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      <h1 id="top">2.6 Relationship between Jaundice and Breastfeeding</h1>
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            <td class="body"><img src="images/key_icon.gif" class="icon" alt="" /><h3>Key Points - Case Study B</h3>
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			Joanne asks you what she can do before the baby is born to help her successfully breastfeed.
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			The <cite>Ten Steps to Successful Breastfeeding</cite>, designed by the <img alt="External" src="design/external.gif" /><a href="http://www.who.int/en/" title="External link" target="_blank">WHO</a> and <img alt="External" src="design/external.gif" /><a href="http://www.unicef.org/" title="External link" target="_blank">UNICEF</a> summarise the maternity practices needed to support and encourage breastfeeding.
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		<dl><dt><a href="topic_2-1.html"><cite>Topic 2.1: Preparation Before Birth</cite></a></dt><dd class="topic-paragraph">Inform all pregnant women about the benefits and management of breastfeeding</dd></dl>
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			Joanne's baby Rosie is born by spontaneous vaginal delivery at 37 weeks following a 15-hour labour. She had been given pethidine (meperidine) and an epidural for pain relief during labour. Are there any features of her birthing experience that may affect breastfeeding?
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		<dl><dt><a href="topic_2-2.html"><cite>Topic 2.2: Birthing Factors that Affect Breastfeeding</cite></a></dt><dd class="topic-paragraph">Labour analgesia and near-term birth</dd></dl>
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		<dl><dt><a href="topic_2-3.html"><cite>Topic 2.3: Management After Birth</cite></a></dt><dd class="topic-paragraph">
				Place Rosie in skin-to-skin contact;
				Encourage breastfeeding on demand;
				Practice rooming-in, allow Joanne and Rosie to remain together 24 hours a day;
				Give Rosie no food or drink other than breastmilk, unless medically indicated;
				Give Rosie no artificial teats or dummies;
				Show Joanne how to breastfeed and how to maintain lactation even if she should be separated from Rosie.
			</dd></dl>
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			Rosie is now 24 hours old. Although she seems interested in the breast, she is not attaching well and tends to slip off the breast easily. What is the most appropriate management to suggest at this time?
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		<dl><dt><a href="topic_2-4.html"><cite>Topic 2.4: Poor Attachment</cite></a></dt><dd class="topic-paragraph">
				Investigate whether there an underlying reason;
				Maximize breastfeeding opportunities;
				Protect the milk supply;
				Feed the baby;
				Nipple shields may be useful.
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			Because Rosie has not been feeding well, the hospital staff are concerned that she may develop hypoglycaemia. Is hypoglycaemia likely to occur in a healthy term breastfed neonate?
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		<dl><dt><a href="topic_2-5.html"><cite>Topic 2.5: Hypoglycaemia</cite></a></dt><dd class="topic-paragraph">Healthy full-term infants do not develop symptomatic hypoglycaemia simply as a result of underfeeding.</dd></dl>
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			On day three, just before Rosie and Joanne are to go home, Joanne mentions that Rosie looks jaundiced and asks if it is due to her breastmilk. What is the relationship between jaundice and breastfeeding?
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		<dl><dt><a href="topic_2-6.html"><cite>Topic 2.6: Relationship between Jaundice and Breastfeeding</cite></a></dt><dd class="topic-paragraph">In the early days jaundice in a breastfed infant may be due to inadequate breastfeeding. Breast milk jaundice usually begins after day five, is associated with increasing milk volumes and is thought to be due to as yet unidentified substance in breast milk. It rarely requires investigation or treatment.</dd></dl>
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			On day three, just before Rosie and Joanne are to go home, Joanne mentions that Rosie looks jaundiced and asks if it is due to her breastmilk. What is the relationship between jaundice and breastfeeding?
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		Unconjugated or indirect bilirubin, derived from the breakdown of haem (mainly red blood cells), is normally bound to albumin and transported to the liver where it is metabolised to conjugated (or direct) bilirubin. Direct bilirubin is excreted via the biliary tree into the small intestine, where it is broken down by bacteria to form urobilinogen. However, urobilinogen and conjugated bilirubin may be converted back to unconjugated bilirubin and resorbed into the portal circulation. 
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		Unconjugated bilirubin is fat soluble and can enter the skin and brain if not bound to albumin causing the yellow colouration of skin and sclera (jaundice) and bilirubin encephalopathy (kernicterus). Jaundice usually appears on the head and progresses caudally with increasing levels of bilirubin.<sup><a href="#note1">1</a></sup>
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			Infants are at risk for increased bilirubin levels postpartum because of an imbalance in bilirubin production and bilirubin elimination due to:
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        <li>An increase in red cell destruction</li>
        <li>An increase in enterohepatic circulation of bilirubin because of:
			<ul><li>an increased load in the intestine (meconium)</li><li>a lack of bacteria to breakdown conjugated bilirubin</li><li>higher levels of B-glucuronidase - the enzyme that converts urobilinogen and conjugated bilirubin to unconjugated bilirubin</li></ul>
		</li>
        <li>
			Immaturity of the enzyme systems in the liver to transport bilirubin into the liver and metabolise it to conjugated bilirubin
		</li>
        <li>
			Lower levels of albumin to transport unconjugated bilirubin and less tight binding.
		</li>
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		Early onset jaundice (within the first 24-48 hours) or raised levels of conjugated bilirubin are nearly always due to a pathologic process and needs investigation and appropriate treatment regardless of the feeding method.
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		Even so, bilirubin levels in most infants begin to rise after birth usually peaking around 95µmol/l (5.5mg/dl) around day 4 (physiological jaundice).<sup><a href="#note2">2</a></sup> These levels drop rapidly by day 5 and then more slowly so that by day 11 bilirubin levels in formula fed infants reach the adult range of less than 25.5µmol/l (1.5mg/dl).<sup><a href="#note1">1</a></sup> Bilirubin levels in normal breastfed infants are reported to be higher than formula fed infants during the first week and can take from three and up to 15 weeks to reach adult levels.<sup><a href="#note1">1</a>,</sup><sup><a href="#note3">3</a></sup> Jaundice is more pronounced in infants with Asian origins as well as those born before term.<sup><a href="#note1">1</a></sup>
	</p>
      <p class="listTitle">Higher than average  levels of bilirubin in breastfed infants arise from increased enterohepatic circulation of bilirubin, although there appears to be different mechanisms for elevated levels within the first week and later.</p>
      <ul>
        <li>
				Before day five, higher bilirubin levels are usually the result of inadequate breastfeeding  enterohepatic circulation is increased because of the delayed passage of meconium, few bacteria are present to break down conjugated bilirubin, and there is a starvation effect. Breastfed infants who feed frequently, have little weight loss and experience early, frequent passage of stools have similar bilirubin levels to formula-fed infants. Conversely, when breastfeeding is less than optimal, infants are at increased risk of developing jaundice and reaching bilirubin levels requiring active treatment. Therefore, how effectively the infant is breastfeeding, the presence (or absence) of jaundice, the age of the infant and the gestational age need to be considered when arranging appropriate follow-up following discharge from hospital.<sup><a href="#note4">4</a>,</sup><sup><a href="#note5">5</a></sup> For example, a 48-hour-old infant who is sleepy, not feeding well and is slightly jaundiced probably needs reassessment within 2448 hours of discharge.
			</li>
        <li>
		With increasing volumes of transitional and mature milk after day 5, a rise in bilirubin levels may be due to breast milk jaundice.<sup><a href="#note3">3</a></sup> An as yet unidentified substance in human milk is thought to increase bilirubin enterohepatic circulation. Bilirubin levels will often plateau around 170200 µmol/l (1012mg/dl) and rarely rise above 300 µmol/l (1718mg/dl).
			</li>
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			Prolonged mild jaundice in a well and thriving breastfed infant is most likely due to breast milk jaundice. However, rare pathological conditions may also present with prolonged jaundice and appropriate investigations should be undertaken especially if:
		</p>
      <ul>
        <li>the level of jaundice is maintained or increases,</li>
        <li>the bilirubin level is unusually high (&gt;300 µmol/l),</li>
        <li>the infant is unwell in any way, or.</li>
        <li>the stools are pale.</li>
      </ul>
      <p>
		These is no need to withhold breast milk from the infant to confirm the diagnosis of breast milk jaundice. In the rare situation where bilirubin levels due to breast milk jaundice are at a level requiring treatment, supplementing the infant with an elemental formula or substituting elemental formula for breastfeeds for a 24-hour period is usually sufficient to reduce it to a satisfactory level.<sup><a href="#note3">3</a></sup>
	</p>
      <div class="section" id="Would_there_be_any_concern_about_Rosie_developing_jaundice_at_this_time_"><h2>Would there be any concern about Rosie developing jaundice at this time?</h2>
		<p>
			As Rosie was born near-term and did not feed well for at least the first 24 hours she is at increased risk of developing clinically apparent jaundice and may require further monitoring. It would be appropriate to check her bilirubin level before discharge and arrange close follow-up.
		</p>
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            <td class="body"><img src="design/group.png" class="icon" alt="" /><h3>Case Study Activity</h3>
		<div></div><div class="activity" id="activity_v">
<script type="text/javascript">
/* <![CDATA[ */
var vqs = {settings : {type : 'response'}, questions : [
	{ c : '\n			<p>\n				<strong>While treating Jan\'s 3yr old daughter for otitis media you notice that 3 week old Karl appears jaundiced.</strong>\n			</p>\n			<p style=\"margin-top: 0px;\">\n				<strong>What information would make you suspect that this was breast milk jaundice?</strong>\n			</p>\n			<p style=\"margin-top: 0px;\">\n				<strong>What actions would you take?</strong>\n			</p>\n		', r : '\n			<p>\n				Karl has no other risk factors for hyperbilirubinaemia. He is exclusively breastfed at least 8 times a day, is well and active, is gaining at least 150 g a week and is passing a number of mustardy, curdy stools a day. Jan states that he is not becoming more yellow. There is no need for further action at this time although a baseline bilirubin (indirect and direct) may be appropriate at times.\n			</p>\n		' }
]};

/* ]]> */</script>
<p class="blurb">Think about what your response would be to the scenario presented, write it into the exercise, then submit it and read the suggestions given.</p></div><script type="text/javascript">renderActivity('v');</script>
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            <td class="body"><a href="http://aappolicy.aappublications.org/cgi/content/full/pediatrics%3B114/1/297" target="_blank"><img src="design/article.png" class="icon" alt="" /></a><h3><a href="http://aappolicy.aappublications.org/cgi/content/full/pediatrics%3B114/1/297" target="_blank">American Academy of Pediatrics Clinical Practice Guideline</a></h3>
		<p>Click on the icon and read the AAP Guidelines: "Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation"</p>
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      <div id="footnotes">
        <h3>Notes</h3>
        <ol>
          <li id="note1"><a href="references.html#gart01a" title="See full details">#</a> Gartner LM et al. (2001) Jaundice and breastfeeding</li>
          <li id="note2"><a href="references.html#sari04" title="See full details">#</a> Sarici SU et al. (2004) Incidence, course, and prediction of hyperbilirubinemia in near-term and term newborns</li>
          <li id="note3"><a href="references.html#gart07" title="See full details">#</a> Gartner LM (2007) Hyperbilirubinemia and breastfeeding</li>
          <li id="note4"><a href="references.html#aaps04" title="See full details">#</a> AAP Subcommittee on Hyperbilirubinemia (2004) Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation</li>
          <li id="note5"><a href="references.html#bhut04" title="See full details">#</a> Bhutani VK et al. (2004) Diagnosis and management of hyperbilirubinemia in the term neonate: for a safer first week</li>
        </ol>
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      <h1>Breastfeeding Essentials</h1>
      <ol>
        <li>0.1 <a href="topic_0-1.html">Introduction</a></li>
        <li>1.0 <a href="topic_1-0.html">Case Study A (Joanne)</a><ol><li>1.1 <a href="topic_1-1.html">Discussing breastfeeding</a></li><li>1.2 <a href="topic_1-2.html">What information to give</a></li><li>1.3 <a href="topic_1-3.html">Effects of Breastfeeding alternatives</a></li><li>1.4 <a href="topic_1-4.html">Common breastfeeding concerns</a></li><li>1.5 <a href="topic_1-5.html">Breast examination</a></li><li>1.6 <a href="topic_1-6.html">Contraindications to breastfeeding</a></li><li>1.7 <a href="topic_1-7.html">Conditions related to lactation outcomes</a></li><li>1.8 <a href="topic_1-8.html">Medications</a></li></ol></li>
        <li>2.0 <a href="topic_2-0.html">Case Study B (Joanne)</a><ol><li>2.1 <a href="topic_2-1.html">Preparation Before Birth</a></li><li>2.2 <a href="topic_2-2.html">Birthing Factors that Affect Breastfeeding</a></li><li>2.3 <a href="topic_2-3.html">Management After Birth</a></li><li>2.4 <a href="topic_2-4.html">Poor Attachment</a></li><li>2.5 <a href="topic_2-5.html">Hypoglycaemia</a></li><li class="current">2.6 <img src="design/bullet_arrow_right.png" alt="*" title="You are here" /><a href="topic_2-6.html">Relationship between Jaundice and Breastfeeding</a></li></ol></li>
        <li>3.0 <a href="topic_3-0.html">Case Study C (Joanne)</a><ol><li>3.1 <a href="topic_3-1.html">Early problems</a></li><li>3.2 <a href="topic_3-2.html">Risk of SIDS</a></li><li>3.3 <a href="topic_3-3.html">Contraception</a></li><li>3.4 <a href="topic_3-4.html">Milk composition</a></li><li>3.5 <a href="topic_3-5.html">Slowing of growth</a></li><li>3.6 <a href="topic_3-6.html">Introducing solids</a></li><li>3.7 <a href="topic_3-7.html">Weaning</a></li></ol></li>
        <li>4.0 <a href="topic_4-0.html">Case Study D (Sally)</a><ol><li>4.1 <a href="topic_4-1.html">Initial assessment</a></li><li>4.2 <a href="topic_4-2.html">Milk production</a></li><li>4.3 <a href="topic_4-3.html">Causes of inadequate infant growth</a></li><li>4.4 <a href="topic_4-4.html">Increasing milk supply</a></li></ol></li>
        <li>5.0 <a href="topic_5-0.html">Case Study E (Anna)</a><ol><li>5.1 <a href="topic_5-1.html">Sore nipples</a></li><li>5.2 <a href="topic_5-2.html">Factors causing nipple damage</a></li><li>5.3 <a href="topic_5-3.html">General treatment for sore nipples</a></li><li>5.4 <a href="topic_5-4.html">Further causes of nipple pain</a></li><li>5.5 <a href="topic_5-5.html">Mastitis – diagnosis</a></li><li>5.6 <a href="topic_5-6.html">Mastitis – treatment and complications</a></li></ol></li>
        <li>6.0 <a href="topic_6-0.html">In conclusion</a><hr /></li>
        <li class="appendix"> <a href="references.html">List of references</a></li>
        <li class="appendix"> <a href="contents.html">Course contents</a></li>
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