Dr Varsha V S, Dr C Jayakumar, Dr Praveena N Bhaskaran, Dr Navya George
AIMS, Kochi
Late preterm AGA male ba born to 26 yrs old P1 / L1 /A 1 mother via normal vaginal delivery with birth weight of 2.59kg with OB incompatibility, no birth asphyxia and mother having no co-morbidities, presented with jaundice .Ba was started on exclusive breast feeds soon after birth. On examination ba was alert, active.
Vitals were stable and systemic examination within normal limits.
Ba passed urine and meconium in the first 24hrs of life.
Ba developed neonatal jaundice at 48hrs of life (TSB: 11.48mg/dl), DCT was negative. Peripheral smear done showed normocytic normochromic blood picture.
Thyroid function test normal.
Ba was started on phototherapy and rebound TSB checked after 24 hrs was normal and he was discharged with stable vitals.
He was advised to review after 2 weeks. On review ba was alert active, on exclusive breast feeds. He was clinically icteric. (Serum Bilirubin: 12.24mg/dl)There is no h/o abdominal distension or passing high coloured urine, clay coloured stools or fever. Ba had good urine output, weight gain is adequate,
Systemic examination done again was normal So advised to follow up after 2 weeks. During this period ba was on exclusive breast milk. On review his icterus persisted but TSB showed a decreasing trend (TSB: 9.69mg/dl). Peripheral smear was repeated and was within normal limits. Urine routine done was normal. Child was advised to follow up after 1 month.
After 1 month on examination he is still have icterus and TSB was repeated and was 8.63mg/dl .There was no family history of jaundice. So Breast milk jaundice was thought of and advised to follow up after 2 weeks.
On follow up at 1month child was icteric and TSB value above normal.
So ba was planned either to stop breast feeding for 48 hrs observe the Bili value or wait for 3 more week without stopping the breast milk. But parents opted for continuing breast feeding. Mother was explained that jaundice is not serious issue if it is unconjugated and next follow up was planned after 3 weeks.
At this time at 3 weeks on follow up ba was not icteric .TSB repeated after 3weeks was 1.85mg/dl which was normal.
Diaganosis
Breast milk jaundice
First described in 1963 when it was noted that some breastfed infants had prolonged, unconjugated hyperbilirubinemia that persisted beyond the third week of life. Breast milk jaundice typically presents after day 3 or 4 in the first or second week of life and it can even persist for 8-12 weeks of life before resolution. Some factors like proteins and enzymes are present in human milk which is thought to inhibit the conjugation of bilirubin and hence its excretion.
ß-glucuronidase is an enzyme naturally present in the muscle that deconjugates bilirubin in the intestinal brush border, leading to increased unconjugated bilirubin levels. Some Studies have shown that the activity of this enzyme within formula milk is negligible, but it is considerable in human milk.
Interleukin IL 1β & IL6 which is present in human milk is thought to have a cholestatic effect that leads to hyperbilirubinemia. The epidermal growth factor is present in higher concentrations in human breast milk and the serum of strictly breastfed infants. The reason is that this substance enhances intestinal resorption of bilirubin and reduces intestinal motility in the neonatal period, leading to increased unconjugated bilirubin levels. The infants exhibit normal weight gain with adequate production of urine and stools.
Treatment is not necessary for breast milk jaundice unless the infant’s total serum bilirubin level is greater than the phototherapy guidelines. If the total serum bilirubin level remains below 12 mg/dL, the recommendation is to continue breastfeeding. If the total serum bilirubin level is higher than 12 mg/dL but below the phototherapy level, and further investigation shows no hemolysis or hypothyroidism, the recommendations are also to continue breastfeeding. When the bilirubin is greater than 20 mg/dL a brief 24-hour cessation of breastfeeding may be beneficial.
According to latest The American Academy of paediatrics (AAP) clinical practice guideline for the management and prevention of hyperbilirubinemia in the new born infant >35 weeks gestation 2022, an updated and more informative Bhutani neonatal bilirubin normogram, based on 140 times the number of subjects included the 1999 version, is now in place in our health care system.
Fig 1 : Phototherapy thresholds gestational age and age in hours for infants with no recognized hyperbilirubinemia neurotoxicity risk factors other than gestational age
Fig 2: Phototherapy thresholds gestational age and age in hours for infants with any recognized hyperbilirubinemia neurotoxicity risk factors other than gestational age.
Latest AAP cut offs
Differential diagnosis include G6PD deficiency, hereditary spherocytosis, Crigler-Najjar, Pyruvate kinase deficiency, Gilbert syndromes.
Infants with breast milk jaundice have excellent prognosis as it is a self-limited condition that usually resolves around 12 weeks of age. The most feared complication is acute bilirubin encephalopathy and kernicterus (chronic bilirubin encephalopathy) in the long term. It is a rare complication of breast milk jaundice and occurs in less than 2% of breastfed term infants.
The carry home message in the above described case is that no need to stop breast feeding at 1 month of age even if jaundice is more than 2mg (which is expected at 1month of age ) if cause is breast milk jaundice.
