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Sunday, June 28, 2009

Jaundice and the Pinoy Baby: A Follow-up

I wrote about this topic and asked for comments from a medical expert. I was lucky that Dr. Francesca Tatad-To, respected pediatrician-neonatologist AND breastfeeding advocate took time out to clarify some issues about jaundice and breastfeeding. I will not be rephrasing her answers as I might misconstrue or misinterpret them. My comments will be in (parentheses and itals)

*Please note that this discussion was based on the facts I presented to Dr. Tatad-To in connection with Naima's specific case. This is no substitute for medical advice given after an actual examination by a board certified doctor of your particular case. This post is for informational purposes only.
Physiologic jaundice follows a pattern - bilirubin increases until it reaches a peak level of about 14 mg/dl at the 5th day of life and then slowly declines. By the 14th day it should be at low levels (less than 10mg/dl) if there is any jaundice at all.

Breastfeeding jaundice, which is jaundice from inadequate caloric intake, common in the first few days of breastfeeding, resolves with more frequent nursing and should really be resolved within the 1st week of life. If it extends beyond this then this is no longer simple breastfeeding jaundice and needs to be addressed. As you know, it is normal for breastfeeding moms to produce small volumes in the beginning but this increases by the 3rd to 5th day, at which time breastfeeding jaundice should begin to resolve.

There are other causes of jaundice, not all are related to breastfeeding. One of the most common causes is G6PD deficiency (glucose 6 phosphatase dehydrogenase), a very common defect in the red blood cells that causes increased bilirubin production. This occurs in 1 in every 50 Filipinos, more commonly among males though. (Naima's Philippine pediatrician, Dr. Mianne Silvestre - also a breastfeeding advocate, suspected G6PD deficiency and requested that a test be conducted. Naima's test was negative - which means she was not deficient.)

Jaundice is concerning because a baby's ability to eliminate bilirubin, is poor. This means that it accumulates in the blood and at certain levels (we think around 25 mg/dl), it may actually enter the brain and cause long-term damage.

The treatment for bilirubin that is elevated ABOVE NORMAL/acceptable for age, is phototherapy - exposure to a special kind of light that turns bilirubin into a form that the baby can excrete. In serious conditions, a procedure called an exchange transfusion is necessary - the baby's blood is removed and exchanged with donor blood simultaneously. (Luckily, Naima's jaundice was resolved with phototherapy and didn't require exchange transfusion.)

We cannot pinpoint exactly what it is that causes breast milk jaundice, but many scientists feel that it is due to the presence of certain substances in breastmilk. These substances prevent the baby from breaking down bilirubin. THE PROBLEM HERE IS NOT A LACK OF MILK. THIS ALSO HAS NOTHING TO DO WITH THE QUALITY OF A MOTHER's BREAST MILK. It is a problem the baby encounters in metabolizing bilirubin. Temporarily withholding breastmilk for a period of no longer than 48 hours is normally sufficient treatment. It is important to know that breast milk jaundice cannot be prevented. However, babies with breast milk jaundice are expected to recover fully. There is no reason for a mother of an infant who develops breast milk jaundice to stop nursing completely. Breastfeeding should resume once bilirubin levels have decreased to an acceptable level. Once this occurs, bilirubin is no longer expected to climb to dangerous levels. The idea behind giving formula is that the baby's enzymes take a break, and can work harder once you resume breastfeeding/giving breastmilk in a day or 2. It is only necessary to stop breastfeeding when the bilirubin level is above normal or puts the baby in danger. If a baby is mildly yellow and the bilirubin level is low (let's say 10 mg/dl) then there is no need to worry as eventually, the baby will eliminate all excess bilirubin on its own.

While jaundice is very very common, it is a serious concern that should not be dismissed. When poorly managed, it can lead to life-long motor deficits and in the worst case, severe brain damage and death. (emphasis mine)

In physiologic jaundice, there is no treatment necessary. For other pathologic causes where bilirubin is elevated above normal, treatment with phototherapy is the gold standard. Water or sugar water have no place in the treatment of jaundice.
The treatment for breastfeeding jaundice is to feed more often, and the treatment for significant breast milk jaundice is to temporarily stop providing breastmilk.

The crucial points to determine in all cases of jaundice are 1)is it serious? (are levels above normal) 2) what is the cause and 3) does it require treatment. (emphasis mine)

The diagnostic test and treatment for breast milk jaundice are the same. If you stop breastfeeding for 2 days and the bilirubin comes down significantly then it's breastmilk jaundice. Stopping breastfeeding should not cause bilirubin levels to drop significantly in any other form of jaundice that occurs at that time period.
So if your baby had elevated levels (particularly as high as 24 mg/dl) and all your pediatrician did was to stop breastmilk for 2 days and it dropped to normal/acceptable then that was definitely breastmilk jaundice. (When Naima was discharged from the hospital, 2 days after birth, her bilirubin level was 9.8 mg/dl. Naima's bilirubin level at day 14 was 24.8 mg/dl. She was re-admitted to the hospital, placed under phototherapy and given exclusive formula. I was asked to express my milk. Within 24 hours, her bilirubin went down to 11.6 mg/dl.)

There is no other 'benign' cause of jaundice at that age (14 days) that would have bilirubin levels that elevated.

*Please note units of bilirubin as sometimes results are relayed in S.I., a different unit of measure

Bilirubin is almost never static. It's not like you get a high level and it stays that way. In brand new babies, it is either on it's way up or on it's way down, so every level/test result has to be taken in that context.
Another way of determining if breastfeeding jaundice/starvation jaundice was truly a factor is to look at her weight at the time and her poop/pee patterns. If her weight at 14 days was not significantly lower than her birth weight, it probably was not breastfeeding jaundice. (Naima's birth weight was 6lbs 5oz. At 14 days, her weight was 6lbs 90z.) Breastfeeding and breast milk jaundice do not co-exist as one is from starvation and the other is from when milk starts to increase in volume.
*Dr. A.M. Francesca Tatad-To specializes in pediatrics and newborn medicine. She can be reached at The New Medical City and also serves as medical consultant to L.A.T.C.H.

What I would like to emphasize is that jaundice is never a reason to end a breastfeeding relationship. I believe that you need to read and know about your baby's condition so you will understand why your doctor is prescribing a certain course of action and not just accept everything blindly. You also must WANT to continue to breastfeed despite this initial set-back. Tell your doctor about your plans and work with him/her towards re-establishing your milk supply and the breastfeeding relationship.


Unknown said...

Hi good post - very detail info for sharing. I was having the same situation like you actually. I have 2 children - both are exclusively breastfed. Both were diagnosed with pro-longed jaundice as they were having jaundice for more than a month. My first child, was even admitted twice to the NICU for photo-theraphy. But I'm glad that despite the jaundice, I was not being asked or requested to stop breastfeeding. The doctor even told me to keep on breastfeeding, so that the bilirubin can be expelled from the body faster. But I was going to the baby-friendly hospital where breastfeeding was strongly being encouraged. I think if I did not go to the baby-friendly hospital, maybe the doctor will say the same thing as in your previous post - to stop breastfeeding. Now my children are 3 yo and 1 yo. They are both healthy and happy children. :)

Melodie said...

Thank you for this. I learned a lot! :)

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