliminated from the body in the stool, in other words, it’s pooped out! So if a baby breastfeeds poorly and nothing goes in the top, then nothing comes out the bottom. The bilirubin is then reabsorbed back into the baby’s blood.

Breastfeeding is normal
Parents need to know that breastfeeding is the normal way to feed a baby. And that breastfeeding (when effective) is not a risk factor for jaundice. A risk factor for jaundice is not breastfeeding, as demonstrated by the baby in the case report. A baby that loses 11 percent of his birth weight is not an exclusively breastfed baby, but an underfed baby.

Too often mothers and babies are separated after birth and given limited opportunity to learn to breastfeed. Studies show that when babies are placed skin-to-skin between their mother’s breasts, they not only regulate body temperature, breath rate, and heart rate, but they take in the calories they need to grow and poop.

Hyperbilirubinemia on the rise
In August 2004, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a Sentinel Event Alert titled, Revised guidance to help prevent kernicterus. JCAHO’s action was prompted by an increase in the incidence of severe hyperbilirubinemia leading to kernicterus (brain damage), an increase that seemed to parallel the increase in breastfeeding rates.

JCAHO recommended that all hospitals and health care professionals caring for newborn infants both inside the hospital and after discharge follow the recommendations cited in the updated American Academy of Pediatrics (AAP) clinical practice guideline, Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation.

A summary of the Academy’s recommendations follow:

• Promote and support successful breastfeeding.
• Establish nursery protocols for the identification and evaluation of hyperbilirubinemia.
• Measure the total serum bilirubin or the transcutaneous bilirubin level of infants jaundiced in the first 24 hours.
• Recognize that visual estimation of the degree of jaundice can lead to errors, particularly in darkly pigmented infants.
• Interpret all bilirubin levels according to the infant’s age in hours.
• Recognize that infants less than 38 weeks gestation, particularly those who are breastfed, are at higher risk of developing hyperbilirubinemia and require closer surveillance and monitoring.
• Perform a systematic assessment for the risk of severe hyperbilirubinemia on all infants prior to discharge.
• Provide parents with written and oral information about newborn jaundice.
• Provide appropriate follow-up based on the time of discharge and the risk assessment.
• Treat newborns, when indicated, with phototherapy or exchange transfusion.

Knowledge and support are keys to success
Breastfeeding is the single most cost effective strategy for preventing disease and maintaining health, but it requires knowledge and support. Even the most dedicated mothers sometimes find that breastfeeding is difficult or frustrating at first.

The time has come for parents and health care professionals, in cooperation with representatives of JCAHO, to identify national standards for breastfeeding care that all JCAHO accredited hospitals and birth centers can be measured against. You can help by communicating your support for this action and contacting a representative of JCAHO today.