As I promised when I posted my Sweeping up after the Elephant Parade
comment - here's my response letter.
Gail
Gail S. Hertz, MD, IBCLC
Resident, Dept. of Pediatrics
PSGHS Children's Hospital
Hershey PA
[log in to unmask]
response to Gourley GR, Kreamer B, Cohnen M, Kosorok MR. Neonatal Jaundice
and Diet. Arch Pediatr Adolesc Med. 1999;153:184-188]
Nutrition and Jaundice: Hold the Bottle - Keep the Breast
The authors are to be commended for bringing to light so clearly what
physicians familiar with breastfeeding have been aware of for many years.
That is that in the initial week of life there is no statistically
difference in levels of physiologic jaundice between babies given standard
infant formula and babies who are breastfeeding effectively.(1,2)
Gourley et al report this finding with surprise - noting that this must be
due to
babies that had higher bilirubin levels receiving treatment and being
excluded from the study.(1) This is likely so. The reason it has come as
such a surprise is because the medical community for years has been unable
to recognize which babies are breastfeeding effectively - that is which
babies are latched-on correctly, and effectively transferring milk.(3) It
is understandable that this is the case since traditionally, physicians
have received little in the way of formal education in the area of
breastfeeding.(3,4,5)
The AAP offers formula supplementation as one of several options in the
treatment of hyperbilirubinemia -others include observation of the infant
or the initiation of phototherapy without the interruption of
breastfeeding.(6) The task at hand is to determine who actually needs
formula supplementation - this number is far fewer than the sponsors of the
article would lead the reader to believe.
If in the case of a healthy breastfeeding newborn there is an elevation of
bilirubin above what would normally be expected that should be a signal to
evaluate the breastfeeding - looking for correct latch-on, nutritive
sucking, signs of milk transfer (from audible swallowing to stool
production) and frequency and duration of feedings. In addition to this,
investigate the environment - many hospital policies work against the
establishment of a good breastfeeding relationship, among them mother &
baby separation, the routine use of pacifiers, and supplementary and
complimentary feedings.(7)
When supplementation is necessary for the breastfed baby, expressed
breastmilk delivered at the breast is the ideal supplement. Breastmilk is
uniformly recognized as the ideal food for the healthy term infant not only
for its age and species appropriate nutritional value, but also for its
immunological benefits.(8,9) A further benefit is that expressing milk,
and providing this expressed milk at the breast both serve to stimulate the
breast to greater milk production.
It is important to recognize that formula supplementation and especially
the interruption of breastfeeding are not required for the treatment of
jaundice, even in the event of phototherapy.(10)
Gail S. Hertz, MD, IBCLC
Pediatric Resident
PennState Geisinger Health System Childrens Hospital
Mail Code H-085
P.O. Box 850
Hershey, PA 17033
References for Nutrition and Jaundice: Hold the Bottle - Keep the Breast
[response to Gourley GR, Kreamer B, Cohnen M, Kosorok MR. Neonatal Jaundice
and Diet. Arch Pediatr Adolesc Med. 1999;153:184-188]
1. Gourley GR, Kreamer B, Cohnen M, Kosorok MR. Neonatal Jaundice and Diet.
Arch Pediatr Adolesc Med. 1999;153:184-188
2. Melnikow J, Bedinghaus M. Management of Common Breastfeeding Problems.
J Fam Pract 1994;39:56-64
3. Freed GL, Clark SJ, Sorenson JR, Lohr JA, Cefalo AC, Curtis P.
National Assessment of Physicians Breastfeeding Knowledge, Attitudes,
Training, aand Experience. JAMA. 1995;273:472-476
4. Freed GL. Breast-feeding: Time to Teach What We Preach. JAMA.
993;269:243-245
5. Freed GL, Clark SJ, Curtis P. Sorenson JR. Breast-feeding Education and
Practice in Family Medicine. J Fam Pract. 1995;40:263-269
6. American Academy of Pediatrics. Provisional Committee for Quality
Improvement and Subcomittee on Hyperbilirubinemia. Practice Parameter:
Management of Hyperbilirubinemia in the Healthy Term Newborn. Pediatrics
1994;94:558-565
7. Perez-Escamilla R, Pollitt E, Lonnerdal B, Dewey KG. Infant Feeding
Policies in Maternity Wards and Their Effect on Breast-Feeding Success: An
Analytic Overview. Am J Public Health. 1994;84:89-97
8. American Academy of Pediatrics, Work Group on Breastfeeding.
Breastfeeding and the use of human milk. Pediatrics 1997;100:1035-9.
9. Lawrence PB. Breast Milk Best Source of Nutrition for Term and Preterm
Infants. Pediatr Clin North America 1994;41:925-941
10. Tan KL. Decreased response to phototherapy for neonatal jaundice in
breast-fed infants. Arch Pediatr Adolesc Med 1998;152:1187-1190.
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