aap clinical practice guideline

1. AAP Clinical Practice Guideline Recently published guidelines of the American Academy of Pediatrics Subcommittee on Hyperbilirubinemia provide guidance to health care professionals evaluating and managing infants with jaundice or risk factors for developing jaundice. The guidelines stress that successful breastfeeding should be promoted and supported. Nursery protocols that allow for the identification of jaundice are recommended. The guidelines indicate that all infants who become clinically jaundiced in the first 24 hours of life should have a serum bilirubin or transcutaneous bilirubin level measured. All bilirubin levels should be interpreted based on the infant�s age in hours and used to predict risk of the infant developing clinically significant levels of hyperbilirubinemia. Objective measurement of bilirubin was encouraged instead of visual estimation. The guidelines provide specific recommendations for initiation of phototherapy or exchange transfusion based on the age of the infant in hours. Recently published guidelines of the American Academy of Pediatrics Subcommittee on Hyperbilirubinemia provide guidance to health care professionals evaluating and managing infants with jaundice or risk factors for developing jaundice. The guidelines stress that successful breastfeeding should be promoted and supported. Nursery protocols that allow for the identification of jaundice are recommended. The guidelines indicate that all infants who become clinically jaundiced in the first 24 hours of life should have a serum bilirubin or transcutaneous bilirubin level measured. All bilirubin levels should be interpreted based on the infant�s age in hours and used to predict risk of the infant developing clinically significant levels of hyperbilirubinemia. Objective measurement of bilirubin was encouraged instead of visual estimation. The guidelines provide specific recommendations for initiation of phototherapy or exchange transfusion based on the age of the infant in hours.

2. 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 Due to increasing reports of bilirubin encephalopathy as breastfeeding rates have increased, all health care professionals should be vigilant in evaluating infants for jaundice. Infants less than 38 weeks should be considered at higher risk and should be closely monitored. Follow-up evaluation is important for all breastfed infants, particularly those with an early hospital discharge.Due to increasing reports of bilirubin encephalopathy as breastfeeding rates have increased, all health care professionals should be vigilant in evaluating infants for jaundice. Infants less than 38 weeks should be considered at higher risk and should be closely monitored. Follow-up evaluation is important for all breastfed infants, particularly those with an early hospital discharge.

3. 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. Breastfeeding jaundice is managed by increasing the frequency and duration of breastfeeding to increase breastmilk ingestion and improve caloric consumption. This increases the stool output, decreases the enterohepatic reabsorption of bilirubin, and helps to lower the serum bilirubin.Breastfeeding jaundice is managed by increasing the frequency and duration of breastfeeding to increase breastmilk ingestion and improve caloric consumption. This increases the stool output, decreases the enterohepatic reabsorption of bilirubin, and helps to lower the serum bilirubin.

4. Breastmilk Jaundice Definition Begins after day of life 5�7. Increased bilirubin reabsorption from intestine. Lasts several weeks to months. Breastmilk jaundice often occurs as an extension of the normal physiologic jaundice of the newborn, beginning after days 5 to 7. It may last weeks to months and has been related to increased reabsorption of bilirubin from the breastfed infant�s intestine. Babies with breastmilk jaundice should be feeding well, be gaining weight, be thriving, and have an elevated total serum bilirubin, but should not have an elevated direct bilirubin fraction or abnormal liver enzymes. Breastmilk jaundice often occurs as an extension of the normal physiologic jaundice of the newborn, beginning after days 5 to 7. It may last weeks to months and has been related to increased reabsorption of bilirubin from the breastfed infant�s intestine. Babies with breastmilk jaundice should be feeding well, be gaining weight, be thriving, and have an elevated total serum bilirubin, but should not have an elevated direct bilirubin fraction or abnormal liver enzymes.

5. 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. Breastmilk jaundice can be managed in a variety of ways. Breastfeeding can be continued, with the bilirubin followed periodically until it normalizes. If the bilirubin exceeds 20 mg/dL, phototherapy should be considered. Other options that may be considered include temporarily supplementing with casein hydrolysate formula or temporarily interrupting nursing and feeding casein hydrolysate formula. Casein hydrolysate formula has been shown to be more effective in inhibiting intestinal bilirubin absorption. It also is less allergenic and a special formula, indicating to the mother that the infant did not need regular formula to handle the problem. If nursing is interrupted for any reason, the mother should be instructed to express her milk frequently to maintain her milk supply. Use of a nursing supplementer or other methods of alternative feeding with a cup, syringe, or gavage tube may help to prevent the infant from developing nipple confusion, if supplements are indicated. Infants with prolonged jaundice should be evaluated for other causes of jaundice, such as ongoing hemolysis due to blood type or group incompatibility, glucose-6-phosphate dehydrogenase (G-6-PD) deficiency, hypothyroidism, extrahepatic biliary atresia, genetic conditions, and intrinsic liver disease.Breastmilk jaundice can be managed in a variety of ways. Breastfeeding can be continued, with the bilirubin followed periodically until it normalizes. If the bilirubin exceeds 20 mg/dL, phototherapy should be considered. Other options that may be considered include temporarily supplementing with casein hydrolysate formula or temporarily interrupting nursing and feeding casein hydrolysate formula. Casein hydrolysate formula has been shown to be more effective in inhibiting intestinal bilirubin absorption. It also is less allergenic and a special formula, indicating to the mother that the infant did not need regular formula to handle the problem. If nursing is interrupted for any reason, the mother should be instructed to express her milk frequently to maintain her milk supply. Use of a nursing supplementer or other methods of alternative feeding with a cup, syringe, or gavage tube may help to prevent the infant from developing nipple confusion, if supplements are indicated. Infants with prolonged jaundice should be evaluated for other causes of jaundice, such as ongoing hemolysis due to blood type or group incompatibility, glucose-6-phosphate dehydrogenase (G-6-PD) deficiency, hypothyroidism, extrahepatic biliary atresia, genetic conditions, and intrinsic liver disease.

6. Nursing Supplementation When supplements are indicated, the use of a nursing supplementer or other methods of alternative feeding with a cup, syringe, or gavage tube may help to prevent the infant from developing nipple confusion or nipple preference. With this method, the supplemental feeding, either expressed breastmilk or infant formula, is placed in the container with a small tube taped in place so it extends just beyond mother�s nipple. As the infant nurses at the breast, the infant also receives the supplement. This method of feeding also can be used to reestablish a milk supply after weaning or induce a milk supply in the case of an adoptive infant. When supplements are indicated, the use of a nursing supplementer or other methods of alternative feeding with a cup, syringe, or gavage tube may help to prevent the infant from developing nipple confusion or nipple preference. With this method, the supplemental feeding, either expressed breastmilk or infant formula, is placed in the container with a small tube taped in place so it extends just beyond mother�s nipple. As the infant nurses at the breast, the infant also receives the supplement. This method of feeding also can be used to reestablish a milk supply after weaning or induce a milk supply in the case of an adoptive infant.

7. 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. If a mother is separated from her infant because of premature birth, maternal or infant illness, or her return to work or school, she should be taught to express her milk so that she can maintain a milk supply and continue to provide her infant with milk. Hand expression or a manual pump is effective for occasional expression. For regular expression because of mother�s return to work or school or to express milk for a premature infant who remains hospitalized or is unable to breastfeed directly, a good-quality electric breast pump is desirable. Expressed milk can be stored in a clean container in the refrigerator for up to 2 days. For longer storage, the milk can be placed toward the back of the freezer, not on the door. Stored milk should be dated and, if it is held at the workplace, carefully labeled.If a mother is separated from her infant because of premature birth, maternal or infant illness, or her return to work or school, she should be taught to express her milk so that she can maintain a milk supply and continue to provide her infant with milk. Hand expression or a manual pump is effective for occasional expression. For regular expression because of mother�s return to work or school or to express milk for a premature infant who remains hospitalized or is unable to breastfeed directly, a good-quality electric breast pump is desirable. Expressed milk can be stored in a clean container in the refrigerator for up to 2 days. For longer storage, the milk can be placed toward the back of the freezer, not on the door. Stored milk should be dated and, if it is held at the workplace, carefully labeled.

8. The mother on the left is demonstrating hand expression, which is done after gentle massage of the breasts by compressing the area of the lactiferous sinuses while pushing toward the chest wall. Many mothers become very adept at hand expression. For prolonged or regular periods of milk expression, a hospital-grade pump, which can be rented or purchased, is desirable. Pumping is most effective and efficient when both breasts are expressed at the same time, as demonstrated on the right.The mother on the left is demonstrating hand expression, which is done after gentle massage of the breasts by compressing the area of the lactiferous sinuses while pushing toward the chest wall. Many mothers become very adept at hand expression. For prolonged or regular periods of milk expression, a hospital-grade pump, which can be rented or purchased, is desirable. Pumping is most effective and efficient when both breasts are expressed at the same time, as demonstrated on the right.

9. 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. When the mother plans to return to work or school after delivery, she should be encouraged to breastfeed and options for continued breastfeeding after resuming employment should be discussed. Ideally, plans for returning to work and breastfeeding should be discussed with the employer prior to maternity leave. It is best to practice exclusive breastfeeding for at least the first 3 to 4 weeks to establish a good milk supply. After that time, bottles usually can be introduced without difficulty. Someone other than the breastfeeding mother may be more successful at getting the infant to accept the bottle. Continued breastfeeding allows the mother to have periods of closeness and relaxation with the baby after the mother�s schedule becomes more hectic. When the mother plans to return to work or school after delivery, she should be encouraged to breastfeed and options for continued breastfeeding after resuming employment should be discussed. Ideally, plans for returning to work and breastfeeding should be discussed with the employer prior to maternity leave. It is best to practice exclusive breastfeeding for at least the first 3 to 4 weeks to establish a good milk supply. After that time, bottles usually can be introduced without difficulty. Someone other than the breastfeeding mother may be more successful at getting the infant to accept the bottle. Continued breastfeeding allows the mother to have periods of closeness and relaxation with the baby after the mother�s schedule becomes more hectic.

10. Employed Mother Breaks for feeding/expressing Private, clean place to pump Refrigerator or cooler with ice packs to store and transport milk After returning to work, many mothers continue exclusive breastfeeding/breastmilk feeding, while other mothers breastfeed when they are with the baby and provide formula when they are not. For the baby older than 6 months, solids may be fed in the mother�s absence. Plans for lactation should be discussed with the employer prior to returning to work so that adequate breaks and location for milk expression and storage are arranged. Some companies provide pumps, breastfeeding rooms, and even lactation specialists to assist their employees in maintaining lactation. After returning to work, many mothers continue exclusive breastfeeding/breastmilk feeding, while other mothers breastfeed when they are with the baby and provide formula when they are not. For the baby older than 6 months, solids may be fed in the mother�s absence. Plans for lactation should be discussed with the employer prior to returning to work so that adequate breaks and location for milk expression and storage are arranged. Some companies provide pumps, breastfeeding rooms, and even lactation specialists to assist their employees in maintaining lactation.

11. 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. Not all new mothers are as prepared and equipped for motherhood. Teen mothers may need extra community support. Adolescent births continue at a high rate in the United States. With good support, adolescent mothers are capable of establishing and maintaining a good milk supply while establishing a close and nurturing relationship with their infants. Many high schools are providing assistance to teenage mothers, and community programs often are in place to make sure that the mother continues her education and is able to obtain basic infant supplies. A reasonable diet; adequate fluids, calories, and protein; and a multi-vitamin supplement, with calcium from dietary sources or a supplement, will help to protect the nutritional status of the lactating adolescent.Not all new mothers are as prepared and equipped for motherhood. Teen mothers may need extra community support. Adolescent births continue at a high rate in the United States. With good support, adolescent mothers are capable of establishing and maintaining a good milk supply while establishing a close and nurturing relationship with their infants. Many high schools are providing assistance to teenage mothers, and community programs often are in place to make sure that the mother continues her education and is able to obtain basic infant supplies. A reasonable diet; adequate fluids, calories, and protein; and a multi-vitamin supplement, with calcium from dietary sources or a supplement, will help to protect the nutritional status of the lactating adolescent.

12. 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. Most maternal illnesses are compatible with continued breastfeeding. Breastfeeding is especially desirable during times of maternal or infant illness, so that the infant can receive the important immunologic components and protective factors from the 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.Most maternal illnesses are compatible with continued breastfeeding. Breastfeeding is especially desirable during times of maternal or infant illness, so that the infant can receive the important immunologic components and protective factors from the 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.

13. 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 When the mother is human immunodeficiency virus (HIV)-positive or is known to be infected with human T-lymphotropic virus type I (HTLV-I) or human T-lymphotropic virus type II (HTLV-II), breastfeeding is not recommended by the American Academy of Pediatrics or the Centers for Disease Control and Prevention in the United States. For recommen-dations outside the United States, contact the appropriate government health authority or the World Health Organization. A few infections involving the breast itself, such as active herpes or syphilis, varicella, or active infectious tuberculosis, require temporary cessation of breastfeeding. The usual recommendation with varicella is to separate the infant from the mother until the mother�s lesions are all crusted and to give Varicella-Zoster Immune Globulin (VZIG) to the infant. Mothers may continue to breastfeed with most other infections, including maternal breast infections, as long as the mother is being adequately treated. When the mother is human immunodeficiency virus (HIV)-positive or is known to be infected with human T-lymphotropic virus type I (HTLV-I) or human T-lymphotropic virus type II (HTLV-II), breastfeeding is not recommended by the American Academy of Pediatrics or the Centers for Disease Control and Prevention in the United States. For recommen-dations outside the United States, contact the appropriate government health authority or the World Health Organization. A few infections involving the breast itself, such as active herpes or syphilis, varicella, or active infectious tuberculosis, require temporary cessation of breastfeeding. The usual recommendation with varicella is to separate the infant from the mother until the mother�s lesions are all crusted and to give Varicella-Zoster Immune Globulin (VZIG) to the infant. Mothers may continue to breastfeed with most other infections, including maternal breast infections, as long as the mother is being adequately treated.