Jaundice and Breastfeeding in Full Term Healthy Babies

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https://sites.google.com/site/problemysdojcenim/jaundice---article-in-english


Jaundice and breastfeeding

Jaundice is a result of many changes that occur in the baby’s body due to the adaptation to the extrauterine life. The main reason is that many red blood cells become abundant and are broken down releasing bilirubin which causes yellowish discoloration of the skin.

Is jaundice a disease or a health problem? Is jaundiced baby in danger? When is it reasonable to intervene and decrease the levels of bilirubin by treatment?

Standard progress of newborn jaundice differs by the food the baby gets


Breastfed babies

Majority of healthy, exclusively breastfed babies who gain weight well has elevated bilirubin levels reaching its maximum in the first week of life and gradually lowering, and lingering in minor degree up to the third month of life or longer.

We like to say that breastfeeding is natural and the breastmilk is considered to be the most suitable food for an infant. If this is really true we should also accept that if majority of breastfed babies are jaundiced, often up to the third month of life, this condition is not a disease, it is normal, even beneficial for the health of the baby. Many studies show that elevated bilirubin levels are important for the newborn as the bilirubin is a powerful antioxidant.

Breastmilk helps the baby to keep the elevated levels of bilirubin which is physiological (natural, normal). That doesn’t mean that breastfeeding and breastmilk make jaundice worse.


Formula fed babies

Majority of healthy term newborns who are partially of fully formula fed are not jaundiced, at least not so much as the breastfed babies. If we believe that the norm is breastfeeding, jaundice in the majority of breastfed babies should not be considered a disease, what should be considered a problem is the absence of newborn jaundice in the formula fed babies. The antioxidative properties of bilirubin help the organism to get rid of free radicals that arise in the body. Formula fed baby has lower levels of bilirubin when compared to the baby receiving natural food (breastmilk). Therefore this phenomenon can be regarded as one of many undesirable side effects of feeding an infant with formula in the period when every baby should not receive anything except breastmilk.

Another issue is that breastfed baby isn’t effectively breastfed just because he is takes the breast. Babies can just pretend to breastfeed and in fact just nibble on the breast most of the time they spend there and drink not enough breastmilk. Unfortunately, this is common in most of the newborns. The cause is not the fact that mother has no milk after birth - a common myth about breastfeeding since almost all mothers produce breastmilk since the 16th week of pregnancy and at the time of birth there is enough colostrum in their breasts. The real cause is that we interfere with the natural start of breastfeeding so much that the baby’s ability to latch correctly is weakened and the baby can’t get enough milk. These babies can have and often have unusually high bilirubin levels which is one of the symptoms of the fact that the baby actually drinks borderline amounts of breastmilk. This is the most common cause of serious newborn jaundice due to which majority of newborns undergoes therapy. Treatment of this problem should not include lowering bilirubin levels but rather fixing the breastfeeding with an experienced lactation consultant.

Even more appropriate approach would be to prevent this problem from happening – by natural birth without unnecessary routine and preventive interventions, by placing the baby on mother’s abdomen skin to skin right after the birth allowing the baby to crawl to the breast all by himself and to breastfeed as long as he wishes, breastfeeding on demand without any routine separation of the mother and baby afterwards and not using any artificial nipples (bottle, pacifier of nipple shields). By preparation for breastfeeding we can help the baby to have a normal, physiological newborn jaundice beneficial for his health.


Does bilirubin really damage baby’s brain?

Not likely. This hypothesis was never tested and proved. On the contrary, there are some proofs that indicate that this assumption is not correct. It is not important to be fixed on the bilirubin levels, what seems to be important is how and why does the bilirubin get to baby’s brain. It is proved that bilirubin can not cross the barrier between blood and brain no matter how high the levels are when this barrier is intact – which it is as long as the baby is healthy. When the health of a baby is compromised by some serious factors, the blood-brain barrier can become impaired and some compounds (also bilirubin) from the blood can enter the brain of this baby. It is likely that the damage of brain cells is caused by some toxic chemicals that cross blood-brain barrier and afterwards bilirubin deposits in the brain cells that are already dead. Which means that bilirubin probably works just as a colourful marker of the fact that the brain cells were previously damaged by some serious health problems. If this theory is truly correct than jaundice never is a problem and should never be treated, and rising levels of bilirubin are just an indicator of the fact that the baby has some health problems which should be treated. However this is just a theory and it probably never will be proved as it is not ethical to test this hypothesis on babies. Therefore therapy is indicated for preventive means when the bilirubin levels exceed the level of 342 µmol/l in healthy and term newborn.


The fear of jaundice comes from the past

Many health professionals still remember terrible complications linked with a massive breakdown of red blood cells that often happened in the past when Rh negative mother had Rh positive child (Rh incompatibility). Rh incompatibility was linked with elevated bilirubin levels and many serious health problems of the baby that caused lifelong health disability (including brain damage) or even death. In the countries with a good health care system this problem almost vanished 30 years ago and currently threatens only a very small percentage of infants. Baby can be endangered if the antenatal care is neglected, if mother’s pregnancy is not observed early and the Rh negative mothers are not monitored. At present, Rh incompatibility can be prevented which is one of the biggest triumphs of medicine.

However, elevated bilirubin levels still do occur as a symptom of some other diseases, just like fever rises when one has flu. Fever (precisely as bilirubin) helps the organism to better cope with the disease. The look on jaundice however remained twisted - the symptom is regarded a cause of the problems.

Another reason why it is common to consider normal newborn jaundice a disease is the fact that the formula fed baby who usually doesn’t display jaundice is considered a norm, a model. Majority of breastfed babies has higher bilirubin levels than the formula fed babies. Instead of considering breastfeeding a norm, many breastfed babies undergo risky therapy in an effort to decrease the amount of bilirubin to the level which is normal in the formula fed babies.


Majority of babies undergoes therapy unnecessarily

Treatment of jaundice is associated with longer hospital stays for mother and child, increased medical and hospital costs, disruption to the early relationship between mother and baby, compromised breastfeeding, and a great deal of anxiety all around. If the approach to jaundice abides by the current scientific knowledge, only a small percentage of newborns will be treated.

Most of the hospitals treat jaundice because of the fear that bilirubin could damage baby’s brain, if the levels of bilirubin are too high. However, the hypothesis about bilirubin being harmful was never tested and there is not a single proof for the accuracy of this theory in scientific studies.

Actually, there is a growing number of evidence that bilirubin is an important antioxidant which has been demonstrated to scavenge potentially toxic free radicals from the body just like vitamin C or E do. With elevated levels of bilirubin the organism of a newborn (and an adult as well) can cope better with some diseases or with stress.

In spite of this, jaundice is feared about as if the elevated bilirubin levels were truly harmful for the health of the baby. Scientific studies however proved clearly that if the newborn is term and healthy bilirubin levels up to 342 µmol/l will not damage brain or the health of the baby.

Safety of the bilirubin levels rising above 342 µmol/l were not studied by any controlled scientific studies. There are only case studies about babies whose bilirubin levels higher exceeded 342 µmol/l even up to 855 µmol/l. If the babies were healthy and term all of them survived these extreme high bilirubin levels without any health problems (in short-term or long-term consequences).

Jaundice experts Jeffrey Maisels and Tom Newman elaborated a review considering all the data available on this topic and they found out that as long as the infant is healthy and term, the fear of bilirubin, no matter how high it rises, is not supported by any evidence. Maisels and Newman recommend changing the traditional approach to jaundice treatment since according to their review there is no proof about the efficiency of the treatment and the treatment is not without risks. They recommend that a healthy and term infant should not be examined for jaundice routinely. Only when there is a suspicion that the baby has abnormal bilirubin levels, check up is in place and the treatment is recommended only in case that the bilirubin levels exceed 342 µmol/l and are still rising. The aim of the treatment of otherwise healthy and term newborn should be to keep bilirubin below 500-400 µmol/l.

According to the available data, bilirubin levels close to 342 µmol/l is observed in 0.5-1 % of the babies. However, treatment of jaundice is recommended when the bilirubin levels are lower than 342 µmol/l in large number of infants. What benefits should provide these interventions when it is clearly proved that bilirubin levels up to 342 µmol/l are not harmful for the brain of a healthy baby is not clear.


Therapy of jaundice



Don’t stop breastfeeding because of jaundice!

Some interventions should never be used for jaundice treatment – no matter how high the bilirubin levels are, whether the children are healthy or ill, term or preterm. This includes all interventions for which breastfeeding is stopped and the baby is given formula, boiled breastmilk or any other food instead of breastmilk. Efficiency as well as safety of these methods were not proved by scientific studies. What’s more, these interventions can seriously jeopardize the success of breastfeeding making them potentially harmful for the health of the baby.

Almost always are these interventions recommended for the babies of which bilirubin levels do not reach the 342 µmol/l. However, safety of these levels of bilirubin for healthy and term newborn is proved babies just like the risks of unsuccessful breastfeeding and feeding newborn with formula to baby’s health. Therefore, the risks of using these methods without any doubt outweigh their positive effects – there are none.

These methods are misused due to incorrect interpretation of the fact why they actually decrease the levels of bilirubin

These methods started to be recommended when some studies were published which stated that elevated bilirubin levels are seen more often in breastfed babies and that the decrease of bilirubin levels occurred faster when the babies were temporarily fed formula by bottle. This led to incorrect conclusion that breastfeeding makes jaundice worse. The reality however is completely different:

Abnormal bilirubin levels for which therapy is considered occur most commonly when the baby gets not enough milk by breastfeeding – when the baby mostly nibbles on the breast without sufficient milk intake.


How can it happen that the baby gets not enough milk by breastfeeding?

Many mothers think that breastfeeding as a natural source of food for their babies is successful all by itself, that they just put the baby to the breast and that’s it. This notion is basically correct so long as the birth and the start of breastfeeding are not influenced by routine and preventive interventions that can weaken the baby’s ability to latch on well. Too many babies have difficulties with breastfeeding after the baby is not given a chance to crawl to his mother’s breast and latch on by himself. Rooming-in for 24 hours a day is also not available in many hospitals and artificial nipples (pacifier, bottle or nipple shields) are misused without considering how badly it affects breastfeeding.

Baby is not born with the ability to breastfeed. Baby only has a sucking reflex. For successful breastfeeding from day one after birth a correct latch is necessary and these negative interventions weaken the ability of the baby to latch on well. The baby is willing to take the breast but sucks just the nipple and he gets only borderline amounts of colostrum. It can hardly be said that this baby is breastfed. More proper would be to say that the baby is nothing-fed. Baby soon becomes hungry, dehydrated and exhausted and thereupon extremely sleepy.

Mothers try to do their best to wake the baby up and when they do, baby takes the breast, nibbles few times and falls asleep again. The only way to wake up a sleepy newborn is the flow of milk and when the baby is not latched on well, he will not get enough colostrum especially in the first few days when the mother’s milk supply is not abundant (there is enough colostrum in the breasts, but the only way to get it in the first three or four days is a correct latch). Poor milk intake becomes evident when the baby still passes black stool (meconium) on the 4th day after birth. If breastfeeding was not fixed by that time, this issue becomes emergency at this point. Problems with breastfeeding can be fixed but the mother has to get a good help from lactation consultant who can show her the difference between good drinking and nibbling, who can help her by better positioning of both baby and the mother (preferably in a cross-cradle hold) and better asymmetric latch to increase the milk intake. Lactation consultant should also be able to show the mother how the baby can get even more breastmilk by compressing the breast when the baby no longer drinks on his own and how to supplement the baby at the breast when necessary.


How can the inefficient milk intake be related with the elevated bilrubin levels?

If the baby does not get enough colostrum in the first days of life, his body is not able to get rid of bilirubin that has already been processed by liver and is meant to be excreted by stool. It is quite common that the baby still passes meconium on day four or five when breastfeeding is not efficient. Bilirubin is excreted to gut but the guts are not emptied properly. Bilirubin is reabsorbed to the blood stream again thereby increasing the levels of bilirubin.

The elevated bilirubin levels are just a symptom of a more serious problem – that the baby is actually starving and not getting enough colostrum. This is where supplementing with anything (boiled breastmilk, formula or even mouse milk) can help and truly decrease the bilirubin levels because most mothers would supplement their babies with a bottle. And the baby who did not get enough colostrum from the breast eventually starts to feed, because finally he starts to get his food from the bottle.

Mother who plans to breastfeed however has another possibility how to solve this problem. Bottle can be an answer to treat the symptom - elevated bilirubin levels, but it doesn’t fix inefficient breastfeeding – the real cause of this situation.

Therefore the only legitimate intervention for jaundice when the baby is healthy and term is to check the breastfeeding and fix potential problems with the lactation consultant.

Only when breastfeeding is okay and the bilirubin levels are above 342 µmol/l and are still rising, it is reasonable to decrease the bilirubin levels since the safety of bilirubin levels that exceeded 342 µmol/l is not sufficiently proved by scientific studies.

The most suitable intervention in this case is phototherapy. If it does not work fast enough, medicamentous treatment or the exchange transfusion are other possibilities.


Phototherapy

Baby’s skin is exposed to a special light that breaks down bilirubin and helps to get rid of it faster. If phototherapy is used for healthy and term newborn whose bilirubin levels are under 342 µmol/l (which according to statistics is true for 99 % of healthy and term newborns), the benefits of this treatment are none since these levels of bilirubin are not dangerous. Phototherapy however brings some risks.

According to current trends in jaundice treatment, phototherapy in healthy and term newborn should be used in order to decrease the levels of bilirubin below 500 – 400 µmol/l. This is approach is probably the least dangerous for jaundice treatment. It should be used when the levels of bilirubin exceed 342 µmol/l, do not decrease after improving the milk intake and still rise.

When it is really necessary to use phototherapy, mother has to get a qualified help with breastfeeding. Often the baby is treated in a special room separated from mother. Breastfeeding on demand is therefore hindered. In addition, baby treated with phototherapy sometimes requires more fluids, which means that efficient breastfeeding with sufficient milk intake is absolutely necessary. Sometimes even with the abundant milk intake, the baby can get dehydrated and needs some extra fluids. If supplementing is not to jeopardize the success of breastfeeding it is essential to avoid using a bottle. Mother can learn how to use a little tube (the so-called lactation aid) that is put into the baby’s mouth and the baby sucks this extra fluid when breastfeeding.


Medicamentous treatment

The baby is given drugs that degrade bilirubin. Most frequently, phenobarbital and black coal are used. Their usage (especially phenobarbital) should be considered thoroughly. Levels of bilirubin that do not exceed 342 µmol/l are proved to be safe for healthy and term newborn, the medicamentous treatment however brings some undesirable side effects.

Many jaundice experts warn against phenobarbital for jaundice treatment since there are serious doubts whether this is a safe drug. Its usage is linked with many serious side effects – sedation, increase of the risk of haemorrhagic disease and it is potentially addictive. It influences the synthesis of some hormones and the hormonal homeostasis heavily.

The black coal brings risks by the fact that it is mostly given in a powder form mixed with water by bottle. In some babies even one bottle can jeopardize breastfeeding seriously. If it is really necessary to give this drug to a baby, the least dangerous way is to give it to the baby by cup or a small tube placed on mother’s finger (finger feeding) or with a syringe or spoon.

Some babies are also given substances that should protect the liver (hepatoprotectives) because of an incorrect assumption that newborns’ liver is immature and it is extremely loaded by bilirubin. These substances are really not necessary for any jaundiced baby.


Exchange transfusion

This intervention brings some really serious risks and it is used rarely. It should only be used in a situation when the bilirubin levels are really high (much more than 342 µmol/l) that do not decrease after increasing the milk intake and phototherapy. This baby is seriously ill and the cause of this condition is to be seeked intensely. If the cause is found and started to be cured, the bilirubin levels should decrease also.