Here is my response to the article on jaundice in the Archives Pediatr
Adolesc Med.

Jack Newman, MD, FRCPC


>To the editor,
>
>I am most concerned about the article by Dr. K.L. Tan in the December issue
>of Arch Pediatr
>Adolesc Med regarding the use of formula in the treatment of jaundice in
>"breastfed" babies.  It is
>true that Dr. Tan suggests that taking the baby off the breast is not
>necessary, an approach which is
>seconded by Dr. DeAngelis in her editorial note.  This is good, because
this
>practice of stopping
>breastfeeding is too common, and unnecessary.  On the one hand this article
>will induce many
>physicians to introduce formula unnecessarily to help treat the jaundice, a
>practice which is already all
>too common as well.  Secondly, it ignores the *real* issue, which is that
>too many physicians and
>nurses working with newborns do not understand that babies are not
>breastfeeding just because they
>have the breast in their mouths and are making sucking motions.
>
>Dr. Tan uses his own data (not available to me), and a study in Pediatrics
>(Maisels MJ, Newman TB,
>Kernicterus in otherwise healthy breastfed term newborns. Pediatrics
>1995;96:730-733) to suggest
>that severe hyperbilirubinemia may occur in breastfed babies.  I do not
>agree, and I do not think the
>article in Pediatrics proves this contention.  Drs. Maisels and Newman, on
>the basis of chart reviews,
>suggest the following sequence: healthy term
>newborn-->breastfeeding-->breastmilk induced
>hyperbilirubinemia of extraordinary levels-->kernicterus as manifested by
>poor feeding etc.  A far
>more likely scenario is: healthy term newborn-->poor feeding-->dehydration
>and
>hyperbilirubinemia-->neurologic sequelae (secondary to dehydration and
>hyperbilirubinemia).  In
>other words, I am not denying the possibility of kernicterus, but the
>assumption that the babies who
>developed kernicterus were "healthy".  They were probably normal at birth,
>though even this is not
>certain, but they were not normal after birth because of poor feeding and
>dehydration.
>
>Dr. Tan implies that the breastfeeding babies were feeding well, because
>they were at the breast
>frequently.  But this is not necessarily so.  A baby can suck and suck
>without getting milk, and it is
>this poor feeding which leads to the increase in bilirubins to higher than
>average levels.  Once the milk
>becomes abundant, of course, the baby does drink more, and the bilirubins
>would drop even without
>phototherapy, though I am not at all suggesting there is *no* role for
>phototherapy in the cases Dr.
>Tan describes.
>
>The real problem with altogether too many studies of breastfeeding,
>particularly in the first few days,
>is that these studies are done without the help and advice of qualified
>lactation specialists who should
>be able to evaluate the adequacy of breastfeeding.  The hyperbilirubinemia
>which Dr. Tan is so
>concerned about, and the terrible cases described in the Pediatrics article
>could have been
>prevented, *if* babies were nursing well from the first hours of life.
>Qualified lactation specialists can
>also help mothers with breastfeeding so that those who are not
breastfeeding
>adequately do
>breastfeed adequately.  Babies do not need a lot of colostrum, but they
need
>*some*.  If they latch
>on to the breast poorly, they cannot get it.
>
>Though statistically, the results of the study show slower response to
>phototherapy amongst breastfed
>babies, from a clinical or management point of view, the differences
>certainly do not seem significant.
>In fact, a baby who is breastfeeding well (shown by *observing the
>breastfeeding*, not by weights
>which can be erroneous and misleading) with a dropping bilirubin does not
>have to stay under the
>lights until a "set" point such as 185 mmol/l.
>
>Dr. Tan also implies that there is a problem in babies remaining visibly
>jaundiced for many weeks
>when they are breastfeeding.  I disagree.  Over years of helping nursing
>mothers and babies, it has
>become obvious to me that *most* exclusively breastfed, well gaining babies
>are visibly jaundiced,
>not only for a few weeks, but sometimes for months, usually just a touch,
>and you have may have to
>make a point of  looking closely for it, but it's there.  This is more
>marked in Chinese babies, as I
>presume the vast majority of patients in Dr. Tan's study were.
>Nevertheless, breastfeeding is the
>physiologic method of infant feeding.  And if breastfed babies (that is,
>babies who are
>breast*feeding*, not just pretending to feed) are usually jaundiced, then
>this should be considered
>normal, not a cause for concern, though, it may occasionally be useful to
>rule out pathologic causes of
>jaundice.  What is not normal is the *hypo*bilirubinemia of the
artificially
>fed baby.
>
>Jack Newman, MD, FRCPC
>Pediatrician (specializing in management of breastfeeding problems)
>