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.