Stop blaming mother’s milk for infant jaundice

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Jaundice in infants is not caused by breast milk. – Copyright: plepraisaeng / 123RF Stock Photo

POOR breast milk. It gets blamed for everything, from baby’s failure to thrive to jaundice.

Dr Hairin Anisa Tajuddin, paediatrician and lactation consultant at Monash University Malaysia, pointed out that breast milk is not to blame for baby’s jaundice, in her presentation entitled “Busting the Myths on Jaundice” at the recent PRISMA 2015 conference, organised by the Malaysian Breastfeeding Peer Counsellor Association.

According to her, there are a lot of myths about what causes infant jaundice, and the biggest myth that she wants to debunk is that breast milk is to blame.

Neonatal jaundice

“Neonatal jaundice is one of the reasons why mothers fail to establish exclusive breastfeeding,” said Dr Hairin Anisa.

Among the myths are that the mother doesn’t have enough milk, she’s not taking enough water, or that her milk is not good. This will influence the mother who wants to breastfeed, making her feel guilty and think that her milk is insufficient. As a result, she might top up her breast milk with formula milk, or she might even stop breastfeeding.

It doesn’t help that the mother and baby are separated in the hospital as soon as the baby is found to have jaundice.

“Sometimes the mother goes home and the baby remains in the hospital. How do you establish breastfeeding like that? What more if the hospital then gives the baby a bottle.

“That will thwart the process of lactation. So, the support is not just important from the family, but also from the health personnel in hospitals as well.

“The lack of knowledge transfer from the medical fraternity to the mothers causes them to fail in breastfeeding,” said Dr Hairin Anisa.

Dr Hairin Anisa Tajuddin: 'Neonatal jaundice is one of the reasons why mothers fail to establish exclusive breastfeeding.'
Dr Hairin Anisa Tajuddin: ‘Neonatal jaundice is one of the reasons why mothers fail to establish exclusive breastfeeding.’

According to a study done in the 1980s on 20,000 newborns, it was found that there is a relationship between breastfeeding and jaundice.

Referring to a more recent study, Dr Hairin Anisa said that in Nepal, a study was done from 2003-2006, involving nearly 19,000 newborns over the span of six days.

Among infants with difficulty in exclusive breastfeeding (EBF), there was an increased risk of jaundice, but among infants with no difficulty breastfeeding, EBF was protective.

There are a few types of neonatal jaundice:

  • physiological (normal) jaundice
  • prolonged jaundice
  • breastfeeding jaundice
  • breast milk jaundice

Physiological and prolonged jaundice

According to Dr Hairin Anisa, physiological jaundice has these features:

  • 60-80% occurrence in newborns (in the first week of life)
  • Total serum bilirubin is less than 15mg/dl
  • It appears after 24 hours of life
  • Maximum intensity is from 4th-7th day of life
  • Typically lasts 14 days (term babies) / 21 days (preterm babies)

Meanwhile, prolonged jaundice is more urgent. It appears before 24 hours and goes on prolonged for more than 14 days (for term babies) and more than 21 days (preterm babies). The total bilirubin is usually more than 15mg/dl and the total serum bilirubin rapidly rises and fluctuates. Today, it might be 12mg/dl and tomorrow it might be 20mg/dl. The infant will also have pale stools.

It can be caused by G6PD (Glucose-6-phosphate dehydrogenase deficiency), UTI (urinary tract infection), hepatitis, and hypothyroid. In addition, if the mother has diabetes, it can cause polycythaemia in the infant, and one of the symptoms is prolonged jaundice.

Breastfeeding jaundice

Dr Hairin Anisa said breastfeeding jaundice occurs in 1/100 breastfed babies.

According to her, due to the poor breastfeeding technique or poor milk flow due to early blocked ducts, there is inadequate milk intake and this results in a lack of fat or low calorie intake and dehydration, causing jaundice.

Babies with breastfeeding jaundice produce only a small amount of urine (less than six times a day). According to Dr Hairin Anisa, this is where the myth about baby not getting enough water and that you should give baby water comes from.

These babies also see a loss of birth weight – more than 10%.

If no action is taken, it can turn into severe jaundice.

According to another study, it was found that breastfeeding is not correlated with significant jaundice in the first few days of life. And, significant jaundice was higher in infants with greater weight loss after birth.

Dr Hairin Anisa explained that what this means is that babies who have problems with breastfeeding suffer more weight loss and this is what causes the higher percentage of jaundice.

“Neonatal jaundice is not associated with breastfeeding per se, but rather with increased weight loss after birth, subject to fasting. This suggests the important role of calorie intake in the regulation of bilirubin.

“So, the conclusion is that failure to establish breastfeeding (poor technique) leads to inadequate milk intake (starvation) and is the factor that exaggerates the incidence of physiological jaundice in newborns,” said Dr Hairin Anisa.

If additional treatment is needed, she said the infant can still go for phototherapy but she recommends that the mother be allowed to be near the baby so that she can still breastfeed while the baby is under therapy.

This is to avoid interruption of the lactation process and the exclusive breastfeeding.

Breast milk jaundice

Dr Hairin Anisa outlined the features of breast milk jaundice:

  • Occurs in 1 out of 200 exclusively breastfed babies
  • It causes prolonged jaundice which may last up to 2-3 months
  • Child looks normal, is happy, has weight gain
  • The only problem is the yellowing of the skin
  • There are many hypotheses about breast milk jaundice

“The management for breast milk jaundice is merely a weekly followup and we recommend the mother continues exclusively breastfeeding the baby.

“The myth is that mothers should stop breastfeeding for two days and then resume.

“Breast milk jaundice has no complications. Why do I say this? Because from all the many studies, it has been proven that breast milk jaundice 100% has no complications,” said Dr Hairin Anisa.

Popular ‘remedies’ for jaundice

She debunked some of the common myths regarding “remedies” for jaundice:

Goat’s milk – Fresh goat’s milk is not suitable for infants below 12 months old because of its lack of folic acid, iron, Vitamin C and lactose. It is high in protein and sodium which the baby’s kidney is not mature enough to accept and can cause kidney failure.

It has higher protein and less fat. This can cause the protein to be turned into urea annd uric acid which can lead to metabolic acidosis. The protein and sodium in goat’s milk is three times the amount in mother’s milk. There is insufficient folic acid in goat’s milk – there is 50mcg of folic acid in 100ml of breast milk; while only 6mcg in 100ml of goat’s milk.

Dr Hairin Anisa explained that goat’s milk and cow’s milk are about the same. The only reason why there are more reported cases of allergy to cow’s milk rather than goat’s milk is because the consumption of goat’s milk is still relatively new and not as common in comparison to cow’s milk.

Give water and other fluids to baby – Nothing is better than breast milk. No other fluid or food is suitable for babies less than 6 months old because of baby’s gut immaturity. Giving the baby any other fluids puts the baby at risk of developing allergies, although in small amounts. Giving the baby water or other fluids also interrupts the lactation and exclusive breastfeeding process. It will reduce the baby’s demand, and thus reduce milk production and flow in the mother.

There is also the risk of water intoxication. Dr Hairin Anisa referred to a case where the baby’s sodium level was low and only when the family was questioned did the doctors find out that the baby had been given water for the past four or five months. The effects of giving water are not seen immediately, and this led the family to think it was okay to give the baby water.

Grape juice/honey feeding – As above, the baby’s gut is not matured yet to be able to digest these. In addition, babies can’t be given grape juice and honey daily as there is a risk of the child developing a sweet tooth later on. It can also cause toxin contamination.

Sunlight exposure – It is not so effective to get rid of jaundice. However, a bit of indirect exposure before 9am can give the baby some Vitamin D. Any later in the day and you risk sunburn and skin cancer later on.

Herbal application to baby’s skin – Best to avoid this because you don’t really know the content of herbal preparations. In addition, if the herbal application makes the baby’s skin yellow, this makes it harder for the doctor when examining the baby. Herbal applications can also absorb into the baby’s blood and affect the liver and the bilirubin level.

Dr Hairin Anisa explained that sometimes mothers may use a herbal application and by coincidence the jaundice goes down around the same time, so the mothers think that the herbal application works.

Mother should avoid turmeric, ginger and herbs – Dr Hairin Anisa suggests mothers just avoid herbal remedies until baby’s condition has settled. Mothers should not take kacip fatimah and ginseng because once it enters mother’s milk it will affect the bilirubin metabolism.

Stop breastfeeding for two days and then resume after that – This interrupts exclusive breastfeeding and will reduce baby’s demand and the mother’s supply, so don’t do it.

More breastfeeding articles from PRISMA 2015

11 COMMENTS

  1. It is lies that are propagated by articles such as this that made me starve and nearly kill my child. It is amazing to me that a profession who watches newborns starve and get admitted every day due to delayed and failed lactogenesis can continue to spout off lies about how there is always breast milk as long as a mother keeps breastfeeding. My child was on my breast for nearly every minute for two days straight on the 3rd and 4th days of life with excellent latch and he nearly died from hypernatremic dehydration and experienced devastating brain injury from sustained hypoglycemia and now has autism and a seizure disorder. There was absolutely no milk present. In a study of 280 mother-baby dyads in Davis, California confirmed that 22% of the mothers did not have onset of copious milk production by 72 hours, well within the time a child can develop pathological weight loss, hyperbilirubinemia, hypernatremia and hypoglycemia from starvation jaundice. Even the Academy of Breastfeeding Medicine in the supplementation protocol admits that 10-18% of exclusively breastfed newborns experience starvation-related jaundice from insufficient breast milk intake, the majority of which is caused by insufficient milk in mothers breasts. Mothers, if you want your child hospitalized like mine, keep listening to B.S. like this.

  2. Where in this article does she say that mother’s always have milk? She doesn’t. This article points to the fact that NORMAL breastfeeding does not cause jaundice. It’s babies that have trouble breastfeeding that suffer from breastfeeding jaundice and in the article she states that something must be done for those babies.

  3. She directly discourages the use of supplementation with formula to treat jaundice with formula supplementation for the majority of these children is the primary mode through which bilirubin removed. Bilirubin is excreted through the gut and the reason why EBF experience greater jaundice than supplemented children is because they don’t get as much milk. If you increase the milk intake with supplementation, the bilirubin will go down. She clearly doesn’t understand that the state of being underfed is the primary cause of the hyperbilirubinemia. Breast milk does not cause jaundice but insufficient breast milk causes it, which is treated with supplementation. She continues the relentless pressure on moms to not supplement while supplementation saves lives and brains. The mothers who have plenty of milk or whose milk come in time don’t have this problem because their children get fed. It is by definition the babies who are losing weight because they are not getting fed sufficiently at the breast mostly due to insufficient supply, not just poor technique, who need supplementation. The data is wrong furthermore because 1 in 10 breastfed babies get breastfeeding jaundice. In fact the largest study to date showed the 1 in 10 EBF vaginally-delivered babies lose greater than 10% and 1 in 4 EBF cesarean delivered lose 10% the majority of whom develop jaundice. It is not rare like she tries to pass off. The weight loss is directly correlated with insufficient breast milk. Therefore, the only way breastfeeding jaundice is treated is through supplementation. If the mother’s milk comes in by that time, it can be with breast milk but up to 22% have to be supplemented with formula to reduce the bilirubin. More importantly, the jaundice is a marker of starvation. The more important issue is that the child is starving by the time they develop levels consistent with breastfeeding jaundice.

  4. Hi, there is no doubt you were offered little breastfeeding support. There are other options that support breastfeeding before supplementing with formula. Hand expression and finger, syringe or cup feeding colostrum. Donor milk is also an option. With better support and knowledgeable practitioners, breastfeeding is more likely to be achieved causing less trauma to baby and mother.

  5. I got breastfeeding support every single day my child was getting nothing from me. The reason why breastfeeding support is insufficient is because you make no attempts to show a mother what she is producing in the first days of life in order to prevent supplementation. So in fact, little to no production is hidden from mothers. This practice of coercion to not supplement by hiding important information like presence and volume of colostrum and telling mothers that colostrum is always enough, when it is not for many babies, is what makes breastfeeding support and the current standard of care dangerous. It is not the particular lactation consultant I received, it is the standard of care of breastfeeding support that is the problem. If you fail to protect more than half of EBF babies from pathological weight loss, how good a job is our healthcare system doing to protect babies from complications? Not very. The answer is to provide mothers with the objective data and the license to supplement their hungry crying babies who are telling them they need supplementation.

  6. She seems to have forgotten that there is this wonderful invention called the…BREAST PUMP!

    “Neonatal jaundice is not associated with breastfeeding per se, but rather with increased weight loss after birth, subject to fasting. This suggests the important role of calorie intake in the regulation of bilirubin.

    “So, the conclusion is that failure to establish breastfeeding (poor technique) leads to inadequate milk intake (starvation) and is the factor that exaggerates the incidence of physiological jaundice in newborns,” — Feeding FM in the interim while the bf-ing issues are sorted out will be the most prudent method then! It’s win-win isn’t it? Baby gets the necessary calories, and both baby and mom get time to work out the problems. Can’t latch, then just pump and bottle feed!

  7. Which is what I educate mothers to do, to pump and manually express to check for presence of milk and to supplement with formula a child that is underfed. But this is a practice that is discouraged by even the authors of the LLLI handbook, the Womanly Art of Breastfeeding, because a mother might discover she has little or no milk to offer. But that is okay because it is more important that she exclusively breastfeed and that it is not possible for a child to get underfed in the first 2-3 days of life, even okay for them to get nothing for 24 hours. I agree that pumping and nursing before supplementation is a win-win and keeps a child from harm and continues the stimulation to promote milk production. But many argue that that practice is harmful, even if it protects a child from being hospitalized for breastfeeding jaundice.

  8. I fail to understand why people can argue that supplementing with FM is worse than baby starving and getting severely jaundiced as a result of insufficient food intake. I think it is all these @$% books that makes people end up not acting in the baby’s best interest

  9. Anytime a baby is “on the breast every minute” as you reported is a cause for concern. The act of breastfeeding did not fail you, your medical professionals failed you. If baby is on the breast that much it’s due to ineffective milk transfer either because a mother has delayed lactogenesis or baby has (for some reason) ineffective milk removal. Someone should have known enough to tell you, as a new mom, that was not normal. If I see a baby feeding that frequently it’s a red flag. It is more often NOT our bodies but our birth practices that cause delayed lactogenesis. I’d be curious what your birth was like. Other then disruption of the normal birth process, this could be a case of insufficient glandular tissue which I would then place blame on the ob/gyn for not asking breast related questions during pregnancy to screen for potential issues. Your story is proof positive that our breastfeeding support needs to be both standardized and more readily and constantly available in the immediate postpartum period.

  10. I just noticed your comment that you had breastfeeding support. Let me tell you, it wasn’t good support if you explained your baby was breastfeeding non stop. I’m sorry you were failed by your lactation consultant in the regard. There is no way I’d ever hear that a newborn was nursing that frequently and not check mothers supply. Again your story makes it clear that we need all lactation professionals to have standardized training.

  11. Christie – maybe instead of blaming lactation consultants; midwives; breastfeeding advocates…maybe look within and ask yourself why you chose to ignore the signs that your baby wasn’t thriving (because as you claim, you were already a baby brain expert!) & instead of blaming external forces you might find that the reason lies within. Take some responsibility for your choices. Admit you screwed up. And move on with your life. Instead of your BS campaign to get new moms to check output via pump and have formula on standby just in case. So many mothers get minimal milk via pump and it is zero indication of supply. Your campaign is a danger to long term population health. Eczema. Asthma. Allergies. Obesity and the myriad associated disorders. Take personal responsibility for neglecting your baby instead of blaming others- you made your choices.
    And contrary to what your inner monologue is telling you when you come across breastfeeding advocacy stories or blogs – it actually isn’t about you!
    Maybe look at the correlation between gut health and autism before blaming breastfeeding on your kids ASD? Who knows, maybe the formula caused it? You cannot know. ASD is still a mystery. Heck, anti-vaxxers claim vax causes it. What you are pushing is the same kind of garbage being spouted by anti-vax conspiracy theorists…except you’re claiming that a significant percentage of the population is causing brain damage to their babies because they’re getting insufficient nutrition before the milk comes in. Get a grip and take your issues to a psychologist instead of projecting onto an entire group. Your narcissism and first world privilege needs checking. The fact that you troll the internet looking for posts like this just to comment on is at a minimum disturbing. At worst…pathological.

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