Newborn jaundice: To supplement or not to supplement, that is the question…

Most of us come into the world red, wrinkly, and hairless. From a purely aesthetic point of view, it’s not a great look – and yet parents usually think their offspring are gorgeous. I don’t know about you, but I sometimes look at newborn photos of my kids and think they had more than a slight resemblance to Benjamin Button (not the hot Brad Pitt version, but the weird old-man baby in the beginning). And I clearly remember thinking both of them were the cutest newborns ever born.
This baby grows up to be Brad Pitt, so it’s all good.
At my daughter’s recent 15-month Well Baby visit, I was utterly shocked to find out that she’d dropped from the 25th to the 10th percentile for weight. I’d actually been joking about how adorably chubby she’d been getting… but as soon as I saw the number on the scale, it was like my eyes refocused; I suddenly thought she looked so scrawny.

When it comes to judging how our kids are doing purely by looking at them, I don’t think parents are really hardwired to be objective.

I’ve been thinking about this the past few days as I’ve researched the topic of neonatal jaundice. Jaundice is a relatively common problem in babies, and therefore is a frequent discussion point in the online parenting world. The other day, I read an online discussion where someone spoke of a baby who sounded pretty darn dehydrated and jaundiced. The advice given was mainly to handle the problem at home or through consulting peer breastfeeding counselors; there were warning about unnecessary interventions which would harm the new breastfeeding relationship. The fear of formula supplementation was palpable. I’m a strong believer in mommy gut and standing up for your parenting philosophies, so on many levels, I understand where these women were coming from.  There are a fair number of overloaded, poorly read-up, and even downright crappy medical professionals out there, and it’s likely that many women are pushed into supplementation when there are other methods which would ultimately achieve the same result. 

However, taking matters into your own hands, or downplaying the seriousness of jaundice, is not the answer. I don’t think a newly postpartum, first-time mom who is already struggling with a poorly-feeding, jaundiced baby is in a position to ascertain her child’s medical status, merely based on appearances. (I don’t recall thinking my son was particularly yellow; in fact, my daughter, who wasn’t jaundiced, looked far more mustard-hued than her brother ever did.) Nor is it fair or noble of us to expect that of her, considering the misinformation and bias running rampant in parenting media. 

Jaundice is a problem which pops up in a number of FFF Friday stories, so I decided it was relevant and necessary to discuss it on this blog, even though it is primarily a breastfeeding mom-related problem (mostly because formula feeding is one of the most common, and most controversial., therapies used to treat it; if you’re already bottle feeding, chances are you’re not freaking out about supplementation). But I know there are some pregnant women and prospective moms who frequent the blog, and you never know who’s going to stumble upon this post in the middle of a frantic newborn night… so this one’s for you. Oh yeah – I figure it’s pretty obvious, but just in case – please note that I am in no way, shape, or form a medical professional (although my dad’s a doctor, so if medical knowledge is passed down genetically I may have an edge up in that respect). The following piece is merely what I’ve gleaned from about 4 days of research and reading, mixed with a little personal knowledge and a hefty dose of opinion – so do with it what you will.

There’s a wide range of opinions on how best to treat jaundice, and much of the debate centers on how affected babies should be fed. But we’ll get to that in a moment – first, let’s define what we’re talking about.

Um, what is frock is ”jaundice”?

Newborn jaundice typically comes in one or some combination of three forms - breastfeeding jaundice, breast milk jaundice, and Type ABO jaundice. In the most general sense, newborn jaundice occurs when your infant has high levels of bilirubin (the substance which is created during the process of blood cell “turnover”) in the blood. The body usually gets rid of the excess bilirubin, but in newborns, this function doesn’t always operate smoothly. That’s because the placenta handles the job while in utero, and once your baby is of the “outside” varietal,  his body might not have completely figured out how to handle this process.  Hence, the mildly yellowish hue so fashionable in the under 48-hours-old set.  Newborn jaundice (also called physiological jaundice) usually resolves in a few days, but sometimes it can be exacerbated by other problems.

One of these problems is a blood type incompatibility between mother and infant, called Type ABO jaundice. My son suffered from this type of jaundice; I am blood Type O, and he’s Type A. When our different types of blood merged during the birth process, my body basically created antibodies against his blood type, which caused a break down of his red blood that made extra bilirubin build up in system. He grew jaundiced. It sucked and I cried… but I digress.

Jaundice also occurs in a different form called “breast milk jaundice“, which MedLine Plus defines as “long-term jaundice in an otherwise healthy, breast-fed baby. It develops after the first week of life and continues up to the sixth week of life… It is probably caused by factors in the breast milk that block certain proteins in the liver that break down bilirubin.” This type of jaundice is typically harmless, and shouldn’t be confused with breastfeeding jaundice, which is caused by insufficient feeding, usually due to poor latching or supply issues, or as some sites somberly state, due to spacing out feedings too far apart or not co-sleeping. The body needs to flush out bilirubin, and it can’t do so if there is inadequate waste output. If a baby isn’t properly hydrated or fed, she can’t poop or pee. So in the case of bilirubin, the saying is actually want not, waste more.

I don’t recall being told much about jaundice in my prenatal classes; it certainly was not discussed in its relation to breastfeeding. This is odd, considering physicians have noted an increase in jaundice since the early 90′s, and severe jaundice is also suspected to be on the rise.


How do I help my baby stop looking like an Oompa Loompa?

Jaundice is treated one of three ways: formula supplementation, phototherapy (having the baby hang out underneath a special kind of light or biliblanket) and exchange transfusions (usually reserved for the most severe cases). The old-school approach to handling newborn jaundice was to supplement with formula; this is one of the quickest and easiest ways to help rid the body of excess bilirubin. You can also use donor milk (just not sugar water or other rehydration substances, which were historically also used as a means of hydration and jaundice therapy), and administer it through a supplemental nursing system (SNS), so “supplementation” doesn’t have to mean formula or bottles. But the new protocol for newborn jaundice is to take more of a wait-and-see approach; the AAP’s position is that breastfeeding should not be interrupted unless absolutely necessary, and that phototherapy be used as a curative measure:


In breastfed infants who require phototherapy, the AAP recommends that, if possible, breastfeeding should be continued (evidence quality C: benefits exceed harms). It is also an option to interrupt temporarily breastfeeding and substitute formula. This can reduce bilirubin levels and/or enhance the efficacy of phototherapy (evidence quality B: benefits exceed harms). In breastfed infants receiving phototherapy, supplementation with expressed breast milk or formula is appropriate if the infant’s intake seems inadequate, weight loss is excessive, or the infant seems dehydrated.
Many internet parenting and breastfeeding sites reassure parents that formula supplementation is hardly ever necessary, and this is probably true in a literal sense; most cases of jaundice will resolve with little intervention, and for those that don’t, there are other treatment options besides formula. But it’s important to know that these other treatments also carry risks, as this review article published on Medscape explains:


Phototherapy is not without disadvantages.. Under fluorescent tubes infants must wear eye protection and are usually separated from the mother in the nursery. Phototherapy may take days to exert the desired effect and, once the phototherapy lights are stopped, rebound hyperbilirubinemia may occur as bilirubin moves from the tissue into the blood. Risk of photooxidative damage to lipoprotein and red blood cell membranes is possible and data suggest that conventional phototherapy (with fluorescent tubes) may decrease postprandial mesenteric blood flow response that may adversely impact the neonatal GI tract.

The same paper also suggests that phototherapy “may not be as successful in decreasing serum bilirubin levels in breastfed infants due to increased enterohepatic circulation; supplementing with formula in addition to phototherapy may be more efficacious in these infants.” This is kind of scary, because is phototherapy doesn’t work… well, that leads me to the next question.


Why do I have to care about jaundice? Maybe I like the color yellow.



The problem with jaundice is that it isn’t a serious problem until it is. Explains the AAP:

Most jaundice is benign, but because of the potential toxicity of bilirubin, newborn infants must be monitored to identify those who might develop severe hyperbilirubinemia and, in rare cases, acute bilirubin encephalopathy or kernicterus. The focus… is to reduce the incidence of severe hyperbilirubinemia and bilirubin encephalopathy while minimizing the risks of unintended harm such as maternal anxiety, decreased breastfeeding, and unnecessary costs or treatment…

Pretty much the only presenting sign of jaundice is a slight yellowing of the skin and eyes. The other symptoms appear when bilirubin levels get dangerously high, putting your baby at risk for brain damage and other serious medical problems. WebMD tell us that the symptoms of jaundice-which-has- gone-too-far (the medical terms for this are “kerincterus” or “acute bilirubin encephalopathy”) include fever, sluggishness, poor feeding, irritability, shrill crying, and arching of the back. Which, except the fever, sounds like how almost every FFF Friday contributor has described her newborn when feeding problems were present. It might be hard to differentiate actual medical risk from normal newborn craziness or other feeding-related issues, and this complicates matters further.


According to the AAP“immediate exchange transfusion is recommended in any infant who is jaundiced and manifests the signs of the intermediate to advanced stages of acute bilirubin encephalopathy (hypertonia, arching, retrocollis, opisthotonos, fever, high-pitched cry) even if the TSB is falling.” TSB is total serum bilirubin, used to determine the severity of jaundice; this means that even if the levels are falling, if your baby is exhibiting these symptoms, doctors may recommend an exchange transfusion. Exchange transfusion is basically a blood transfusion; it can be lifesaving when jaundice becomes dangerous, but it also carries the risk of anemia, air embolism…and even death. These are rare side effects, and even getting to the point that you need an exchange transfusion is relatively rare. But on the other hand, a 2009 study out of the Netherlands found that “all healthy newborns are at potential risk of kernicterus if their newborn jaundice is unmonitored and/or managed inappropriately…we have estimated that 1 in 700 well newborns can develop extreme hyperbilirubinemia; these infants can be at major risk for kernicterus if there are no failsafe, system-based protocols.”

Okay, okay. Say I don’t want an oompaloompa baby. What’s my best plan of action?

First of all, know your risks. The AAP states that “infants at less than 38 weeks’ gestation, particularly those who are breastfed, are at higher risk of developing hyperbilirubinemia and require closer surveillance and monitoring.” This risk increases significantly if you are having feeding problems. A 2009 study published in BMC Pediatrics found that “significant weight loss increase(s) approximately 4 times the risk to develop severe non-hemolytic hyperbilirubinemia in breastfed term infants and it seems to be worst when the cut point to define significant weight loss is higher (infants with a weight loss of 10% have odds 4.2 times higher). Both hyperbilirubinemia and feeding problems persist worldwide despite well-intentioned guidelines for care…” And, if you’re blood type O, you also are at higher risk for Type ABO jaundice. 

Now, here’s the controversial bit: while it’s true that the major medical organizations are no longer recommending formula supplementation as the first line of treatment, you also have a right to know that providing formula or donated milk does improve jaundice.  If your baby is feeding well, it’s probably not necessary to supplement; the phototherapy will most likely do the trick. But if things are not going well with breastfeeding, supplementing – in some way, shape or form – can help.  

I fully comprehend why breastfeeding experts frown on supplementation. Interrupting the breastfeeding relationship in its literal infancy is not a great idea. Let’s look at this another way for a minute, though:

1. If the jaundice is caused or exacerbated by feeding issues, the breastfeeding relationship is already in jeopardy. A hungry, dehydrated, frustrated baby is often not a patient or energetic baby; how would you feel if you had fasted for 2-3 days? (Impressionable Fearless Husband has talked me into juice fasts a few times and I was certainly no fun to be around, nor did I have the “focused energy” all those diet plans promised…) I have yet to meet a woman whose baby wasn’t latching or whose milk didn’t come in, and had the situation spontaneously turn around without first ensuring that the baby was fed. I have, on the other hand, met several women who did supplement, and with some work and a good lactation consultant, got the baby to latch, improved their milk supply, and went on to exclusively breastfeed.

2. Having your baby end up in the hospital under the phototherapy lights, being monitored for a significant amount of time, is counterproductive to a struggling breastfeeding relationship, too. Phototherapy (as well as jaundice) can make a baby too tired to suck efficiently, and having a newly postpartum, stressed out mom is never a good thing, either.  Phototherapy and hospitalization is a necessary evil for many of us, but if the medical authorities admit that supplementation (especially with a hypoallergenic formula, interestingly) will hasten the process, we have a right to know this. Some may still choose to stay away from formula, and I get that – as a vegetarian, I personally would do whatever I could to avoid giving my child a steak. (Although to be honest, if his life depended on it, I would be shoving veal cutlets down his throat. I love baby cows, but I love my son more.) But for those of us who don’t see a little formula as the be-all, end-all to child health, it is important to have this knowledge.

3. I have to wonder if the current recommendations regarding jaundice and supplementation have more to do with the demonization of formula  than actual evidence. As a purely medical issue, we have a cure with no real, quantifiable risks – even if you believe that the risks of formula are 100% proven without a doubt, a small amount of the stuff administered as a one-shot deal hasn’t been proven to cause physiological harm (except for that whole virgin gut theory, about which I’ve yet to see any quality evidence). The breastfeeding relationship has been shown in studies to be affected by early bottle feeding, but this research is also somewhat questionable - the concept of nipple confusion has been questioned by breastfeeding guru Marianne Neifert herself. 

4. There is so much conflicting advice regarding jaundice, and I worry that parents are seeing jaundice prevention/treatment and breastfeeding protection/promotion as competing entities. This is not true, and it is detrimental to all parties involved to think this way. A passage from a physician-penned article about the clinical presentation of jaundice explains the relationship between the two rationally and clearly:

Identifying the infants who become dehydrated secondary to inadequate breastfeeding is also important. These babies need to be identified early and given breastfeeding support and formula supplementation as necessary. Depending on serum bilirubin concentration, neonates with hyperbilirubinemia may become sleepy and feed poorly… The most rapid way to reduce the bilirubin level is to interrupt breastfeeding for 24 hours, feed with formula, and use phototherapy; however, in most infants, interrupting breastfeeding is not necessary or advisable… Detailed history and physical examination showing that the infant is thriving and that lactation is well established are key elements to diagnosis. Breastfed babies should have 3-4 transitional stools and 6-7 wet diapers per day and should have regained birth weight by the end of the second week of life or demonstrate a weight gain of 1 oz/d.




In summary, newborn jaundice is not a serious problem for most babies, which is why all those breastfeeding sites tell you that supplementing isn’t necessary. Some even suggest that breastmilk jaundice is biologically normal, and we just don’t realize it because no one has been breastfeeding much for the past 50 years. But jaundice can become serious, and you might not be able to distinguish serious jaundice from feeding issues or fussy-newborn-ness, so please don’t shy away from medical observation because you’re scared they might make you supplement. Your best bet is to find a breastfeeding-friendly pediatrician prior to giving birth; this way, you’ll know you can trust that the two of you have the same goals in mind. Lactation consultants are not experts in jaundice (unless of course your LC is a really well-trained, thoroughly-researched RN or an MD, which luckily some are), so it’s probably not safe to rely on them or your postpartum doula to judge whether your baby needs medical intervention. 

Chances are no one will force you to supplement, but since you may have the ball thrown into your court,  make sure you are able to weigh your options without misinformation or subtle pressure in any direction. Opting against supplementation is probably not going to lead to terrible medical consequences, unless you’re in a very specific, very serious situation.  On the other hand, a few bottles of formula given in the span of a day or two is not going to put the kibosh on your breastfeeding relationship, and it may get rid of the jaundice faster and with less extreme interventions – which will allow you to get back to forging not only a breastfeeding relationship with your newborn, but a relationship, plain and simple.



Sources

http://www.nlm.nih.gov/medlineplus/ency/article/000995.htm

http://pediatrics.aappublications.org/content/114/1/297.full: 

http://emedicine.medscape.com/article/973629-overview#a0199

http://archpedi.ama-assn.org/cgi/content/abstract/153/2/184 -

http://www.bestforbabes.org/fast-facts-how-to-deal-with-common-breastfeeding-issues

http://www.nejm.org/doi/full/10.1056/NEJMct0708376

http://www.medscape.com/viewarticle/497028_6

http://www.indianpediatrics.net/jan2007/jan-32-36.htm

http://www.biomedcentral.com/1471-2431/9/82

http://www.nature.com/jp/journal/v20/n7/abs/720041

http://onlinelibrary.wiley.com/doi/10.1111/j.1651-2227.2009.01230.x/abstract;jsessionid=B04E9CEFBDE7EFE1F2EEA02364908DDE.d01t01?systemMessage=Wiley+Online+Library+will+be+disrupted+24+March+from+10-14+GMT+%2806-10+EDT%29+for+essential+maintenance

http://www.clinchem.org/content/50/3/477.long

About the Author:

Suzanne Barston is a blogger and author of BOTTLED UP. Fearless Formula Feeder is a blog – and community – dedicated to infant feeding choice, and committed to providing non-judgmental support for all new parents. It exists to protect women from misleading or misrepresented “facts”; essentialist ideals about what mothers should think, feel, or do; government and health authorities who form policy statements based on ambivalent research; and the insidious beast known as Internetus Trolliamus, Mommy Blog Varietal.

Suzanne Barston – who has written posts on Fearless Formula Feeder.


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36 thoughts on “Newborn jaundice: To supplement or not to supplement, that is the question…

  1. Great article! My son was born a month early and was formula fed from birth at the request of the hospital (I'm working on a story to submit to you!), but still ended up jaundice. He was 1 measly point away from having to go under the lights. I suspect it was b/c he had a very hard time eating anything in the beginning. Fortunately things improved and he never had to use the lights.

  2. Quick observation from your friendly LC…. :-)
    Here's some of what I have observed:
    One of the issues with jaundice is that some babies get very sleepy. Some parents do not recognize that things are not “normal” at the breast. Sleepy babies may hang out at the breast – sometimes latch – but are not always transferring milk or “feeding”. This is more like insufficient breastfeeding jaundice. With jaundice, resolving it is a lot to do with *quantity* of milk transferred to get them stooling vs. what is fed to the baby. If there is no breastmilk going into the baby (from breast or pumped), formula is used.
    The ABO babies have things escalate much more rapidly than the normal newborn jaundice and are monitored more carefully – or should be.
    Sometimes babies are re-admitted to our facility for hyperbilirubinemia – and if mom cannot get baby to breastfeed efficiently or is unable to pump adequate amounts yet – formula is needed to get the baby stooling and reduce levels of jaundice along with phototherapy use. We are always called to consult and observe a feed to see what's happening (or not happening), latch check, etc. Sometimes breast compressions with baby at breast feeding can increase milk transfer.
    And a feed cannot take hours or then the phototherapy does not have a chance to do its thing because baby is not under the lights enough.
    Late pre-term babies (34-37 wks) often have a harder time resolving the bilirubin in the first place – and this may be in conjunction with inefficient feeds that we sometimes see in this group of babies.

    Babies ideally are followed up after delivery post-discharge within 24-48 hours to monitor the level and then the ultimate peak of the bilirubin and to catch babies who are in trouble. (Unlike when I had my kids in the 80s and we didn't followup until 2 weeks.)
    I've seen a presentation at a lactation conference on kernicterus and the permanently damaging aspects of it and it is heartbreaking. Very avoidable. While jaundice is a nuisance for the breastfeeding relationship – it should be dealt with appropriately.
    Is there over-intervention at times? Probably. As the LC, we just try to work with the situation, the pediatrician, the parents – to preserve supply and get baby feeding at breast again if that's mom's goal.

  3. Thank you for this. My son had jaundice in part because I was O- and he was O+. We also had a host of latch issues. He wound up on the blanket and started to get better when we were supplementing, but once I stopped got orange again. Once we switched to formula all the way he got better so so fast. It was amazing.

  4. This is so important because I think many don't understand that, from a medical perspective, formula supplementation is often suggested because it serves as a medical intervention. I had my second baby at a military hospital that had record breaking rates of breastfeeding success (hooray!), but they also had almost everyone “supplementing” until their milk came in. It was plain and simple a “medication” to clear the jaundice and feed your baby until your milk came in. Because the staff treated formula as supportive care for breastfeeding moms and not as an evil poison/better choice dichotomy, lots of babies were super healthy and lots of mommies kept nursing long term. i don't see a downside here. As you so well pointed out, the key is not forcing someone to feed a certain way, but keeping babies healthy and well fed while allowing good bonding, bonding that comes in oh so many forms, with new parents.

  5. Having not read the entire post (sorry love you) I will say that I supplemented with formula for both kids and then stuck them both in the window so the sun could metabolize the bilirubin. It's not a path all breastfeeding moms would've chosen, but it worked well for us. Their pedi told us that was the fastest way for their little bodies to metabolize the bilirubin. Whether it was the best way, who knows? But the pedi told us that if the bilirubin reached a certain level, back to the hops they went. I did everything & anything I could to prevent that from happening. Much the same way I did to get Sean out of the nice when he was born.

    I look back at their newborn pics & they were ORANGE like curtains circa 1973.

  6. Thanks, this is informative.

    My boys developed some jaundice (they were 36wk, and pretty small, so it was probably a given), but the pediatrician in the hospital observed them, and said just keep supplementing with formula. Then they saw a pediatrician after we got home, and she said the same thing. She also said that if they didn't get better or got worse over a day or two, that they would need to be brought back to the hospital for phototherapy. So she viewed the phototherapy as a 2nd line of defense for a more serious case. As it was, the babies did not get any worse, and all was well.

    I had said at the hospital that I wanted to try BFing, but the boys were supplemented from Day 1 because 1)they were tiny, and 2)I had no milk until Day 4 and 3)they were trying to prevent/decrease jaundice. It never occurred to me that supplementing could interfere with BFing…I knew there was no breastmilk and they had to eat something, so formula it was. This was no big deal for me.

    We used an SNS to give them the formula, so they thought they were BFing, but even if they had been given bottles, I would have been fine with that. To be completely honest, I couldn't understand why they weren't giving them bottles, and what was up with this stupid SNS thing? It only occurred to me later that I had stated I wanted to BF, and as a result the hospital was obligated to get them fed any way possible EXCEPT for bottles. I probably should have just told the nurses to give bottles. (this hospital would have done that, they weren't militant lactivists)

    Anyway, the ultimate point is: here, at least (n=1), formula supplementation seems to be considered the best and first option. Even knowing I was “BFing”, the hospital staff never even suggested phototherapy as an alternative.

  7. I'm in Canada, and was also told to supplement with formula as a first line of defense. The nurse said they would do phototherapy only if the jaundice reached a certain level. My baby was also dehydrated and excessively losing weight though, I think when the hydration and weight gain are ok, the recommendation for jaundice is to breastfeed more often.

    Jaundice is how we ended up on formula, but not because of the formula. The jaundice made her too sleepy to nurse so we fed her expressed breastmilk (and some formula) from a bottle. She developed a preference for the bottle – I think we probably could have gotten her back on the breast with the help of an LC, but my confidence in breastfeeding was pretty much shot. But my baby made it through the jaundice in good health, and that's the important thing to me.

  8. In my case we were advised to do both supplementation and phototherapy. We did not have to be separated to do phototherapy. They were able to bring an isolette into my hospital room. I was also allowed to stay in the hospital an extra day because she was required to stay the extra day until her bilirubin went down. The only downside re: breastfeeding is we were only allowed to take her out of the isolette every 2-3 hours for 30 minutes to feed her, so we weren't able to do as much skin to skin contact. And they did not give me the option of using an SNS, which I think is key for many women who want to breastfeed. In my case, I had other issues which prevented me from having any supply, so it didn't make much difference. But I don't see why it has to interrupt breastfeeding. Formula can just be added to help flush out the bilirubin, but I think it depends on whether the woman's milk is in or not. It's probably less necessary if she has a full supply of milk, but if she's 2 days postpartum and dry as a bone (like I was) then supplementation would probably be more advised.

  9. Hi, just wanted to point out it's impossible for the mother to be an O blood type and for the baby to be AB….O is recessive, so the mother only has O blood type genes to pass on, making the baby either A or B blood type (from the dad) :)

  10. Phototherapy is recommended for infants based on their blood bili levels regardless of whether or not they receive supplementation in all the practices in my area. If the bili level isn't significantly high and the infant can be discharged, infants at my hospital receive follow up levels, again, regardless of feeding methods. There is an algorithm followed that doesn't vary with feeding method, nor should it, as formula doesn't work for most babies as a magic bullet when severe jaundice develops early on. These infants likely have other physiologic issues that contribute. When jaundice develops after several days of life or continues to rise at that point then the most common cause is that the baby isn't being fed enough which is a problem we see in breastfeeding mothers whose babies aren't transferring milk, and also in formula fed babies whose parents aren't following recommended feeding practices. When the problem is intake, the solution is obvious. Feed the baby. Feed the baby expressed breastmilk, or feed the baby formula.
    When people talk about jaundice they need to differentiate between normal physiologic jaundice and pathologic jaundice. This distinction is important in deciding a course of action. I would be wary of encouraging mothers to supplement with formula as a “preventative” to jaundice. We see plenty of kids under the lights who have never had a drop of breastmilk. Particularly in my own practice which has a large Asian population.
    The question of whether or not the baby is “hungry” and being “starved” in the first few days is an interesting one. Newborns who are healthy, full term and transitioned normally after delivery have brown fat around internal organs that is burned for energy after delivery. The average newborn takes in 2tbs daily of colostrum in the first two days and the volume increases as the mature milk comes in. This isn't surprising when you consider how small the newborns stomach is. When the baby requires supplementation, it doesn't need to be a large quantity. In fact, formula feeding mothers should consider starting small and gradually increasing their babies feeds for the same reason. No one feels good with a distended stomach.
    Board Certified Lactation Consultants as a group are trained, and in my experience believe, that the priority is always that the baby be fed. Babies do poorly at the breast without energy reserves.

  11. All great information, CKmidwife. From what I've been told from various pediatric specialists, weight loss in excess of 10% is considered a potential problem. Anything below that is physiologically normal. My daughter was breastfed for only 2 days, but in that time (when I obviously only had colostrum) she didn't lose much weight at all. My son, on the other hand, lost 12% of his already low birthweight within the first 2 days. So while I agree that babies only need colostrum in those first few days, if they aren't able to latch enough to get whatever the mom is producing, it's an issue. And of course as you stated, this is all under the assumption that the baby was of healthy weight and gestation at birth.

    I'm thinking that I need to get my medical records from my son's birth so that I can figure out how this all went down, but I guess they must have put him under the lights at some point. I just have a vague recollection of them explaining the Coombs thing to me, and offering supplementation as a possible therapy that might allow the jaundice to pass more quickly and thus allow us to leave the hospital. The point I was trying to make was that supplementation could speed up the process and lead to less time in phototherapy/less chance of the jaundice getting to the point of needing more serious intervention – NOT as a magic bullet, by any means.

    Also, not sure if you thought I was implying that formula fed babies don't get jaundice… they do. But they don't worry about supplementation, and that was the point of this post – to examine the meme that there was “no need to supplement” in most cases of jaundice. However, many of the articles and studies I cited did state that most babies treated for jaundice were breastfed rather than fully formula fed, except in cases of ABO incompatibility or certain ethnic groups – so in studies at least, formula feeding does seem to be associated with less chance of jaundice, in general.

  12. Also, interestingly, according to that article, Rh and ABO aren't the only kinds of blood incompatibilities that can cause HDN.

    “Less common causes of HDN include antibodies directed against antigens of the Kell blood group (e.g., anti-K and anti-k), Kidd blood group (e.g., anti-Jka and anti-Jkb), Duffy blood group (e.g., anti-Fya), and MNS and s blood group antibodies. To date, antibodies directed against the P and Lewis blood groups have not been associated with HDN.”

    A quick look on the NIH site pulled up a little more info:

    Kell is apparently the most potent after Rh and ABO as far as causing HDN: http://www.ncbi.nlm.nih.gov/books/NBK2270/

    Kidd generally seems to cause mild cases but there has been at least one severe documented case: http://www.ncbi.nlm.nih.gov/books/NBK2272/

    Duffy is apparently typically mild as well: http://www.ncbi.nlm.nih.gov/books/NBK2271/

    MNS and s blood group incompatibities are apparently uncommon but potentially really severe: http://www.ncbi.nlm.nih.gov/books/NBK2274/

    It just amazes me that more of this information isn't readily available for new moms. ABO incompatibility is not uncommon at all–yet why is the general advice among breastfeeding sites (and particularly peer-support forums) that any supplementation is from the devil and just part of a large conspiracy to booby trap you? This is a potentially fatal condition, and even if you think formula is risky, breast is not always best–any reasonable person ought to see that.

  13. My comment is not about formula feeding in any way but about jaundice. As the mom of a child with liver disease, I just want to recommend that, if a child's jaundice persists more than two weeks after birth, it's important for the pediatrician to draw labs and obtain a total bilirubin, direct bilirubin, and indirect bilirubin. Newborn liver disease can be hard to distinguish from normal physiological jaundice – and those labs help distinguish what is happening when jaundice does not improve after a few weeks. While liver disease in infants is very rare, if a baby does have it, time is of the essence. The difference in outcome for a baby identified at 4 weeks versus 12 weeks is huge – and identifying a baby too late can lead to a liver transplant before age one. I know too many babies, including my own son, who were diagnosed late because medical professionals didn't draw labs or thought the jaundice was just breastfeeding jaundice, etc.

  14. Well, that serves me right for asking my husband what blood type FC is. I couldn't remember and he said “AB”. I'm gonna fix that in the post… He could be A or B, but I'm going to pretend it's A. Whatever it was, it was incompatible with my O! :)

  15. Duh. I'm a moron. You're so right. I honestly don't know if FC is A or B. He's one of them. I asked my husband if he knew while I was writing the post and he said AB. Serves me right for listening to him! I probably should know if my child is type A or B, though, huh?

  16. Good points. Your work seem to be a veryy tricky balancing act sometimes… like when a baby receiving phototherapy has to be under the lights much of the time, needs lots of breast milk and/or formula and has trouble feeding quickly.

  17. Sorry, posted too soon.

    Or whether or not to recommend supplementation to a nursing mom. Besides providing great information, I think your comments promote understanding between medical professionals and parents. :-)

  18. Amen! I'm always grousing to docs about how they treat us as morons and don't give us the reasoning behind blanket recommendations. We women get science, really, and are more likely to follow recommendations if we know the reasoning behind them.

  19. If it makes you feel any better, I was tested (to determine by blood type) when I born, but my parents never got the results. The hospital told them to ask my pediatrician. My pediatrician said to ask the hospital. *headdesk* They gave up. I didn't know my blood type until I had surgery 21 years later. =X

  20. I have heard of several people who used “bili-blankets,” which is basically portable light therapy, and were able to have contact with their babies. These can even be used out of hospital.

  21. My parents told me my whole life my blood type was A. That's what I put on all medical forms. When I did my first trimester bloodwork they told me my blood type was O. My daughter's blood type is also O. It was really strange finding out that I had been told the wrong thing all these years.

  22. I always thought I was A too. I thought both of my parents were. When we started TTC, the fertility doc told us that I was O, and I was stunned. It doesn't really make a difference and I am certain that the doctors knew when I was in the hospital for other reasons, but it was kind of odd that I thought I was one blood type for so long when I clearly wasn't.

  23. Another great and interesting post as always! Sigh…my daughter had high jaundice levels from a bad start at breastfeeding (she was being a sleepy sucker and getting virtually nothing) and only had 2 stools total her first 5 days of life. We ended up back in the hospital under the lights for 2 days and nights. I breastfed every 2 hours day and night crying the whole time thinking my crappy breastfeeding had caused the jaundice. No one ever told me that supplementing with just a little formula could've helped the process. It certainly couldn't have hurt as I ended up pumping and bottle feeding breastmilk to measure her intake anyway. I was stressed and heartbroken and frankly formula could've taken a little off my shoulders just for that short time…if anyone had provided the option and explained the benefits. We ended up on it anyway as ppd killed my breastfeeding chances…but that is another story for some Friday down the road.

  24. Ha, ha, I'm a geneticist so I couldn't let it go. :) I love your blog, it's very well researched. I read a LOT of primary literature before deciding to switch to FF and came to many of the same conclusions as yourself!

  25. I'm a mother of four and severe jaundice with high levels of bilirubin runs in both mine and my husband's family, this is regardless of feeding method and regardless of intake of either formula or breast milk. From what I have seen in my extended family jaundice for us is mainly due to hereditary factors and so supplementing with anything doesn't really help. Yet at first when children in my family are seen by health professionals about them being jaundiced it is always assumed that the jaundice is due to them not getting enough

  26. My was jaundice when he was born. He was getting to a very dangerous level. We switched him to formula and it made the jaundice go away.

  27. Hi I just want to ask regarding my 1 month old baby. He got jaundice from his face, body & eyes before and yellowness of skin lessens but only chin remains yellow. my baby is formula fed since birth. Pls we need your advice.

    Thanks

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