while I’ve mentioned the level of the bilirubin, notice that it’s in the context
of the gestational and the chronological age of the baby and the timing of the
jaundice (and by my addition) how well the baby is transferring breastmilk.
had this fabulously scarring episode when I was a very tired resident in which I
mentioned that a child’s white blood cell count was 13.5 (yes, I still remember
that number). My attending stopped me, wrote 13.5 on a piece of paper and
threw it into the air. When it landed at my feet, he said “Jenny, what’s
that?” I dutifully replied “It’s this child’s white blood cell count.”
He then uttered words that have stuck with me forever. “No, it’s a random
number flying through the air.”
short, the level of bilirubin can’t be interpreted without knowing more about
Let’s try a case. (I wrote this one for the AAP Breastfeeding Curriculum)
This 3-day-old exclusively breastfed girl, born at term after an induced
vaginal delivery. The baby nursed well in the delivery room within an hour after
delivery and has been skin-to-skin with mom. She has been feeding every 3 hours
since. The baby’s last stool, about 18 hours ago, was black and tarry. The baby
and mother have the same blood type. A bedside transcutaneous bilirubin
measurement at 24 hours of age places the baby in the “high intermediate” range.
Her nipples are cracked and bleeding
Her breasts are soft and it doesn’t seem as though her milk has “come in” yet
The baby has lost weight
The baby does not seems as alert as she was the day before
What factors may be contributing to the baby’s hyperbilirubinemia?
Healthy breastfed infants normally have increased, non-pathologic, elevations in
serum bilirubin, sometimes called "breastmilk jaundice." Breastmilk jaundice can
last for weeks, and is thought to be beneficial to the infants because bilirubin
is an antioxidant.
This is important because, as I mentioned above, newborns do not have other
sources of antioxidants.
Breastmilk jaundice needs to be distinguished from "starvation jaundice" which
may indicate a pathologic condition. One of these conditions is decreased
caloric intake and in our case, this caloric deprivation is likely secondary to
a breastfeeding problem.
This baby girl is likely to have starvation jaundice because of poor milk
transfer. Nipple trauma is caused by a poor latch. If the baby is latched
incorrectly, she cannot transfer milk and will not get the calories need to
facilitate the excretion of bilirubin. Another indication of poor milk transfer
is the presence of black, tarry meconium stool at day of life 3. Colostrum, the
first milk made for the baby, is a laxative promotes the excretion of meconium.
In general, meconium should be well past dark and tarry by this point. The
weight loss is another article for me to write. (And PS. I really
dislike the term “milk coming in.” It’s been there all along. Just a
What does it mean to be in the “high intermediate” range?
American Academy of Pediatrics recommends performing an assessment of every
infant for the risk of severe hyperbilirubinemia. Transcutaneous bilirubin
levels are a way to estimate the serum bilirubin level. Once obtained, that
level is plotted on a nomogram (sometimes referred to as the "Bhutani curve")
according to the baby's age in hours. That nomogram is divided into to
risk levels. " High Intermediate" risk means that the babyhas a high
intermediate risk of subsequent bilirubin level exceeding the 95th percentile of
bilirubin levels. It means the baby has a high intermediate risk of the
bilirubin getting higher. What the magic number where danger occurs is not
goal of these measurement and subsequent graph plotting is to prevent
kernicterus, a totally preventable, devastating neurologic disease.
Nothing about this cheking levels and graph plotting involves “assessing a
feeding.” We should work on getting that in there.
While this screening can identify babies at risk for severe hyperbilirubinemia,
it does not predict the risk of kernicterus or other complications of severe
hyperbilirubinemia. Again, the "curve" does not predict the risk of
kernicterus. It predicts who is at risk for the bilirubin getting higher.
No screening test currently exists that will reliably identify all infants
at risk of developing kernicterus. Most children are not at risk for the
development of kernicterus and not all children with kernicterus have a
history of hyperbilirubinemia. [1, 2] (Makes you wonder why we screen... sorry,
What do we do next?
Since the cause of the baby's jaundice is likely "starvation jaundice," we need
to increase the baby's caloric intake. We need to feed the baby. We need
to evaluate the latch or enlist the help of someone, such as lactation
consultant, who can help this mother breastfeed without pain. If the baby would
need to be supplemented, our first choice is her mother's expressed breast milk,
so we need to supply her with a pump and show her how to appropriately use it.