And another old note from an old Lactnet, from L. Gartner, MD, author of
papers on the subject, as well as a member of the AAP work group on
breastfeeding.

Date:    Tue, 11 Feb 1997 11:42:50 -0600
From:    "Lawrence M. Gartner" <[log in to unmask]>
Subject: Breastfeeding-Related Jaundice

         After three messages on jaundice and breastfeeding, I can no longer
resist adding my own comments on the subject.  The comments have been quite
on the mark and I appreciate all of the concerns about the terminology
"BreastFEEDING Jaundice".  Of course, one should never assume knowledge
about anything from a title alone.  It is necessary to read the "book."  I
coined the term BreastFEEDING Jaundice for this early exaggeration of
physiologic jaundice of the newborn to indicate that the mechanism of the
jaundice was related to poor feeding technique or to inadequacy of milk
intake and to differeniate it from the later onset BreastMILK Jaundice in
which the jaundice or hyperbilirubinemia results from a naturally occurring
component (as yet unidentified) in the majority of human milks.  Every
descriptive name I have given to these clinical phenomena (not syndromes
and not diseases) has met with some objection.  There are no perfect names
for anything.
         BreastFEEDING Jaundice is the newborn equivalent of the adult
phenomenon known as "starvation jaundice."  Virtually everyone who fasts
for more than 24 hours, even while freely drinking water, will double their
serum builirubin concentration.  The mechanism of this starvation jaundice
is debated, but appears at least in part to be due to an increase in the
intestinal absorption of bilirubin (unconjugated).
         BreastMILK Jaundice occurs much more frequently than the incidence
stated by one of the correspondents.  While it was once thought to be a
rare occurrence, recent clinical studies from The University of Chicago
have demonstrated that about two-thirds of all breastfed infants during the
third week of life have an elevated serum bilirubin concentration in
comparison with artificially-fed infants.  About half of these infants, or
about one-third of the total population of breastfed infants have a
sufficient elevation of serum bilirubin (greater than 5 mg/dl or 105 uM/L)
to appear clinically jaundiced.  A few infants will be very jaundiced and
very high serum bilirubin concentrations.  It was the recognition of the
high frequency of this phenomenon that led us to consider BreastMILK
jaundice to be an naturally occurring extension of physiologic jaundice of
the newborn.
         I appeal to everyone to quote recent literature and not to harken
back to data that was published 25 years ago.  It is true that when we
first described BreastMILK Jaundice, we thought it occurred in only one in
a hundred or one in two hundred breastfed infants, but that was only
because we were seeing the severe cases (serum bilirubin concentrations
above 20 mg/dl; 340 uM/L) that were referred to us.  BreastFEEDING Jaundice
is very frequent and can last several months.  Breastfeeding should not be
interrupted to make a diagnosis.  All other causes of exaggerated and
prolonged jaundice can be ruled out by physical examination and by
performing a few appropriate laboratory studies.  Even some relatively
recently published pediatric textbooks have given this erroneously low
frequency for BreastMILK Jaundice.
         Starvation or inadequate caloric intake in breastfed infants can
also occur after the first few days of life simultaneous with BreastMILK
Jaundice and these two phenomena can interact with each other, often
presenting a confusing picture and leading to confusing diagnoses.  In
addition, the newborn who has exaggerated early jaundice (due to starvation
or hemolysis) is also likely to have higher serum bilirubin levels later in
the first months of life because the bilirubin pool in the body is larger.

         For those who wish to read more extensively about jaundice in the
breastfed infant, I refer you to the following papers:

Gartner, L.M., Auerbach, K.G.: Breastmilk and Breastfeeding Jaundice.
Advances in Pediatrics 34:249-274, 1987.

Gartner, L.M.  Neonatal Jaundice.  Pediatrics In Review 15:422-432, 1994

Gartner, L.M.:  On the Question of the Relationship Between Breastfeeding
and Jaundice in the First 5 Days of Life.  Seminars in Perinatology
18:502-509, 1994

                                                 Larry

------------------------------

Kathleen B. Bruce, BSN, IBCLC co-owner Lactnet, Indep. Consultant
mailto:[log in to unmask]
http://homepages.together.net/~kbruce/kbblact.html
LACTNET Archives http://peach.ease.lsoft.com/archives/lactnet.html
"Be impeccable with your word.
Don't take anything personally.
Don't make assumptions.
Always do your best." Don Miguel Ruiz

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