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
(III)
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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.

Management of Breastfeeding in the Newborn with Jaundice

When discussing any treatment options with parents, healthcare providers should emphasize that all treatments are compatible with continuation of breastfeeding. Because parents may associate breastfeeding with the development of jaundice requiring special treatment or hospitalization, they may be reluctant to continue breastfeeding, particularly if infant formula supplementation or interrupting breastfeeding is suggested as treatment. Healthcare providers should offer special assistance to these mothers to ensure that they understand the importance of continuing to breastfeed and know how to maintain their milk supply if temporary interruption is necessary.
  • Special care should be taken to address and discuss any guilt parents have about their feeding decisions, both because such guilt can be counterproductive to continued breastfeeding
(III)
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  • and because many factors contribute to jaundice and the relative contribution of each factor is often unknown.
()
(III, IV)
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Treatment options

Phototherapy

Phototherapy is the most frequently used treatment option when TSB concentrations exceed treatment thresholds, especially when levels are rising rapidly. Phototherapy can be used while continuing full breastfeeding or it can be combined with supplementation of expressed breast milk or infant formula if maternal supply is insufficient. Only in extenuating circumstances is temporary interruption of breastfeeding with replacement feeding necessary.
  • Only in extenuating circumstances is temporary interruption of breastfeeding with replacement feeding necessary.
(IV)
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  • Phototherapy can be done in the hospital or at home. Home phototherapy is acceptable for low-risk infants provided TSB levels are monitored.
(IV)
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  • In the hospital, it is best done in the mother’s room or a hospital room where the mother can also reside to minimize mother–infant separation and so that breastfeeding can be continued. Interruption of phototherapy for durations of up to 30 minutes or longer to permit breastfeeding without eye patches does not alter the effectiveness of the treatment.
()
(III, IB)
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  • Although phototherapy increases insensible water loss to some degree, infants under phototherapy do not routinely require extra oral or intravenous fluids.
(IV)
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However, if newborns receiving phototherapy are too sleepy to breastfeed vigorously, or if breastfeeding appears ineffective, mothers should express milk to feed by syringe, bottle, or gavage until newborns are vigorous enough to transfer milk effectively. The routine provision of intravenous fluids is discouraged because they may inhibit thirst and diminish oral intake. However, they may be indicated in cases of infant dehydration, hypernatremia, or inability to ingest adequate milk.
In settings where phototherapy is not readily available, results in significant mother–infant separation, or has other potential negative consequences, physicians may consider recommending supplementary feedings at levels of bilirubin approaching those recommended for initiating phototherapy. Such decisions should be individualized with the goal of keeping mother and infant together as well as preserving and optimizing breastfeeding while effectively preventing or treating the hyperbilirubinemia.
  • First and best supplement is expressed own mother’s milk. It can be hand expressed into a small cup or spoon and directly fed to the infant with help from staff who are knowledgeable in this technique. In this way, breastfeeding is best supported.
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  • If own mother’s milk is not available, supplementing with donor human milk will increase enteral intake. Breastfeeding infants supplemented only with donor milk meet the World Health Organization definition of exclusive breastfeeding. The specific effect of donor milk supplementation on bilirubin levels has not been studied.
()
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  • It may be necessary to supplement with infant formula if neither own mothers’ milk nor donor human milk is available. The impact of introducing formula to an exclusively breastfed infant must be considered. The effect of supplementation with donor human milk versus infant formula is not well studied.
()
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Supplementation with water or glucose water is contraindicated because it does not reduce serum bilirubin, interferes with breastfeeding, and might cause hyponatremia. ()
(IIA, III)
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  • Supplementation of breastfeeding should preferably be undertaken using a cup, spoon, syringe, or supplemental nursing system (if infant is latching) simultaneously with or immediately following each breastfeed. Nipples/teats and bottles should be avoided where possible. However, there is no evidence that any of these methods are unsafe or that one is necessarily better than the other.
(IA)
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When TSB levels are very high or associated with evidence of poor breast milk intake despite appropriate intervention, supplementation with infant formula can eliminate the deleterious effect of UGT1A1 polymorphisms on serum bilirubin and is a reasonable addition if it can be done in a way that is supportive of breastfeeding. Depending on the TSB level, follow-up TSB measurements within 4–24 hours are needed. Supplementation cannot be substituted for phototherapy in the treatment of infants with hemolytic hyperbilirubinemia. (IIA)
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  • Supplementation of breastfeeding with infant formula. As infant formula inhibits the intestinal reabsorption of bilirubin, it may sometimes be used to lower TSB in breastfeeding infants.
(IV)
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  • Small-volume (10–15 mL) feedings of formula immediately following a breastfeeding may be preferred to intermittent large-volume (30–60 mL) supplementation so as to maintain frequent breastfeeding and preserve maternal milk production at a high level.
(IA)
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Temporary interruption of breastfeeding
Temporary interruption of breastfeeding is very rarely needed, but may be considered for specific clinical scenarios in which rapid reduction in TSB is urgently needed or if phototherapy is unavailable. (IIA)
If urgent clinical needs necessitate the temporary interruption of breastfeeding, it is critical to maintain maternal milk production by teaching the mother to effectively and frequently express milk by hand or pump. The infant needs to return to a good supply of milk when breastfeeding resumes, or poor milk supply may result in a return of higher TSB concentrations.
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Larger volumes may be required if the infant is not receiving sufficient milk at the breast (i.e., low milk supply or poor milk transfer).

Post-treatment follow-up and evaluation

Infants who have had any of the above treatments for excessive hyperbilirubinemia need to be carefully followed with repeat TSB determinations and support of breastfeeding because suboptimal breast milk intake may result in recurrence of hyperbilirubinemia.
Encouragement to continue breastfeeding is of the greatest importance since many parents will be fearful that continued breastfeeding may result in more jaundice or other problems. Parents can be reassured that almost all hyperbilirubinemia requiring treatment resolves within the first 5 days after birth. Even those infants with more prolonged breast milk jaundice who required and received treatment rarely have sufficient rise in bilirubin with continued breastfeeding to require further intervention. ()
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Recommendation Grading

Overview

Title

Management of Jaundice in the Breastfeeding Infant 35 Weeks or More of Gestation

Authoring Organization

Publication Month/Year

September 14, 2017

Last Updated Month/Year

June 9, 2022

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

Provide guidance in determining whether and how breastfeeding may or may not be contributing to infant jaundice. To review evidence-based strategies for ameliorating jaundice in the breastfeeding infant. To provide protocols for supporting breastfeeding while infants are being evaluated and/or treated for jaundice

Inclusion Criteria

Female, Male, Adult, Infant

Health Care Settings

Ambulatory, Emergency care, Home health, Hospital, Outpatient

Intended Users

Nurse midwife, dietician nutritionist, nurse, nurse practitioner, physician, physician assistant

Scope

Counseling, Management, Treatment

Diseases/Conditions (MeSH)

D001942 - Breast Feeding, D064186 - Prenatal Education, D051556 - Hyperbilirubinemia, Neonatal, D007232 - Infant, Newborn, Diseases

Keywords

postpartum, Breastfeeding, jaundice, infant jaundice, Hyperbilirubinemia

Supplemental Methodology Resources

Data Supplement

Methodology

Number of Source Documents
34
Literature Search Start Date
January 1, 1980
Literature Search End Date
December 31, 2005
Description of External Review Process
Yes. The draft protocol is peer reviewed by individuals outside of contributing author/expert panel, including specific review for international applicability. The Protocol Committee's sub-group of international experts recommends appropriate international reviewers. The Chair and/or protocol resource person institutes and facilitates this process. Reviews are submitted to the committee Chair and resource person. The contributing author/expert panel and/or designated members of protocol committee work to amend the protocol as needed. The draft protocol is submitted to the Academy of Breastfeeding Medicine (ABM) Board for review and approval. Comments for revision will be accepted for three weeks following submission. The Chair, resource person and protocol contributor(s) amend the protocol as needed. Following all revisions, the protocol has the final review by original contributor(s) to make final suggestions and ascertain whether to maintain contributing authorship. The final protocol is submitted to the Board of Directors of ABM for approval. A two-thirds majority of Board members' positive vote is required for final approval.
Specialties Involved
Obstetrics And Gynecology, Neonatology And Perinatology, Pediatric Emergency Medicine, Pediatric Endocrinology, Pediatrics, Pediatrics, Pediatrics
Description of Systematic Review
Expert Consensus from systematic reviews with evidence tables.
List of Questions
Yes. Definitions, clinical manifestations, outcomes, etiologic mechanisms, management and prevention will be reviewed.
Description of Study Criteria
Yes. The inclusion criteria used for the searched were: humans, review articles, primary research articles, and English. Broader issues of neonatal jaundice unrelated to breastfeeding, bilirubin metabolism and sequelae of hyperbilirubinemia (bilirubin encephalopathy, kernicterus) will not be reviewed here.
Description of Search Strategy
Yes. See Methods below.
Description of Study Selection
Yes. Consensus-based. Led by Chair.
Description of Evidence Analysis Methods
General Methods An initial search of relevant published articles written in English in the past 75 years in the fields of medicine, psychiatry, psychology, and basic biological science is undertaken for a particular topic. Once the articles are gathered, the papers are evaluated for scientific accuracy and significance. Specific Methods The search was conducted using PubMed. In addition, a search of the original references and literature searches (from the previous version) were used to look for additional supportive articles. The time frame for the literature search was January 1980 to December 2005. The inclusion criteria used for the searched were: humans, review articles, primary research articles, and English. The specific search terms used were: breastfeeding, primary care, physician, pediatrician, obstetrician, family physician.
Description of Evidence Grading
General Methods An initial search of relevant published articles written in English in the past 75 years in the fields of medicine, psychiatry, psychology, and basic biological science is undertaken for a particular topic. Once the articles are gathered, the papers are evaluated for scientific accuracy and significance. Specific Methods The search was conducted using PubMed. In addition, a search of the original references and literature searches (from the previous version) were used to look for additional supportive articles. The time frame for the literature search was January 1984 to December 2016. The inclusion criteria used for the searched were: humans, review articles, primary research articles, and English. The specific search terms used were: breastfeeding, primary care, physician, pediatrician, obstetrician, family physician.