Nelson Textbook of Pediatrics
Nineteenth Edition 2011
Part XII - The Fetus and the Neonatal Infant
Chapter 96 - Digestive System Disorders
96.3 Jaundice and Hyperbilirubinemia in the Newborn

Jaundice Associated with Breast-Feeding

Significant elevation in unconjugated bilirubin (breast milk jaundice) develops in an estimated 2% of breast-fed term infants after the 7th day of life, with maximal concentrations as high as 10-30 mg/dL reached during the 2nd-3rd week. If breast-feeding is continued, the bilirubin gradually decreases but may persist for 3-10 wk at lower levels. If nursing is discontinued, the serum bilirubin level falls rapidly, reaching normal range within a few days. With resumption of breast-feeding, bilirubin seldom returns to previously high levels. Phototherapy may be of benefit (Chapter 96.4). Although uncommon, kernicterus can occur in patients with breast milk jaundice. The etiology of breast milk jaundice is not entirely clear but may be attributed to the presence of glucuronidase in some breast milk.

This syndrome should be distinguished from an early-onset, accentuated unconjugated hyperbilirubinemia known as breast-feeding jaundice, which occurs in the 1st week of life in breast-fed infants, who normally have higher bilirubin levels than formula-fed infants (Fig. 96-9). Hyperbilirubinemia (>12 mg/dL) develops in 13% of breast-fed infants in the 1st wk of life and may be due to decreased milk intake with dehydration and/or reduced caloric intake. Prophylactic supplements of glucose water to breast-fed infants are associated with higher bilirubin levels, in part because of reduced intake of the higher–caloric density breast milk. Frequent breast-feeding (>10/24 hr), rooming-in with night feeding, and ongoing lactation support may reduce the incidence of early breast-feeding jaundice. Even when breast-feeding jaundice develops, breast-feeding should be continued if possible. It is an option to temporarily interrupt breast-feedings and substitute formula for a day or two. In addition, frequent feeding and supplementation with formula or expressed breast milk is appropriate if the intake seems inadequate, weight loss is excessive, or the infant appears dehydrated.