Hi Sam,

You have most of the bilirubin story correct. One of the most important
points to note (and physicians should know this!) is that very little
bilirubin is ever excreted through the kidneys, thus making flushing with
water suppplements extremely inefficient. The great majority of bilirubin is
eliminated in stools as a substance known as stercobilin which gives stool
its brownish color. By filling a baby's tiny belly with water, you are
making it less likely that he will want to ingest the amount of colostrum
(or formula) necessary to eliminate the bilirubin through the stools.

Albumin in the bloodstream binds with the unbound, unconjugated (indirect)
bilirubin so that is becomes bound unconjugated bilirubin which can then be
processed by the liver into conjugated (direct) bilirubin which is then
further broken down and eventually eliminated via the stools.  One of the
reasons that premature babies can get into bilirubin trouble so quickly is
that they tend to have lower levels of albumin available for binding and
thus the levels of unbound unconjugated bilirubin can rise rapidly in the
baby's bloodstream. It is this unbound bilirubin that can eventually bind to
cells in brain (and other organs) causing the permanent brain damage called
kernicterus and it is why premature and/or sick babies are treated
aggressively for  hyperbilirubinemia at levels far lower that those at which
healthy, term babies are treated.  It should be noted that the lab test for
total bilirubin does not distinguish between bound and unbound unconjugated
bilirubin, so doctors assume that very young or otherwise compromised babies
have more unbound bilirubin and are thus at greater risk even if the total
bilirubin values are not very high. Elevated levels of conjugated or direct
bilirubin indicates a liver problem and so these levels can help the
physician to eliminate liver damage or disease as the cause of an elevated
total bilirubin count and indeed the conjugated bilirubin level is usually
quite low in most babies.

Babies are born with meconium in their intestinal tracts. This substance
contains large amount of conjugated bilirubin. If the meconium (or stool)
remains in the GI tract for too long, it can become unconjugated and can
then be reabsorbed into the bloodstream.  Therefore, it is important for
newborns to nurse frequently in order to move this substance quickly out of
the body.  Ingestion of water will slow the passage of meconium and indeed
this has been documented in studes done many years ago, so this is not new
information.

The other issue is whether or not giving formula will lower bilirubin levels
more rapidly that breastmilk will.  The real issue here is what is the
biological norm for bilirubin levels in the newborn and does it make any
clinical difference to the baby's health whether or not the levels fall from
14 to 10 in one day or two days or whatever.  Since there is no evidence
that there is any danger to a healthy newborn until bilirubin levels reach
at least 20 mg/dL or higher, the rush to lower levels which are not even
close to those considered dangerous is questionable at best. In fact, there
are researchers that believe that bilirubin acts as an antioxidant in
newborns and has protective properties for the infant.  There is no
scientific evidence that the rush to get bilirubin levels as low as possible
as quickly as possible in normal newborns has any positive short or long
term benefits for the baby.  Why does formula feeding seem to lower levels
more rapidly? One is that the volume of formula given is often much higher
than the amount of colostrum that a healthy human baby consumes during the
same period of time. Also, there seems to be a substance in breastmilk (some
or all and in what amounts, we don't know yet) that may hasten the
reabsorption of bilirubin from the GI tract and also to interfere with the
action of the enzyme which conjugates bilirubin in the liver, thus causing
most formula fed babies to have abnormally low levels of bilirubin within a
few days after birth.

Those of us who have been around for a while have seen the bilirubin issue
come full circle. Twenty-tive years ago, babies stayed in the hospital for a
long enough time for jaundice to become visible and elevated bilirubins were
treated quite aggressively in all babies. Then came the rush to get mothers
out of the hospital as quickly as possible and babies were often not seen by
a physician for two to four weeks after they were born.  In my experience,
many pediatricians went from being overly concerned about breastfeeding not
going well to being very unconcerned and not suggesting that mothers come in
to be seen, even when they voiced concerns that their babies were not
feeding well. Babies who were not feeding properly or had other issues,
developed elevated bilirubins that remained undetected until they became
quite high. The numbers of kernicterus cases rose and the health care
community became alarmed. Anyone who has seen a baby with kernicterus will
never forget it - I have once and it was a terrible thing, a young mother
who waited too long to get help for her very orange, now very brain-damaged,
baby.  Anyways, all of a sudden jaundice became a big issue again and was
treated very aggressively once more. Except that once the doctors realized
they could often lower the levels quickly by giving large amounts of
formula, it then became easier to just order a few formula feeds for all
babies rather than to worry about having the levels get high enough to have
to mess with phototherapy and all that or to offer meaningful lactation
assistance to those dyads that were having problems.  The shotgun approach
is so much easier when you have large numbers of patients to deal with. And
if I were a busy physician who didn't really see the value of exclusive
breastfeeding, I would probably do the same thing.

So I digress into policy issues.  With the nurses, I would keep it simple.
Bilirubin does not get excreted through the kidneys.  Frequent breastfeeding
will clear bilirubin at the rate that is biologically normal for humans.
For babies who are having problems at the breast, expressed colostrum will
usually get the job done. Unless the levels are dangerously high, there is
no proven benefit to lowering levels very quickly. Formula fed babies
probably have abnormally low levels of bilirubin (not sure how that would
fly with the medical establishment, LOL). The rules are different for
premature or sick babies.

Good luck. This issue makes me crazy, especially since I was not allowed to
breastfeed my jaundiced baby for five days (30 years ago) leading to
terrible allergy and other issues. This is a well-researched topic, so there
is plenty of information out there for those that care to read it.  I have
some handouts from a session I did on this topic at a conference that I
could send you if you like.  It includes a simplified flow chart for
bilirubin metabolism.

Warmly,
Sharon Knorr, LC and medical technologist in New York

             ***********************************************

Archives: http://community.lsoft.com/archives/LACTNET.html
To reach list owners: [log in to unmask]
Mail all list management commands to: [log in to unmask]
COMMANDS:
1. To temporarily stop your subscription write in the body of an email: set lactnet nomail
2. To start it again: set lactnet mail
3. To unsubscribe: unsubscribe lactnet
4. To get a comprehensive list of rules and directions: get lactnet welcome