Breastmilk jaundice: a nurse perspective

INTRODUCTION

A condition known as hyperbilirubinemia is also known as jaundice, which is a sickness linked to bilirubin. There are two different kinds of jaundice: Physiological and Pathological. Pathologic jaundice occurs within 48 hours of life and has specific etiological variables, whereas physiologic jaundice occurs after 48 hours of life or in new-borns who are 2-4 days old.

Breastfeeding is the best natural feeding technique. It meets the infant's dietary, emotional, and psychological demands. It is the best food for infants, is readily digested, and allows for six months of what is known as exclusive breastfeeding.¹

It contains a variety of nutrients, such as 90% water, 4% lipid, 1% lactose, 1% lactoferrin, 1% polyunsaturated fatty acids (PUFA), vitamins, and minerals (iron, zinc, calcium, sodium, chloride, magnesium, and selenium).² It contains the Bifidus factor, macrophages, lymphocytes, IgA, IgM, and other crucial immune system constituents. By releasing oxytocin, it improves the bond between mother and child while also reducing the risk of postpartum haemorrhage and other problems.³

Jaundice frequently appears in breastfed new-borns 24 to 72 hours after delivery, peaks (>12 mg/dl) between 5 and 15 days later, and then disappears by the third week. The bilirubin levels in these new-borns have been found to be greater. In new-borns who are breastfed, mild jaundice may develop 10–14 days after delivery or may come back while the baby is still nursing.⁴

It's important to distinguish between breastfeeding and breast-milk jaundice. Breast-feeding jaundice only affects babies who struggle to nurse and don't get enough breast milk. However, infants with breast milk jaundice are able to latch on to the breast and consume an acceptable amount of breast milk.⁵

Etiology

True breast milk jaundice's exact cause is unknown. Theories have centered on the contributions of pregnancy-related increases in enzyme activity and free fatty acid levels in breast milk. According to one theory, real breast milk jaundice develops when the amount of ß-glucuronidase in breast milk increases, which causes bilirubin to be absorbed more readily by the digestive tract.

Pregnanediol is hypothesized to prevent bilirubin from conjugating, which prevents bilirubin excretion. A naturally occurring enzyme called ß-glucuronidase breaks down bilirubin at the intestinal brush barrier, increasing serum absorption rather than excretion. Human breast milk and the serum of exclusively breastfed new-borns contain higher levels of the epidermal growth factor. This compound increases intestinal absorption of bilirubin while decreasing intestinal motility in the newborn period, which raises levels of unconjugated bilirubin.⁵ The UGT1A1 gene's coding area mutations have been linked to an increased risk of breast milk jaundice, according to several studies. Crigler-Najjar and Gilbert syndrome, two diseases known to result in persistent hyperbilirubinemia, is known to be caused by mutations in this gene's regulatory region.⁶

PATHOPHYSIOLOGY

Some predisposing factors include an increase in blood volume and haemoglobin concentration, a reduction in the average lifespan of red blood cells, and physiological immaturity of the liver enzymes. The creation of an unconjugated form, which is not water-soluble, is relatively high as a result of several variables working together.

The bilirubin uridine diphosphate glucuronosyltransferase (bilirubin-UGT) enzyme, whose synthesis is controlled by the UGT1A1 gene, catalyses the conjugation reaction inside the hepatocyte. As a result, individuals with hereditary abnormalities in this gene have poor bilirubin conjugation. Additionally, this enzyme is substantially less active in new-born than in adults, which results in less effective conjugation. The bilirubin is expelled from the hepatocytes after conjugation, and it then travels to the small intestine where it is transformed into stercobilin by the gut flora and then eliminated through the faeces (Figure 1).⁷

The amount of gut flora required for this process is lower in infants than in adults, which results in a larger concentration of bilirubin persisting in the digestive tract. Bilirubin that is still present in the intestine will be deconjugated by the enzyme ß-glucuronidase. Following this procedure, it is transported back to the liver via portal circulation for reconjugation (Figure 2).⁷

Clinical manifestation

The skin and eye whites are both yellow-colour, fatigue\listless, poor weight gain, and weeping with a loud voice.

ASSESSMENT

History and physical examination

From the new-born’s parents and other family members, the nurse should obtain the whole medical history i.e., previous incidence of jaundice (physiological jaundice), diseased caused haemolysis (i.e., ABO and Rh incompatibility, G6PD deficiency, hereditary diseases related to RBC like sickle cell, spherocytosis), breastfeeding related problems like inadequate milk consumption, genetic disorders (Crigler-Najjar, pyruvate kinase deficiency and Gilbert syndromes), liver or gallbladder related disorders (biliary atresia, neonatal hepatitis, choledochal cyst, and disorders of bilirubin excretion). Perform complete systemic and head-toe examination and communicate the findings to health care providers.

Bilirubin blood/serum test

Babies' jaundice is typically assessed with a bilirubinometer. Blood tests are typically only required if the baby's jaundice appeared within 24 hours after birth or the reading is unusually high.

Doctor suspects newborn may have a liver condition or a red blood cell abnormality; more tests may be necessary. These tests could consist of: liver function test, urine test, and ultrasonography.

MANAGEMENT

We should adhere to the proper treatment plans to battle hyperbilirubinemia such as exclusive breastfeeding, continuous monitoring, phototherapy, exchange transfusion and ensure that the infant is in a healthy state.

Exclusive breastfeeding will be advice to mother and family member and promote the breastmilk to baby for continuous 6 month, and after 6-month weaning can be started.⁸

Infants with jaundice in the first 24 hours should undergo continuous monitoring and their transcutaneous bilirubin (TcB) or total serum bilirubin (TSB) levels should be assessed.⁹ Consider the infant's age in hours and interpret any elevated bilirubin levels, and keep in mind that babies who are breastfed and/or born at less than 38 weeks of gestation have a higher risk of developing hyperbilirubinemia and need stricter supervision and monitoring. Visual assessment of the severity of jaundice can be inaccurate, especially in infants with dark pigmentation.

Phototherapy is another option for treatment, when the total serum bilirubin level is at or above 15 mg/dl (257 mol/l) in infants 25 to 48 hours old, 18 mg/dl (308 mol/l) in infants 49 to 72 hours old, and 20 mg/dl (342 mol/l) in infants older than 72 hours, phototherapy should be started, or it can be started when the total blood bilirubin level is greater than five times the baby's birth weight is a frequent practise in the neonatal intensive care unit (NICU).¹⁰ As a result, phototherapy is initiated at a bilirubin level of 5 mg/dl in infants weighing 1 kg, 10 mg/dl in infants weighing 2 kg, and so on.¹¹

Exchange transfusion is indicated by cord bilirubin levels greater than 5 mg/dl, bilirubin levels rising more than 1 mg/dl every hour, or indirect bilirubin levels greater than 20 mg/dl.¹² For healthy term babies who were born between the first 25–48 hours of life and had bilirubin levels of 340 µmol/l (19.88 mg/dl); for healthy term babies who were born beyond 48 hours and had bilirubin levels of 430 µmol/l (25.15 mg/dl).¹³ For preterm infants, the following guidelines should be followed: birth weight (BW) greater than 2000 g; bilirubin levels between 260 and 290 µmol/l (15.20-16.96 mg/dl); BW between 1001 and 1500 g; bilirubin levels between 170-260 µmol/l (9.94-15.20 mg/dl); and BW less than 1000 g at bilirubin levels between 136 and 170 µmol/l.⁽¹³⁾

Nursing interventions

The nurse should carry out certain interventions i.e., assess the vital sign of the patient every 4 hour, collect the detailed family and clinical history and assess for factors/signs and symptoms for diseases associated with jaundice like haemolytic diseases (family history of haemolytic diseases, onset of jaundice in new-born before 24 hr of birth, phototherapy's inability to reduce the TSB, after 24 to 48 hours, the TSB level quickly increased (G6PD deficiency), ethnicity indicative of an inherited illness), increased RBC breakdown (other than haemolysis such as polycythaemia (haematocrit >65), cephalohematoma, ecchymosis), and rise in the frequency of hyperbilirubinemia (infant of a diabetic mother, GA <37 weeks).

Nurse should follow more general intervention i.e., remove excessive clothing, blanket to maintain the normal temperature, assess for symptoms like dark urine or bilirubin present in urine, light coloured stool, jaundice that persists for more than three weeks, they may associate with any liver or gallbladder pathology, perform the investigations i.e., Hgb and erythrocyte count, blood grouping, indirect and direct coomb test and serum bilirubin (direct, indirect and total) as ordered, monitor the weight of baby and record, teach the mother and family member about breastfeeding (time, benefits, and techniques), disease condition and its treatment, encourage mother to provide breastfeeding effectively, if the baby is on phototherapy – continuous observation of new-born and machine (phototherapy light, and temperature) should be perform, eyes and genitalia of new-born should be covered properly during phototherapy treatment, new-born baby ongoing with phototherapy treatment should be assessed for rashes, lethargy, abdominal distension, eye damage, dehydration, hyperthermia, insensible water loss and bronze baby syndrome, administer the medication and fluids as prescribed, communicate all possible complication related to disease and treatment to patient’s family member and ensure the safety of the new-born baby.

Nursing diagnosis

Risk for injury related to elevated level of bilirubin, risk for fluid volume deficit related to phototherapy and its effect, diarrhoea related to phototherapy effect, risk for impaired skin integrity related to phototherapy, knowledge deficit related to condition, treatments and care, altered family process related to maturational crisis of team infant, and anxiety related to medical therapy given to the baby.

CONCLUSION

Jaundice in new-borns brought on by nursing is known as breast milk jaundice. It happens during the first week of life as a result of an abnormal build-up of bilirubin, which causes jaundice, or a yellow stain on the new-born’s skin. The digestive tract can more easily absorb bilirubin as the level of ß -glucuronidase in breast milk rises. Another component of breast milk, such as the epidermal growth factor, elevates levels of unconjugated bilirubin by increasing intestinal bilirubin absorption while reducing intestinal motility in the newborn period. Various measures are followed to combat breastmilk jaundice, like exclusive breastfeeding, phototherapy and exchange transfusion. The nurse plays a crucial role in the management of this condition, she/he educates the mother and relatives about exclusive breastfeeding. She/he also provides comprehensive care like continuous monitoring of newborn, administration of medication and reporting to the doctor.

The postpartum nurse should evaluate both the mother and the newborn. If she notices any symptoms like jaundice, she should let the associate doctor know right once so that treatment may start right away. This study will aid medical personnel in comprehending breastmilk jaundice, its symptoms, and several treatment approaches.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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