Learning Outcome

By the end of this activity, the participant will be able to:

1. Identify and report pathologic jaundice.
2. Differentiate between physiological neonatal jaundice and breastmilk jaundice.
3. Discuss the nursing management of breastmilk jaundice

Introduction

Infant jaundice, also known as hyperbilirubinemia, is a frequently encountered clinical problem in neonates. Estimates are that between 60-80% of all term or late-term, healthy newborns exhibit physiologic jaundice with no cause found (idiopathic).[1] The definition of neonatal hyperbilirubinemia has typically been total serum bilirubin (TSB) levels within the high-risk zone, or greater than the 95th percentile for age within the first six days of life.[1] Jaundice within the first 24 hours could be pathological and must be reported to the health care provider. When total serum bilirubin levels rise, a yellowish discoloration of the infant’s skin and sclera occurs and is referred to as jaundice. Neonatal hyperbilirubinemia has a higher frequency in breastfed infants compared to formula-fed infants.[2] The two common mechanisms for this are “breastfeeding jaundice” and “breast milk jaundice.”

Breast milk jaundice was first described in 1963 when it was noted that some breastfed infants had prolonged, unconjugated hyperbilirubinemia that persisted beyond the third week of life. Breast milk jaundice typically presents after day 3 or 4 in the first or second week of life and usually spontaneously resolves even without discontinuation of breastfeeding. However, it can persist for 8-12 weeks of life before resolution.[2] Infants with breast milk jaundice often have higher peaks of serum bilirubin and an overall slower decline than infants without it, leading to longer resolution time.[3] Usually, pathologic causes of persistent, unconjugated hyperbilirubinemia are ruled out before a diagnosis of breast milk jaundice can be made.

Nursing Diagnosis

1. Risk for injury related to treatment
2. Risk for injury related to skin breakdown
3. Risk for impaired parent-infant bonding related to potential separation during treatment

Causes

The exact etiology of breast milk jaundice has not been determined (idiopathic). In early-onset breastmilk jaundice that is visible on assessment in the first 2-3 days, the causes are closely related to other causes of physiologic jaundice such as dehydration or delayed stool, and are difficult to differentiate. Most of the proposed etiologies of late-onset breastmilk jaundice beginning at 4 to 5 days or later, involve the factors present in the human breast milk itself. Another area of investigation into the causes of neonatal jaundice has been the potential genetic mutations present in the affected neonates.

Some factors in human breast milk that may be related to the etiology of breast milk jaundice include proteins and enzymes thought to inhibit the conjugation of bilirubin that allows for its excretion. ß-glucuronidase is an enzyme naturally present in the body that deconjugates bilirubin in the intestinal brush border, leading to increased unconjugated bilirubin levels.[2] Studies have shown that the activity of this enzyme within formula milk is negligible, but it is considerable in human breast milk.[4] Interleukin IL1ß e IL6 is thought to have a cholestatic effect that leads to hyperbilirubinemia.[5] The epidermal growth factor is present in higher concentrations in human breast milk and the serum of strictly breastfed infants. The reason is that this substance enhances intestinal resorption of bilirubin and reduces intestinal motility in the neonatal period, leading to increased unconjugated bilirubin levels.[[2]The serum of babies with breast milk jaundice often has elevated levels of alpha-fetoprotein. The mechanism underlying this is not yet understood.

Several studies have shown that mutations in the coding region of the UGT1A1 gene increase the risk of developing breast milk jaundice. Mutations in this gene's regulatory region are known to cause Crigler-Najjar and Gilbert syndrome, two syndromes known to cause persistent hyperbilirubinemia[6]

Risk Factors

The frequency of breast milk jaundice within the United States is thought to be 20-30% for neonates from 3 to 4 weeks of age whose feeding is predominantly via breastfeeding. About 30-40% of breastfed infants are expected to have bilirubin levels greater than or equal to 5 mg/dL, with about 2-4% of exclusively breastfed infants having bilirubin levels above 10 mg/dL in week 3 of life.[1] International studies in countries such as Turkey and Taiwan found that 20-28% of neonates had breast milk jaundice present at four weeks of age. Total serum bilirubin levels were also noted to be greater than or equal to 5 mg/dL in these cases.[6] The international frequency of breast milk jaundice is not extensively reported but is thought to be similar to the frequency in the United States. No reports exist demonstrating a gender predilection.

Assessment

Breast milk jaundice typically presents in the second half of the first week of life, or in the second week of life, with an unconjugated hyperbilirubinemia in an otherwise healthy infant whose nutritional intake is predominantly via breastfeeding. These infants exhibit normal weight gain with the normal production of urine and stools.[2]. A total serum bilirubin level above 1.5 mg/dL is considered elevated at this time, but most infants will not appear jaundiced until the serum level is above 5 mg/dL. If the infant does appear jaundiced, this yellowish discoloration of their skin and/or sclera is typically first noted in the face and then proceeds to the trunk and extremities. Identification of visible jaundice in an infant less than 24 hours could be a sign of pathologic jaundice and needs to be reported to the provider. Skin assessment of the newborn should be conducted in a well-lit room. To detect jaundice, it is sometimes necessary to apply mild pressure to blanch the skin of its normal newborn ruddiness and look for the yellow discoloration in the blanched area. Jaundice progresses in a cephalocaudal fashion (head-to-toe), so jaundice will be visible on the forehead or nose before it will be visible on the chest. Jaundice recedes in the opposite direction. The level of jaundice must be assessed daily. The nurse should also monitor the serum bilirubin level and assess the infant’s behavior, output, and feeding pattern to rule out other causes of jaundice.

Evaluation

All newborn infants should be assessed with a high index of suspicion for jaundice. Evaluation of a patient presenting with hyperbilirubinemia suspicious for breast milk jaundice must include methods to rule out other pathologic causes of hyperbilirubinemia. First, both unconjugated and conjugated bilirubin levels must be measured. Conjugated bilirubin levels less than 1 mg/dL or 20% of the total bilirubin level are considered normal. Conjugated bilirubin levels in excess of this indicate other disorders such as biliary atresia, neonatal hepatitis, and disorders of bilirubin excretion. Both breast milk jaundice and hemolytic anemias cause elevated unconjugated bilirubin levels. Hemolytic causes for hyperbilirubinemia, such as ABO incompatibility, G6PD deficiency, and hereditary spherocytosis, must be ruled out. Assessment should include direct Coombs’ testing, measurement of hemoglobin, hematocrit and reticulocyte count, a peripheral blood smear, and genetic testing.

The clinician will investigate other possible causes of hyperbilirubinemia if jaundice does not resolve by 12 weeks of age. Galactosemia and hypothyroidism have also been identified as causes of unconjugated hyperbilirubinemia and should be ruled out via standard newborn screening tests.[2][7][2]

Medical Management

Treatment is not necessary for breast milk jaundice unless the total serum bilirubin level of the infant is greater than 20 mg/dL. If this occurs, the recommendation is for phototherapy treatment. Phototherapy is the use of light to convert bilirubin molecules into water-soluble isomers that can be excreted by the body.  If the total serum bilirubin level remains below 12 mg/dL, the recommendation is to continue breastfeeding of the infant and to expect the resolution of jaundice by 12 weeks of age. If the total serum bilirubin level is between 12-20 mg/dL, and further investigation shows no evidence of hemolysis, the recommendations are the same.[2] When the bilirubin is greater than 20, a brief 24-hour cessation of breastfeeding often leads to a sharp decline in the bilirubin levels.

Nursing Management

In addition to the routine medical management of hyperbilirubinemia, which for breastmilk jaundice involves monitoring the jaundice without changes in the infant’s breastfeeding, nursing management includes providing education and support for the parents of infants with jaundice. Anything outside of normal can cause stress for new parents. In the rare cases where an infant needs to stop breastfeeding for 24 hours, nurses need to educate the mother on proper pumping procedure and safe storage of breastmilk. Infants who will continue breastfeeding should be encouraged to breastfeed every 2 to 3 hours until they learn to self-pace their own feedings. A sleepy jaundiced baby sometimes does not stay awake long enough for a good feeding, which can worsen hyperbilirubinemia. The mother may need breastfeeding assistance, and referral to a lactation consultant is a good option in areas where that is available. In addition, as bilirubin is excreted, the infant’s stools may become rather explosive. Reassure parents this is normal, and the more green that comes out in the stool, the less yellow will be in the baby’s skin. Education on infant bathing and appropriate diapering and skincare to prevent breakdown is important.

When To Seek Help

Notify the provider if jaundice is visible in an infant less than 24 hours of age. While monitoring serum bilirubin levels, notify the provider if levels exceed 15mg/dL. If infant demonstrates behavioral change (lethargy or irritability, decreased urine output, decreased stool or other signs of possible dehydration, encourage the infant to feed more frequently, and notify the provider if the infant is more than 3 days old and has fewer than 6 wet diapers in 24 hours or experiences weight loss.

Coordination of Care

Although jaundice in breastfed infants is a common and usually a benign finding, it cannot be ignored. Close communication between all members of the health care team and the parents is necessary to rule out other causes of neonatal hyperbilirubinemia. Combined with routine newborn evaluations and indicated lab tests, kernicterus, the most severe complication of neonatal hyperbilirubinemia, is preventable, and the successful continuation of breastfeeding is possible.

Health Teaching and Health Promotion

Parents of affected patients should be educated about the nature of the condition. The infant should continue to be breastfed unless otherwise contraindicated.[8][9]

Discharge Planning

Breastmilk jaundice is rarely recognized prior to routine mother-baby discharge. If the infant stays in the hospital longer for other treatment, early breastmilk jaundice may be seen on day 4 or 5 of life. The nurse will continue to teach the parents routine infant care and assist with breastfeeding. It is possible for an infant to experience physiologic hyperbilirubinemia in the first 2-3 days, and then have jaundice worsen again from breastmilk jaundice. Continue to reassure the parents, and encourage them to spend as much time with the infant as possible. Teach parents the expected output patterns and encourage frequent breastfeeding. Refer to a lactation consultant for a home visit, if possible. Reassure parents that while breastfeeding is natural, it is not always easy. Nursing measures supportive of parents and breastfeeding are expected. If the provider recommends caloric supplementation, educate the parents about the option of using supplemental nursing systems, rather than an artificial nipple.

Pearls and Other issues

While breastfeeding is natural, it is not always easy. Breastfeeding is a learned skill that requires patience and practice, and for some women, the learning stages can be frustrating and uncomfortable. Like any other skill, it gets easier with practice.

If a baby falls asleep at the breast within a couple of minutes, unwrap the baby or even undress the baby down to a diaper to wake him up again.

Frequent breastfeeding helps eliminate bilirubin and helps establish the mother’s milk supply. If an infant is sleeping more than 3 hours at a time during the day, gently wake the baby by undressing and changing the diaper, then encourage the infant to breastfeed.

If the mother’s nipples become sore from frequent breastfeeding, encourage her to expose her nipples to air as much as possible to avoid skin breakdown and further irritation. Also, encourage the mother to hold the infant in a different position for each feeding session so the mouth and tongue are not in the same spot on the breast at every feeding.  Observe the infant breastfeeding, and be sure the infant’s mouth is wide open and the lips curved around the breast tissue, and not only latched to the nipple tissue. A lactation consultant can help the mother with breastfeeding techniques, and is covered by many insurance companies.