Response to: "Decreased Response to Phototherapy for Neonatal Jaundice in
Breast-fed Infants" from the December issue :

The article on phototherapy by Dr. Tan highlights several important issues
for consideration.  While he reports a "decreased response" to phototherapy
 in his breastfed only group, (1) I believe what he is observing is an
interaction between the act of beastfeeding and the results of initiating
phototherapy.  It has been established that mother and baby separation has
a negative effect on breastfeeding (2).  Phototherapy , as it is often
done, requires that the baby be in a nursery or central area where mothers
are only allowed visitation.  Additionally, it gives the baby an
"untouchable" aura resulting in longer intervals between handling.  These
types of mother baby separation interfere with the frequent interactions
needed for effective breastfeeding.  In this article, the group 2 babies
began feeding at 15-60 minute intervals but changed to an average of 3 hour
intervals while undergoing phototherapy.   The author credits this change
to "lactation presumably established" noting that it matched feeding
patterns from birth in the other two groups.

This highlights a second issue, that in the first several days of life,
exclusively breastfeeding infants (especially those with jaundice) need to
be actively feeding more frequently than an average of every 3 hours.  It
also raises the question whether these 34 babies were feeding effectively
from birth.  Jaundice in otherwise healthy breastfeeding babies after 1 day
of age, peaking by 1 week is commonly referred to as breastfeeding
jaundice. This is actually due to needing more breastmilk, not breastmilk
itself, as Dr. DeAngelis' comment would lead one to believe. This situation
is often precipitated by poor milk transfer and infrequent feeding.

Finally, as the likely cause of this jaundice is ineffective breastfeeding,
the proper solution to the problem is not supplementation with formula as
Dr. Tan concludes.  The American Academy of  Pediatrics Work Group on
Breastfeeding indicates that human milk is the preferred feeding for all
infants. (3)  If  supplementation is deemed necessary, the best choice is
expressed breastmilk given at the breast by a supplementation device.  The
benefits of this are threefold: 1. Milk expression, whether by hand or by
pump will serve to increase the mothers' milk supply.  2. Human milk is
nutritionally and immunologically the best food for human babies. 3.
Supplementing at the breast will further stimulate milk production.
Supplementation  with formula holds none of these benefits and in fact is
linked to early breastfeeding termination and a reduction in the
immunologic protection that exclusive breastfeeding affords.(4)

It is to Dr. Tan's credit that he recognizes that breastfeeding should not
be suspended when dealing with hyperbilirubinemia.

Gail S. Hertz, MD, IBCLC
Pediatric Resident
PennState Geisinger Health System Children's Hospital
PO Box 850
Hershey, Pennsylvania 17033

1.      Tan KL. Decreased response to phototherapy for neonatal jaundice in
breast-fed infants. Arch Pediatr Adolesc Med  1998;152:1187-1190.
2.      Cadwell K.  Bilirubin status as an outcome measure in monitoring
adherence to Baby-Friendly breastfeeding policies in hospitals and birthing
centers in the United States.  J Hum Lact  1998;14(3):187-9.
3.      American Academy of Pediatrics, Work Group on Breastfeeding.
Breastfeeding and the use of human milk. Pediatrics 1997;100:1035-9.
4.      Hill PD,Humenick SS, Brennan ML, Woolley D.  Does early supplementation
affect long-term breastfeeding? Clin Pediatr 1997;36(6):345-50.