In response to the questions from Dr. Mira Leibovich:

How long can breastmilk 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.

Another related question - at what bili level can the baby be circumcised?
(This is Israel, so this is very important.)
THIS IS A VERY INTERESTING QUESTION.  YEARS AGO I MET WITH SEVERAL RABBIS
TO DISCUSS THIS ISSUE.  THEY CONSIDERED THE ISSUE OF NOT CIRCUMCISING A
JAUNDICED BABY TO BE RELATED TO THE SMALL BUT REAL RISK THAT THE INFANT
MIGHT HAVE A DISEASE (LIVER DISEASE) WHICH WOULD PLACE THE INFANT AT RISK
FOR INCREASEED BLEEDING.  THEY WERE SEEKING WAYS IN WHICH THE NORMAL
INCREASE AND PROLONGATION OF JAUNDICE (UNCONJUGATED HYPERBILIRUBINEMIA IN A
HEALTH BABY), ESPECIALLY IN A BREASTFED BABY, COULD BE DIFFERENTIATED FROM
A SICK CHILD - USING TALMUDIC TEXT REFERENCES.  I BELIEVE THERE WAS SOME
TALMUDIC BASIS FOR MAKING SUCH A DISTINCTION, BUT I AM NOT A TALMUDIC
SCHOLAR AND CAN NOT RECALL THE SOURCE.  IF YOU FIND FURTHER INFORMATION
ABOUT THIS ISSUE, I WOULD BE MOST INTERESTED IN HAVING MORE DETAILS.

                        Larry Gartner





Lawrence M. Gartner, M.D.
Professor of Pediatrics and Obstetrics/Gynecology
The University of Chicago
MC6060
5841 S. Maryland Avenue
Chicago, IL 60637
Phone: (773) 702-0389
FAX: (773) 702-0764
E-Mail: [log in to unmask]