母乳喂养、胆红素与黄疸 (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:

婴儿在出生后的几天内出现黄疸是很普遍和正常的。引起宝宝皮肤变黄的胆红素有保护作用的（它是一种抗氧化剂）。我们经常在一种恐慌状态下对高于平均胆红素水平的黄疸进行治疗。很少有人会在婴儿出生之后、出现黄疸之前常规的去观察宝宝在乳房上吃奶的情况。一旦婴儿的黄疸水平开始让病房的医务人员担心，解决方案几乎总是光疗而忽略了真正的问题：

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.

宝宝喝奶的情况好吗？宝宝是真的正在从母亲的乳房得到乳汁，还是只是把乳房放在嘴里做出吸吮的动作但还没有吃到奶？宝宝还没吃到奶正是因为这时他把乳房放在嘴里正在吸吮乳房。如果大家知道如何分辨宝宝的含乳姿势好不好以及实际上吃没吃到奶，那么接下来发生的一切都会有所不同。如果一个出现黄疸的宝宝吃奶情况不好，他需要得到母乳喂养方面的帮助。

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?

宝宝在出生后的头几天出现黄疸是正常的（虽然通常不会在第一天出现）。引起宝宝皮肤变黄的胆红素水平通常在第三天达到峰值，然后降下来。因为这是正常现象，所以被称为“生理性黄疸”。那么胆红素是从哪里来的呢？

Mothers used to breastfeed in the middle ages also
在中世纪母亲们也进行母乳喂养

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.

胆红素是在衰老的红细胞死亡并释放出血红蛋白时形成的。血红蛋白中的球蛋白被回收，与血红素分离。因为分离出的血红素是有毒的，身体就想清除它，所以会分解血红素并从中回收一个铁分子，形成一种叫做胆绿素的化合物。 胆绿素又被一种酶转化成胆红素。新生儿出现黄疸的原因是由于胎儿和新生儿的血红蛋白与成人的有所不同：

• 与成年人相比，胎儿和新生儿的血红蛋白寿命要短得多（胎儿的血红蛋白的寿命平均是80天，成人的血红蛋白平均寿命是120天）
• 新生儿体内有大量的红细胞，平均比成年人多很多
• 婴儿的肝脏可能还没有能力去处理所有的红细胞。

How bilirubin is formed from dying red blood cells
从衰老的红细胞形成胆红素的过程

How bilirubin is formed from dying red blood cells
从衰老的红细胞形成胆红素的过程

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.

其实身体本来可以不生成胆红素，因为胆绿素，也就是生成胆红素的前一个步骤的生成物，是很容易被身体清除掉的。然而胆红素确实被生成了。身体不会无缘无故这样做。事实上，为了从胆绿素生成胆红素，身体所花的能量成本是相当可观的。每一分子胆绿素都会消耗一分子的NADPH（还原型辅酶 II）才能被化成胆红素。如果你们在学校里学过生物化学并且还记得，就应该知道NADPH具有强大的能量。

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.

胆红素是一种抗氧化剂，有很好的证据表明轻度至中度胆红素水平有助于保护我们的细胞免受氧化应激。有一个有趣的关联，有一种叫做吉尔伯特综合征的遗传性疾病（一种导致胆红素长期温和上升的疾病），患者的胆红素要高于平均水平，但同时动脉粥样硬化的发生率比较低。动脉粥样硬化现在被认为是一种炎症性疾病。吉尔伯特综合征的患者在感染或紧张情况下，胆红素水平会升高。这再次表明胆红素具有保护作用。那么出生3、4天的胆红素过高的宝宝是否也是如此呢？如果一个母乳喂养的宝宝胆红素水平高于平均值，通常意味着宝宝的喂养情况不好。解决方法是帮助母亲改善母乳喂养让宝宝能够得到更多乳汁：改善宝宝的含乳姿势、使用乳房按压的方法、如果需要，用辅助喂奶器给宝宝添加补充物。宝宝的问题不是胆红素，而是摄入不足。胆红素是一个“无辜的旁观者”。因为脱水、酸中毒等代谢异常而导致脑损伤时，胆红素就背了“黑锅”。其实脱水和酸中毒等都是由严重的喂养不良引起的。光疗可能会让胆红素水平降低，但并不能解决根本问题。根本问题是婴儿喂养不良。 如果在情况恶化之前改善母乳喂养，大多数情况下其实不需要进行光疗和添加补充物。

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.

对于ABO血型不兼容或其它不兼容的情况，如果宝宝母乳喂养情况良好，没有理由添加补充物。额外的添加意味着母乳是造成黄疸的原因，但实际上并非如此。溶血性黄疸的问题来自于红细胞的快速分解，而不是母乳。如果宝宝母乳喂养情况不好，首先要做的是帮助母亲和宝宝改善母乳喂养。

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.

正是由于上述原因，就像大多数的医生似乎相信的那样，对纯母乳喂养的婴儿来说，出生后直到3个月或更长的时间会出现的所谓的“母乳性黄疸”不是什么问题。如果婴儿母乳喂养的情况良好、喝奶情况很好（宝宝喝奶喝得很好）、体重增长情况良好、并且没有肝脏问题的迹象（这会导致另一种黄疸），那么，“母乳性黄疸”是一个好现象，胆红素会起到保护婴儿的细胞的作用。

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

如需母乳喂养方面的帮助，可以向我们的诊所预约。