AAP Clinical Practice Guideline AAP Subcommittee on Hyperbilirubinemia. Pediatrics. 2004;114:297–316 Copyright © 2003, Rev 2005 American Academy of Pediatrics  Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation Nomogram for designation of risk in 2840 well newborns at 36 or more weeks’ gestational age with birth weight of 2000 g or more or 35 or more weeks’ gestational age and birth weight of 2500 g or more based on the hour-specific serum bilirubin values.

Jaundice and Breastfeeding  Infants <38 weeks’ gestation and breastfed at higher risk  Systematic assessment on all infants before discharge for the risk of severe hyperbilirubinemia  Provide parents with written and verbal information about newborn jaundice  Provide appropriate follow-up based on the time of discharge and the risk assessment Copyright © 2003, Rev 2005 American Academy of Pediatrics

Management of Breastfeeding Jaundice Increase caloric intake. Increase breastfeeding frequency to 10–12 feedings/day. Increase duration of breastfeeding. Improve latch and positioning. Provide supplements only when medically indicated. Enhance milk production and transfer. Decrease enterohepatic reabsorption. Increase stool output. Lower serum bilirubin. Copyright © 2003, Rev 2005 American Academy of Pediatrics

Breastmilk Jaundice  Definition  Begins after day of life 5–7.  Increased bilirubin reabsorption from intestine.  Lasts several weeks to months. Copyright © 2003, Rev 2005 American Academy of Pediatrics

Breastmilk Jaundice  Definition  Begins after day of life 5–7.  Increased bilirubin reabsorption from intestine.  Lasts several weeks to months.  Management  Avoid interruption of breastfeeding in healthy term babies.  No routine indication for water or formula supplementation.  If bilirubin >20 mg/dL, consider phototherapy.  Rule out other causes of prolonged jaundice. Copyright © 2003, Rev 2005 American Academy of Pediatrics

Nursing Supplementation Copyright © 2003, Rev 2005 American Academy of Pediatrics Illustration by Tony LeTourneau

Milk Expression  Wash hands before manual or hand expression.  Use a good-quality electric pump for regular expression.  Milk storage  Chill as soon as possible.  Refrigerate milk for up to 2 days.  Freeze for longer storage. Copyright © 2003, Rev 2005 American Academy of Pediatrics

Milk Expression Copyright © 2003, Rev 2005 American Academy of Pediatrics Photo © Jane Morton, MD, FAAP Photo © Kay Hoover, MEd, IBCLC

Return to the Workplace or School  Continued breastfeeding is feasible and desirable for mother and infant.  Prepare ahead by discussing with the employer or school personnel.  Delay introduction of bottles until milk supply well established at 3–4 weeks. Copyright © 2003, Rev 2005 American Academy of Pediatrics

Employed Mother  Breaks for feeding/ expressing  Private, clean place to pump  Refrigerator or cooler with ice packs to store and transport milk Workplace Support Copyright © 2003, Rev 2005 American Academy of Pediatrics Illustration by Tony LeTourneau

Adolescents and Breastfeeding  Highly recommended for adolescent mothers.  Prenatal education and postpartum support are essential.  Arrange with school personnel to express milk at school or use on-site child care program, if available.  Maintain healthy diet with adequate calories, 1,300 mg calcium per day, 15 mg iron, and a daily multivitamin. Copyright © 2003, Rev 2005 American Academy of Pediatrics

Breastfeeding and Maternal Illness  Most maternal acute minor illnesses and infections are compatible with breastfeeding.  Breastfed infant receives protective components from mother’s breastmilk.  Interruption of nursing may predispose an infant to an upper respiratory or gastrointestinal tract infection or may increase the risk of severity if an infection occurs. Copyright © 2003, Rev 2005 American Academy of Pediatrics

Breastfeeding and Maternal Illness  A few infections are not felt to be routinely compatible with breastfeeding in the US.  HIV, HTLV-I, HTLV-II  Some infections require temporary cessation.  Lesions on the breast due to active herpes or syphilis  Active, infectious tuberculosis until treatment is initiated  Varicella, if developed 5 days or less before delivery and within 48 hours after delivery AAP Committee on Infectious Diseases, 2003 Copyright © 2003, Rev 2005 American Academy of Pediatrics