Breastfeeding, bilirubin and jaundice

It is usual and normal for babies to become jaundiced in the days after birth.  But the bilirubin that causes the yellow colour of the baby’s skin is protective (it’s an antioxidant) and too often we treat higher than average bilirubin levels in a sort of panic state. Hardly ever does anyone routinely take time to watch babies drinking at the breast right after birth and before they become jaundiced.  Once the jaundice becomes a worry for the staff on the ward, the solution always becomes phototherapy which misses the real issue:


Is the baby breastfeeding well? Is the baby actually getting breastmilk from the breast or is the baby just holding the breast in his mouth and making sucking motions without drinking?  A baby is not getting breastmilk from the breast just because he has the breast in his mouth and makes sucking movements.  Knowing how to tell whether the baby is latched on well and actually getting breastmilk makes a difference to everything that should happen next. If a jaundiced baby is not drinking well at the breast, that baby needs help with breastfeeding.


It is normal for babies to have jaundice during the first few days of life, (though not usually on day 1). The bilirubin which causes the yellow colour of the baby’s skin rises to a peak, usually on the third day of life and then decreases. It is called “physiologic jaundice” because it is normal. Where does the bilirubin come from?



breastfeeding art

Mothers used to breastfeed in the middle ages also


Bilirubin is formed when old red blood cells die and release their hemoglobin. The globin part of the hemoglobin is recycled leaving heme, which is toxic and the body wants to get rid of it. So it breaks down the heme to salvage an iron molecule from it, and forms a compound called biliverdin. The biliverdin, in its turn, is transformed by an enzyme into bilirubin. The jaundice that occurs in newborns is due to the fact that the hemoglobin of the fetus and newborn is different from that of the adult and has a much shorter life span than the hemoglobin of adults (80 days on average for the fetal hemoglobin compared to 120 days on average for the adult hemoglobin), to the fact that newborns have a lot of red blood cells, many more on average than an adult, and to the fact that the baby’s liver may not have the capacity to deal with all these red cells.


Bilirubin comes from the breakdown of dying red blood cells

How bilirubin is formed from dying red blood cells


The body does not need to make bilirubin. Biliverdin, the step before the production of bilirubin, is easy to get rid of. Yet the body does make bilirubin and the body rarely does something without a good reason. Indeed, the energy cost to the body in order to make bilirubin from biliverdin is considerable. Every molecule of biliverdin that is converted to bilirubin uses up one molecule of NADPH, and for those of you who might actually remember the biochemistry you learned (or didn’t) in school, that’s a powerful lot of energy.


Bilirubin is an antioxidant and there is good evidence that mild to moderate levels of bilirubin helps protect our cells against oxidative stress. There is a fascinating association of higher than average levels of bilirubin in an inherited condition called Gilbert’s syndrome (a condition that results in life long mild elevations of bilirubin) and a lower incidence of atherosclerosis, now believed to be an inflammatory disease. When people with Gilbert’s syndrome get an infection or are stressed, their bilirubin goes up, again suggesting that bilirubin helps protect.


So how does this all fit with the problem of too high bilirubin in a 3 or 4 day old baby? When a breastfed baby has a higher than average bilirubin level, it usually means that the baby is not breastfeeding well. The approach is to help the mother breastfeed the baby better so the baby gets more milk from the breast, done by improving the baby’s latch, by using breast compressions and if necessary, supplementing the baby with a lactation aid at the breast. The problem is not the bilirubin, the problem is inadequate feeding. The bilirubin is an “innocent bystander”, blamed for brain damage when it is the dehydration, acidosis and other metabolic abnormalities that are the problem in severe cases of poor breastfeeding. Phototherapy may bring down the bilirubin, but it doesn’t fix the problem, which is that the baby is not breastfeeding well. Fix the breastfeeding before the situation deteriorates and phototherapy and supplementation would not be necessary most of the time.


With regard to ABO incompatibility or other causes of incompatibility, if the baby is breastfeeding well, there is no reason for supplementation. This implies that breastmilk causes jaundice. It doesn’t. In the case of hemolysis, it’s the rapid breakdown of red blood cells that is the problem, not breastmilk. If the baby is not breastfeeding well, the first thing to do is help the mother and baby with breastfeeding.


It is for this reason that the so called “breastmilk jaundice” which is seen in exclusively breastfed babies up to 3 or more months after birth is not a problem as most physicians seem to believe. If the baby is breastfeeding well, drinking well at the breast (This baby is drinking very well at the breast) and gaining weight well and there are no signs of liver problems (which causes another sort of jaundice), then “breastmilk jaundice” is good, not bad, the bilirubin acting to protect the baby’s cells.


If you need help with breastfeeding, make an appointment at our clinic.


Copyright: Jack Newman, MD, FRCPC, 2017

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