Many parents ask me if breastfeeding can cause neonatal jaundice?
The quick answer is that newborn jaundice may be associated with breastfeeding and breast milk; however, it is not directly caused by them. The fact is that most formula-fed babies after birth will also have some degree of jaundice after birth.
I will explain below two scenarios in which breastfeeding may contribute to increased jaundice in a baby, but first, I want to give you some general information on jaundice.
Basic information about newborn jaundice
Newborn jaundice is a common health condition affecting most babies during their first two weeks of life. Sometimes, it requires treatment, and occasionally it may even be dangerous for their life or future development. You can find my detailed article on newborn jaundice here.
We can diagnose jaundice on examination by detecting yellow skin color and yellow eyes in a baby. Also, we can do laboratory tests measuring bilirubin levels. Bilirubin is a culprit in jaundice. It is a chemical that we all continuously produce in our bodies and have ways of excreting it using different mechanisms.
Bilirubin is a by-product of red cells’ breakdown. Babies are born with a higher number of red cells than adults, and red cells have a shorter life span in newborns. Thus, babies produce more bilirubin than adults.
Bilirubin circulates in our blood, but some of it gets to the liver, where it undergoes enzymatic changes so it can be excreted with bile into the gut. From there, some of the bilirubin load is reabsorbed back into our blood circulation, and some is excreted out with bowel movements.
All newborn babies are born with decreased amount and activity of liver enzymes responsible for bilirubin excretion into the gut.
Additionally, due to poor feedings and relatively low milk volume and caloric intake in the first few days of life, reabsorption of bilirubin is much higher initially than after two weeks of life, when regular feedings are well established.
One can summarize that three physiologic mechanisms are contributing to neonatal jaundice after birth:
- increase in the initial load of bilirubin (more red cells and shorter life span)
- decreased excretion via liver (lower liver enzyme levels)
- increased reabsorption of bilirubin in the gut
In addition, there may be multiple pathologic conditions contributing to neonatal “physiologic” jaundice. If an entity contributes to increased bilirubin levels (jaundice), it will always work through at least one of the three mechanisms described above (increased load, decreased excretion, or increased reabsorption).
For example, one of the common conditions causing jaundice in newborn babies is blood group incompatibility. The mother produces antibodies due to the difference between the mother’s and baby’s blood groups. After passing through the placenta into the baby’s system, the antibodies will cause faster destruction of the baby’s red cells resulting in the rapid rise of bilirubin levels. Thus, the blood group incompatibility contributes to neonatal jaundice by quickly increasing a bilirubin load after birth (My articles on jaundice due to blood group incompatibilities are here: ABO-incompatibility and RH-incompatibility).
How can breastfeeding affect newborn jaundice?
Association of breastfeeding with jaundice is common but rarely necessitates aggressive treatment. Breastfeeding failure may contribute to early jaundice in the first 2-3 days (breastfeeding failure jaundice). On the other hand, unique components of breast milk can exaggerate jaundice after five days of life and contribute to its persistence even beyond three weeks (breast milk jaundice). Let’s look into each of these entities separately (CDC resource here).
Breastfeeding failure jaundice
Breastfeeding failure may contribute to increased jaundice during the first week of life, particularly during the first 2-3 days after the birth.
Breastfeeding a newborn baby effectively is often tricky. Mothers who encounter most problems are first-time mothers, mothers who underwent cesarean sections, and mothers of premature babies. Common issues that make this process difficult include inappropriate technique, breast engorgement, cracked and flat nipples, and fatigue.
In addition, neonatal factors can also contribute to breastfeeding problems. Those are prematurity, small or very large birth weight, sucking and swallowing problems, breathing difficulties, separation of mother and baby, and many others.
Ineffective breastfeeding leads to decreased oral intake in a baby, resulting in delayed meconium passage and subsequent infrequent bowel movements. Additionally, relative stasis of intestinal contents leads to increased reabsorption of bilirubin in the gut leading to higher bilirubin load in the baby’s body. Obviously, an increased amount of bilirubin equals more jaundice (Simpler explanation here).
How do we treat breastfeeding failure jaundice?
First of all, we should try to prevent it from the very beginning by encouraging mothers to breastfeed often and provide opportunities for bonding with their babies. Furthermore, having lactation specialists available to all mothers may help resolve certain problems early and prevent babies from getting dehydrated and developing jaundice.
If bilirubin levels are at treatment levels, phototherapy needs to be started promptly, and close follow-up is necessary (my article on phototherapy).
Finally, suppose despite all our efforts, breastfeeding is ineffective, or the baby’s bilirubin is at very high levels. In that case, we have to consider supplementing the baby with formula, donor breast milk, and IV fluids.
The prognosis for breastfeeding jaundice is excellent. Jaundice will resolve quickly after proper nutrition, hydration, and phototherapy are started.
Breast milk jaundice (due to breast milk components)
According to epidemiologists, 10%-30% of breastfed babies are affected by “breast milk jaundice.” Bilirubin can rise in these babies after five days of life and may last for another 3-12 weeks. We do not know what exactly is the cause for that. However, we suspect that genetic factors and the composition of breast milk may play a role in putting some babies at risk of developing such prolonged jaundice.
Notably, one should know that this type of jaundice occurs in babies who are well hydrated and are receiving adequate nutrition through breastfeeding.
The mechanism of “breast milk jaundice” is not well understood, but we believe it to be through increased intestinal bilirubin reabsorption as well. In experimental studies, when we took breast milk from mothers of babies with breast milk jaundice and gave it to the rats, it caused increased reabsorption of bilirubin in the gut, leading to higher bilirubin load in their bodies.
How do we diagnose breast milk jaundice?
First, we have to confirm that baby indeed has jaundice by checking bilirubin levels. The second step should always be to exclude other pathologic causes of jaundice, such as metabolic diseases (thyroid problems), infections, blood group incompatibilities, and many others.
Finally, after excluding other causes, if we want to prove that breast milk is the cause of jaundice, we can stop breastfeeding for 1-3 days (use the formula in the meantime) to see if bilirubin levels start dropping. Later, bilirubin will probably rise again once we reintroduce the breast milk again.
Stopping breastfeeding is not usually necessary, but it will often reassure parents and doctors that we are not missing other rare conditions causing jaundice.
Treatment of breast milk jaundice
The treatment of breast milk jaundice is non-specific. Usually, it does not require stopping breastfeeding. If bilirubin values are at treatment levels, almost always, the first line of treatment is phototherapy.
If phototherapy is not effective enough and bilirubin remains very high, endangering the baby’s brain, we can consider double exchange blood transfusion. However, the latter treatment is unlikely to be needed in “pure” breast milk jaundice. We should always look for other pathologies contributing to such severe jaundice. Considering other causes of jaundice may allow us to target treatment of jaundice better.
Prognosis in breast milk jaundice is good. With time it resolves and never comes back again. However, one should realize that in some babies, it may last up to three months after birth.
Frequent questions related to breastfeeding and jaundice
Can I breastfeed when my baby has jaundice?
Yes, Yes, and Yes (my article on benefits of breastfeeding for babies). I described above that breastfeeding failure may be associated with a greater degree of jaundice . Dehydration and suboptimal caloric intake lead to increased reabsorption of bilirubin from the gut and decreased expulsion of bilirubin with bowel movements. Therefore, jaundice in such babies will be getting worse.
If your baby has jaundice, you should try to breastfeed your baby even more often to maximize your baby’s chances of getting proper hydration and caloric intake. Ideally, you should consult with a lactation specialist to make sure that you are doing everything right.
Sometimes, breastfeeding may not be enough despite your best efforts, and supplementation with formula or IV fluids is necessary. But, again, it is a decision that should be discussed with your baby’s doctor.
If your baby’s jaundice is at dangerous levels, your doctor may tell you to stop breastfeeding to maximize your baby’s time under phototherapy. This approach may be necessary for no more than 12-24 hours. During that time baby will be receiving formula or pumped breast milk and IV fluids.
Is formula better than breastmilk for babies with jaundice?
In general, the formula is never better than breastmilk. Human milk has so many positive health effects on the baby and the mother that we always want the newborn baby to benefit from it.
Having said that, we need to understand that a newborn affected by jaundice requires good hydration and caloric nutrition. If the baby is not receiving that from breastmilk, supplementing with formula may be the next best solution. In my opinion, adding formula to the baby’s diet is better than putting such a baby on intravenous fluids. Starting IV fluids involves needle sticks, pain and may be associated with the risk of infections and electrolyte abnormalities.
Galactosemia is one congenital condition associated with jaundice where breastmilk may be contraindicated, and unique formula without lactose is used for feedings. If your baby has galactosemia, it will likely be diagnosed during the first two weeks of life on the newborn state screen.
Can a breastfeeding mother’s diet affect baby’s jaundice?
This is very unlikely to occur unless the mother is consuming toxins or poisons with her diet, which can get into the baby’s system through breastmilk and damage the baby’s liver.
What should a breastfeeding mother eat if a baby has jaundice?
We recommend the same diet for all breastfeeding mothers regardless of what conditions affect their newborn babies.
Breastfeeding mothers need extra 300-400 calories in their diet to provide proper nutrition to their babies. Diet should include protein reach foods, a variety of grains, fruits, and vegetables. While eating seafood, avoid the ones known to have high levels of mercury. Drink plenty of non-sugary fluids, and avoid too many caffeinated products. Alcohol and nicotine should also be eliminated while you are breastfeeding.
If you are a vegetarian, I strongly encourage you to talk to a dietician. Most vegetarian mothers will need various supplements to ensure that their breastfed baby does not become deficient in minerals and vitamins (particularly Vit B12, Vit D, and calcium)
Can exposure to the sun help a newborn baby with jaundice?
Doctors do not recommend exposing newborn babies to the sun as a treatment for jaundice. Placing a baby under the sun may cause skin burns or skin irritation and can be dangerous. Instead, the best approach to a baby with jaundice is to make sure that baby is receiving enough milk (breastmilk or formula) to stay well hydrated, and if bilirubin levels reach treatment levels, phototherapy should be started as soon as possible. Finally, any baby with jaundice needs very close follow-up from medical providers familiar with this problem.
This article is only for general information purposes. It should not be viewed as any medical advice. There is always a chance that information here may be inaccurate. It would be best if you always discussed all health-related matters with your doctor before making any decisions that may affect yours or your family members’ health.