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