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Breast feeding jaundice
From WikEM
Contents
Background
Breast feeding jaundice occurs within the first first week of life and overlaps with breast milk jaundice and physiologic jaundice and is the result of inadequate breast milk volume and neonatal volume contraction relative to the amount of bilirubin.
Clinical Features
- Jaundice within the first 4-7 days of life
Differential Diagnosis
Indirect (Unconjugated) Hyperbilirubinemia
More common causes are listed first, followed by less common causes
- Breast milk jaundice
- Due to substances in milk that inhibits glucuronyl transferase. It may start as early as 3rd day and reaches peak by 3rd week of life. It is unlikely to cause kernicterus
- Breast feeding jaundice
- Patient does not receive adequate oral intake which then causes reduced bowel movement/bilirubin excretion. Best diagnosed by looking for signs of dehydration and comparing weight to birth weight.
- Blood group incompatibility: ABO, Rh factor, minor antigens
- Diabetic mother/gestational diabetes
- Internal hemorrhage
- Physiologic jaundice
- Polycythemia
- Sepsis
- Hemoglobinopathies: thalassemia
- Red blood cell enzyme defects: G6PD Deficiency, pyruvate kinase
- Red blood cell membrane disorders: spherocytosis, ovalocytosis
- Hypothyroidism
- Immune thrombocytopenic purpura
- Mutations of glucuronyl transferase (i.e., Crigler-Najjar syndrome, Gilbert syndrome)
Direct (Conjugated) Hyperbilirubinemia
Conjugated bilirubinemia implies a hepatic or post hepatic cause. More common causes are listed first.
- Hyperalimentation cholestasis
- Neonatal hepatitis
- Cytomegalovirus infection
- Sepsis
- TORCH infection
- Biliary atresia
- Cystic fibrosis
- Hepatic infarction
- Inborn errors of metabolism (e.g., galactosemia, tyrosinosis)
Evaluation
- The most important component of the workup is differention of direct vs indirect bilirubinemia
- See BiliTool and the phototherapy guide for total bilirubin cutoff by age recommendations
- History extremely important
- Mother's blood type (important if mother is RH negative or O blood type)
- Assess for any signs of decreasing oral intake or signs of dehydration?
- Baby's general appearance (well appearing?)
- Total bilirubin/Direct bilirubin levels
- CBC (for evaluation of hemolytic anemia or polycythemia vera)
- Consider coombs or T&S (mom & baby)
Management
- The mother should supplement lack of breast milk with formula until quantity of milk increases
- Phototherapy may be necessary and the following chart and [BiliTool] can be used as a reference for treatment
Phototherapy Guidelines
| Age | Low Risk | Medium Risk | High Risk |
| Birth | 7.0 | 5.0 | 4.0 |
| 24h | 11.5 | 9.0 | 8.0 |
| 48h | 15 | 14 | 10 |
| 72h | 17.5 | 15 | 14 |
| 96h | 20 | 17.5 |
14.5 |
| 5+days | 21 | 17.5 | 15 |
- Low Risk: ≥38 weeks + no risk factors
- Medium Risk: (≥38 weeks + risk factors) or (35-37 weeks and no risk factors)
- High Risk: 35-37 weeks + risk factors
Disposition
- Bilirubin levels of 12 mg/dL (170 µmol/L) to 17 mg/dL can generally be rechecked within 24hrs and supplementation with formula
- Bilirubin levels of >17 mg/dL (294-430 µmol/L) should have phototherapy as well as formula supplementation while continuing breast feeding
