BackgroundArias first described breast milk jaundice (BMJ) in 1963. [1, 2] This condition is a type of neonatal jaundice associated with breastfeeding that is characterized by indirect hyperbilirubinemia in an otherwise healthy breastfed newborn that develops after the first 4-7 days of life, persists longer than physiologic jaundice, and has no other identifiable cause. [3, 4, 5] Show
Breast milk jaundice should be differentiated from breastfeeding jaundice, which manifests in the first 3 days of life, peaks by 5-15 days of life, disappears by week 3 of life, and is caused by insufficient production or intake of breast milk. [4] In contrast to babies with breast milk jaundice, infants suffering from breastfeeding jaundice generally exhibit mild dehydration and weight loss in the first few days of life. [5]  PathophysiologyBreast milk jaundice is a common cause of indirect hyperbilirubinemia. The etiology of breast milk jaundice is not clearly understood, but a combination of genetic and environmental factors may play a role. [5] The following factors may contribute:
Epidermal growth factor (EGF) is responsible for growth, proliferation, and maturation of the gastrointestinal tract in newborns, and it is vital for adaptation after birth. Higher EGF serum and breast milk levels have been noted in patients with breast milk jaundice. [11] Reduced gastrointestinal motility and increased bilirubin absorption and uptake are thought to be the mechanisms. Serum alpha fetoprotein levels have been found to be higher in infants with breast milk jaundice. [12] The exact significance of this finding is unknown. Breast milk is an important source of bacteria in establishing infantile gut flora. Tuzun et al demonstrated that Bifidobacterium species in breast milk may protect against breast milk jaundice. [13] The exact significance of this finding is unknown. A phase I trial that evaluated the safety and tolerability of Bifidobacterium longus subspecies infantis EVC001 supplementation in 34 healthy term breastfed infants compared to 34 who received lactation support alone found no differences between the groups in mean gestational age at birth, weight at postnatal months 1 and 2, and breast milk intake. [14] B infantis supplementation was safe and well tolerated, and infants receiving this supplementation had fewer and better formed stools than those in the lactation support–only group. Please see the Medscape Drugs and Diseases article Neonatal Jaundice for an in-depth review of the pathophysiology of hyperbilirubinemia. EtiologyReplacement of breastfeeding with oral glucose solution does not appear to decrease the prevalence or degree of jaundice. [15] Note the following causes of breast milk jaundice:
EpidemiologyUnited States dataJaundice occurs in 50-70% of newborns. Excess physiologic jaundice (bilirubin level >12 mg/dL) develops in 4% of bottle-fed newborns, compared to 14% of breastfed newborns. Exaggerated physiologic jaundice (bilirubin level >15 mg/dL) occurs in 0.3% of bottle-fed newborns, compared to 2% of breastfed newborns. [26] A strong familial predisposition is also suggested by the recurrence of breast milk jaundice in siblings. In the exclusively breast fed infant, the incidence during the first 2-3 weeks has been reported to be 20-30%, [27] although a more recent review indicates about 2-4% of exclusively breastfed infants have jaundice with bilirubin levels above 10 mg/dL in week 3 of life. [4] InternationalThe international frequency of breast milk jaundice is not extensively reported but is thought to be similar to that in the United States. Race-, sex-, and age-related demographicWhether racial differences are observed in breast milk jaundice is unclear, although an increased prevalence of physiologic jaundice is observed in babies of Chinese, Japanese, Korean, and Native American descent. No sex predilection is known. Breast milk jaundice manifests after the first 4-7 days of life and can persist for 3-12 weeks. PrognosisThe prognosis is excellent, although jaundice in breastfed infants may persist for as long as 12 weeks. MorbidityBreast milk jaundice in otherwise healthy full-term infants rarely causes kernicterus (bilirubin encephalopathy). Case reports suggest that some breastfed infants who suffer from prolonged periods of inadequate breast milk intake and whose bilirubin levels exceeded 25 mg/dL may be at risk of kernicterus. [28] Note that kernicterus is a preventable cause of cerebral palsy. Another group of breastfed infants who may be at risk of complications is late preterm infants who are nursing poorly. Kernicterus may occur in exclusively breastfed infants in the absence of hemolysis or other specific pathologic conditions. Distinguishing between breastfeeding jaundice and breast milk jaundice is important, because bilirubin-induced encephalopathy occurs more commonly in breastfeeding jaundice. Near-term infants are more likely to manifest breastfeeding jaundice because of their difficulty in achieving adequate nursing, greater weight loss, and hepatic immaturity.
Author Coauthor(s) Sameer Wagle, MBBS, MD Consulting Staff, Division of Neonatology, Northwest Medical Center of Springdale and Willow Creek Women’s Hospital Sameer Wagle, MBBS, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association Disclosure: Nothing to disclose. Specialty Editor Board Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Nothing to disclose. Brian S Carter, MD, FAAP Professor of Pediatrics, University of Missouri-Kansas City School of Medicine; Attending Physician, Division of Neonatology, Children's Mercy Hospital and Clinics; Faculty, Children's Mercy Bioethics Center Brian S Carter, MD, FAAP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Hospice and Palliative Medicine, American Academy of Pediatrics, American Pediatric Society, American Society for Bioethics and Humanities, American Society of Law, Medicine & Ethics, Society for Pediatric Research, National Hospice and Palliative Care Organization Disclosure: Nothing to disclose. Chief Editor Muhammad Aslam, MD Professor of Pediatrics, University of California, Irvine, School of Medicine; Neonatologist, Division of Newborn Medicine, Department of Pediatrics, UC Irvine Medical Center Muhammad Aslam, MD is a member of the following medical societies: American Academy of Pediatrics Disclosure: Nothing to disclose. Additional Contributors Oussama Itani, MD, FAAP, FACN Clinical Associate Professor of Pediatrics and Human Development, Michigan State University; Medical Director, Department of Neonatology, Borgess Medical Center Oussama Itani, MD, FAAP, FACN is a member of the following medical societies: American Academy of Pediatrics, American Association for Physician Leadership, American Heart Association, American College of Nutrition Disclosure: Nothing to disclose. Acknowledgements The authors and editors of Medscape Drugs & Diseases gratefully acknowledge the contributions of previous author Timothy Ramer, MD, to the development and writing of this article. What signs indicate your infant has an adequate amount of breast milk?Signs your baby is getting enough milk. Your baby starts feeds with a few rapid sucks followed by long, rhythmic sucks and swallows with occasional pauses.. You can hear and see your baby swallowing.. Your baby's cheeks stay rounded, not hollow, during sucking.. They seem calm and relaxed during feeds.. What are the four 4 signs of adequate nutrition in a breastfed infant?Breastfed babies who are getting enough breast milk do not become constipated. Your baby is bright, alert and responsive with moist lips and good skin tone. They are reaching their developmental milestones. They are having a steady weight gain when averaged out over a four week period.
What are the signs that a baby is receiving enough breastmilk How will you teach this to families?How can I tell if my newborn is getting enough milk?. Your baby is feeding at least eight to 12 times in 24 hours . ... . Breastfeeding feels comfortable and pain-free. ... . Your breasts feel softer and less full after feeds .. Your nipple looks the same shape after you've fed your baby, not squashed, pinched, or white.. Which of the following signs may indicate a baby is not receiving sufficient breast milk?Here are some signs that your newborn may not be getting enough breast milk. Your newborn is not breastfeeding well. Your child is very sleepy and does not wake up for most feedings. Your little one has pink, red, or very dark yellow concentrated urine or less than six wet diapers a day after the fifth day of life.
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Which behavior would the infant exhibit if an adequate amount of breast milk is being ingested
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