EVERY baby is born with jaundice.
The newborn levels of bilirubin are always higher than the normal adult range. For nine months, a baby is snuggly tucked in mom's womb focusing on the hard work of developing organs, growing bones, strengthening muscles while mom does all the work supplying the food and taking care of the waste. His immature liver doesn't need to be concerned about the bilirubin being created by the blood cells that are quickly building and breaking down at twice the rate of his parents. Mom has that taken care of. A healthy baby will send this orange yellow pigmented broken down blood cells called unconjugated bilirubin through the placenta to mom's blood stream. Unconjugated simply means it is not attached to something else, which may be water or fat. This beautiful exchange takes place protecting the baby. The unbonded bilirubin passes through the placenta and bonds with albumin in mom's blood which helps it becomes execrated in mother's waste. Babies are in a low oxygen state in the womb and produce only 1% of liver enzymes needed to conjugate bilirubin. Through normal development, a baby is usually protected from being born with jaundice, unless there is a abnormality such as mom has HEELP syndrome which may put baby at risk. The extra workload placed on mom's liver is one reasons why your midwife will preach the necessity of eating 80-100 grams of protein every day.
At the first scream, while you are counting fingers, gazing into your baby's eyes and comparing who he looks like, his body is transitioning to life outside the womb. There are many things going on that you don't even stop to think about. His oxygen levels are rising, the flow of blood is changing as the umbilical cord is no longer needed. His body will not only have to work to bring food in, but the immature liver will have to work hard to get rid of it as well. As the liver and intestines are working at starting their processes, bilirubin is building in the baby's body. This is a good process. Re-read that. This is a good process! _______________________ Bilirubin protects the baby's brain from oxidative stress. __________________________________
So why is there all the concern? The newborn produces 8-10 mg/kg/day of bilirubin, two times the adult level. These levels can reach the point of causing hyperbilirubinemia, high bilirubin in the blood, to the point of causing kernicterus which is a very rare form of brain damage. This happens in 1 in 50,000 to 100,000 babies of all ages, risk factors and ethnicities. It is far less common in full term babies.
What is normal? There are different opinions on what levels are dangerous, but the general consensus is anything above 22 mg/dl needs to be treated. However, a better indicator of a concerning level would be looking at the whole picture and not just a one size fits all number. So, we are going to discuss a few factors. There are two types of jaundice. Pathological and Physiological. Pathological jaundice is caused by RH or ABO incompatibility, genetic anomalies, hemorrhage, severe bruising or sepsis to name a few. This jaundice happens quickly. There can already be an elevated bilirubin level in the baby's intestines which within hours can cause yellowing to show on the baby's skin. This is why jaundice that is noticeable before 24 hours may be very concerning. This would require a doctor consultation for an out of hospital midwife. Red flags would be lethargy, decreased alertness, vomiting, lack of muscle tone, difficulty feeding and temperature instability. If a baby starts to have a high pitched cry, muscle spams especially arching of the back or neck, there is most likely neurological damage from high brain bilirubin. Pathological is a very rare form of jaundice. Most jaundice that midwives or parents will ever see is physiological jaundice. Again, refocus on the benefits of this jaundice and that it is normal. Formula fed babies usually clear up the yellow skin tone by day 5. The exceptions to this would be Asian, Indian and preterm babies which may take up to 2 weeks. However, breastfed babies may take up to 6 weeks.
Did you know that babies that are only yellow in their face at 24 hours are very unlikely to develop hyperbilirubinemia?
There are several theories on why breastfed babies take so long. Insert author opinion here: Maybe it is what happens when we do things the way God designed. A protection of built in antioxidants to the vulnerable baby. One explanation is that 20-40% of women have above average levels of Beta-glucuronidase in their milk, which is the substance which deconjugates or unbinds the bilirubin, increasing and prolonging bili levels. The levels of Beta-glucuronidase become increased with diets high in processed foods, alcohol, sugar and some antibiotics. These levels may be lowered with Cal/Mag, Milk Thistle and Fenugreek. Unconjugated, unbound or free bilirubin can cross the blood brain barrier which is a concern with high bilirubin levels. Another theory is that breastfed babies are eating less than formula fed babies and getting less protein than formula fed babies. So, they have less protein to bind to the bilirubin. I also read a study that showed albumin, a protein that binds to bilirubin, will cross from mom's diet and show up in breastmilk within a few hours and peak at 6 hours. Eggs are high in albumin. Though, I could not find any studies that showed if a change in diet would help babies with jaundice. Let's take a look at numbers. It is completely normal for levels to go to 20 mg/dl in a breastfed baby. There has been no universal pathology in levels up to 24 mg/dl. Overall, the risk of chronic neurotoxicity (kernicterus) in babies with TSB levels greater than 30 mg/dL is about one in seven. If your baby is yellow through the abdomen but not the limbs, the TSB levels are about 12. If baby is yellow through the fingers and toes, the TSB levels are at least 15. The best indicator of how your baby is doing is based on their symptoms. Is he alert at least 2 combined hours of time in a day? Is he lethargic or having trouble staying awake to nurse? Is he dehydrated? Has he pooped? Meconium contains 100-200 mg of bilirubin. Meconium passage within 24 hours decreases the chance of hyperbilirubinemia. Is his tone good? Are his stools pale tan (a sign of liver concerns)? Is he nursing well? A baby that is behaving normally is less concerning. A baby with 18-20 mg/dl levels with no concerning symptoms, I would just monitor but would not send to the hospital. A baby at lower levels WITH concerning symptoms, I would send to the hospital.
There are certain situations where babies with physiological jaundice should be monitored closer ...
A baby that:
is having breastfeeding struggles, especially combined with more than 10% weight loss or dehydrated
has sustained moderate or more bruising in delivery. Bruising increases the amount of bilirubin that is needing to be broken down.
had low oxygen levels
born early term. Early term babies breakdown blood cells faster and have more bilirubin.
has any risk factors for pathological jaundice
has not passed meconium within 24 hours, especially by 72 hours. Conjugated bilirubin that sits in the gut may be unconjugated and reenter the blood stream.
has G6PD, a genetic condition in 10% of black males
had a mom who was induced for delivery.
nurse often, eat high protein, cuddle and enjoy the sunlight together
Babies with jaundice need to nurse every 2 hours. Frequent nursing will encourage mom's milk to come in but also provides a regular supply of protein to bond with bilirubin. Mom needs to eat lots of protein, especially eggs, and keep hydrated to encourage her milk supply to increase. Taking Cal/Mag, probiotics, and eating healthy will lower Beta-glucuronidase in mom's milk. Lots of skin to skin if you are struggling with milk supply. Put a naked baby every couple hours for 5 minutes in the sun, 2-3 minutes each side. Sunlight causes bilirubin to bond with water and disposed of, but this effect only lasts a couple hours which is why it must be done often.
Remember, jaundice is beneficial. Values to the low 20s are not a risk in babies with no other concerns. As long as babies do not get worse or show symptoms listed above, nurse cuddle and enjoy the sunlight together. Breast feeding jaundice may take 6 weeks to completely go away, so snuggle that adorable little one and kiss that yellow belly.
This article is not intended as medical advise but for information only. Discuss all treatments options and plans with your provider.
“Bilirubin Links Heme Metabolism to Neuroprotection by Scavenging Superoxide”. Chirag Vasavda et al.
Cell Chemical Biology. doi:10.1016/j.chembiol.2019.07.006
Can proteins eaten by a mother get into her breast milk? | Questions | Naked Scientists (thenakedscientists.com)
I highly recommend doing the HiveCe.com course on jaundice for any professional.
Other random sources not documented, sorry not my strongest point to remember.
Some books I have read through. Anne Fryes Holistic Midwifery, Maternal newborn nursing.
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