Overview
Definition:
Breastfeeding jaundice, also known as early-onset breastfeeding-associated jaundice, is a type of exaggerated physiological jaundice that occurs in the first week of life in breastfed infants
It is often attributed to insufficient milk intake, leading to reduced gut motility, decreased bilirubin excretion, and increased enterohepatic circulation of bilirubin
It should be differentiated from true breast milk jaundice, which is a later-onset phenomenon and less common.
Epidemiology:
Breastfeeding jaundice affects a significant proportion of breastfed neonates, with estimates varying widely, but commonly cited to occur in up to 10-25% of exclusively breastfed infants
Risk factors include inadequate latch, infrequent feeding, maternal factors (e.g., primiparity, delayed milk onset), and infant factors (e.g., prematurity, congenital anomalies affecting feeding).
Clinical Significance:
Understanding and managing breastfeeding jaundice effectively is crucial to prevent severe hyperbilirubinemia, which can lead to acute bilirubin encephalopathy (kernicterus)
Inappropriate management, such as unnecessary cessation of breastfeeding, can have detrimental effects on infant growth, maternal-infant bonding, and successful lactation
Evidence-based management focuses on optimizing breastfeeding rather than interrupting it.
Clinical Presentation
Symptoms:
Infant presents with yellowing of skin and sclera, typically starting on the face and progressing downwards
Lethargy
Poor feeding
Decreased urine output
Decreased stool frequency or output
Irritability (in later stages if untreated).
Signs:
Visible jaundice (icterus)
Decreased muscle tone
Poor suckling reflex
Dehydration signs (sunken fontanelle, dry mucous membranes).
Diagnostic Criteria:
Diagnosis is primarily clinical, based on the timing of jaundice onset (typically days 2-7 of life), exclusive breastfeeding, and exclusion of other causes of hyperbilirubinemia
Laboratory confirmation includes elevated total serum bilirubin (TSB) levels, predominantly unconjugated, with a TSB typically > 12-15 mg/dL in breastfed infants
Bilirubin levels generally rise and then fall as feeding improves.
Diagnostic Approach
History Taking:
Detailed feeding history is paramount: frequency of feeds, duration of feeds, effectiveness of latch, signs of adequate milk transfer (e.g., audible swallowing, wet diapers, stooling pattern)
Maternal medical history and perinatal events
History of previous neonatal jaundice or kernicterus in the family
Infant's birth weight, gestational age, and any complications at birth
Assessment for factors contributing to poor intake.
Physical Examination:
Assess for jaundice using Kramer's rule or blanching of the skin
Evaluate hydration status (skin turgor, fontanelle, mucous membranes)
Assess infant's alertness and tone
Examine for any congenital anomalies that might impair feeding or suggest other causes of jaundice
Auscultate bowel sounds
Palpate abdomen.
Investigations:
Total serum bilirubin (TSB) measurement, with differentiation into direct and indirect bilirubin
Transcutaneous bilirubinometry can be used as a screening tool but is less accurate in significant jaundice
Complete blood count (CBC) to rule out hemolysis or infection
Blood type and Coombs test if hemolytic disease is suspected
Reticulocyte count if hemolysis is likely
G6PD deficiency screening if indicated by ethnicity or family history
Liver function tests (LFTs) and thyroid function tests (TFTs) if prolonged or significant direct hyperbilirubinemia is present.
Differential Diagnosis:
Physiological jaundice: Breastfeeding jaundice is an exaggeration of physiological jaundice
Breast milk jaundice: Later onset (after 7 days), typically benign, attributed to substances in breast milk inhibiting bilirubin conjugation
Hemolytic disease of the newborn (e.g., ABO or Rh incompatibility): Usually earlier onset, higher bilirubin levels, positive Coombs test, increased reticulocyte count
Neonatal sepsis: Usually associated with fever, lethargy, poor feeding, and other signs of illness
may have conjugated hyperbilirubinemia
Gilbert's syndrome: Rare in neonates, usually chronic and mild
Hypothyroidism: Can cause prolonged unconjugated hyperbilirubinemia
check TFTs
Biliary atresia/obstruction: Characterized by direct hyperbilirubinemia, pale stools, and dark urine.
Management
Initial Management:
The cornerstone of management is optimizing breastfeeding
This involves frequent, effective feeding (8-12 times in 24 hours)
Ensuring a good latch and effective suckling
Supplementation should be avoided unless absolutely necessary and with careful consideration, as it can interfere with milk supply and breastfeeding
Hydrotherapy (e.g., bathing) is not a primary treatment but can improve infant comfort.
Medical Management:
Phototherapy is indicated for significant hyperbilirubinemia based on established nomograms (e.g., American Academy of Pediatrics (AAP) guidelines)
The decision to initiate phototherapy depends on the TSB level, infant's age in hours, gestational age, and presence of risk factors
Phototherapy should be continuous, with brief interruptions for feeding and care
Ensure adequate hydration
Double phototherapy or fiberoptic blankets may be used for higher bilirubin levels or when standard phototherapy is insufficient
Exchange transfusion is rarely indicated for breastfeeding jaundice but is considered for extremely high bilirubin levels unresponsive to phototherapy or in cases of acute bilirubin encephalopathy.
Surgical Management:
Not applicable for breastfeeding jaundice
Surgical intervention is reserved for underlying anatomical issues that might contribute to feeding difficulties or complications like biliary atresia.
Supportive Care:
Close monitoring of infant's weight gain, hydration status (urine output, stool frequency), and bilirubin levels
Continued support and education for breastfeeding mothers, including lactation consultant referral if needed
Ensure adequate maternal hydration and nutrition
Educate parents on signs of worsening jaundice and when to seek medical attention.
Complications
Early Complications:
Dehydration
Electrolyte imbalances
Poor weight gain
Failure to establish adequate lactation
Increased risk of hospital readmission due to dehydration or hyperbilirubinemia
Acute bilirubin encephalopathy (kernicterus) if hyperbilirubinemia is severe and untreated.
Late Complications:
Chronic bilirubin encephalopathy (cerebral palsy with auditory neuropathy, gaze abnormalities, etc.) if kernicterus occurs
Developmental delays
Impaired cognitive function.
Prevention Strategies:
Early and frequent initiation of breastfeeding
Ensuring effective latch and adequate milk transfer
Educating mothers on signs of adequate intake
Prompt identification and management of suboptimal feeding
Close monitoring of infant weight and hydration in the first few days of life
Timely initiation of phototherapy when indicated.
Prognosis
Factors Affecting Prognosis:
The degree of hyperbilirubinemia, timeliness and effectiveness of management, and presence of risk factors significantly impact prognosis
Infants with well-managed breastfeeding jaundice, where feeding is optimized and phototherapy is used appropriately, have an excellent prognosis.
Outcomes:
With optimal breastfeeding support and appropriate management of hyperbilirubinemia, most infants recover completely with no long-term sequelae
Successful establishment of breastfeeding leads to optimal infant growth and development.
Follow Up:
Follow-up should focus on ensuring sustained weight gain, adequate hydration, and continued successful breastfeeding
Monitor for signs of recurrent jaundice or feeding difficulties
Regular postnatal check-ups are essential
Long-term neurological follow-up is usually not required unless there were signs of acute bilirubin encephalopathy.
Key Points
Exam Focus:
Differentiate breastfeeding jaundice from breast milk jaundice
Understand AAP guidelines for phototherapy initiation based on TSB, age, and risk factors
Recognize that optimizing breastfeeding is the primary management
Know the signs of dehydration and acute bilirubin encephalopathy.
Clinical Pearls:
Always assess feeding effectiveness first in a jaundiced breastfed baby
Do not advise stopping breastfeeding without a clear indication and a structured plan to re-establish it
Supplementation should be judicious
consider if the infant is dehydrated or failing to gain weight, and monitor impact on milk supply
Frequent follow-up in the early postnatal period is key.
Common Mistakes:
Prematurely advising mothers to stop breastfeeding without adequate assessment or support
Over-reliance on TSB levels without considering the clinical context (feeding, hydration, weight gain)
Not recognizing breastfeeding jaundice as an exaggeration of physiological jaundice rather than a separate pathological entity
Failing to rule out other causes of hyperbilirubinemia in persistently jaundiced infants.