Most of us come into the world red, wrinkly, and hairless. From a purely aesthetic point of view, it’s not a great look – and yet parents usually think their offspring are gorgeous. I don’t know about you, but I sometimes look at newborn photos of my kids and think they had more than a slight resemblance to Benjamin Button (not the hot Brad Pitt version, but the weird old-man baby in the beginning). And I clearly remember thinking both of them were the cutest newborns ever born.
|This baby grows up to be Brad Pitt, so it’s all good.
At my daughter’s recent 15-month Well Baby visit, I was utterly shocked to find out that she’d dropped from the 25th to the 10th percentile for weight. I’d actually been joking about how adorably chubby she’d been getting… but as soon as I saw the number on the scale, it was like my eyes refocused; I suddenly thought she looked so scrawny.
When it comes to judging how our kids are doing purely by looking at them, I don’t think parents are really hardwired to be objective.
I’ve been thinking about this the past few days as I’ve researched the topic of neonatal jaundice. Jaundice is a relatively common problem in babies, and therefore is a frequent discussion point in the online parenting world. The other day, I read an online discussion where someone spoke of a baby who sounded pretty darn dehydrated and jaundiced. The advice given was mainly to handle the problem at home or through consulting peer breastfeeding counselors; there were warning about unnecessary interventions which would harm the new breastfeeding relationship. The fear of formula supplementation was palpable. I’m a strong believer in mommy gut and standing up for your parenting philosophies, so on many levels, I understand where these women were coming from. There are a fair number of overloaded, poorly read-up, and even downright crappy medical professionals out there, and it’s likely that many women are pushed into supplementation when there are other methods which would ultimately achieve the same result.
However, taking matters into your own hands, or downplaying the seriousness of jaundice, is not the answer. I don’t think a newly postpartum, first-time mom who is already struggling with a poorly-feeding, jaundiced baby is in a position to ascertain her child’s medical status, merely based on appearances. (I don’t recall thinking my son was particularly yellow; in fact, my daughter, who wasn’t jaundiced, looked far more mustard-hued than her brother ever did.) Nor is it fair or noble of us to expect that of her, considering the misinformation and bias running rampant in parenting media.
Jaundice is a problem which pops up in a number of FFF Friday stories, so I decided it was relevant and necessary to discuss it on this blog, even though it is primarily a breastfeeding mom-related problem (mostly because formula feeding is one of the most common, and most controversial., therapies used to treat it; if you’re already bottle feeding, chances are you’re not freaking out about supplementation). But I know there are some pregnant women and prospective moms who frequent the blog, and you never know who’s going to stumble upon this post in the middle of a frantic newborn night… so this one’s for you. Oh yeah – I figure it’s pretty obvious, but just in case – please note that I am in no way, shape, or form a medical professional (although my dad’s a doctor, so if medical knowledge is passed down genetically I may have an edge up in that respect). The following piece is merely what I’ve gleaned from about 4 days of research and reading, mixed with a little personal knowledge and a hefty dose of opinion – so do with it what you will.
There’s a wide range of opinions on how best to treat jaundice, and much of the debate centers on how affected babies should be fed. But we’ll get to that in a moment – first, let’s define what we’re talking about.
Um, what is frock is “jaundice”?
Newborn jaundice typically comes in one or some combination of three forms – breastfeeding jaundice, breast milk jaundice, and Type ABO jaundice. In the most general sense, newborn jaundice occurs when your infant has high levels of bilirubin (the substance which is created during the process of blood cell “turnover”) in the blood. The body usually gets rid of the excess bilirubin, but in newborns, this function doesn’t always operate smoothly. That’s because the placenta handles the job while in utero, and once your baby is of the “outside” varietal, his body might not have completely figured out how to handle this process. Hence, the mildly yellowish hue so fashionable in the under 48-hours-old set. Newborn jaundice (also called physiological jaundice) usually resolves in a few days, but sometimes it can be exacerbated by other problems.
One of these problems is a blood type incompatibility between mother and infant, called Type ABO jaundice. My son suffered from this type of jaundice; I am blood Type O, and he’s Type A. When our different types of blood merged during the birth process, my body basically created antibodies against his blood type, which caused a break down of his red blood that made extra bilirubin build up in system. He grew jaundiced. It sucked and I cried… but I digress.
Jaundice also occurs in a different form called “breast milk jaundice“, which MedLine Plus defines as “long-term jaundice in an otherwise healthy, breast-fed baby. It develops after the first week of life and continues up to the sixth week of life… It is probably caused by factors in the breast milk that block certain proteins in the liver that break down bilirubin.” This type of jaundice is typically harmless, and shouldn’t be confused with breastfeeding jaundice, which is caused by insufficient feeding, usually due to poor latching or supply issues, or as some sites somberly state, due to spacing out feedings too far apart or not co-sleeping. The body needs to flush out bilirubin, and it can’t do so if there is inadequate waste output. If a baby isn’t properly hydrated or fed, she can’t poop or pee. So in the case of bilirubin, the saying is actually want not, waste more.
How do I help my baby stop looking like an Oompa Loompa?
Jaundice is treated one of three ways: formula supplementation, phototherapy (having the baby hang out underneath a special kind of light or biliblanket) and exchange transfusions (usually reserved for the most severe cases). The old-school approach to handling newborn jaundice was to supplement with formula; this is one of the quickest and easiest ways to help rid the body of excess bilirubin. You can also use donor milk (just not sugar water or other rehydration substances, which were historically also used as a means of hydration and jaundice therapy), and administer it through a supplemental nursing system (SNS), so “supplementation” doesn’t have to mean formula or bottles. But the new protocol for newborn jaundice is to take more of a wait-and-see approach; the AAP’s position is that breastfeeding should not be interrupted unless absolutely necessary, and that phototherapy be used as a curative measure:
In breastfed infants who require phototherapy, the AAP recommends that, if possible, breastfeeding should be continued (evidence quality C: benefits exceed harms). It is also an option to interrupt temporarily breastfeeding and substitute formula. This can reduce bilirubin levels and/or enhance the efficacy of phototherapy (evidence quality B: benefits exceed harms). In breastfed infants receiving phototherapy, supplementation with expressed breast milk or formula is appropriate if the infant’s intake seems inadequate, weight loss is excessive, or the infant seems dehydrated.
Many internet parenting and breastfeeding sites reassure parents that formula supplementation is hardly ever necessary, and this is probably true in a literal sense; most cases of jaundice will resolve with little intervention, and for those that don’t, there are other treatment options besides formula. But it’s important to know that these other treatments also carry risks, as this review article published on Medscape explains:
Phototherapy is not without disadvantages.. Under fluorescent tubes infants must wear eye protection and are usually separated from the mother in the nursery. Phototherapy may take days to exert the desired effect and, once the phototherapy lights are stopped, rebound hyperbilirubinemia may occur as bilirubin moves from the tissue into the blood. Risk of photooxidative damage to lipoprotein and red blood cell membranes is possible and data suggest that conventional phototherapy (with fluorescent tubes) may decrease postprandial mesenteric blood flow response that may adversely impact the neonatal GI tract.
The same paper also suggests that phototherapy “may not be as successful in decreasing serum bilirubin levels in breastfed infants due to increased enterohepatic circulation; supplementing with formula in addition to phototherapy may be more efficacious in these infants.” This is kind of scary, because is phototherapy doesn’t work… well, that leads me to the next question.
Why do I have to care about jaundice? Maybe I like the color yellow.
The problem with jaundice is that it isn’t a serious problem until it is. Explains the AAP:
Most jaundice is benign, but because of the potential toxicity of bilirubin, newborn infants must be monitored to identify those who might develop severe hyperbilirubinemia and, in rare cases, acute bilirubin encephalopathy or kernicterus. The focus… is to reduce the incidence of severe hyperbilirubinemia and bilirubin encephalopathy while minimizing the risks of unintended harm such as maternal anxiety, decreased breastfeeding, and unnecessary costs or treatment…
Pretty much the only presenting sign of jaundice is a slight yellowing of the skin and eyes. The other symptoms appear when bilirubin levels get dangerously high, putting your baby at risk for brain damage and other serious medical problems. WebMD tell us that the symptoms of jaundice-which-has- gone-too-far (the medical terms for this are “kerincterus” or “acute bilirubin encephalopathy”) include fever, sluggishness, poor feeding, irritability, shrill crying, and arching of the back. Which, except the fever, sounds like how almost every FFF Friday contributor has described her newborn when feeding problems were present. It might be hard to differentiate actual medical risk from normal newborn craziness or other feeding-related issues, and this complicates matters further.
According to the AAP, “immediate exchange transfusion is recommended in any infant who is jaundiced and manifests the signs of the intermediate to advanced stages of acute bilirubin encephalopathy (hypertonia, arching, retrocollis, opisthotonos, fever, high-pitched cry) even if the TSB is falling.” TSB is total serum bilirubin, used to determine the severity of jaundice; this means that even if the levels are falling, if your baby is exhibiting these symptoms, doctors may recommend an exchange transfusion. Exchange transfusion is basically a blood transfusion; it can be lifesaving when jaundice becomes dangerous, but it also carries the risk of anemia, air embolism…and even death. These are rare side effects, and even getting to the point that you need an exchange transfusion is relatively rare. But on the other hand, a 2009 study out of the Netherlands found that “all healthy newborns are at potential risk of kernicterus if their newborn jaundice is unmonitored and/or managed inappropriately…we have estimated that 1 in 700 well newborns can develop extreme hyperbilirubinemia; these infants can be at major risk for kernicterus if there are no failsafe, system-based protocols.”
Okay, okay. Say I don’t want an oompaloompa baby. What’s my best plan of action?
First of all, know your risks. The AAP states that “infants at less than 38 weeks’ gestation, particularly those who are breastfed, are at higher risk of developing hyperbilirubinemia and require closer surveillance and monitoring.” This risk increases significantly if you are having feeding problems. A 2009 study published in BMC Pediatrics found that “significant weight loss increase(s) approximately 4 times the risk to develop severe non-hemolytic hyperbilirubinemia in breastfed term infants and it seems to be worst when the cut point to define significant weight loss is higher (infants with a weight loss of 10% have odds 4.2 times higher). Both hyperbilirubinemia and feeding problems persist worldwide despite well-intentioned guidelines for care…” And, if you’re blood type O, you also are at higher risk for Type ABO jaundice.
Now, here’s the controversial bit: while it’s true that the major medical organizations are no longer recommending formula supplementation as the first line of treatment, you also have a right to know that providing formula or donated milk does improve jaundice. If your baby is feeding well, it’s probably not necessary to supplement; the phototherapy will most likely do the trick. But if things are not going well with breastfeeding, supplementing – in some way, shape or form – can help.
I fully comprehend why breastfeeding experts frown on supplementation. Interrupting the breastfeeding relationship in its literal infancy is not a great idea. Let’s look at this another way for a minute, though:
1. If the jaundice is caused or exacerbated by feeding issues, the breastfeeding relationship is already in jeopardy. A hungry, dehydrated, frustrated baby is often not a patient or energetic baby; how would you feel if you had fasted for 2-3 days? (Impressionable Fearless Husband has talked me into juice fasts a few times and I was certainly no fun to be around, nor did I have the “focused energy” all those diet plans promised…) I have yet to meet a woman whose baby wasn’t latching or whose milk didn’t come in, and had the situation spontaneously turn around without first ensuring that the baby was fed. I have, on the other hand, met several women who did supplement, and with some work and a good lactation consultant, got the baby to latch, improved their milk supply, and went on to exclusively breastfeed.
2. Having your baby end up in the hospital under the phototherapy lights, being monitored for a significant amount of time, is counterproductive to a struggling breastfeeding relationship, too. Phototherapy (as well as jaundice) can make a baby too tired to suck efficiently, and having a newly postpartum, stressed out mom is never a good thing, either. Phototherapy and hospitalization is a necessary evil for many of us, but if the medical authorities admit that supplementation (especially with a hypoallergenic formula, interestingly) will hasten the process, we have a right to know this. Some may still choose to stay away from formula, and I get that – as a vegetarian, I personally would do whatever I could to avoid giving my child a steak. (Although to be honest, if his life depended on it, I would be shoving veal cutlets down his throat. I love baby cows, but I love my son more.) But for those of us who don’t see a little formula as the be-all, end-all to child health, it is important to have this knowledge.
3. I have to wonder if the current recommendations regarding jaundice and supplementation have more to do with the demonization of formula than actual evidence. As a purely medical issue, we have a cure with no real, quantifiable risks – even if you believe that the risks of formula are 100% proven without a doubt, a small amount of the stuff administered as a one-shot deal hasn’t been proven to cause physiological harm (except for that whole virgin gut theory, about which I’ve yet to see any quality evidence). The breastfeeding relationship has been shown in studies to be affected by early bottle feeding, but this research is also somewhat questionable – the concept of nipple confusion has been questioned by breastfeeding guru Marianne Neifert herself.
4. There is so much conflicting advice regarding jaundice, and I worry that parents are seeing jaundice prevention/treatment and breastfeeding protection/promotion as competing entities. This is not true, and it is detrimental to all parties involved to think this way. A passage from a physician-penned article about the clinical presentation of jaundice explains the relationship between the two rationally and clearly:
Identifying the infants who become dehydrated secondary to inadequate breastfeeding is also important. These babies need to be identified early and given breastfeeding support and formula supplementation as necessary. Depending on serum bilirubin concentration, neonates with hyperbilirubinemia may become sleepy and feed poorly… The most rapid way to reduce the bilirubin level is to interrupt breastfeeding for 24 hours, feed with formula, and use phototherapy; however, in most infants, interrupting breastfeeding is not necessary or advisable… Detailed history and physical examination showing that the infant is thriving and that lactation is well established are key elements to diagnosis. Breastfed babies should have 3-4 transitional stools and 6-7 wet diapers per day and should have regained birth weight by the end of the second week of life or demonstrate a weight gain of 1 oz/d.
In summary, newborn jaundice is not a serious problem for most babies, which is why all those breastfeeding sites tell you that supplementing isn’t necessary. Some even suggest that breastmilk jaundice is biologically normal, and we just don’t realize it because no one has been breastfeeding much for the past 50 years. But jaundice can become serious, and you might not be able to distinguish serious jaundice from feeding issues or fussy-newborn-ness, so please don’t shy away from medical observation because you’re scared they might make you supplement. Your best bet is to find a breastfeeding-friendly pediatrician prior to giving birth; this way, you’ll know you can trust that the two of you have the same goals in mind. Lactation consultants are not experts in jaundice (unless of course your LC is a really well-trained, thoroughly-researched RN or an MD, which luckily some are), so it’s probably not safe to rely on them or your postpartum doula to judge whether your baby needs medical intervention.
Chances are no one will force you to supplement, but since you may have the ball thrown into your court, make sure you are able to weigh your options without misinformation or subtle pressure in any direction. Opting against supplementation is probably not going to lead to terrible medical consequences, unless you’re in a very specific, very serious situation. On the other hand, a few bottles of formula given in the span of a day or two is not going to put the kibosh on your breastfeeding relationship, and it may get rid of the jaundice faster and with less extreme interventions – which will allow you to get back to forging not only a breastfeeding relationship with your newborn, but a relationship, plain and simple.