So-called Breastmilk Jaundice
See the article on early onset jaundice.
So called “breastmilk jaundice” is considered abnormal by many physicians, perhaps even the majority of physicians. Even those who understand that it is usually normal for babies of 3 or 6 weeks of age to have visually obvious jaundice, may, due to the general fear of jaundice, advise the mother to interrupt breastfeeding for 24 to 48 hours in order to “prove” that the problem is due to breastfeeding. I have been contacted by mothers who were told they needed to interrupt breastfeeding for a week, and occasionally even completely because of this “problem”.
In fact, stopping breastfeeding and giving formula by bottle for even 24 to 48 hours can cause significant problems with breastfeeding, and stopping the breastfeeding for a week may mean stopping the breastfeeding altogether for this baby. Where the notion of stopping breastfeeding for a week comes from is obvious. The idea is that stopping breastfeeding for 24 to 48 hours is to “prove the jaundice is due to breastmilk”. But when a doctor says to a mother that she must stop for a week, the doctor is saying “Oh no, jaundice! Bilirubin is so dangerous! It will take a week to get rid of the jaundice.”
It is typical of babies with “breastmilk jaundice” to be bursting with obvious good health. There is nothing in the baby’s story of concern, no physical findings of concern and observation of the feeding shows a baby drinking very well at the breast.
On the other hand, a baby who is jaundiced because he is not getting enough from the breast may remain jaundiced into the second and even the third week of life, so one cannot simply assume that a baby of 2 or 3 weeks of age who is jaundiced has “breastmilk jaundice”. Interestingly enough, most exclusively breastfed babies who are not getting enough from the breast are not jaundiced.
Bilirubin is an antioxidant, a powerful cytoprotectant and there is good evidence that mild to moderate levels of bilirubin may protect the body against oxidative stress. There is a fascinating association of higher than average levels of bilirubin in an inherited condition called Gilbert’s syndrome and a lower incidence of atherosclerosis, now believed to be an inflammatory disease. This has been known for many years. One physician with whom I trained in 1970 had Gilbert’s syndrome and he lorded it over us because he kept insisting his risk of myocardial infarction was much lower than ours. And he always looked as if he had a nice tan, 12 months of the year. In fact, people with Gilbert’s are apparently otherwise normal. Frequently, the jaundice is not really noticeable in such people, but with infection or stress, the bilirubin may rise. Interesting? Maybe bilirubin is a good thing, rising to protect the individual.
If there is any question that the baby may have liver disease, a serum bilirubin, asking for both indirect and direct levels of bilirubin should be done. It is usually easy to suspect liver disease causing jaundice. The baby’s urine is often brownish and the bowel movements are paler than usual, though this is not so easy to notice as a baby’s bowel movements are paler than an adult’s. The most common cause in a newborn baby is a condition called biliary atresia, where the ducts leading from the liver to the baby’s intestinal tract are blocked. On physical examination by a physician or nurse practitioner, the liver is usually enlarged and the spleen is also often enlarged as well.
The baby in this photo is 7 weeks old. He was born slightly premature at 36 weeks gestation. Surprisingly he was exclusively breastfed in hospital, which would be unusual in most hospitals, where too often such a baby of 36 weeks gestation, in spite of no medical problems, would automatically receive formula. Why? Because such a baby is at risk of low blood sugar. Ah, no, that is not really true, not if he is breastfeeding well.
Here are his weights: At birth 2.87 kg (6lb 5oz). At 7 weeks when I first saw 4.57 kg (10lb 1oz). I think all will agree that the weight gain is quite good.
So what did I do?
I did not worry the mother by saying that the jaundice was a problem.
However, I did tell her that it was normal for many exclusively breastfed well gaining babies to be jaundiced so that if anyone did worry her about it she wouldn’t worry (interestingly, the mother had not noticed the jaundice).
I did not do any blood tests, but I did ask about the colour of the urine and I did examine the baby’s abdomen to make sure the baby did not have a big liver and spleen.
I did not tell her to interrupt breastfeeding and I urged her to continue exclusive breastfeeding.
I did help her to overcome her sore nipples. That was easy, simply by helping her adjust how the baby was latching on.
The following photo shows a 1 month old exclusively breastfeeding baby with “breastmilk jaundice”.
Unlike the previous baby, this baby’s mother was under pressure to stop breastfeeding both from the baby’s doctor and from the mother’s family. There was no reason to stop breastfeeding, even for one feeding.
And here a 16 day old with jaundice who is breastfeeding beautifully. Unfortunately, I did not manage to film this baby in time to show how well he was drinking. But he was drinking a lot of milk. Remember how to know a baby is drinking well (pauses in the chin)
So why not interrupt breastfeeding for 48 hours in the above babies?
Well, it is definitely easier for the doctor, true, but….
Not necessarily easier for the mother. It’s easy to say that the mother express her milk while the baby is being fed formula, but not always easy for the mother to do so. Sometimes mothers become painfully engorged despite the pumping.
Not necessarily easier for the baby. Here is a secret. Many babies do not respond well to formula. We don’t hear much about the negative effects of babies drinking formula. For example, many vomit formulas. Some, even by 3 weeks of age will not drink from a bottle.
May undermine the mother’s confidence in breastfeeding and breastmilk. Mothers get messages from public health departments, from magazines, from their doctors that “breast is best”. But when the baby has “breastmilk jaundice”, “you need to stop breastfeeding and give formula”. What’s the message? Breastfeeding is dangerous.
May result in breastfeeding difficulties. The common myth amongst many health professionals that there is no problem with giving breastfed babies bottles. How can they think this if they had any experience with breastfeeding and helping breastfeeding mothers? It can only come from the idea that breastfeeding and bottle feeding are the same. Of course, there is no lack of various companies flogging their bottles as “just like breastfeeding” but that’s marketing and not true.
May result in the mother thinking: “My milk is dangerous for the baby”. Many doctors will use the “brain damage” card if the mother is reluctant to stop breastfeeding, but even pushing the mother to stop breastfeeding is enough to plant the seed in the mother’s mind that breastfeeding is dangerous.
“My baby is getting all these tests done”. Some mothers have stopped breastfeeding in order to stop the baby being stuck for blood every few days. And what information comes from these tests? Rarely, if ever, does the physician get any more information than the level of the bilirubin that day. And how does that change the situation?
A sad case and a good question, the first from a mother’s personal blog, the second from an email
- “My nipples looked like hamburger meat, yet I kept going. I wanted to succeed. Then his pediatrician told me he had breast milk jaundice. She gave me 3 cans of formula and told me to take him off breast milk for 3 days and feed him the formula instead. I was distraught. All I could think was “I have gone through all of this to breast feed him and here I was poisoning him the entire time” (my italics). His jaundice cleared up in 2 days and I quit breastfeeding. I lost all control over my emotions in the parking lot of the doc’s office and called my husband to tell him I will never breastfeed again for as long as I live.”
My comments: Well, if the mother’s nipples were sore, then the baby did not have a good latch. This is not “maybe the baby had a poor latch”. The baby definitely had a poor latch! And much could have been done to help the mother. In fact, it’s often very easy to help a mother with sore nipples, if one knows how. But then what do most doctors know about helping mothers? Most know nothing.
What did the pediatrician do to help this mother? Nothing, it seems. It sounds as if she did not even bother to refer her to someone who could help her. I guess this is yet another pediatrician who believes that it is normal to have sore nipples when breastfeeding. Does the pediatrician really believe that the fact that she is a pediatrician mean that she cannot help the mother because “the baby is my patient, not the mother”? A breastfeeding mother and baby are a pair, a dyad, a couple, intimately connected to each other and because of that, the mother is also the pediatrician’s patient. The mother is the pediatrician’s patient because this pediatrician probably learned only one thing in her training: Breast is best. So if the mother stops breastfeeding, she is taking away from the baby the best feeding, which is breastfeeding. Many mothers with the sort of pain this mother had, would have quit well before she went to the pediatrician. But “breastmilk jaundice” was the last straw, it seems.
As mentioned already in this chapter, “breastmilk jaundice” is not only not bad for the baby, but actually is probably good. But “breastmilk jaundice” and three cans of formula sealed the fate of this mother’s breastfeeding. And because of the poor latch, it is possible the baby actually was not getting enough milk and the problem wasn’t “breastmilk jaundice” at all, but rather “not enough breastmilk jaundice”.
And the pediatrician gave the mother 3 cans of formula? That is appalling. That is not help. And it’s not a gift, because this mother will now spend a lot of money in the next months to pay for that “gift”. Who gains? The formula company, of course, because chances are the mother will then go on to buy the same brand of formula for the entire time the baby is formula fed. By what right does this pediatrician become a marketing agent for formula?
What message did the mother receive from this simple exchange with the pediatrician? “I have gone through all of this to breast feed him and here I was poisoning him the entire time”. Poisoning her baby with bilirubin! Well done doctor. And not surprisingly, she will not breastfeed any of her babies to come.
- “I think it is a bit odd that the doctors were really adamant about feeding him every 3 hours in the hospital and making sure he was nursing really well before we went home and now they think that is what is making him sick. I guess what I am emailing you for is to see if I can get a clearer explanation for this and for my child’s affliction.”
My comments: Maybe these doctors are more supportive than the pediatrician in the previous case, but maybe not. Yes, they want to make sure the baby feeds well, a worthy goal. But they may be nervous and worried about breastfeeding working out because they don’t know what to expect from breastfeeding and don’t know how to know a baby is getting milk. As with many doctors and other health professionals, they believe in the numbers. But it’s not how frequently a baby drinks, it’s how well the baby drinks. A baby who drinks well 6 times a day is better off than a baby that drinks poorly 8 or 10 or 12 times a day. See chapter 2 for how to know a baby is drinking well at the breast.
And what message did the mother get from the doctors? That breastmilk makes your baby “sick”. Not just sick, but the baby has an “affliction”, a word of Biblical resonance. Something like the 11 plagues of Egypt: Blood, frogs, lice, jaundice…
Need help with breastfeeding? Make an appointment at the International Breastfeeding Centre.
Copyright: Jack Newman, MD, FRCPC. 2017