Shedding Light on Neonatal Hyperbilirubinemia: Removing “Breastfeeding Jaundice” From Our Lexicon

A G1P1 mother aged 28 years delivers a healthy 38 4/7-week infant via cesarean section due to failure to progress. After 48 hours of moderately successful breastfeeding attempts with the help of both postpartum nursing and the lactation consultant team, a bilirubin level results high enough to warrant phototherapy. On family-centered rounds the next day, the medical student discusses the infant’s feeding, weight, and available maternal milk supply, then excitedly states that the most likely diagnosis is “breastfeeding jaundice.” The exhausted mother immediately begins crying, convinced that her inability to breastfeed is the cause of her infant’s suffering.The link between breastfeeding and jaundice has been reported since the 1960s.1 In 1981, Poland noted that infants receiving inadequate fluid volumes were more likely to become jaundiced. This prompted a correspondence article challenging this statement in The Journal of Pediatrics titled “Breastfeeding Jaundice.” Although the title was the first use of the term breastfeeding jaundice in the literature, the term was not actually used in the content of the letter.2,3 In 1986, an article published in The Journal of Pediatrics by Lascari appears to use the term “breastfeeding jaundice” as an entity for the first time to describe the increased incidence of indirect hyperbilirubinemia in breastfed infants. Lascari divides this entity into early and late subtypes, with “early breastfeeding jaundice” referring to what continues to be referred to as breastfeeding jaundice today.4The term breastfeeding jaundice is commonly used to describe neonatal jaundice resulting from suboptimal fluid and caloric intake during the first 7 days of life.5 This more specific understanding of the term dates to 1987 when Gartner and Auerbach recognized early and late breastfeeding jaundice as separate entities and labeled them as breastfeeding jaundice syndrome and breast milk jaundice syndrome, respectively.1 Since then, the term has been well established in the medical community.Recently, however, some have recognized the use of the term breastfeeding jaundice as flawed, and there has been a shift in the medical literature toward alternative terms such as suboptimal intake jaundice to describe this phenomenon.6 Despite this transition in the literature, the term is still commonly used colloquially by providers in conversations with other clinicians, trainees, and families. All authors of this paper have recently encountered this term during our rounds with trainees.Exclusive breastfeeding has been established as the optimal feeding practice for infants younger than 6 months of age, providing multiple benefits for both the birthing parent and the infant. It is well known that maternal mental and emotional health are positively associated with exclusive breastfeeding.7 As such, efforts should be made to provide a supportive and encouraging environment for breastfeeding parents.In contrast to the supportive environment necessary for successful breastfeeding, the term breastfeeding jaundice may be misleading and potentially stigmatizing toward breastfeeding, implying that breastfeeding itself is the cause of the jaundice. In birthing parents whose infants have hyperbilirubinemia secondary to low intake, the term breastfeeding jaundice may be detrimental, contributing to feelings of guilt or loss of confidence in the ability to breastfeed and care for their child. In a study by Vieira et al, mothers who scored low in breastfeeding self-efficacy had a median duration of exclusive breastfeeding of 21 days, whereas those with high self-efficacy levels had a median duration of 148 days.8 When birthing parents feel safer and less anxious, they gain confidence in their ability to overcome difficulties in breastfeeding.Using the diagnosis of breastfeeding jaundice may inadvertently imply to parents that breast milk is harmful to their child. Although exclusively breastfed infants may be at increased risk of developing jaundice as breast milk supply takes time to establish, the newly revised 2022 hyperbilirubinemia guidelines no longer risk stratify patients based on whether the infant is breastfed or formula fed. Even for infants with hyperbilirubinemia, the American Academy of Pediatrics recommends the continuation of breastfeeding while providing family-centered breastfeeding support to ensure sufficient intake.5 Therefore, it is critical that birthing parents feel encouraged and supported during this process. One simple suggestion for reducing anxiety and unnecessary guilt and blame placed on breastfeeding is to discard the use of the term breastfeeding jaundice and reframe the way we discuss this process with families.Recently, others have also identified breastfeeding jaundice as a harmful term, and a small movement toward renaming this type of jaundice has evolved. Various terms have been used in the literature to replace breastfeeding jaundice, including some variations of suboptimal intake jaundice, breastfeeding failure jaundice, or starvation jaundice;6 however, these alternative terms are also not ideal as they too impose a sense of inadequacy or guilt on parents. We discourage the use of the term breastfeeding jaundice and its substitute terms and rather encourage the use of the general term neonatal jaundice with a descriptive approach. One example of this script when talking with parents may be, “Newborns often experience neonatal jaundice due to elevated bilirubin levels as part of their natural transition from the womb to life outside it, and some proportion of infants will have bilirubin levels rise to a level needing treatment.” By describing the process instead of labeling it, we can better depict the underlying cause of the jaundice and normalize the changes that occur during the extrauterine transition to breastfeeding as the source of nutrition.Phasing out the term breastfeeding jaundice requires action on several fronts. In your work with trainees, explain why this term can be harmful and discouraging. Reinforce that transitioning to breastfeeding from intrauterine life is a normal process, including the jaundice that may occur as a result. This change should also be reflected in the language used when communicating with parents. Provide trainees with the skills to assess infant feeding and support breastfeeding parents in optimizing intake, emphasizing a nonstigmatizing approach that encourages parents to seek help without feeling guilt or shame. Although many textbooks have moved away from this term, examine the resources that you use and that you provide your trainees and families. If any include the term breastfeeding jaundice, either edit them yourself if possible or consider writing to the editor or publisher to recommend a change. Discouraging the use of this term is a concrete step in the right direction to continue to support breastfeeding.