“Safe & Healthy Beginnings (SHB),” a resource toolkit for hospitals and physicians was released in January 2009 as part of a larger American Academy of Pediatrics (AAP) initiative titled, the Quality Improvement Innovation Network (QuIIN).  QuIIN is a joint effort of the AAP and the Center for Health Care Quality at Cincinnati Children’s Hospital Medical Center.

The SHB toolkit reflects the latest research regarding jaundice and highlights three key aspects of the AAP hyperbilirubinemia clinical practice guideline:

1. Assessment of Hyperbilirubinemia (severe jaundice)
2. Breastfeeding Support
3. Coordination of Care

The kit is intended for newborn nursery staff, pediatric primary care providers, and parents to improve the quality of newborn care.

Among the materials in the toolkit are:

• Safe & Healthy Beginnings Fact Sheet
• Risk factors for Development of Severe Hyperbilirubinemia
• Phototherapy Guidelines for Newborns 35 or More Weeks Gestation
• Booklet for Parents on Breastfeeding
• Brochure for Parents on Jaundice
• Sample Newborn Nursery Inventory
• Sample Hospital Breastfeeding Policy for Newborns
• Suggested Questions for Clinicians to Assess Breastfeeding in Primary Care Practice
• Sample Letter from Hospital to Primary Care Physician Regarding Newborn Follow-up

It’s important to note that Breastfeeding is not listed as a risk factor for jaundice rather, breastfeeding that is not going well is among the conditions “which require more attention for jaundice.”  The same risk applies when formula-feeding is not going well.  When babies feed poorly they have fewer stools. Bilirubin, the substance that causes jaundice, is excreted through the stool. When the stool remains in the gastrointestinal tract, the bilirubin is reabsorbed into the baby’s blood increasing the risk for severe jaundice.

Before any decision can be made about treatment strategies, clinicians must first identify the type and cause(s) of jaundice.

• What is the gestational age, post-birth age, and health of the baby?
• Does the baby have an underlying medical condition?
• Is there a blood incompatibility?
• Is the mother’s milk production inadequate?
• Is the baby able to achieve an effective latch and adequately transfer milk?
• Are there breastfeeding routines in place that limit the frequency of feeds or restrict the length of feeds?

These and other questions need to be answered before an individualized care plan can be implemented.

Supplementation with formula
In 1997, Giovanna Bertini and colleagues conducted a study to determine whether there was a relationship between type of feeding and incidence of neonatal jaundice in the first week of life. The results of their study, published in the March 2001 issue of Pediatrics under the title, “Is Breastfeeding Really Favoring Early Neonatal Jaundice?” confirmed that underfeeding plays a role in the development of hyperbilirubinemia, but breastfeeding per se does not seem related to the increased incidence of jaundice. However, the researchers did identify a small subpopulation of breastfed infants with higher serum bibrubin levels, and concluded that these infants, when inadequately fed, could be at higher risk for severe hyperbilirubinemia. (While breast milk jaundice may explain the elevated bilirubin levels, the cause of breast milk jaundice remains unclear.)

While Bertini does not recommend routine supplementation, he does say, “In our nursery, the attending neonatologist commonly prescribed supplementary formula if certain parameters applied (birth weight less than 2,500 grams, weight loss greater than 4 percent after day one, 8 percent after day two, or 10 percent after day three).”

Parents and health professionals agree that all babies need to be adequately fed. Where the disagreement arises is over how best to achieve that goal. The need to establish guidelines for quality newborn care is why Safe & Healthy Beginnings was launched. But nowhere in the SHB toolkit is any mention made of routine formula supplementation. Moreover, numerous references are made to “ensuring that newborns who are exclusively breastfed are feeding at least 8 to 12 times per day” and that each feeding is documented (time and intake) along with output (stools and urinations).

Because formula is not risk-free, routine formula supplementation should be avoided unless there is a true medical indication. If the newborn assessment shows that supplementation is necessary, and a mother’s own milk or donor milk is not available, then formula may be the appropriate option, but formula should always be a last choice rather than a first choice and certainly not a routine choice.