What is the management for a breastfeeding infant with hyperbilirubinemia (elevated bilirubin) at 26 days?

From the Guidelines

Breastfeeding should be continued in infants with hyperbilirubinemia at 26 days, as the benefits of breastfeeding outweigh the risks, and phototherapy can be used if bilirubin levels are very high, as recommended by the American Academy of Pediatrics 1.

Management of Hyperbilirubinemia

The management of a breastfeeding infant with hyperbilirubinemia at 26 days should focus on identifying the underlying cause, as this is considered prolonged jaundice.

• The infant should undergo a thorough evaluation including:
  • Total and direct (conjugated) bilirubin levels
  • Complete blood count
  • Blood type
  • Liver function tests
  • Assessment for infection
• If the direct bilirubin is elevated (>2 mg/dL or >20% of total), this suggests cholestatic jaundice requiring urgent referral to pediatric gastroenterology.
• For indirect (unconjugated) hyperbilirubinemia, which is more common, management depends on severity.

Phototherapy and Breastfeeding

• Continued breastfeeding should be encouraged in most cases, as breast milk jaundice typically resolves spontaneously by 12 weeks.
• Phototherapy is rarely needed at this age unless bilirubin levels are very high, and it can be used in conjunction with breastfeeding, as stated in the guidelines 1.
• If breast milk jaundice is suspected and bilirubin levels are concerning, a temporary breastfeeding interruption test (12-24 hours) with formula supplementation may be considered, though this is not routinely recommended.

Monitoring and Follow-up

• The infant should be monitored with follow-up bilirubin measurements until resolution.
• Prolonged jaundice at this age often represents benign breast milk jaundice, but other causes such as hypothyroidism, urinary tract infection, hemolytic disorders, or liver disease must be excluded through appropriate testing, as recommended in the latest guidelines 1.

From the Research

Management of Hyperbilirubinemia in Breastfeeding Infants

• The management of hyperbilirubinemia in breastfeeding infants involves specific interventions to lower the unconjugated or indirect-reacting bilirubin level in infants at risk, as discussed in 2.
• Frequent breastfeeding (at least 8 times a day) and fewer supplementary feeds can help increase breast milk intake, reduce weight loss, and lower bilirubin concentrations, as noted in 3.

Breastfeeding Practices and Hyperbilirubinemia

• Optimal breastfeeding practices, which result in minimal initial weight loss and early onset of weight gain, are associated with both reduced breastfeeding jaundice and minimization of the intensity of breastmilk jaundice, as mentioned in 4.
• Hyperbilirubinemia may have a negative effect on breastfeeding and milk intake, with bilirubin levels above 12 mg/dL adversely affecting breastfeeding, as found in 5.

Phototherapy and Hyperbilirubinemia

• Phototherapy can be an effective treatment for hyperbilirubinemia in breastfeeding infants, with intensified phototherapy plus feeding with milk potentially reducing serum bilirubin levels, as reported in 6.
• In cases of extreme jaundice, phototherapy and interruption of enterohepatic bilirubin circulation may be beneficial in reducing serum bilirubin levels and minimizing the risk of neurotoxicity, as discussed in 6.

Monitoring and Follow-up

• Breastfed infants with hyperbilirubinemia should be monitored closely, with daily weigh-ins and assessments of feeding and jaundice, as recommended in 3.
• If an infant has lost more than 10% of its birth weight, drinks poorly, or fails to gain weight despite frequent breastfeeding, referral to a pediatrician for further diagnosis and treatment is necessary, as noted in 3.