In reply to Nicole Bernshaw's inquiry about the onset of jaundice in a
five-week old breastfed infant, this is a difficult query to answer without
considerably more information.  First, a great deal more data is
needed about both the history of jaundice in this family (numbers of people
and relationship, duration of jaundice, what laboratory studies they have
had, etc.).  Second, one must determine whether the infant has an
unconjugated (indirect-reacting) or conjugated (direct-reacting)
hyperbilirubinemia.  Late onset of unconjugated hyperbilirubinemia may
indicate a hemolytic problem (inherited possibly), or a non-hemolytic cause
of increased bilirubin production, or a functional problem in bilirubin
transport or metabolism in the liver (Gilbert's, Crigler-Najjar I or II).
Any of these can be either benign or signs of a more serious problem.  If
the bilirubin in the baby is of the conjugated type, then the risk of the
baby having a primary liver disease is significantly greater and could
include such dignoses as biliary atresia, neonatal hepatitis and a wide
range of inherited metabolic disorders.  Most these diseases with conjugated
hyperbilirubinemia are much more serious than the former group.  Some of
them may be inherited.  Of course, the baby's jaundice may not be related
at all to the disorder that the other members of the family have and a full
diagnostic workup will be necessary to understand the cause of the jaundice.
    It must also be considered that the baby may,in fact, have been
jaundiced from a much earlier time and that it was only noticed for the
first time at five weeks.  In that case, it is possible that it is a
continuation of breastmilk jaundice, which has its onset in the first or
second weeks of life, but may persist as long as three or four months,
although with progressively declining serum bilirubin concentrations.
Breastmilk jaundice is a benign condition, except for the very rare
possibility of having a serum bilirubin level so high that it could cause
kernicterus, but this theoretical more than demonstrated.  In any event,
stopping breastfeeding in a five week old is certainly not indicated and
will do nothing to clarify the cause of the infant's jaundice.  The infant
needs a preliminary workup to determine what further studies are needed.
Several recent review articles in the pediatric textbooks and journals
(including my own in Pediatrics-In-Review November 1994) should help
determine how to proceed diagnostically.
                                    Larry Gartner
Lawrence M. Gartner, M.D.
Professor of Pediatrics and Obstetrics/Gynecology
The University of Chicago
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