Bilirubin levels may be lower in formula-fed babies for several reasons. One
is that they may receive an abnormally high volume of food during the first
few days of life compared to many breastfeeding babies born in hospital.
However, even if the volume is the same, the levels may be slightly lower in
the formula-fed baby due to the presence,in human milk, of B-glucuronidase,
an enzyme which deconjugates conjugated bilirubin in the intestine and
allows it to be absorbed again into the bloodstream (enterohepatic
circulation)rather than being eliminated through the stool. Other
unidentified pathways may also be at work. 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. Dr.
Jack Newman states that most of the breastfeeding babies in his practice are
at least slightly jaundiced for more than a month. It would seem to me that
this indicates a normal condition found in human babies ingesting human
milk.

The bilirubin levels found in healthy, newborn breastfeeding infants should
be considered the norm.  Bilirubin is a potent anti-oxidant and its presence
may protect the newborn from various insults during the early weeks of life.
The real question seems to be at what level of jaundice is there danger to
the infant.  Kernicterus, a type of irreversible brain damage caused by high
bilirubin levels, is usually not seen until levels reach at least 20 gm/dl
in a healthy newborn, lower in premature or otherwise compromised infants.  

Babies who will not go to the breast cannot be classified as healthy in the
strictest sense of the word.  These babies need to be supplemented with
expressed or pumped MOM or donated human milk in order to prevent
hyperbilirubinemia due to lack of feeding. Phototherapy could be used if
levels do not drop even with supplementation. Formula could be considered if
phototherapy was not working.

What I think has happened is that after being almost ridiculously obsessed
with bilirubin levels in breastfeeding babies for quite a few years,
pediatricians suddenly seemed to take a very laissez-faire attitude, being
very unconcerned about babies that were not feeding well at the breast.  I
was amazed by how much weight loss was being tolerated before any
intervention was considered.  Babies were not being seen for many weeks
postpartum and some got into a lot of trouble, including severe
hyperbilirubinemia. 

So now the pendulum is swinging again. Breastfeeding is cited by the AAP as
a risk factor for severe hyperbilirubinemia. Switching to complete formula
feeding is offered as an option by the AAP to bring down bilirubin levels
more quickly, with or without phototherapy. If formula can bring down levels
more quickly, why not just give a little of it to every breastfeeding baby,
just to make sure there aren't any problems?  Giving formula may be seen as
being easier or even safer than using phototherapy.  So it is now a shotgun
therapy. It is easier to write standing orders for all babies than to
evaluate each on a case by case basis, especially if you have a large case
load and even more so if you have already had a couple of breastfeeding
babies get into trouble. This is not doctor bashing. It is just the way it
is in many places. Compromises are always being made, risk vs benefit being
weighed. A physician may make the determination that the risk of any one
baby developing hyperbilirubinemia leading to brain damage outweighs the
risk of using formula in all babies.  Others may disagree.

The bottom line for me is that slightly elevated bilirubin levels appears to
be normal for a healthy, breastfeeding baby. Healthy babies that are
breastfeeding well should not be candidates for formula supplementation as a
treatment for hyperbilirubinemia unless phototherapy is not working and
bilirubin levels are approaching dangerous levels, usually designated as at
least 20 mg/dl. Just because you can lower levels more quickly with formula
doesn't mean you should. You could do an exchange transfusion on every baby,
too, but obviously you shouldn't do that either.  Always we return to risk
versus benefit.  

I would like to emphasize that we are talking about normal, healthy newborns
here. Premature or sick babies are another story, similar in some ways, very
different in others.
 

Hope this helps. Sorry so long.

From snowy upstate New York,
Sharon Knorr, BSMT, IBCLC

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