Management of Jaundice in the Breastfeeding Infant 35 Weeks or More of Gestation
Publication Date: September 14, 2017
Last Updated: March 14, 2022
Recommendations
Evidence-Based Strategies for Preventing or Ameliorating Jaundice in the Breastfeeding Infant
Initiate early breastfeeding
Initiate breastfeeding as early as possible, preferably in the first hour after birth even for infants delivered by cesarean section. In the vast majority of births, breastfeeding should be initiated in the first hour. (IA)
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Encourage frequent exclusive breastfeeding
Frequent breastfeeding (8–12 times or more in 24 hours) is crucial both to increase infant enteral intake and to maximize breast emptying, which is essential for the establishment of milk supply. Feeding anything before the onset of breastfeeding delays the establishment of good breastfeeding practices and may hinder milk production, increasing the risk of reduced enteral intake and exaggerated hyperbilirubinemia. There is a positive association between the number of breastfeeds a day and lower TSB. (III)
It is unnecessary to give glucose water to test the infant’s ability to swallow or avoid aspiration.
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Hand expression or pumping of colostrum or breast milk can provide extra milk to support intake in some infants at risk for suboptimal intake jaundice and exaggerated hyperbilirubinemia and assist in establishing a good milk supply. Although pumping is commonly used, it is noteworthy that hand expression may be better tolerated by mothers in the immediate postpartum period. Randomized trials have shown that the initiation of pumping may reduce milk transfer and eventual breastfeeding duration for some populations of infants. (IB)
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Optimize early breastfeeding management
Ensure comfortable positioning (that avoids nipple compression or rubbing), effective latch, and adequate milk transfer (swallowing) from the outset by having a healthcare provider trained in breastfeeding management (e.g., nurse, lactation consultant, midwife, or physician) and evaluate position and latch, providing recommendations as necessary. ()
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Support skin-to-skin contact for all mothers and infants (in a safe manner when the mother is awake and alert), but particularly for those breastfeeding, starting immediately after birth and throughout the postpartum period as it helps with milk supply and makes mother’s milk easily available to the infant in the first days and weeks of life. (IA)
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Provide education on early feeding cues
Teach the mother to respond to the earliest cues of infant hunger, such as moving about or restlessness, lip smacking, hand movements toward the mouth, and vocalizing. Most newborns need to be fed every 2 ½ to 3 hours. Infants should be put to the breast before the onset of crying as crying is a late sign of hunger and often results in a poor start to the breastfeeding episode. Attention should also be paid to infants who are sleepy or do not show signs of hunger. ()
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Identify mothers and infants at risk for hyperbilirubinemia
Some maternal factors (e.g., diabetes, Rh sensitization, and past family history of jaundiced infants) increase the risk of hyperbilirubinemia in the newborn. Primiparous mothers are at risk for delayed secretory activation as are those who give birth through cesarean section or have a maternal body-mass index over 27 kg/m2. Infants of these mothers are therefore at risk for suboptimal intake. (III)
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With the exception of infants with pathologic conditions such as Rh or ABO hemolytic disease and glucose-6-phosphate dehydrogenase (G6PD) deficiency, the single most important clinical risk factor for hyperbilirubinemia in newborns is decreasing gestational age. For each week of gestation below 40 weeks, the odds of developing a TSB ‡428 lmol/ L (25 mg/dL) increase by a factor of 1.7 (95% CI 1.4–2.5). Management of 34–37-week late preterm and early term infants who are not breastfeeding well can be found in the relevant ABM Clinical Protocol. (IV)
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Significant bruising or cephalohematoma can increase the risk of hyperbilirubinemia due to the increased breakdown of heme. East Asian newborns also have a higher risk of jaundice, perhaps related to their ethnic or genetic background. (III)
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The above factors can be additive with suboptimal intake jaundice and/or breast milk jaundice and produce even higher bilirubin levels than would otherwise be seen. When risk factors are identified, it is prudent to seek assistance with breastfeeding in the early hours after birth to ensure optimal breastfeeding management. Mothers may benefit from early instruction about milk expression by hand or pump to protect the milk supply. ()
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Do not supplement infants with anything other than mother’s own expressed milk in the absence of a specific clinical indication. Indications for supplementation are discussed briefly below. Full details on indications for supplementation, choice of supplement, and methods of supplementation are available in ABM Clinical Protocol #3: Supplementary Feedings in the Healthy Term Breastfed Neonate, Revised 2017. (IV)
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While management of newborns varies from country to country, most infants discharged before 72 hours of age should be seen by a healthcare provider within 2 days of discharge from birth hospitalization. This is especially important for exclusively breastfed infants.
- Close follow-up of the breastfeeding newborn both facilitates prevention of excess weight loss that may contribute to hyperbilirubinemia
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and ensures that elevated bilirubin concentrations are promptly treated. (IV)
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Individual clinical judgment regarding follow-up can be used, such as in the case of an experienced multiparous mother who has breastfed previous infants and is going home with an infant who has no hyperbilirubinemia risk factors.21 Protocols for monitoring bilirubin vary from country to country and within countries. While the U.K. guidelines do not recommend measuring bilirubin levels at follow-up unless the infant is visibly jaundiced, frequent monitoring using a TcB meter is recommended by the Japanese Society for Neonatal Health and Development.
Overview
Title
Management of Jaundice in the Breastfeeding Infant 35 Weeks or More of Gestation
Authoring Organization
Academy of Breastfeeding Medicine