Karen raises an interesting question.

There is a difference between giving hydrolized formula and regular 
formula or breastmilk in the inhibition of enterohepatic recirculation 
of bilirubin. I don't know what the mechanism is, I don't know if it's 
known, but the hydrolized stuff seems to impair the decongugation or 
reuptake somehow.

I agree that normal levels of bilirubin are normal and therefore do not 
need treatment. But there are children with enzyme variants that cause 
slower congugation of bilirubin, children with faster than usual 
hemolysis (breakdown of red blood cells, releasing more hemoglobin to be 
recycled into bilirubin) and mothers that seem to have a higher level of 
beta glucoronidase in their milk. Some of these children will need 
treatment for jaundice.

The biggest issue, I think, in exaggerated physiologic jaundice is that 
poor breastfeeding is not identified and treated soon enough. (How many 
moms have we all seen who said that hospital staff praised their baby's 
perfect latch when it was abysmal? If something as simple as attachment 
is not properly assessed, forget the nuances!) Low levels of bilirubin 
are normal in baby mammals, but excessive bilirubin is one sign of 
either one of the metabolic issues above, or POOR FEEDING. If we 
identify the poor feeding on day 1 or 2, we can intervene and fix the 
issue or feed the baby expressed colostrum to help protect supply and 
child both. How to make society value breastfeeding sufficiently that it 
becomes and important part of all health care curricula is the 
challenge. Ideas, anyone?
Catherine Watson Genna, IBCLC  NYC

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