Dear Gonneke,

There can be several separate scenarios here which could also merge together.  Gartner is saying that normal, healthy, well-fed breasted babies usually have higher baseline bilirubin levels than their formula-fed counterparts.  This would seem to be a biological norm seen even in breastfed babies who nurse frequently and well right from birth.  Now superimposed on that physiologically normal elevation can be a pathological elevation caused by poor feeding - a starvation induced hyperbilirubinemia, if you will.  I think that the rationale of the conservative pediatricians will be that in the case of a baby with an elevation in a certain range, eliminating breastmilk will in itself cause some drop in the bili, in addition to the drop caused simply by feeding the baby a bunch of formula.  The fact is, if breastfeeding is supported properly, then a pathological state would not develop in the first place, and sometimes even just a day of heavy-duty nursing/pumping can get enough food into the baby to get the bili started on a downward trend.  Poor discharge instructions/follow-up is often the culprit.  This is exactly what happened to me with my first baby.  The birth was traumatic, there was a possible ABO incompatability, he was not feeding vigorously when we left the hospital and his bili was moderately high and had not yet peaked when we left.  We were directed to keep him in sun as much as possible and do daily bili checks.  Having never breastfed before, I didn't know how well he was or wasn't doing and when his bili hit 19, he was admitted into the hospital for a full sepsis workup and put on total formula feeds for five days, plus bibi lights around the clock.  I hand-expressed drops of milk to maintain my meager supply (LLL was my salvation and cheering squad in addition to my wonderful husband).  Now this was over twenty years ago, but the ped was a laid-back guy who gave me the impression that everything was just fine - but it wasn't.  And I see this today in a lot of peds who seem to have become very complacent when faced with babies who are obviously not feeding or gaining well - they have gone from overzealous to unconcerned.  It is the LC who is getting anxious before the physician does.  We don't seem to have found the balanced center yet.

In addition to all this, there is the condition which I would call true breastmilk jaundice in which bilirubin levels remain quite high for many months in some breastfed babies.  This does not seem to be pathological in that the babies are normal and healthy, but the bili levels can seem quite alarming, sometimes >20 mg/dl.  It would seem to be a genetic condition since it is often seen in siblings, but it is not clear yet whether it is the milk itself or the babies physiology which is the root cause.  I seem to remember some study which postulated that there was some risk to infants with this syndrome when the bili was allowed to get extremely high, but I will have to research this.

Once again, the key thing here is very early, thorough follow-up with all breastfeeding dyads.  Hospitals and offices need to coordinate so that there are no cracks for these moms to fall through.  Unfortunately, hospital LCs are generally overloaded to the max and most ped offices still do not employ LCs to provide the kind of services required by their breastfeeding clients.  It still astounds me that the health and monetary value of LC care is not appreciated by large numbers of the health care/insurance community.

One cautionary note.  If you are helping a mom with a baby who already has a high bili, do not forget that kernicterus is a very real and irreversible condition.  Anyone who has ever cared for one of these infants will never forget the consequences that hyperbilirubinemia can sometimes have.  Also, there are many factors that influence how high the bilirubin can go in any particular infant before damage is done.  This can be part of a very complex medical situation, so make sure you have all the facts before you start making recommendations.




Warmly,
Sharon Knorr, BSMT, ASCP, IBCLC
Newark, NY (near Rochester on Lake Ontario)
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