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Breastfeeding jaundice

OVERVIEW

What is breastfeeding jaundice?

Breastfeeding jaundice, also known as insufficient breastfeeding jaundice, failed breastfeeding jaundice, or early-onset breast milk jaundice, occurs in breastfed or predominantly breastfed newborns. In the first few days after birth, inadequate breast milk intake due to various reasons delays meconium excretion, increasing enterohepatic circulation and resulting in higher bilirubin levels compared to formula-fed newborns, sometimes reaching intervention thresholds. Breastfeeding jaundice is often accompanied by physiological weight loss >10%.

Management primarily involves assisting mothers in establishing successful breastfeeding to ensure adequate milk intake, with formula supplementation if necessary. Newborns meeting intervention criteria require prompt treatment as per neonatal jaundice guidelines.

Depending on bilirubin levels, interventions may include continued breastfeeding support, formula supplementation, or phototherapy. No other treatments—such as sun exposure, probiotics, or jaundice-reducing medications—are typically needed. With timely intervention and no complications, breastfeeding jaundice does not affect routine vaccinations.

SYMPTOMS

What are the manifestations of breastfeeding jaundice?

Breastfeeding jaundice is a special type of neonatal jaundice related to breastfeeding. It mainly occurs in newborns who are breastfed or primarily breastfed, typically within the first week after birth, most commonly in the initial 2–3 days. If insufficient feeding persists beyond the first week after birth, it can also lead to elevated jaundice or a slow decline in bilirubin levels.

Bilirubin deposits in the skin, mucous membranes, and subcutaneous tissues, causing them to turn yellow, primarily manifesting as "jaundice," i.e., yellowing of the skin and sclera. There is often a physiological weight loss of >10%, along with reduced urine output (yellow or brick-red in color), decreased stool frequency, and poor subsequent weight gain.

Furthermore, factors such as the mother's lack of knowledge about breastfeeding techniques, untreated breastfeeding-related complications (e.g., breast engorgement, cracked nipples, and fatigue) before discharge, ineffective sucking by the newborn, or limited breast milk supply within 24–48 hours after birth can affect breastfeeding success. This may lead to insufficient or reduced milk production, leaving the newborn in a state of hunger, dehydration, and nutritional deficiency. As a result, meconium excretion is delayed, enterohepatic circulation increases, excessive weight loss occurs, and jaundice worsens, potentially leading to complications such as dehydration, hypoglycemia, and malnutrition.

Studies show that up to 13% of newborns have jaundice levels exceeding 12 mg/dl (205.2 μmol/L) within the first week after birth.

Can breastfeeding jaundice cause acute bilirubin encephalopathy?

Breastfeeding jaundice often occurs within the first week after birth, coinciding with the peak period of neonatal jaundice. While it may not significantly affect newborns with mild jaundice, it can exacerbate pathological jaundice, leading to higher bilirubin levels. Regardless, jaundice should be monitored in the first 7 days after birth, with follow-ups as advised by a doctor. Active management of hyperbilirubinemia can reduce the risk of acute bilirubin encephalopathy.

Regardless of the cause, severe jaundice increases the risk of acute bilirubin encephalopathy. Pure breastfeeding jaundice rarely exceeds 20 mg/dl (342 μmol/L). However, when total bilirubin levels reach ≥25 mg/dl (428 μmol/L), healthy full-term infants are at risk of neurological dysfunction. With prompt intervention, acute bilirubin encephalopathy caused by abnormally high jaundice may be reversible, but it can also lead to permanent neurological damage (kernicterus).

How to assess the severity of neonatal jaundice?

CAUSES

What causes breastfeeding jaundice?

Breastfeeding jaundice primarily occurs due to insufficient breastfeeding, leading to inadequate milk and calorie intake in infants, resulting in hypovolemia and significant weight loss. Reduced intake also delays the passage of meconium, decreases bowel movements, slows bilirubin clearance, and increases enterohepatic circulation, subsequently raising total bilirubin levels. These factors contribute to hyperbilirubinemia (jaundice), and some infants may also develop hypernatremia, with serum sodium levels >150 mmol/L.

Compared to full-term infants, late preterm infants (gestational age 34–36+6 weeks) may face greater challenges in establishing successful breastfeeding. Late preterm infants tend to sleep more, tire easily, and/or struggle to maintain latch due to immature oral coordination and swallowing mechanisms, often failing to fully empty the breast. Therefore, these infants and their mothers require additional support and close monitoring.

With increasing birth rates and shorter postpartum hospital stays for newborns and mothers, establishing successful breastfeeding and subsequent monitoring has become more difficult. Successful breastfeeding and monitoring are key measures in preventing hyperbilirubinemia.

DIAGNOSIS

How is breastfeeding jaundice diagnosed?

In exclusively or predominantly breastfed newborns, if jaundice is abnormally elevated or resolves slowly (refer to neonatal jaundice standards), accompanied by insufficient breast milk intake, delayed meconium passage, physiological weight loss >10%, or slow weight gain (refer to growth rate in Chinese or WHO growth charts), and the newborn exhibits reduced urine output, yellow or brick-red urine, or decreased stool frequency, breastfeeding jaundice may be considered.

After successfully establishing breastfeeding, ensuring adequate breast milk intake, and supplementing with formula if necessary, if the abnormal symptoms improve and jaundice resolves accordingly, a clinical diagnosis of breastfeeding jaundice can be made.

What conditions should breastfeeding jaundice be differentiated from?

If the rise and fall of jaundice do not match the characteristics of breastfeeding jaundice, other causes or pathological jaundice should be considered.

It should also be distinguished from "breast milk jaundice":

Breast milk jaundice refers to jaundice persisting beyond the physiological range after the first week of life (7–14 days). It typically occurs in exclusively or predominantly breastfed newborns, appearing around 6–7 days after birth, peaking at 2–3 weeks, and may last 4–6 weeks or extend to 2–3 months. If breastfeeding is paused, jaundice significantly subsides within 48–72 hours. The newborn shows normal growth and development, and other causes of non-physiological hyperbilirubinemia are excluded.

TREATMENT

Which department should I go to for breastfeeding jaundice?

Neonatology, Pediatrics, or Child Health departments are all suitable.

How is breastfeeding jaundice treated?

When breastfeeding jaundice is suspected or typical symptoms appear, mothers should be guided and assisted in establishing successful breastfeeding to ensure adequate milk and energy intake for the newborn. Formula supplementation may be necessary if required.

Frequent breastfeeding (>10 times/24 hours) around the clock with proper lactation guidance can reduce the incidence of early breastfeeding jaundice. Even if breastfeeding jaundice occurs, breastfeeding should be continued as much as possible.

If the infant shows insufficient intake, excessive weight loss, or signs of dehydration, feeding frequency should be increased, and formula or breast milk should be supplemented.

Temporarily interrupting breastfeeding and replacing it with formula for 1-2 days can quickly correct insufficient intake, excessive weight loss, or dehydration.

Newborns under 1 week old who meet intervention criteria should receive timely intervention according to neonatal jaundice treatment guidelines.

For infants over 1 week old, phototherapy is recommended if serum total bilirubin (via blood test) exceeds 342 μmol/L (20 mg/dl).

Can babies with breastfeeding jaundice be exposed to sunlight?

No, the key for babies with breastfeeding jaundice is increasing milk intake.

For all jaundiced infants, normal outdoor activities are sufficient. Although direct sunlight has been shown to reduce bilirubin levels, it is not recommended as a treatment for severe hyperbilirubinemia due to the risk of sunburn from direct exposure.

Additionally, direct sunlight exposes infants to unnecessary and potentially harmful UV radiation, increasing the risk of skin malignancies.

Can oral medication be used for breastfeeding jaundice?

The key for babies with breastfeeding jaundice is increasing milk intake. Medications are generally unhelpful when phototherapy is needed, and no medication is required if phototherapy is unnecessary. Therefore, follow the phototherapy protocol and avoid any oral medications claiming to treat jaundice, including probiotics, herbal remedies, or chemical drugs like phenobarbital.

DIET & LIFESTYLE

Does breastfeeding jaundice require dietary restrictions?

No, nursing mothers can maintain a normal diet with balanced nutrition.

Can babies with breastfeeding jaundice receive vaccinations?

Breastfeeding jaundice typically does not occur after the baby's first month. As long as the baby is generally healthy without complications, it does not affect routine vaccinations.

PREVENTION

Can breastfeeding jaundice be prevented?

Yes.

Mothers can learn proper breastfeeding techniques and guide their babies to latch correctly to reduce the chances of insufficient feeding. At the same time, inadequate breast milk intake can be detected early through observation and actively addressed: