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Neonatal Jaundice &  Breast-Feeding Dr Elizabeth V á rady Consultant  Neonatologist, IBCLC Tawam Hospital
NEONATAL JAUNDICE Incidence 2  of  3 full term newborns
Relation of  Incidence of  Jaundice  & Breastfeeding Jaundice occurs more frequently  in breast-fed infants   compared to ...
Relation of  Incidence of  jaundice & Breast-feeding >50%  of all breast-fed neonates have  exaggerated and prolonged  unc...
Why the concern about jaundice? <ul><li>Bilirubin is a cell toxin   -  if excessive , </li></ul><ul><li>causing tissue nec...
Acute Kernicterus 1984-2000   Johnson et al J.Pediatr. 2002:140:396 <ul><li>80 infants reported in literature/person/litig...
Can kernicterus occur in a healthy breastfed infant?
Kernicterus in Healthy Breastfed Term Infants   Maisels, J.Pediatrics 1995;96:730 <ul><li>Criteria </li></ul><ul><li>>  37...
Risk of being readmitted for Px 30000 discharges from WB nursery - 4.2/1000 readmitted   Maisels,Pediatrics,1998 3.2 LOS<7...
NEONATAL  JAUNDICE A/  PHYSIOLOGIC  use  instead DEVELOPMENTAL -higher Bilirubin (B)  production -higher B absorption - ...
Neonatal bile pigment metabolism
Neonatal bile pigment metabolism
Pathologic Jaundice A/ Predominantly  Indirect / Unconjugated <ul><li>Increased RBC destruction </li></ul><ul><li>Isoimmun...
PATHOLOGIC JAUNDICE B/Predominantly Conjugated/Direct   <ul><li>In early infancy 60-80% of all cases </li></ul><ul><li>Neo...
Management of Jaundice in  term & near-term infants more complex than in the pre-terms   <ul><li>WHY? </li></ul><ul><li>Sh...
Why kernicterus reappeared? <ul><li>Short hospital stay </li></ul><ul><li>Decreased concern about B toxicity </li></ul><ul...
Root Causes   MaiselsNeoprep 2003     Major contributors to cases of kernicterus <ul><li>Failure to evaluate jaundice in t...
Root Causes  MaiselsNeoprep 2003    Major contributors to cases of kernicterus <ul><li>Failure to establish standing nurse...
WHO IS JAUNDICED? <ul><li>AAP: Measure TSB  if the jaundice is  </li></ul><ul><li>“ clinically significant  by medical jud...
Dermal zones  &  Total Serum Bilirubin ( TSB) Levels “ Kramer Scheme” <ul><li>Dermal Zone   Mean SBR </li></ul><ul><li>mg/...
Physical Exam of NB for Jaundice  Pressure Blanching  on forehead,    mucous membranes of lower jaw   sternum
 
“ NORMAL”  SERUM BILIRUBIN LEVELS? Total Serum Bilirubin (TSB)  SMOOTHED CURVE  from studies in diverse populations  Expec...
Total Serum Bilirubin
TSB - Smoothed Curve <ul><li>>95% - evaluation &  FU </li></ul><ul><li>approaching 95% -close FU </li></ul><ul><li><50% -m...
Zones of risk for  pathologic hyperbilirubinaemia   based on hour specific  pre-discharge bilirubin levels in healthy term...
Zones of Risk
A/  High Risk Zone >95% Probability of Disease 2/5
B/Upper Intermediate Risk Zone  75-95% Probability of Disease 1/8
C/Lower Intermediate Risk Zone  40-75% Probability of Disease 1/46
D/Low Risk Zone < 40th % Probability of Disease  0 (only if term)
Population of  healthy term and near-term infants at risk for kernicterus   1.2 %   of  them having >20 mg%=>340 umol/L TS...
Incidence of severe  hyperbilirubinaemia in term and near term infants 0  -0.032%  1:10000 TSB >99.99%  >30mg/dl 0.16%  1:...
Common  Family & Obstetric Risk  Factors  for   Non-haemolytic  Hyperbilirubinaemia  in Healthy  Term &  Near-term infants...
Common  Neonatal Risk Factors for  Non-haemolytic Hyperbilirubinaemia  in Healthy Term and Near-term Infants <ul><li>Gesta...
Guidelines for Initial Evaluation  and Follow Up of Jaundice  in  Apparently Healthy  Term & Near-Term Infants Klaus & Fan...
I.Onset of Jaundice in first 24 hrs 1/Clinical evaluation + TSB 2/Blood group (ABO, Rh) Direct Coombs test CBC Smear for r...
II.Onset of jaundice 24-72 h 1. Clinical Evaluation 2. Assess cephalo-caudal distribution  Transcutaneous B (TcB), if  NA,...
Additional Laboratory Evaluation of the Jaundiced  T & Near-T Infant 1/ Indications   Suspicion of  haemolytic  disease or...
Additional Laboratory Evaluation of the Jaundiced T. & Near-T. Infant 1. Indications   1a/ Ethnic origin compatible with  ...
Additional Laboratory Evaluation of the Jaundiced T. & Near-T infant <ul><li>1. Indication :  Jaundice beyond 3 wk of age ...
Additional Laboratory Evaluation of the Jaundiced T &  Near-Term Infant Klaus & Fanaroff, 2001 <ul><li>1.  Indication   : ...
ASSOCIATION  between    BREAST-FEEDING & JAUNDICE  <ul><li>EARLY JAUNDICE WHILE BREASTFEEDING </li></ul><ul><li>Synonyms <...
Early Jaundice While Breastfeeding <ul><li>Occurs: 2-5 days of age Transient: 10 days </li></ul><ul><li>More common in  pr...
Cause of  Early Breastfeeding Jaundice Cause associated with  poor feeding practice   and not with any change in milk  com...
What Problems may lead to  “Not Enough BM” Jaundice <ul><li>Maternal factors – intrapartum </li></ul><ul><li>Anaesthesia /...
What Problems may lead to  “Not Enough BM “Jaundice <ul><li>Maternal factors - postpartum </li></ul><ul><li>Lack of proper...
What Problems may lead to “Not Enough BM” Jaundice <ul><li>Breast feeding management problems </li></ul><ul><li>Delayed Fe...
Why on demand breastfeeding on day 1 decreases the incidence of early jaundice <ul><li>Earlier passage  of  meconium </li>...
What Problems may lead to  Not Enough BM jaundice <ul><li>Neonatal Factors   </li></ul><ul><li>related to ineffective suck...
Late Onset Jaundice <ul><li>Peak: 9-15th day  </li></ul><ul><li>May persist  > one month,  up to 16 wks </li></ul><ul><li>...
Typical patterns of TSB during neonatal jaundice  Gartner 2001   X:FT healthy,Asian  :FT healthy , artificially fed    :...
Treatment Options for Jaundiced Breast-Fed Infants 1. OBSERVE 2. Continue breast-feeding (BF)  with increased frequency   ...
Interruption of nursing and feeding with artificial  formula for 1-3 days  in breast-milk jaundice <ul><li>TSB -  promptly...
AAP GUIDELINES 2001 <ul><li>To  avoid  kernicterus </li></ul><ul><li>Keep in mind risk factors </li></ul><ul><li>Outpatien...
IF A NEWBORN IS DISCHERGED AT <36 HOURS,THE BILIRUBIN LEVEL CAN ONLY BE GOING IN ONE DIRECTION UP   Maisels Neoprep 2003
NEWBORN FOLLOW UP  IN 1-2 WEEKS IS ABONDENMENT   Maisels Neoprep 2003
Points to look at  FU visit <ul><li>Weighing  </li></ul><ul><li>Clinical evaluation of jaundice </li></ul><ul><li>>  7% we...
Breastfeeding counselling  3 steps 1. Decide whether the baby is getting  enough milk 2. If not -  try to decide the reaso...
How to decide  whether baby gets enough milk <ul><li>Two reliable signs </li></ul><ul><li>poor weight gain </li></ul><ul><...
How to decide  whether baby gets enough milk <ul><li>Possible signs </li></ul><ul><li>Baby not satisfied after BF </li></u...
How to decide  whether baby gets enough milk <ul><li>Possible signs  – cont. </li></ul><ul><li>Baby has infrequent small s...
REASONS WHY A BABY  MAY NOT GET ENOUGH MILK <ul><li>Breastfeeding factors </li></ul><ul><li>Psychological factors of the m...
Successful breastfeeding counselling results in   prevention of    “not enough  breastmilk jaundice”   increase in  exclus...
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Jaundicel b fsept2004

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Jaundicel b fsept2004

  1. 1. Neonatal Jaundice & Breast-Feeding Dr Elizabeth V á rady Consultant Neonatologist, IBCLC Tawam Hospital
  2. 2. NEONATAL JAUNDICE Incidence 2 of 3 full term newborns
  3. 3. Relation of Incidence of Jaundice & Breastfeeding Jaundice occurs more frequently in breast-fed infants compared to bottle-fed infants
  4. 4. Relation of Incidence of jaundice & Breast-feeding >50% of all breast-fed neonates have exaggerated and prolonged unconjugated hyperbilirubinaemia <1% reach TSB levels that cause concern (>20 mg/dl)
  5. 5. Why the concern about jaundice? <ul><li>Bilirubin is a cell toxin - if excessive , </li></ul><ul><li>causing tissue necrosis </li></ul><ul><li>in brain – kernicterus </li></ul><ul><li>in other organs: </li></ul><ul><li>kidneys, intestines, pancreas </li></ul><ul><li>Kernicterus reappeared </li></ul><ul><li>in developed countries (USA, Europe) </li></ul>
  6. 6. Acute Kernicterus 1984-2000 Johnson et al J.Pediatr. 2002:140:396 <ul><li>80 infants reported in literature/person/litigation </li></ul><ul><li>66 % male </li></ul><ul><li>98 % breastfed </li></ul><ul><li>(2 formula fed were G6PD deficient) </li></ul><ul><li>Discharge age 12-75 hr </li></ul><ul><li>33 % < 37 wk </li></ul>
  7. 7. Can kernicterus occur in a healthy breastfed infant?
  8. 8. Kernicterus in Healthy Breastfed Term Infants Maisels, J.Pediatrics 1995;96:730 <ul><li>Criteria </li></ul><ul><li>> 37 weeks </li></ul><ul><li>No hemolysis </li></ul><ul><li>No jaundice in first 24 hours </li></ul><ul><li>No sepsis </li></ul><ul><li>No cause of hyperbilirubinaemia </li></ul><ul><li>other than breastfeeding </li></ul>
  9. 9. Risk of being readmitted for Px 30000 discharges from WB nursery - 4.2/1000 readmitted Maisels,Pediatrics,1998 3.2 LOS<72 hrs 7.8 Jaundice in nursery 4.2 Breast-feeding 7.5 36-38 wks 13.2 <36 wks ODDS RATIO RISK FACTOR
  10. 10. NEONATAL JAUNDICE A/ PHYSIOLOGIC use instead DEVELOPMENTAL -higher Bilirubin (B) production -higher B absorption -  in B clearance from plasma ( deficiency in ligandin &  activity of UDPGT ) B /PATHOLOGIC
  11. 11. Neonatal bile pigment metabolism
  12. 12. Neonatal bile pigment metabolism
  13. 13. Pathologic Jaundice A/ Predominantly Indirect / Unconjugated <ul><li>Increased RBC destruction </li></ul><ul><li>Isoimmunization </li></ul><ul><li>RBC enzyme /structural defects </li></ul><ul><li>Extravascular blood </li></ul><ul><li>Infection </li></ul><ul><li>Disorders of conjugation </li></ul><ul><li>Disorders of entero-hepatic circulation </li></ul><ul><li>eg. intestinal obstruction </li></ul><ul><li>Miscellaneous - eg. drugs </li></ul>
  14. 14. PATHOLOGIC JAUNDICE B/Predominantly Conjugated/Direct <ul><li>In early infancy 60-80% of all cases </li></ul><ul><li>Neonatal Hepatitis </li></ul><ul><li>Biliary atresia </li></ul><ul><li>EHBA Incidence:1:10-15 000 </li></ul><ul><li>To diagnose before one month of age </li></ul><ul><li>crucial for outcome (duration of survival w/o </li></ul><ul><li>liver transplant) </li></ul><ul><li>jaundice w  Direct B+ pale stool + dark urine </li></ul>
  15. 15. Management of Jaundice in term & near-term infants more complex than in the pre-terms <ul><li>WHY? </li></ul><ul><li>Shorter hospital stay </li></ul><ul><li>Need for outpatient surveillance & Rx </li></ul><ul><li>Occasional extreme hyperbilirubinaemia / </li></ul><ul><li>kernicterus </li></ul>
  16. 16. Why kernicterus reappeared? <ul><li>Short hospital stay </li></ul><ul><li>Decreased concern about B toxicity </li></ul><ul><li>Increased prevalence of breast-feeding </li></ul><ul><li>Desire to minimize laboratory testing </li></ul><ul><li>Inexperience of young professionals on </li></ul><ul><li>appearance of severe jaundice </li></ul>
  17. 17. Root Causes MaiselsNeoprep 2003 Major contributors to cases of kernicterus <ul><li>Failure to evaluate jaundice in the 1 st 24 hrs </li></ul><ul><li>Failure to recognize risk factors </li></ul><ul><li>including GA<38 wks and BF </li></ul><ul><li>Failure to interpret bilirubin levels according to the infants age in hours </li></ul>
  18. 18. Root Causes MaiselsNeoprep 2003 Major contributors to cases of kernicterus <ul><li>Failure to establish standing nursery </li></ul><ul><li>protocol for assessment of jaundice </li></ul><ul><li>Failure to provide timely follow up after hospital discharge </li></ul><ul><li>Underestimation of bilirubin level by visual assessment </li></ul><ul><li>Failure to respond to parental concerns regarding jaundice, poor feeding and changes in newborn behaviour </li></ul>
  19. 19. WHO IS JAUNDICED? <ul><li>AAP: Measure TSB if the jaundice is </li></ul><ul><li>“ clinically significant by medical judgement” </li></ul><ul><li>Problems: </li></ul><ul><li>Ability of clinicians varies </li></ul><ul><li>Clinical significance depends also </li></ul><ul><li>on age (hrs) + postconceptional age </li></ul><ul><li>Universally defined “jaundiced” </li></ul><ul><li>if TSB >12 mg/dl (205 umol/L) </li></ul>
  20. 20. Dermal zones & Total Serum Bilirubin ( TSB) Levels “ Kramer Scheme” <ul><li>Dermal Zone Mean SBR </li></ul><ul><li>mg/dl umol/L </li></ul><ul><li>Head & neck 6 102 </li></ul><ul><li>Trunk to umbilicus 9 154 </li></ul><ul><li>Groin incl. upper thighs 12 205 </li></ul><ul><li>Knees and elbows </li></ul><ul><li>to ankles & wrists 15 256 </li></ul><ul><li>Feet&hands incl. palms&soles >15 >256 </li></ul>
  21. 21. Physical Exam of NB for Jaundice Pressure Blanching  on forehead,  mucous membranes of lower jaw  sternum
  22. 23. “ NORMAL” SERUM BILIRUBIN LEVELS? Total Serum Bilirubin (TSB) SMOOTHED CURVE from studies in diverse populations Expected Velocity in the 1st 96 hrs of life Maisels MJ
  23. 24. Total Serum Bilirubin
  24. 25. TSB - Smoothed Curve <ul><li>>95% - evaluation & FU </li></ul><ul><li>approaching 95% -close FU </li></ul><ul><li><50% -minimal surveillance & FU </li></ul><ul><li>NOTE! Values must be plotted according to infant’s age in hours </li></ul>
  25. 26. Zones of risk for pathologic hyperbilirubinaemia based on hour specific pre-discharge bilirubin levels in healthy term and near-term infants Bhutani, Pediatrics, 1999
  26. 27. Zones of Risk
  27. 28. A/ High Risk Zone >95% Probability of Disease 2/5
  28. 29. B/Upper Intermediate Risk Zone 75-95% Probability of Disease 1/8
  29. 30. C/Lower Intermediate Risk Zone 40-75% Probability of Disease 1/46
  30. 31. D/Low Risk Zone < 40th % Probability of Disease 0 (only if term)
  31. 32. Population of healthy term and near-term infants at risk for kernicterus 1.2 % of them having >20 mg%=>340 umol/L TSB if left unmonitored & untreated
  32. 33. Incidence of severe hyperbilirubinaemia in term and near term infants 0 -0.032% 1:10000 TSB >99.99% >30mg/dl 0.16% 1: 700 TSB >99.9% >25 mg/dl 1 - 2% 1: 50 TSB >98% >20mg/dl 8.1-10% 1: 9 TSB >95% >17mg/dl Incidence Severe hyperbilirubinaemia
  33. 34. Common Family & Obstetric Risk Factors for Non-haemolytic Hyperbilirubinaemia in Healthy Term & Near-term infants <ul><li>Previous jaundiced sibling </li></ul><ul><li>East Asian race </li></ul><ul><li>Oxytocin use in labor </li></ul><ul><li>Macrosomic infant of diabetic mother </li></ul><ul><li>Bruising cephalhaematoma, </li></ul><ul><li>vacuum extraction </li></ul>
  34. 35. Common Neonatal Risk Factors for Non-haemolytic Hyperbilirubinaemia in Healthy Term and Near-term Infants <ul><li>Gestation 35-38 weeks </li></ul><ul><li>Male sex </li></ul><ul><li>Breast-feeding </li></ul><ul><li>Caloric deprivation and larger weight loss </li></ul><ul><li>Visible jaundice before discharge </li></ul><ul><li>G6PD deficiency </li></ul><ul><li>Short hospital stay </li></ul>
  35. 36. Guidelines for Initial Evaluation and Follow Up of Jaundice in Apparently Healthy Term & Near-Term Infants Klaus & Fanaroff In:Care of the High-Risk Neonate Saunders 2001
  36. 37. I.Onset of Jaundice in first 24 hrs 1/Clinical evaluation + TSB 2/Blood group (ABO, Rh) Direct Coombs test CBC Smear for red cell morphology Reticulocyte count 3/Repeat TSB in 4-24 hr
  37. 38. II.Onset of jaundice 24-72 h 1. Clinical Evaluation 2. Assess cephalo-caudal distribution Transcutaneous B (TcB), if NA, TSB 3. Clinical evaluation and TcB or TSB within 24-72 h and repeat as necessary
  38. 39. Additional Laboratory Evaluation of the Jaundiced T & Near-T Infant 1/ Indications Suspicion of haemolytic disease or anaemia (eg. early jaundice, pallor, TSB >8mg/dl=137 umol/L by 24 hr or >13 mg/dl=222 umol/L by 48 h of age) 2. Action Blood type, group & Coombs’ test if not known, CBC and smear, retic.
  39. 40. Additional Laboratory Evaluation of the Jaundiced T. & Near-T. Infant 1. Indications 1a/ Ethnic origin compatible with potential for G6PD deficiency with TSB>15 mg/dl (257 umol/L) 1b/ Any infant with late onset jaundice or TSB > 18 mg/dl (308 umol/L) 2. Action : Measure G6PD
  40. 41. Additional Laboratory Evaluation of the Jaundiced T. & Near-T infant <ul><li>1. Indication : Jaundice beyond 3 wk of age </li></ul><ul><li>2. Action </li></ul><ul><li>Total and direct B level, </li></ul><ul><li>Urine dipstick for B, </li></ul><ul><li>Inspect stools for color, </li></ul><ul><li>Check result of thyroid screen and </li></ul><ul><li>evaluate clinically for hypothyroidism </li></ul>
  41. 42. Additional Laboratory Evaluation of the Jaundiced T & Near-Term Infant Klaus & Fanaroff, 2001 <ul><li>1. Indication : Infant ill </li></ul><ul><li>2. Action </li></ul><ul><li>Total & direct B level, </li></ul><ul><li>urine for reducing substances , </li></ul><ul><li>consider galactosaemia </li></ul><ul><li>and other inborn errors, </li></ul><ul><li>evaluate for sepsis </li></ul>
  42. 43. ASSOCIATION between BREAST-FEEDING & JAUNDICE <ul><li>EARLY JAUNDICE WHILE BREASTFEEDING </li></ul><ul><li>Synonyms </li></ul><ul><li>Breast-feeding jaundice (syndrome) </li></ul><ul><li>“ Not enough breast-milk” jaundice </li></ul><ul><li>LATE –ONSET JAUNDICE </li></ul><ul><li>Synonyms </li></ul><ul><li>Breast milk jaundice </li></ul><ul><li>Breast milk jaundice syndrome </li></ul>
  43. 44. Early Jaundice While Breastfeeding <ul><li>Occurs: 2-5 days of age Transient: 10 days </li></ul><ul><li>More common in primiparas </li></ul><ul><li>History of </li></ul><ul><li>infrequent feeds </li></ul><ul><li>infrequent and delayed stools </li></ul><ul><li>receiving water or dextrose water </li></ul><ul><li>Bilirubin peaks < 15 mg/dl (210 umol/L) </li></ul><ul><li>Exaggeration of physiologic jaundice </li></ul>
  44. 45. Cause of Early Breastfeeding Jaundice Cause associated with poor feeding practice and not with any change in milk composition
  45. 46. What Problems may lead to “Not Enough BM” Jaundice <ul><li>Maternal factors – intrapartum </li></ul><ul><li>Anaesthesia /analgesia </li></ul><ul><li>(including epidural) </li></ul><ul><li>Augmentation /Induction </li></ul><ul><li>Oxytocin use </li></ul><ul><li>Excessive bleeding </li></ul>
  46. 47. What Problems may lead to “Not Enough BM “Jaundice <ul><li>Maternal factors - postpartum </li></ul><ul><li>Lack of proper technique /knowledge </li></ul><ul><li>Breast problems </li></ul><ul><li>previous breast surgery </li></ul><ul><li>sore /cracked / flat /inverted nipples </li></ul><ul><li>engorged breasts </li></ul><ul><li>Tired, stressed mother </li></ul>
  47. 48. What Problems may lead to “Not Enough BM” Jaundice <ul><li>Breast feeding management problems </li></ul><ul><li>Delayed Feeding (mother / baby at risk, staff not keen) </li></ul><ul><li>Limitation of feeding ( infrequent feeding < 8x/day </li></ul><ul><li>limitation of length ) </li></ul><ul><li>Poor latch </li></ul><ul><li>Early use of artificial nipples , Nipple cream </li></ul><ul><li>Supplementation with water, dextrose-water/formula </li></ul><ul><li>Other problems </li></ul><ul><li>No 24 h rooming in, separation of m/b >3 h </li></ul><ul><li>More than 5 visitors/day </li></ul>
  48. 49. Why on demand breastfeeding on day 1 decreases the incidence of early jaundice <ul><li>Earlier passage of meconium </li></ul><ul><li>Lower maximal weight loss </li></ul><ul><li>Breast milk flow established sooner </li></ul><ul><li>Larger volume of milk intake on day 3 </li></ul><ul><li>Yamaouchi (1990) Pediatrics </li></ul>
  49. 50. What Problems may lead to Not Enough BM jaundice <ul><li>Neonatal Factors </li></ul><ul><li>related to ineffective suck </li></ul><ul><li>< 37 wks, </li></ul><ul><li>< 2500 g , >4000 g </li></ul><ul><li>IDM </li></ul><ul><li>low Apgar score </li></ul><ul><li>facial anomaly (eg. cleft lip/palate) </li></ul>
  50. 51. Late Onset Jaundice <ul><li>Peak: 9-15th day </li></ul><ul><li>May persist > one month, up to 16 wks </li></ul><ul><li>All children of a given mother </li></ul><ul><li>Milk volume not a problem </li></ul><ul><li>No supplements </li></ul><ul><li>Normal stooling </li></ul><ul><li>Prolongation of “physiologic jaundice” </li></ul><ul><li>Bilirubin may be >20 mg/dl = >340 umol/L </li></ul><ul><li>Mechanism?  entero-hepatic shunt </li></ul>
  51. 52. Typical patterns of TSB during neonatal jaundice Gartner 2001 X:FT healthy,Asian  :FT healthy , artificially fed  :FT,healthy, breastfed X:FT healthy,Asian  :FT,healthy, breastfed  :FT healthy , artificially fed
  52. 53. Treatment Options for Jaundiced Breast-Fed Infants 1. OBSERVE 2. Continue breast-feeding (BF) with increased frequency r/o haemolysis administer phototherapy (Px) if indicated 3. Supplement BF with formula, (never with dextrose water or water ) with or w/o Px 4. Interrupt BF ??; substitute formula + Px
  53. 54. Interruption of nursing and feeding with artificial formula for 1-3 days in breast-milk jaundice <ul><li>TSB - promptly decreases </li></ul><ul><li>to half or less of the original level </li></ul><ul><li>Resumption of nursing causes </li></ul><ul><li>- small but significant increase of TSB </li></ul><ul><li>by 1-3 mg/dl (17-51 umol/L) </li></ul><ul><li>- or arrest of decline in TSB </li></ul><ul><li>NOT RECOMMENDED AS A ROUTINE PROCEDURE </li></ul>
  54. 55. AAP GUIDELINES 2001 <ul><li>To avoid kernicterus </li></ul><ul><li>Keep in mind risk factors </li></ul><ul><li>Outpatient follow up of </li></ul><ul><li>discharged newborns </li></ul><ul><li>within 3 days </li></ul>
  55. 56. IF A NEWBORN IS DISCHERGED AT <36 HOURS,THE BILIRUBIN LEVEL CAN ONLY BE GOING IN ONE DIRECTION UP Maisels Neoprep 2003
  56. 57. NEWBORN FOLLOW UP IN 1-2 WEEKS IS ABONDENMENT Maisels Neoprep 2003
  57. 58. Points to look at FU visit <ul><li>Weighing </li></ul><ul><li>Clinical evaluation of jaundice </li></ul><ul><li>> 7% weight loss- look for BF problem </li></ul><ul><li>> 10% danger of hypernatraemia </li></ul><ul><li>Physical examination </li></ul><ul><li>Identify infants with </li></ul><ul><li>BF problems and ACT ON IT </li></ul>
  58. 59. Breastfeeding counselling 3 steps 1. Decide whether the baby is getting enough milk 2. If not - try to decide the reason, why 3. Decide, how to help the mother and baby
  59. 60. How to decide whether baby gets enough milk <ul><li>Two reliable signs </li></ul><ul><li>poor weight gain </li></ul><ul><li>passing small amount of </li></ul><ul><li>concentrated urine </li></ul>
  60. 61. How to decide whether baby gets enough milk <ul><li>Possible signs </li></ul><ul><li>Baby not satisfied after BF </li></ul><ul><li>Baby cries often </li></ul><ul><li>Very frequent breastfeeds </li></ul><ul><li>Very long breastfeeds </li></ul><ul><li>Baby refuses to breastfeed </li></ul><ul><li>Baby has hard dry or green stools </li></ul>
  61. 62. How to decide whether baby gets enough milk <ul><li>Possible signs – cont. </li></ul><ul><li>Baby has infrequent small stools </li></ul><ul><li>No milk comes out when mother expresses </li></ul><ul><li>Breasts did not enlarge –during pregnancy </li></ul><ul><li>Milk did not “come in” - after delivery </li></ul>
  62. 63. REASONS WHY A BABY MAY NOT GET ENOUGH MILK <ul><li>Breastfeeding factors </li></ul><ul><li>Psychological factors of the mother </li></ul><ul><li>Physical condition of the mother or baby </li></ul>
  63. 64. Successful breastfeeding counselling results in prevention of “not enough breastmilk jaundice” increase in exclusive breastfeeding rates <ul><li>Sources of support in hospital </li></ul><ul><li>antenatal clinics </li></ul><ul><li>all health care staff dealing with BF mums </li></ul><ul><li>well baby clinic in conjunction with lactation support clinic </li></ul>
  64. 65. Thank You

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