A few months ago I asked about jaundice, and got an exellent answer from
Prof. Gartner. He wrote
(my questiones and Prof. Gartners answers):
>How long can breast milk jaundice last?
>ALTHOUGH SERUM BILIRUBIN LEVELS IN INFANTS WITH BREASTMILK JAUNDICE DECLINE
>PROGRESSIVELY AFTER A PEAK IN THE SECOND OR THIRD WEEKS OF LIFE, CLINICAL
>JAUNDICE MAY STILL BE PRESENT UP TO 6 OR EVEN 8 WEEKS.  ELEVATED SERUM
>BILIRUBIN LEVELS (GREATER THAN 1.3 MG/DL) CAN BE FOUND UP TO THREE OR FOUR
>MONTHS.  PLEASE KEEP IN MIND THE FACT THAT AT LEAST TWO-THIRDS OF ALL
>BREASTFED INFANTS HAVE ELEVATED SERUM BILIRUBIN LEVELS DURING THE THIRD
>WEEK OF LIFE AND THAT ONE-THIRD OF ALL BREASTFED INFANTS ARE CLINICALLY
>JAUNDICED DURING THE THIRD WEEK OF LIFE.  THIS CONTRASTS WITH THE COMPLETE
>ABSENCE OF JAUNDICE AND HYPERBILIRUBINEMIA IN ARTIFICIALLY-FED INFANTS.
>
>Assuming a healthy, thriving, fully breastfed infant, with indirect
>bilirubinemia, when would you do more
>tests, and which, how often check bili levels?
>YOUR QUESTION INDICATES CLEARLY THAT YOU HAVE ALREADY CHECKED FOR AN
>ELEVATION OF THE DIRECT PORTION OF THE BILIRUBIN AND RULED THAT OUT, AN
>IMPORTANT COMPONENT IN BEING SURE THE INFANT DOES NOT HAVE BILIARY
>OBSTRUCTION OR METABOLIC DISEASE/INFLAMMATORY DISEASE OF THE LIVER.  THE
>OTHER TWO MAJOR CONCERNS ARE TO RULE OUT HYPOTHYROIDISM, WHICH CAN PRODUCE
>PROLONGED UNCONJUGATED HYPERBILIRUBINEMIA AND HEMOLYTIC DISEASE.  THYROID
>SCREENS, IF RELEIABLE, ARE PROBABLY SUFFICIENT IN THE ABSENCE OF CLINICAL
>SYMPTOMS TO RULE OUT HYPOTHYROIDISM. HEMATOCRIT/HEMOGLOBIN AND RED CELL
>SMEAR FOR MORPHOLOGY ARE PROBABLY SUFFICIENT TO RULE OUT HEMOLYSIS.
>RETICULOCYTE COUNTS ARE NOT NEEDED IN THE ABSENCE OF ANEMIA.
>
>Every once in a while I encounter a baby several weeks old, still
>jaundiced, sometimes with quite high bili levels. Often these babies are
>referred to me by LLL leaders or LC after they were recomended to stop bf
>for 48 hrs (by their doctors). Sometimes it is a telephone consultation.
>How would you handle this?
>IF THE BABY IS THRIVING AND ENTIRELY HEALTHY AND THE BILIRUBIN LEVEL IS
>UNDER 20 MG/DL, I WOULD DO NOTHING MORE, OTHER THAN THE TESTS NOTED ABOVE
>EXCEPT POSSIBLY TO RECHECK THE BILIRUBIN IF THE INFANT IS LESS THAN A MONTH
>OR IF CLINICAL JAUNDICE IS INCREASING RATHER THAN DECREASING.  IF THE
>BILIRUBIN IS BETWEEN 20 AND 25 I WOULD REPEAT THE BILIRUBIN SOON THEREAFTER
>TO SEE WHERE IT IS GOING AND WHETHER THE ORIGINAL DETERMINATION WAS
>CORRECT.  IF THE REPEAT IS AGAIN BETWEEN 20 AND 25, BUT NOT RISING, I WOULD
>OBSERVE.  IF RISING OR ABOVE 25 I WOULD MAKE SOME EFFORTS TO REDUCE THE
>BILIRUBIN BY EITHER SUPPLEMENTING WITH FORMULA USING A NURSING SUPPLEMENTER
>OR CUP FEEDING (OR EVEN A BOTTLE IF BREASTFEEDING IS WELL ESTABLISHED) OR
>PHOTOTHERAPY FOR A DAY (IF A YOUNGER INFANT).  I WOULD INTERRUPT
>BREASTFEEDING ONLY IF THESE TECHNIQUES WERE NOT WORKING OR WERE NOT
AVAILABLE.
>

I think this answers the question about the bili of 10 asked recently, and
I am in a process to publish this advice to as many doctors as possible
(with Prof. Gartner's permission).

Mira Leibovich, MD