Stop blaming mother’s milk for infant jaundice

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.

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 4^th-7^th 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.

 

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