Breast milk jaundice

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Background

Newborns produce bilirubin at a rate that exceeds adults due to the relative polycythemia and increased RBC turnover.[1]. Breastmilk jaundice is an indirect hyperbilirubinemia in breastfed newborn that develops within the first 4-7 days of life. It does not generally cause kernicterus.

Cause

The etiology is unknown but may be related to inflammatory cytokines in human milk and the presence epidermal growth factor.[2]

Clinical Features

  • Jaundice within the first 4-7 days of life

Differential Diagnosis

Indirect (Unconjugated) Hyperbilirubinemia

More common causes are listed first, followed by less common causes

  • Breast milk jaundice
    • Due to substances in milk that inhibits glucuronyl transferase. It may start as early as 3rd day and reaches peak by 3rd week of life. It is unlikely to cause kernicterus
  • Breast feeding jaundice
    • Patient does not receive adequate oral intake which then causes reduced bowel movement/bilirubin excretion. Best diagnosed by looking for signs of dehydration and comparing weight to birth weight.
  • Blood group incompatibility: ABO, Rh factor, minor antigens
  • Diabetic mother/gestational diabetes
  • Internal hemorrhage
  • Physiologic jaundice
  • Polycythemia
  • Sepsis
  • Hemoglobinopathies: thalassemia
  • Red blood cell enzyme defects: G6PD Deficiency, pyruvate kinase
  • Red blood cell membrane disorders: spherocytosis, ovalocytosis
  • Hypothyroidism
  • Immune thrombocytopenic purpura
  • Mutations of glucuronyl transferase (i.e., Crigler-Najjar syndrome, Gilbert syndrome)

Direct (Conjugated) Hyperbilirubinemia

Conjugated bilirubinemia implies a hepatic or post hepatic cause. More common causes are listed first.

  • Hyperalimentation cholestasis
  • Neonatal hepatitis
  • Cytomegalovirus infection
  • Sepsis
  • TORCH infection
  • Biliary atresia
  • Cystic fibrosis
  • Hepatic infarction
  • Inborn errors of metabolism (e.g., galactosemia, tyrosinosis)

Evaluation

  • The most important component of the workup is differention of direct vs indirect bilirubinemia
  • See BiliTool and the phototherapy guide for total bilirubin cutoff by age recommendations
  • History extremely important
    • Mother's blood type (important if mother is RH negative or O blood type)
    • Assess for any signs of decreasing oral intake or signs of dehydration?
    • Baby's general appearance (well appearing?)
  • Total bilirubin/Direct bilirubin levels
  • CBC (for evaluation of hemolytic anemia or polycythemia vera)
  • Consider coombs or T&S (mom & baby)

Management

  • The mother does not not need to routinely stop breast-feeding.
  • Phototherapy may be necessary and the following chart and [BiliTool] can be used as a reference for treatment

Phototherapy Guidelines

Total Bilirubin Cutoff by Risk Group
Age Low Risk Medium Risk High Risk
Birth 7.0 5.0 4.0
24h 11.5 9.0 8.0
48h 15 14 10
72h 17.5 15 14
96h 20 17.5

14.5

5+days 21 17.5 15
  • Low Risk: ≥38 weeks + no risk factors
  • Medium Risk: (≥38 weeks + risk factors) or (35-37 weeks and no risk factors)
  • High Risk: 35-37 weeks + risk factors

Disposition

  • Bilirubin levels of 12 mg/dL (170 µmol/L) to 17 mg/dL can generally be rechecked within 24hrs and supplementation with formula
  • Bilirubin levels of >17 mg/dL (294-430 µmol/L) should have phototherapy as well as formula supplementation while continuing breast feeding

See Also

External Links

BiliTool

References

  1. Gartner LM, Herschel M. Jaundice and breast-feeding. Pediatr Clin North Am. 2001;48:389–99.
  2. Gotze T et al. Neonatal cholestasis - differential diagnoses, current diagnostic procedures, and treatment. Front Pediatr. 2015. 3:43