1. Neonatal Jaundice & Breast-Feeding Dr Elizabeth V á rady Consultant Neonatologist, IBCLC Tawam Hospital

2. NEONATAL JAUNDICE Incidence 2 of 3 full term newborns

3. Relation of Incidence of Jaundice & Breastfeeding Jaundice occurs more frequently in breast-fed infants compared to bottle-fed infants

4. Relation of Incidence of jaundice & Breast-feeding >50% of all breast-fed neonates have exaggerated and prolonged unconjugated hyperbilirubinaemia <1% reach TSB levels that cause concern (>20 mg/dl)

7. Can kernicterus occur in a healthy breastfed infant?

9. Risk of being readmitted for Px 30000 discharges from WB nursery - 4.2/1000 readmitted Maisels,Pediatrics,1998 3.2 LOS<72 hrs 7.8 Jaundice in nursery 4.2 Breast-feeding 7.5 36-38 wks 13.2 <36 wks ODDS RATIO RISK FACTOR

10. NEONATAL JAUNDICE A/ PHYSIOLOGIC use instead DEVELOPMENTAL -higher Bilirubin (B) production -higher B absorption -  in B clearance from plasma ( deficiency in ligandin &  activity of UDPGT ) B /PATHOLOGIC

11. Neonatal bile pigment metabolism

12. Neonatal bile pigment metabolism

21. Physical Exam of NB for Jaundice Pressure Blanching  on forehead,  mucous membranes of lower jaw  sternum

23. “ NORMAL” SERUM BILIRUBIN LEVELS? Total Serum Bilirubin (TSB) SMOOTHED CURVE from studies in diverse populations Expected Velocity in the 1st 96 hrs of life Maisels MJ

24. Total Serum Bilirubin

26. Zones of risk for pathologic hyperbilirubinaemia based on hour specific pre-discharge bilirubin levels in healthy term and near-term infants Bhutani, Pediatrics, 1999

27. Zones of Risk

28. A/ High Risk Zone >95% Probability of Disease 2/5

29. B/Upper Intermediate Risk Zone 75-95% Probability of Disease 1/8

30. C/Lower Intermediate Risk Zone 40-75% Probability of Disease 1/46

31. D/Low Risk Zone < 40th % Probability of Disease 0 (only if term)

32. Population of healthy term and near-term infants at risk for kernicterus 1.2 % of them having >20 mg%=>340 umol/L TSB if left unmonitored & untreated

33. Incidence of severe hyperbilirubinaemia in term and near term infants 0 -0.032% 1:10000 TSB >99.99% >30mg/dl 0.16% 1: 700 TSB >99.9% >25 mg/dl 1 - 2% 1: 50 TSB >98% >20mg/dl 8.1-10% 1: 9 TSB >95% >17mg/dl Incidence Severe hyperbilirubinaemia

36. Guidelines for Initial Evaluation and Follow Up of Jaundice in Apparently Healthy Term & Near-Term Infants Klaus & Fanaroff In:Care of the High-Risk Neonate Saunders 2001

37. I.Onset of Jaundice in first 24 hrs 1/Clinical evaluation + TSB 2/Blood group (ABO, Rh) Direct Coombs test CBC Smear for red cell morphology Reticulocyte count 3/Repeat TSB in 4-24 hr

38. II.Onset of jaundice 24-72 h 1. Clinical Evaluation 2. Assess cephalo-caudal distribution Transcutaneous B (TcB), if NA, TSB 3. Clinical evaluation and TcB or TSB within 24-72 h and repeat as necessary

39. Additional Laboratory Evaluation of the Jaundiced T & Near-T Infant 1/ Indications Suspicion of haemolytic disease or anaemia (eg. early jaundice, pallor, TSB >8mg/dl=137 umol/L by 24 hr or >13 mg/dl=222 umol/L by 48 h of age) 2. Action Blood type, group & Coombs’ test if not known, CBC and smear, retic.

40. Additional Laboratory Evaluation of the Jaundiced T. & Near-T. Infant 1. Indications 1a/ Ethnic origin compatible with potential for G6PD deficiency with TSB>15 mg/dl (257 umol/L) 1b/ Any infant with late onset jaundice or TSB > 18 mg/dl (308 umol/L) 2. Action : Measure G6PD

45. Cause of Early Breastfeeding Jaundice Cause associated with poor feeding practice and not with any change in milk composition

52. Typical patterns of TSB during neonatal jaundice Gartner 2001 X:FT healthy,Asian  :FT healthy , artificially fed  :FT,healthy, breastfed X:FT healthy,Asian  :FT,healthy, breastfed  :FT healthy , artificially fed

53. Treatment Options for Jaundiced Breast-Fed Infants 1. OBSERVE 2. Continue breast-feeding (BF) with increased frequency r/o haemolysis administer phototherapy (Px) if indicated 3. Supplement BF with formula, (never with dextrose water or water ) with or w/o Px 4. Interrupt BF ??; substitute formula + Px

56. IF A NEWBORN IS DISCHERGED AT <36 HOURS,THE BILIRUBIN LEVEL CAN ONLY BE GOING IN ONE DIRECTION UP Maisels Neoprep 2003

57. NEWBORN FOLLOW UP IN 1-2 WEEKS IS ABONDENMENT Maisels Neoprep 2003

59. Breastfeeding counselling 3 steps 1. Decide whether the baby is getting enough milk 2. If not - try to decide the reason, why 3. Decide, how to help the mother and baby

65. Thank You