What Safety Guidance Should Farm Families Be Aware Of?

Patient Presentation
A 6-year-old male and a 9-year-old male came to clinic with their mother for their health supervision visits. The boys both had attention deficit disorder (with hyperactivity and inattention) and were using stimulant medication without side effects. Their mother reported they were doing well in school. The 9-year-old reported that the medicine “helped my brain stay calmer.” The social history showed that the parents were a firefighter and a nurse who also ran a farm with animal stock and crops.

The pertinent physical exam showed healthy boys with growth parameters in the 10-50% for the 6-year-old and 25-50% for the 9-year-old. Their examinations were normal.

The diagnosis of healthy boys with attention deficit disorder was made.
When discussing anticipatory guidance the pediatrician asked about safety rules they had for the farm. The mother asked the 6 year old, “When you’re outside, where can you play?” He said, “I have to stay on the grass, I can’t go in the road.” “And what if you are by the barns with Dad or Grandpa?” she went on. “I can’t go in the barns without them. If I am by the barns and something is moving then I have to put my hand on the barn, the fence or a tree,” he replied. The mother said that the grass was by the house and most of it was fenced off. The driveway separated the house from the barns and they had taught the children if they were in the barn area with adults and a car, tractor, or large animals were moving, then they had to go next to something big and sturdy like the barn itself or a tree. The 9-year-old said, “We can’t be in the barn by ourselves. I’m still too little to be by the steers, but this summer Dad says I can help him with the goats,” the 9-year-old said proudly. “I get to help with the baby goats, though” the 6-year old protested. “Yes but I get to do that AND be with the big goats,” he again said proudly. “We’re pretty strict about the rules. Grandpa wanted to let them drive the golf cart with him. I even vetoed that one. With their ADHD I’m not sure when I am going to let them drive anything with wheels,” the mother said.

“The agriculture industry is consistently ranked as one of the most hazardous industries in the United States with some of the highest rates of work related injuries and deaths. Agriculture is a unique profession in that children who live on farms are exposed to, and in participate in, the family business of farming. Moreover, children who work on their family farm fall outside the regulation of governmental safety and labor practices….There is often little separation between work areas and play or living areas, thus children living on or visiting a farm may be in close proximity to safety hazards.

The rates of agriculture-related injuries are decreasing. Children have overall fewer injuries but their injuries are more severe. A study of 0-19 year olds with agricultural-related injuries from 2001-2006 found an annual incidence of ~26,600 injuries. Of these 29% were work-related, 0.32% were fatal (n=84), with falls (35.2%), machinery (3.7%), transportation (14.4%), assaults and self-harm (11.7%), and fire and explosions (0.63%) being the most common causes of injuries. Of the fatalities, machinery (21.4%), fire and explosions (14.2%), transportation (10.7%) and drowning (9.5%) were the most common causes. Boys report more exposure to potential hazards and are injured more than girls.

Farming is a heterogeneous industry and the activities vary widely. It is important to ask the family the type of farming they engage in when assessing the safety risk factors.

Potential exposures on a farm include:

  • Tractors, machinery, cars/trucks, small vehicles (e.g. Gator® utility vehicles, all-terrain vehicles, motorcycles, golf carts, snowmobiles etc.).
  • Water hazards – ponds, drainage ditches, water tanks, etc.
  • Falls – buildings, machinery and equipment (e.g. hayloft, silos)
  • Chemicals, petroleum and pesticide product exposures
  • Animal exposures – large animals, domestic animals, wild animals, rodent/insect, etc.
  • Farm product exposure – grain dust, raw milk, product holding areas such as grain bins
  • Recreational activities – horse-back riding, hunting, shooting, archery, snowmobiling, rodeo, fishing, boating, camping
  • Temperature and weather related exposures

Tractors injuries are the leading cause of trauma on the farm for all age groups. This includes operating or being a passenger on a tractor. Tractors and other farm machinery including lawn mowers are designed for adults. The throttles, gears, pedals, and steering wheels are designed for adults and may be beyond the reach of children and youth (anyone < 19 years old), and they often take more strength to operate properly than a child has. As children are not as tall, they can have a reduced field of view. Children and youth also have poorer executive function and lack experience. Impulse control may not occur until adulthood.

Learning Point
Methods to decrease all workplace injuries are the 3 E’s of industrial safety, which are engineering, education and enforcement.

  • Engineering design eliminates or reduces the potential hazard. For example, separation from the hazard such as fencing around the home to make a safe area for children to play in.
    Understanding ergonomic loads on children to determine if, and how, a child or youth can safely perform a specific farm task.

  • Education for both parents and children to understand risks and ways to mitigate them. Various methods can be used including school, organizations, community events and educational materials such as farm safety camps, safety certification programs, etc.
  • Enforcement by both parents and children again can help to mitigate problems. Parental and older sibling modeling of appropriate safety has been shown to decrease injuries.
  • Appropriate supervision is always necessary for children of any age. Supervision includes the adult’s attention (i.e. listening and watching), proximity (within reach or beyond) and supervision continuity over time (intermittent or continuous).

Risks are increased, as would be expected, when parents are farming, or the child is exposed to equipment or animals. Tractor injuries as noted before carry the highest risk. This includes being the driver or a passenger on a tractor or piece of equipment.

While many of the usual safety suggestions may seem logical, like any environment, they may be difficult to implement on a consistent basis. A permanent fence around a pond may be easier to implement than locking up every small tool in a workshop every time. Injuries will occur in any workplace or home and children must also be taught basic first aid and how to obtain help if needed. Basics such as good sleep hygiene and appropriate rest periods can have big effects on the decisions adults and children make for their own and others safety.

Guidance for farm safety includes:

  • Engineering
    • Make sure children know what areas of the farm are unsafe
    • Keep children away from dangerous equipment and water hazards by fencing in play areas
    • Layout workspaces to encourage safety – chemicals and petroleum products locked up in a separate area, workshop with tools can be locked, etc.
    • Safety equipment should be readily available to encourage their use such as fire extinguishers, first aid kits, respirators, etc.
  • Education
    • Check equipment regularly to ensure safety features are working properly
    • Children should not play on equipment, even with adult supervision
    • Monitor changing weather conditions
    • Children < 16 years of age should not operate farm vehicles. Allow youths ages 16 to 18 years to operate farm vehicles on public roads only if they have a motor vehicle license and are graduates of a state-approved tractor and farm vehicle safety training program.
    • Never allow extra riders on tractors, mowers or ATVs, etc.
    • Seat belts should always be used on tractors or any other vehicle
    • Limit young children’s access to large animals
    • Teach children not to run or speak loudly around animals
    • Participate in farm safety events and certificate training programs (e.g. farm vehicle safety, hunter safety, boating safety, etc.)
    • Teach and practice a safety plan for common problems that do occur. For example, what to do when they are near a barn when a tractor drives into the area, or animal is startled, or they find a potentially dangerous tool, or need to get emergency help, etc.
  • Enforcement
    • Children should be adequately supervised at all times
    • Make sure children know how and use all safety equipment properly
      • Use basic safety equipment – seat belts, eye and ear protection, respirators, clothing, etc.
      • Specialized safety equipment should be used appropriately and with additional supervision
    • Children should be properly attired for the work
      • Appropriate clothing that provides comfort while working yet is protective such as closed toed shoes, long sleeve-shirts, pants, hats
      • Hair should be kept short or tied back
      • No loose clothing or hair
    • Encourage children to ask for help when they encounter problems

Questions for Further Discussion
1. What professional organizations offer farm safety education and training?
2. What is the extension? Program information can be found here and a specific example in the State of Iowa can be found here
3. What diseases are related to livestock exposure?
4. When can a child mow a lawn? A review can be found here

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Farm Health and Safety

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Rasch H. Down on the farm: Don’t let children fall victim to injuries. AAP News. 2012;33(8):25-25. doi:10.1542/aapnews.2012338-25d

Zaloshnja E, Miller TR, Lawrence B. Incidence and Cost of Injury Among Youth in Agricultural Settings, United States, 2001-2006. Pediatrics. 2012;129(4):728-734. doi:10.1542/peds.2011-2512

Schwebel DC, Pickett W. The role of child and adolescent development in the occurrence of agricultural injuries: an illustration using tractor-related injuries. J Agromedicine. 2012;17(2):214-24. doi: 10.1080/1059924X.2012.655120.

Morrongiello BA, Zdzieborski D, Stewart J. Supervision of children in agricultural settings: implications for injury risk and prevention. J Agromedicine. 2012;17(2):149-62. doi: 10.1080/1059924X.2012.655127.

Gallagher SS. Characteristics of evaluated childhood agricultural safety interventions. J Agromedicine. 2012;17(2):109-26. doi: 10.1080/1059924X.2012.664033.

McCallum DM, Murphy S, Reed DB, Claunch DT, Reynolds SJ. What we know about the effectiveness of farm safety day programs and what we need to know. J Rural Health Off J Am Rural Health Assoc Natl Rural Health Care Assoc. 2013;29(1):20-29. doi:10.1111/j.1748-0361.2012.00426.x

Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

What Are the Different Types of Myasthenia Gravis?

Patient Presentation
A 6-year-old male came to clinic for a cough and runny nose for 4 days. He initially had a low grade fever but this had resolved. He continued to cough more at night which was disturbing his sleep. He had no pain. The past medical history was positive for ocular myasthenia gravis that had been diagnosed at age 3. He took pyridostigmine. The review of systems was otherwise negative.

The pertinent physical exam showed a somewhat tired appearing male, wearing glasses and tilting his head backward. His vital signs were normal without a measured fever. His growth parameters were around the 50th percentile. He had bilateral ptosis, moderate clear rhinorrhea, with normal pharynx and ear examinations. He had coarse upper airway sounds but no wheezing or other adventitial breath sounds on lung examination. He had no rashes. His neurological examination showed no other obvious muscle weakness.

The diagnosis of an upper respiratory tract infection was made. The physician commented on the ptosis to the family. The mother said that it seemed to get worse with minor infections but then improved. “He always has some droopiness, so this is just part of being sick,” she noted. The physician discussed symptomatic treatment and reiterated signs of respiratory distress with the family. The mother indicated that she was always looking for respiratory distress and knew when to call neurology or go to the emergency room.

Myasthenia gravis (MG) is a problem of the neuromuscular junction which causes muscle weakness. It can occur in all ages and have a range of symptoms from mild localized disease to mortality-threatening respiratory failure. MG occurs in 1.7-30 cases/million, with a prevalence of 77.7 cases/million. Pediatric patients comprise 10-15% of all patients with MG. In various Asian populations, the juvenile MG can be up to 50% of all of the MG cases. Fluctuations in muscle weakness is a hallmark of the disease.

As a reminder, “[i]n normal synaptic transmission in the neuromuscular junction, the axon is depolarized and this depolarization travels to the axon terminal. Voltage-gated calcium channels open, leading to acetylcholine containing vesicles to fuse to the cell membrane. Acetylcholine is then released from synaptic vesicles into the synaptic cleft from the axon terminal. The acetylcholine travels across the synaptic cleft to the AChR [acetylcholine receptor] sites where binding causes sodium channels to open, depolarizing the motor end plate of the muscle fiber. Acetylcholinesterase degrades the acetylcholine, and the sodium channels close, allowing repolarization of the muscle fiber.”

The diagnosis of MG is made by history of fatiguable weakness, clinical examination trying to fatigue muscles such as continuous upward gaze (patients worsen with this activity), physiological testing such as the Tensilon test (which has improved symptoms when the drug is given), electrophysiological testing (worsening with repeated muscle stimulation) and serological testing for antibodies. Treatment varies from none, to acetylcholinesterase inhibitors, immunosuppressive medications, intravenous immunoglobulin and plasmapheresis. Surgical treatment by thymectomy is also used as there appears to be an association with thymomas. Prognosis depends on the type of MG and remissions do occur.

MG is worsened by “systemic illness, pregnancy, the menstrual cycle, drugs that affect neuromuscular transmission,…, increase temperature, hyperthyroidism or hypothyroidism and emotional upset.”

Learning Point
Patients are formally classified by disease severity, but MG has 2 basic forms based on clinical type:

  • Ocular MG
    • Muscles of the eye are preferentially affected in MG and if only ocular muscles are affected it is termed ocular MG (OMG)
    • OMG patients can have ptosis, strabismus or diplopia. Because this is a fatigable muscle disease, patients may have improved symptoms in the morning and worsen throughout the day
    • Patients may complain of difficulty walking not because of affected extremity weakness but because of difficulty seeing where they are walking, particularly with stairs
    • OMG can be unilateral or bilateral
    • Rates of progression to generalized MG are 8-49%. Preadolescents are less likely to progress than adolescents
    • Spontaneous remission with OMG is common
  • Generalized MG
    • Any muscle can be affected
    • Patients will relate various abnormalities in muscular endurance and exercise intolerance
    • Weakness of the respiratory muscles can cause respiratory distress including respiratory failure
    • Patients with bulbar weakness can have problems with chewing or swallowing, which may cause choking including having nasal regurgitation of food
    • Speech can be affected including slurring, quieter voice or having a nasal voice as fatigue worsen even over a day
    • Patients may also have issues with basic hygiene such as toileting, brushing their teeth or washing their hair

MG has 3 forms based on cause:

  • Transient neonatal MG
    • Cause: Maternal antibodies are transplacentally passed to the newborn
    • Occurs in 5-30% of infants of mothers with MG
    • Presents at or shortly after birth
    • Ocular MG or more generalized weakness may occur – weak cry, poor suck, generalized weakness or respiratory distress
    • Diagnosis is by detecting the antibodies
    • Resolves when antibodies are gone
  • Congenital MG
    • Cause: Functional or structural abnormalities in the proteins involved in the neuromuscular junction
    • Most commonly the AChR proteins and function are affected
    • Mutation specific treatment is important as treatment for one type may worsen another
    • It must be distinguished from myopathies or other neurological conditions
    • Fatigable weakness usually at young age even infancy is the usual presentation
    • Ocular MG or more generalized weakness may occur
  • Juvenile MG
    • Cause: Autoimmune disorder causing dysfunction of the AChR
    • Auto antibodies targeted against various structural proteins, mainly the AChR but also muscle-specific kinase (MuSK)
    • Patients with MuSK antibodies have more severe disease

Questions for Further Discussion
1. What causes ptosis? A review can be found here
2. What causes muscle weakness? A review can be found here
3. What causes hypotonia? A review can be found here
4. What causes peripheral neuropathy? A review can be found here

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Myasthenia Gravis and Neuromuscular Disorders.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Della Marina A, Trippe H, Lutz S, Schara U. Juvenile myasthenia gravis: recommendations for diagnostic approaches and treatment. Neuropediatrics. 2014;45(2):75-83. doi:10.1055/s-0033-1364181

Jastrzebska A, Jastrzebski M, Ryniewicz B, Kostera-Pruszczyk A. Treatment outcome in juvenile-onset myasthenia gravis. Muscle Nerve. 2019;59(5):549-554. doi:10.1002/mus.26445

Peragallo JH. Pediatric Myasthenia Gravis. Semin Pediatr Neurol. 2017;24(2):116-121. doi:10.1016/j.spen.2017.04.003

Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

When Does Executive Function Happen?

Patient Presentation
A 7-year-old male came to clinic with his mother who was an elementary school teacher for his health supervision visit. He had just gotten a cast off his right arm that was caused by being thrown off a bike he rode down a rock-covered ravine. He had broken the other arm flying off a swing set the previous year. He was doing well overall in school, with his siblings and loved playing soccer. He didn’t have attentional problems in general. His mother called him a daredevil as he seemed to have little fear and said, “He hasn’t got the executive function yet to really stop himself. He actually plans some of this thinking it would be fun like riding down the ravine. He just needs some more time to get some more common sense.”

The pertinent physical exam showed a healthy boy with growth parameters at 25% and normal vital signs. He had multiple scratches and bruises on the extensor surfaces of his arms and legs. The rest of his examination was normal.

The diagnosis of a healthy boy was made. The pediatrician discussed how important it was to use safety equipment for his activities, and to really stop and think if it is a good idea to do some things. “I’m glad you were wearing your helmet, but riding down the ravine probably wasn’t the best idea. How about if you stop and ask yourself, if you think your mother or teacher would think it would be good idea before you do it. If you think they would approve, then you’re probably okay. If you think they might get upset then ask them first,” the pediatrician offered. The mother and the pediatrician laughed together as they both realized that probably only more time would help his insight.

Executive function (EF) is the “…cognitive processes that facilitate goal-directed action and problem solving, such as working memory, cognitive flexibility, inhibitory control, and self-monitoring. EF skills are important for the conscious, effortful control of thoughts and behaviors.”

EF allow us to inhibit ingrained behaviors that could get us into trouble, e.g. shouting out in a classroom, driving the wrong-way down a one-way street. EF also allow us to pay attention to what is meaningful for the time and situation e.g. academic testing, paying attention to traffic and not the radio while driving. Additionally, EF allows us to organize our thoughts in the face of distraction, complexity, and stress, e.g. sports games, figuring out how to drive to a new location, being aware of personal items when walking down a crowded street to avoid theft.

EF are primarily housed in the prefrontal cortex yet have numerous other brain areas that support these skills such as the cingulate cortex, parietal cortex, basal ganglia, amygdala and hippocampus.

EF is distinct from Theory of Mind (ToM) which “is the social-cognitive ability to understand human actions in terms of the psychological states that motivate behavior, such as beliefs, emotions, desires and intentions.” EF and ToM are linked as they seem to develop together and are the neurobiological basis for this shared development. However the exact linking of the two is still not truly understood. Does the motivation influence the behavior, or does the behavior and it consequences influence the motivation, or is it truly a reciprocal/meshed relationship?

Learning Point

EF milestone development includes:

  • 0-2 years
    • Episodic mental representations
    • Episodic thoughts and goals – past experiences and actions are intertwined with current actions
    • Example – put blocks of same shape in a shape-sorter toy
  • 2-4 years
    • Emerging realistic mental representations
    • Automatic self-based actions or instruction-based actions
    • Example – bathing a toy doll or following simple request such as “bring toy here.”
  • 4-6 years
    • Integration of realistic mental representations
    • Control of attentional focus, can shift between actions depending on instructions/situation
    • Example – transitioning between activities, “It’s time to eat now, then you can play.”
  • 6-8 years
    • Emerging rule-based mental representations
    • Rule-based action plans
    • Example – turn-taking in games
  • 8-11 years
    • Integration of rule-based mental representations
    • Flexible shifting across conceptual systems
    • Example – apply rules to mathematical concepts (multiple or divide numbers before adding and subtracting), shift between memory and inference such as “Before, we went to the ice cream store by driving this way, if mom turns down the next road, she probably is taking us to get ice cream.”
  • 11-13 years
    • Emerging principle-based mental representation
    • Automation of conceptual systems
    • Example – Complex everyday plans such as homework planning, organizing errands in local order of execution
  • 14-16 years
    • Integrated principles
    • Inferential relevance of mental representations
    • Example – long-term planning such as life after high school

Questions for Further Discussion
1. What other examples of executive function can you give for the different developmental stages above?
2. What is in the differential diagnosis of attentional problems? A review can be found here
3. What are indications for referral to a psychologist or psychiatrist?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Child Development and Teen Development.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Blair C. Educating executive function. Wiley Interdiscip Rev Cogn Sci. 2017;8(1-2). doi:10.1002/wcs.1403

Demetriou A, Makris N, Kazi S, Spanoudis G, Shayer M. The developmental trinity of mind: Cognizance, executive control, and reasoning. Wiley Interdiscip Rev Cogn Sci. 2018;9(4):e1461. doi:10.1002/wcs.1461

Wade M, Prime H, Jenkins JM, Yeates KO, Williams T, Lee K. On the relation between theory of mind and executive functioning: A developmental cognitive neuroscience perspective. Psychon Bull Rev. 2018;25(6):2119-2140. doi:10.3758/s13423-018-1459-0

Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

What Do You Do For Breast Milk Jaundice?

Patient Presentation
A 28-day-old female came to clinic for her 1-month health maintenance examination. She and her family were doing well with good breastfeeding every 2.5 – 3 hours, and good urine and stooling output. She was regarding her parents’ faces, cooing, following lights and responding to sounds.

The past medical history showed a 39 4/7 week infant born to a G2P2 A+ Caucasian mother with a normal pregnancy and delivery. Her newborn screening test was also normal. She had gone home on time and at 10 days of life had regained her birth weight. At that time she was still somewhat jaundiced but her total transdermal bilirubin was decreasing and was 11.1 mg/dL. The family history was significant for Parkinson’s disease in a great grandparent, and skin cancer in the paternal grandmother.

The pertinent physical exam revealed her to be gaining weight at 29 grams/day, and all of her growth parameters were at the 75%. Her examination was normal including no hepatosplenomegaly, except for continued jaundice that was noticed over her lower abdomen. The diagnosis of a healthy breastfeeding infant with prolonged jaundice was made.

The laboratory evaluation showed her transdermal bilirubin to be 11.5 mg/dL. Because of the continued hyperbilirubinemia, the pediatrician reviewed her chart confirming her previous history, noting that she had already had one direct bilirubin of 0.6 mg/dL but the patient did not have a previous Coombs test. The father had blood type A+. The pediatrician did an additional work-up of a complete blood count with smear and reticulocytes, and another direct bilirubin. All of these were normal for age and did not reveal evidence of hemolysis. The diagnosis of breast milk jaundice was made and the infant was discharged. The patient’s clinical course at her 2-month check up showed much less jaundice but her transdermal level was still 9.8 mg/dL. At a 3-month appointment, her jaundice had resolved and her transdermal level was normal.

Almost all infants in the first few days of life have some elevation of their bilirubin because of the various physiologic changes they undergo in the transition to extra-uterine life. This is a common problem managed by many different inpatient and outpatient healthcare providers. This hyperbilirubinemia is usually unconjugated and resolves in the first 1-2 weeks of life. However, when it does not resolve, health care providers have 3 general paths to follow when considering a cause: inadequate breast milk intake, an underlying organic cause or breast milk jaundice.

Inadequate breastfeeding is not uncommon and can be caused by many problems such as inadequate maternal education/experience or support, difficulties with latching or sucking, inadequate number of breastfeeding attempts or duration, or maternal fatigue or health issues. It is uncommon that inadequate milk supply is the cause but it does occur for some women. Often after the first 1-2 weeks, once breastfeeding appears to be established, the mother may increase the breastfeeding intervals slightly which decreases the number of attempts/day. For most healthy infants this is not a problem. For other infants especially younger ones, decreasing the number of feeds by 1-2/day may cause inadequate breastfeeding, slower weight gain and possibly prolonged hyperbilirubinemia. Some people term prolonged hyperbilirubinemia due to inadequate breastfeeding as breastfeeding jaundice. Some authors note “…this term is misleading and should be avoided. We refer to this clinical entity as ‘not enough breastfeeding jaundice,’… because the underlying aetiology is not breast feeding itself but its converse, lack of adequate breast feeding.”

Breast milk jaundice is a benign condition of prolonged unconjugated hyperbilirubinemia (usually considered less than 12 mg/dL total bilirubin) in a healthy breastfeeding infant. Infants have normal weight gain, normal urine and stooling patterns and normal physical examination. It can persist for up to 12 weeks before resolution and usually does not need treatment. In the past, breastfeeding cessation and feeding with formula was used by some as a confirmatory test, but it is not necessary nor recommended for infants suspected of having breast milk jaundice. Breast milk jaundice is considered a diagnosis of exclusion after reasonable clinical and laboratory evaluations are made. The exact cause of breast milk jaundice is not known but most likely one or more of factors within the breast milk itself and genetic variations in the newborn.

Causes of prolonged unconjugated hyperbilirubinemia include:

  • Not enough breastfeeding
  • Breast milk jaundice
  • Hemolysis
    • ABO or Rh incompatibility
    • Bruising
    • Cephalohematoma
    • Polycythemia
    • Red blood cell membrane defects – G6PD deficiency, pyruvate kinase deficiency, etc.
    • Red blood cell enzyme defects – hereditary spherocytosis, etc.
  • Metabolic
    • G6PD deficiency
    • Galactosemia
    • Hypothyroidism
  • Bilirubin conjugation
    • Crigler Najjar syndrome
    • Gilbert syndrome
  • Other
    • Undiagnosed conjugated hyperbilirubinemia – biliary atresia, hepatitis
    • Intestinal obstruction
    • Pyloric stenosis
    • Medications

A review of the pathophysiology of hyperbilirubinemia and differential diagnosis of neonatal unconjungated hyperbilirubinemia can be found here

The differential diagnosis of conjugated hyperbilirubinemia can be found here

A brief review of Gilbert’s disease can be found here.

Learning Point
Additional evaluation for breast milk jaundice should be done before this diagnosis is made. A review of the medical records may provide a great deal of information before additional laboratory testing is conducted. Mother’s and infant’s blood types may be known and a Coomb’s test may already have been recorded. A cephalohematoma or bruising may have been noted in the delivery record along with potential risk factors for polycythemia (e.g. twin-twin transfusion, infant of a diabetic mother, etc.). The neonatal screening test covers many metabolic problems but hypothyroidism may need to be tested for again. A direct bilirubin test may have already been recorded too, but some providers will do a second testing out of the early neonatal period to confirm this finding. Most infants are not taking any medications other than Vitamin D but this should be reviewed with the family. If a medication is being taken then determining if there is a risk of hyperbilirubinemia should be done.

Additional testing to determine if hemolysis is occurring should be considered with a complete blood count, reticulocyte count and review of the peripheral blood smear. If these indicate potential hemolysis, appropriate consultation with a hematologist can be considered for advice about potential additional evaluation and/or treatment. Without evidence of hemolysis, most infants can be followed without additional intervention until around 12 weeks of age when breast milk jaundice should resolve. If the hyperbilirubinemia does not resolve then additional consultation with a gastroenterologist or hematologist should be considered. Evaluation for Criglar-Najjar and/or Gilbert Syndrome is often investigated at this time point.

Questions for Further Discussion
1. What are the functions of the liver? A review can be found here
2. What causes hemolytic anemia? A review can be found here

Related Cases

    Disease: Breast Milk Jaundice | Jaundice

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Jaundice

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Bratton S, Stern M. Breast Milk Jaundice. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2019. http://www.ncbi.nlm.nih.gov/books/NBK537334/. Accessed October 21, 2019.

Poddighe D, Castelli L, Marseglia GL, Bruni P. Prolonged, but transient, elevation of liver and biliary function tests in a healthy infant affected with breast milk jaundice. BMJ Case Rep. 2014;2014. doi:10.1136/bcr-2014-204124

Preer GL, Philipp BL. Understanding and managing breast milk jaundice. Arch Dis Child Fetal Neonatal Ed. 2011;96(6):F461-466. doi:10.1136/adc.2010.184416

Tan H-S, Balasubramaniam I-S, HSS A-S, et al. Impact of a standardized protocol for the Management of Prolonged Neonatal Jaundice in a regional setting: an interventional quasi-experimental study. BMC Pediatr. 2019;19. doi:10.1186/s12887-019-1550-3

Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa