Hi Carrie,
Don't confront the doctor just yet. Do some google searches for neonatal
hyperbilirubinemia and various combinations of words like formula +
breastmilk. If you have access to Peds journals, you should be able to find
many articles and you should read the Academy of Breastfeeding Medicine
protocol for jaundice, which can be found on a web search. At the end of my
post I've listed one that I found but couldn't access + don't see a
publication date. Also if you haven't already, you will find it very
informative to study the algorithms from the AAP on when to start
phototherapy for term, preterm, high risk, low risk, intermediate risk
babies. This will give you an idea of what situations are more worrisome
than others.

There is something about formula which appears to get bilirubin conjugated
faster, or there is something in breastmilk which makes bili conjugate
slower (normally, really). All of this is not really a problem for healthy
term babies that are bf well, and have bili levels below about 15 in the
first week. The problem comes in when healthy term babies are not eating
well or not eating often enough, or not getting milk due to low supply or
when preterm babies are affected and who are more vulnerable to bilirubin
encephalopathy at lower bili levels or when pathology is present such as ABO
incompatibility or sepsis, for example.

Now, this is a complicated issue (which I have posted on before, btw, and
those should be in the archives). The management of which often depends on
the doctors comfort level with bf, comfort level with various levels of
bilirubin, comfort level with parent's compliance and followup ability etc.
If one is following a several days old healthy term infant and mother who
needed some early guidance on bf management, and all is well, and the bili
level is under 15, one can just fix/support the bf and continue on. If one
is following a preterm baby whose bili levels are not excessively high, but
who is not feeding very well, and if mother has adequate milk production,
then one can supplement with ebm. The problem comes in when the health care
provider feels the level is too high (often rightly so), or that the
breastmilk itself will make the bili go up, and it's already pretty high, or
the baby is only a day or two old, and likely his bili will go up the next
day or two regardless......

My suggestion is to observe and ask exactly what the doctor thinks is going
on, and rationale for the management chosen, and then possibly throw your 2
cents in where applicable. Like "Dr. Jones, I've been working with Mrs.
Smith, and she was having trouble getting the baby positioned and latched.
We fixed that and the baby is now bf very well. She has a good milk supply.
Since the baby is full term with no risk factors, how would you feel about
having her supplement with her own milk for the next 24 hrs? [stop here or
maybe go on to say] He's 4 days old and still below the level he would need
phototherapy and mother seems to understand really well about feeding him
often and making sure he's pooping." (probably not necessary even to
supplement, but you get the idea of working with the doc).
Well sorry to go on so long about this, it is one of my areas of interest
and luckily at this employment I am blessed to have doctors who manage this
quite well with low intervention. This has not been the case at other places
I have worked, where healthy term babies with levels of 10 were removed from
their mothers and given phototherapy. AARGH!
Laurie Wheeler, RN, MN, IBCLC
Mississippi USA

Breastfeeding, Diet, and Neonatal Hyperbilirubinemia
*Glenn R. Gourley, MD

 **OBJECTIVES*

*After completing this article, readers should be able to:*

Compare and contrast the incidence of hyperbilirubinemia between breastfed and
formula-fed infants throughout the neonatal period and its relationship to
early hospital discharge.
Describe possible reasons for the occurrence of hyperbilirubinemia in
breastfed infants.
Compare and contrast the incidence of hyperbilirubinemia related to
different infant formulas.

Among the many factors related to neonatal hyperbilirubinemia is the
composition of an affected infant's diet. In 1879, Frerichs suggested that
"bad nursing" could "exercise a powerful influence" on neonatal
hyperbilirubinemia. Much has been learned since this suggestion was made.

* **EPIDEMIOLOGY*
Many investigations have documented that the consumption of human milk is
related to neonatal hyperbilirubinemia, including one review of 12 studies
involving more than 8,000 infants in the first week of life and controlled
for factors such as hemolysis to enable comparison of dietary effects alone.
Moderate hyperbilirubinemia (total serum bilirubin [TSB], 205 mcmol/L [12
mg/dL]) was present in 12.9% of the breastfed infants and 4% of the
formula-fed infants (*P*<0.00001). Severe hyperbilirubinemia (TSB, 256 mcmol/L
[15 mg/dL]) was present in 2% of the breastfed infants and 0.3% of the
formula-fed infants (*P*<0.00001). Breastfed infants have higher serum
bilirubin levels on each of the first 5 days of life, and this
hyperbilirubinemia can persist for weeks to months. The association between
feedings of human milk and neonatal hyperbilirubinemia has been reported in
preterm infants fed banked human milk or mixtures of human milk and formula
and among various races.

More recent studies of otherwise healthy newborns have used
noninvasive transcutaneous
devices to assess hyperbilirubinemia daily (Figs. 1[image: Go] and 2[image:
Go] ). These studies agree with earlier conclusions that otherwise healthy
infants exclusively fed human milk will have higher levels of
hyperbilirubinemia than infants who consume formula. The difference begins
to become significant *. . . [Full Text of this
Article<http://neoreviews.aappublications.org/cgi/content/full/neoreviews;1/2/e25>
]*

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