Educational Resources 

Does jaundice have to affect breastfeeding?

Jaundice is an elevation of bilirubin levels in the blood which gives a yellow tinge to the skin. Although elevated levels of bilirubin can indicate a condition that needs treatment, the great majority of jaundice that occurs in full-term, healthy newborns is considered normal and requires no intervention. Some babies, specifically those living at high altitudes and of Chinese, Japanese, Korean, Native American or South American ancestry, have a greater prevalence of elevated bilirubin levels.

Recent studies show that more than half of all babies will show some signs of jaundice and that about two-thirds of all breastfed babies will continue to have elevated levels of bilirubin for several days or weeks. In light of this new information, combined with the fact that the jaundice experienced by most babies has no short or long term ill effects, the medical community is changing the way they look at jaundice and the recommendations they make for its treatment.

When jaundice occurs is important:

• Occurring during the first 24 hours
Jaundice that is evident at birth or during the first 24 hours of life is of the most concern since it may indicate a disease or condition which requires immediate treatment, especially if the levels are rapidly rising or abnormally high. Standard laboratory tests can usually determine the cause of such jaundice. Regardless of the treatment indicated, breastfeeding 10-12 times every 24 hours is the recommended feeding schedule. This assures that the baby has optimal nutrition resulting in frequent stooling which helps to rid the baby of the excess bilirubin. Also, because jaundice can often make the baby sleepy and less likely to nurse well, frequent feeding and waking will assure that the jaundice will not be exaggerated by inadequate caloric intake and the mother’s milk supply will be maintained at desired levels.

A baby who is premature or one who develops jaundice in the first 24 hours of life is not considered a healthy baby and information regarding jaundice and the healthy baby may not apply.

The American Academy of Pediatrics suggests that when jaundice is present in the first 24 hours:
• Phototherapy by considered when bilirubin levels reach 12 mg/dl,
• Phototherapy be started at 15 mg/dl,
• Exchange transfusion be done at 20 mg/dl, and
• Both exchange transfusion and intensive phototherapy be done when levels reach 25 mg/dl.


• Occurring two to five days after birth
When the level of bilirubin elevates on the second to fifth day, it is often referred to as physiologic, or normal, jaundice. This kind of jaundice usually resolves itself without treatment within a few days or weeks and is caused by an increased amount of bilirubin production by the baby, an increased amount of bilirubin absorption from the intestines and the inability of the baby to process the bilirubin due to immaturity of the liver. Usually up to two weeks is necessary for the baby to mature sufficiently to effectively handle the bilirubin. The baby who nurses early and frequently will be less likely to display exaggerated levels of jaundice because frequent feeding causes the meconium (the stool present in the baby’s intestine at the time of birth and rich in bilirubin) to be excreted quickly and lessens the amount of bilirubin necessary for the baby to process.

As long as the baby is healthy, nursing effectively (10-12 times/24 hours and stooling 2-5 times a day) and not showing exaggerated levels of bilirubin, no treatment is necessary. The American Academy of Pediatrics suggests for jaundice occurring at this point in the baby’s life that phototherapy be considered at bilirubin levels of 15 mg/dl, phototherapy be started at 18 mg/dl, exchange transfusion be done at 25 mg/dl and both exchange transfusion and intensive phototherapy are indicated at 30 mg/dl.

• Continuing after the fifth day
In the past, jaundice that occurred or persisted past the first week of life was labeled with the name “late onset’ or “breast milk jaundice” and was thought to occur in about 4% of all babies. This phenomenon is now considered to be simply a prolongation of physiologic jaundice. New research indicates that about one-third of healthy, normal breastfed infants have bilirubin levels higher than 5 mg/dl (visible to the eye) and another third have levels between 1.5 and 5 mg/dl (not visually apparent). This is beginning to be considered “a normal extension of physiologic jaundice of the newborn” by some health care providers and is changing the perception of normal jaundice from being a disease requiring treatment to being part of a normal breastfed infant’s development. Since bilirubin is known as a powerful antioxidant, some experts speculate that these higher bilirubin levels may be beneficial to the newborn since higher bilirubin levels have been linked with a reduced incidence of disease in term and preterm babies. In the healthy, full-term baby, bilirubin levels between 23-29 mg/dl have not been associated with any short or long-term risks.

For the baby over 72 hours old, the American Academy of Pediatrics recommends considering phototherapy at 17 mg/dl, starting phototherapy at 20 mg/dl, using an exchange transfusion at 25 mg/dl and instituting both transfusion and intensive phototherapy at 30 mg/dl.

Treatment options

• Assure effective nursing patterns
Effective treatment of jaundice does not require discontinuing breastfeeding. In cases where poor feeding patters are contributing to the higher bilirubin levels, short-term supplementation using a small cup or other feeding devise while breastfeeding practices are improved and the mother’s milk supply is increased, may be appropriate.

If bilirubin levels are 20 mg/dl or below and the baby is nursing well, foregoing interventions and monitoring the baby through blood tests is appropriate as long as the levels are rising slowly or appear to be peaking. Care should be taken in making sure that the baby is feeding frequently and effectively – this is best indicated by 2-5 bowel movements a day.

• Use indirect sunlight
Place the baby near a source of indirect sunlight, making sure that the sun doesn’t shine directly on the baby, causing sunburn. Undress the baby down to the diaper to expose as much of the skin area as possible to the light.

• Don’t use water supplements
Supplemental water does not “flush” the bilirubin out of the baby as was once believed. Research has confirmed that water supplements may elevate bilirubin levels and interfere with the timely excretion of meconium. The use of a bottle to give the water may also contribute to nipple confusion and cause ineffective feeding resulting in less nutritional intake and raising of bilirubin levels.

• Phototherapy
Phototherapy, which uses a machine to produce light energy to break down bilirubin through the skin, is a common treatment for jaundice. Phototherapy does not have to be continuous for long periods of time to be effective so mothers should not hesitate to pick up and nurse their babies frequently. Phototherapy can make the baby sleepy so the mother may need to wake her baby to nurse.

• Blood exchange transfusions and medications
The need for exchange transfusion is rare and most medications used to lower bilirubin levels are not used on infants in the United States.

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