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Newborn and Infant Care

Biliary atresia

10/15/2004

Question:

My pediatrician has recommended I do blood work on my 5 week old to determine if he has biliary atresia. He was 6 lb 12 oz at birth and has gained 3 lb 1 oz in 35 days. He is exclusively breast fed and has frequent wet diapers and poops (yellow mustard color) 6+ times a day. He is clinically jaundiced: his eyes are a bit yellow but his levels have not been checked. He is my third child and he seems `fine` to me. I`ve read that jaundice affects 2/3 of all 3 week old breast fed infants. Physicians are so used to seeing formula infants that what is normal for nursed infants is not widly known. What are your thoughts? I take my responsibility as a health care partner seriously and try to educate myself. I`m not opposed to testing him if there seems to be just cause. But jaundice seems to be the only `symptom` my son is exhibiting. Thank you so much for your time and consideration.

Answer:

I appreciate your reasonable approach to a difficult choice. Let me start by sharing some information on jaundice in newborns that others may find helpful as well.

There are basically four types of jaundice or hyperbilirubinemia in early infancy. The most common is called physiologic jaundice and is the result of a normal process of destruction of the excessive number of red blood cells most fetuses have before birth as a result of the relatively oxygen poor environment of the placenta. With birth, the baby enters our oxygen-rich environment and no longer needs a large number of red blood cells. When red blood cells are destroyed, a large amount of bilirubin is produced and this is what causes jaundice or the yellow appearance of the baby's skin and the whites of the eyes, as you describe in your son. The bilirubin level peaks at about 3-5 days of age and then gradually declines. The highest level considered normal is 15. You can see the jaundice by bringing the baby into bright sunlight at a window and depressing the skin over a bony area. The yellow tint is visible in the blanched skin. Jaundice is first visible in the face at a bilirubin level of 5 and progresses down the body. If the extremities show jaundice, the bilirubin level is 15 or higher.

Breastfeeding jaundice usually peaks after 7 days of age and is related to an inadequate supply of breastmilk. Because bilirubin leaves the body through the stool, a baby not taking in an adequate amount of breastmilk cannot stool out the bilirubin quickly enough to prevent the intestines from reabsorbing bilirubin already processed by the liver. This is not at all consistent with your son's history, since he stools more than the minimum of 3 stools per day for a young infant and with such a large weight gain, obviously your breastmilk supply is abundant. Newborns typically gain 1/2 to 1 ounce per day once they have regained any weight lost  after birth. At 35 days of age, your son has gained 49 ounces.

The third type of jaundice, breastmilk jaundice, is indeed associated with normal term breastfed infants and peaks at 10-15 days of age with a slow decline thereafter, typically taking as long as 12 weeks of age to completely disappear. The cause of this type of jaundice is not well understood but is thought to be due to an unidentified substance in breastmilk which inhibits processing of the bilirubin. Bilirubin levels may be higher than 15 and as high as 30. There is no evidence that breastmilk jaundice is harmful, but we do not know this for certain. This may be the case for your son. The most common treatment is to withhold breastfeeding for 24 hours, which results in a rapid drop in bilirubin levels. Although it rebounds somewhat when breastfeeding resumes, the level is lower than before. Mothers need to pump their breastmilk during the 24 hour break for the sake of their comfort as well as maintaining their milk supply.

The fourth and most concerning type of jaundice, pathologic jaundice, may arise from a variety of serious medical conditions. These may include abnormal red blood cell destruction from blood group incompatibilities between mother and baby, bile duct absence or obstruction, and metabolic problems such as G6PD deficiency, hypothyroidism, or galactosemia. The last two problems are tested for in newborn screening tests routinely done in Ohio and most states shortly after the baby is born. If these were abnormal, your doctor and you would already have been notified by the Ohio Department of Health. Blood group incompatibility problems show up in the first days of life, so these are a very unlikely cause of your son's jaundice. G6PD deficiency is a hereditary red blood cell enzyme defect resulting in the abnormal breakdown of red blood cells. Jaundice occurs later in the newborn and early infancy period than does the other types of jaundice and it is seen in male infants, particularly those of Jewish, Mediterranean, or Asian descent. This is consistent with your son's history. The remaining serious problems are all structural resulting from a problem in bile flow.

The only way to tell whether or not your son's prolonged jaundice is due to breastmilk jaundice or a more serious disease process is to have blood tests. I recommend confirming with your son's pediatrician that his newborn screening results for hypothyroidism and galactosemia have returned as normal, and, for peace of mind, request screening for G6PD deficiency. In addition, I strongly support your pediatrician's desire to make sure that there is no serious underlying problem. Recently the American Academy of Pediatrics revised its hyperbilirubinemia management guidelines (September 2004), recommending conscientious follow up for infants with jaundice falling outside normal levels or lasting for prolonged periods in order to prevent a condition called kernicterus. Kernicterus results from bilirubin entering the brain cells and can cause mental retardation or, more commonly, hearing loss. If the problem is biliary obstruction, the resulting jaundice will not harm the brain cells, but there is a serious problem that requires treatment. The guideline is available for review at www.aap.org in the Policies and Guidelines web pages.

If you are concerned about the painfulness of the blood tests, you can request that your son be offered Sweet-Ease. It is a glucose solution shown to effectively reduce the distress of painful procedures for young infants. This should be available in hospitals with newborn intensive care units, which should also have lab facilities for drawing blood samples.

I wish you well and hope you receive the reassuring word that your son has nothing more serious than a resolving case of breastmilk jaundice.

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Response by:

Mary M Gottesman, PhD, RN, CPNP, FAAN Mary M Gottesman, PhD, RN, CPNP, FAAN
Professor of Clinical Nursing
College of Nursing
The Ohio State University