Jaundice in Breastfed Infant
1
L. M. Gartner, M.D.
ABM Clinical Protocol
Guidelines for Management of Jaundice in the Breastfeeding Infant
Lawrence M. Gartner
PURPOSE
To provide guidance in distinguishing those causes of jaundice in the newborn that are
directly related to breastfeeding from those that are not directly related to breastfeeding.
To guide monitoring of jaundice and bilirubin concentrations and management of these
conditions so as to preserve breastfeeding while protecting the infant from potential risks
of toxicity from hyperbilirubinemia.
To provide a structure for hospital and office procedures for optimal management of
jaundice and hyperbilirubinemia in the breastfed newborn and young infant.
Biologic Basis for Jaundice in the Newborn
The reader is referred to several comprehensive reviews of bilirubin metabolism
and jaundice in the newborn that are listed in the references for a more complete
discussion of the biology and pathobiology of jaundice in the newborn.1,2,3 Although
management of breastfeeding and jaundice varies among the nations, these principles and
recommendations apply universally.
1. Physiologic Jaundice of the Newborn. Hyperbilirubinemia is defined as having a
total serum bilirubin concentration that exceeds 1.5 mg/dl. All newborns have some
degree of unconjugated (indirect-reacting) hyperbilirubinemia compared with the adult
normal of 1.5 mg/dl, due to a combination of increased production of bilirubin from heme
degradation, decreased hepatic uptake and conjugation of bilirubin and increased
intestinal reabsorption of bilirubin.4
2. Hyperbilirubinemia of the Newborn. Since elevated serum bilirubin concentrations
occur in all newborns, it is normal or physiologic to have unconjugated or indirectreacting hyperbilirubinemia. This is known as physiologic hyperbilirubinemia of the
newborn. Approximately one-quarter to one-half of all newborns in the first week of life
will have total serum bilirubin concentrations in excess of 5.0 mg/dl, and those that
exceed 5.0 mg/dl are likely to appear clinically jaundiced.5,6
3. Breastmilk Jaundice. Breastfed infants regularly and with high frequency (two-thirds
or more) have unconjugated hyperbilirubinemia that extends into the second and third
weeks of life and often up to 8 to 12 weeks of life.7,8 In contrast to artificially-fed infants,
approximately half of all breastfed infants may appear slightly to moderately jaundiced in
the second and later weeks of life. This prolongation of physiologic jaundice due to
breastfeeding is known as Breastmilk Jaundice.7 At least two-thirds of transitional and
Jaundice in Breastfed Infant
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L. M. Gartner, M.D.
mature human milk enhances the intestinal absorption of unconjugated bilirubin in rats,
presumably due to an unidentified substance in human milk 7,40 Over time, the jaundice
and elevated serum unconjugated bilirubin declines to normal adult values even while
breastfeeding continues. The rate of decline is highly variable from infant to infant.
4. Abbreviated Hyperbilirubinemia of the Artificially-fed Infant. Artificially-fed infants
have an abbreviated period of physiologic jaundice in which their hyperbilirubinemia
ends at about the 10th or 11th days of life.4
5. Starvation Jaundice of the Newborn. Total serum bilirubin concentrations in the first
five days of life are the same in optimally breastfed and artificially-fed infants.5,9 It is
important to recognize that not all breastfed infants will receive optimal milk intake
during this period. Absence of caloric intake in normal adults, even for as brief a period
as 24 hours and with good hydration, results in a small increase in unconjugated
hyperbilirubinemia of about 1 to 2 mg/dl above the adult normal total serum bilirubin
concentration of 1.5 mg/dl.10,11,12 In newborns, reduced caloric intake below the optimal
intake for age, even without absolute starvation, results in greater increases in serum
unconjugated bilirubin concentrations because normal developmental limitations in
bilirubin metabolism and transport that are already present in the newborn infant.13,14,15
While it is often reported that breastfed infants routinely have increased serum bilirubin
concentrations and greater weight loss during the first five days of life compared with
artificially-fed infants, it is apparent from a number of studies that when breastfeeding is
managed optimally with sufficient frequency of breastfeeding, good positioning and
effective latch, there are no differences in serum bilirubin concentrations during the first
five days of life.5,16 Starvation jaundice of the newborn is more often seen during the first
week of life when breastfeeding is being initiated, but it can occur later in the newborn
period (first 28 days of life) and even into infancy. The mechanism of starvation jaundice
has been shown to be an increase in intestinal absorption of unconjugated bilirubin.
Thus, after the first 5 days of life, starvation further enhances the normally increased
intestinal bilirubin absorption of the breastfed infant, possibly resulting in toxic bilirubin
concentrations.
6. Interaction of Starvation Jaundice and Breastmilk Jaundice. Poor breastfeeding
with inadequate caloric intake during the first days of life increases intestinal bilirubin
absorption due to relative starvation.12,13,14 Poor intake also delays emptying of
meconium, a reservoir of considerable unconjugated bilirubin, and enhances transfer of
bilirubin from meconium into the infant’s circulation.17 This enlarges the circulating
bilirubin pool in the infant, as reflected in higher than normal serum unconjugated
bilirubin concentrations. With a larger bilirubin pool and with gradual maturation of
hepatic bilirubin transport and metabolism, greater amounts of bilirubin will be excreted
by the liver into the intestine.4 With the appearance of mature breastmilk at the end of
the first week of life the intestine is now bathed in the factor that enhances intestinal
bilirubin absorption. If the concentration of bilirubin in the intestine is increased beyond
the normal amount, intestinal bilirubin absorption will also be increased, returning greater
amounts of bilirubin than normal back into the infant’s circulation and increasing serum
unconjugated bilirubin concentrations. This results in abnormally increased serum
Jaundice in Breastfed Infant
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L. M. Gartner, M.D.
unconjugated bilirubin concentrations in the second and third weeks of life, and even
beyond, which can be potentially toxic. This same exaggeration of the bilirubin pool and
delayed, exaggerated serum bilirubin concentrations in the breastfed infant can be seen in
infants with early hemolysis or internal bleeding which increases early bilirubin
production. Optimal breastfeeding which prevents starvation jaundice will mitigate
against the development of late exaggerated serum bilirubin concentrations in both
normal infants and in those with increased bilirubin production.12,13
7. Kernicterus and Bilirubin Encephalopathy. Concern about unconjugated
hyperbilirubinemia derives from the potential risk for a type of brain damage known as
kernicterus or bilirubin encephalopathy when markedly elevated levels of unconjugated
bilirubin exceed the binding capacity of serum albumin and bilirubin crosses the bloodbrain barrier to enter neurons in the basal ganglia and cerebellum.18,19,20,21,22,23 Guidelines
have been developed that provide guidance on management of hyperbilirubinemia to
protect against development of bilirubin encephalopathy, as will be discussed below.3
Management of Jaundice
I. Prevention of Potentially Toxic Serum Bilirubin
Concentrations
While not all exaggerations of unconjugated hyperbilirubinemia in breastfed
infants can be prevented, optimal management of breastfeeding to insure against even
small degrees of starvation can be very effective in preventing the development of
potentially toxic serum bilirubin concentrations.20,24 Prevention is of the greatest
importance because once potentially toxic serum bilirubin concentrations develop,
breastfeeding may be compromised either due to essential management procedures or to
maternal anxiety resulting from the apparent association between breastfeeding and the
child’s severe jaundice. The following measures are recommended to keep serum
bilirubin concentrations in the normal, safe range while maintaining exclusive
breastfeeding:
1. Early Initiation: Initiate breastfeeding as early as possible, preferably in the
first 30 minutes after birth.25,26 Even with infants born by C-Section, breastfeeding can
be started in the first hour.
2. No Feeds Prior to Breastfeeding: Do not offer water, glucose water or
formula prior to the initiation of breastfeeding. It is unnecessary to test the infant’s
ability to swallow or avoid aspiration. Feeding anything prior to the onset of
breastfeeding delays the establishment of good breastfeeding practices by the infant and
delays establishment of adequate milk production, increasing the risk of starvation and
exaggerated hyperbilirubinemia.
3. Optimize Breastfeeding from the Beginning: Assure ideal position and latch
from the outset by have a trained breastfeeding counselor (nurse, lactation consultant,
lactation educator or physician) evaluate position and latch, making whatever
recommendations are needed for correction from the very beginning of breastfeeding or
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L. M. Gartner, M.D.
reassuring the mother that her breastfeeding is going well.27,28 Continuing poor
breastfeeding practices and poor milk transfer prolongs the period of inadequate milk
production and intake.
4. Early Feeding Cues: Teach mother to respond to the earliest cues of infant
hunger, including lip smacking, hand movements toward the mouth, restlessness and
vocalizing.29,30 Infants should be put to the breast before the onset of crying. Crying is a
late sign of hunger and often results in a poor start to the breastfeeding episode.
5. No Supplementation: Breastfeeding infants should not be supplemented with
water, glucose water or formula. (See Section on treatment of hyperbilirubinemia for use
of supplementation in the infant with excessive serum bilirubin concentrations.)
31,32,33,34,35,36
Supplementation with expressed breastmilk, banked human milk, or formula
should be limited to infants with at least one of the following37,38:
1. A clear indication of inadequate intake as defined by weight loss in
excess of 10% after attempts to correct breastfeeding problems.
2. Failure in milk production or transfer adjusted for duration of
breastfeeding and documented by pre- and post feeding weights after attempts to
increase milk production and milk transfer.
3. Evidence of dehydration defined by significant alterations in serum
electrolytes, especially hypernatremia, and/or clinical evidence of significant
dehydration (poor skin turgor, sunken fontanelle, dry mouth, etc.).
6. Avoid Anticipatory Supplementation: Prophylactic supplementation is not
recommended for any breastfeeding infants, including prematures, who are making an
adequate attempt to feed at the breast. In the first 2 days of life, normal breastfeeding
patterns may be irregular with variable intervals of sleep and feeding. This should not be
interpreted as inadequate breastfeeding. Continuous sleep in excess of 4 to 6 hours in the
first few days of life may indicate the need to rouse and stimulate the infant to breastfeed
if prior breastfeeding episodes were infrequent.39 Breastfeeding frequency of 10 to 12
sessions per day is optimal during the first week of life to establish a good milk supply
and minimize jaundice.
II. Treatment of Excessive Hyperbilirubinemia
The following guidelines and recommendations are based on extensive research
and clinical experience. The reader is advised to carefully read and utilize the Clinical
Practice Guideline on Management of Hyperbilirubinemia in the Newborn Infant 35 or
More Weeks of Gestation published in Pediatrics 2004;114:297-316 and obtainable on
the website of the American Academy of Pediatrics
(http://aappolicy.aappublications.org/cgi/content/full/pediatrics;114/ 1/297 – 302)
A. General Principles: When efforts to prevent the rise of serum bilirubin
concentrations into potentially toxic ranges in the breastfed infant have failed, four
treatment options are available: 1) temporary supplementation with special formula; 2)
temporary interruption of breastfeeding and substitution of infant formula; 3)
phototherapy; and 4) exchange transfusion. These management options may be
Jaundice in Breastfed Infant
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L. M. Gartner, M.D.
combined. All of these modes of treatment are compatible with continuation of
breastfeeding. Since the parents may associate breastfeeding with the development of
jaundice requiring special treatment or hospitalization, they may be reluctant to continue
breastfeeding. Health care providers should offer special assistance to these mothers to
insure that they understand the importance of continuing breastfeeding and know how to
maintain their milk supply if temporary interruption is necessary.
B. Guidelines: Hyperbilirubinemia which has risen to levels requiring treatment
is very specifically defined in the AAP Clinical Practice Guideline on Management of
Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation (Figures 2 and
3).3 These guidelines apply to the breastfed infant as well as the artificially-fed infant.
There is no basis for allowing serum bilirubin levels in the breastfed infant to rise above
the limits defined in this document, even when the apparent cause of the
hyperbilirubinemia is either breastmilk jaundice or starvation. In some cases in which
serum bilirubin concentrations reach levels requiring specific therapy in breastfed infants,
an underlying pathologic cause is responsible and can be diagnosed, including starvation.
It is rare that well managed breastfeeding alone will result in elevation of bilirubin
sufficient to require specific treatment.
Hyperbilirubinemia which is below the recommended level for specific treatment
should not be treated.
Total serum bilirubin concentrations are utilized in the guidelines for treatment;
only total serum bilirubin concentrations should be used in applying these guidelines.3
Direct-reacting bilirubin concentrations should not be subtracted from the total. Indirectreacting (unconjugated) bilirubin levels should not be used in applying the guidelines.
C. Treatment Options
1. Supplementation of Breastfeeding: Cow’s milk based formulas have
been shown to inhibit the intestinal absorption of bilirubin.40 Therefore,
supplementation of breastfeeding with small amounts of infant formula can be used
to lower serum bilirubin levels in breastfeeding infants.37 Hydrolyzed protein
formulas (elemental formulas) have been shown to be more effective than standard
infant formulas in preventing intestinal absorption of bilirubin.41 Since these
hydrolyzed formulas are less likely to induce milk allergy or intolerance and will be
viewed by the parents as other than “switching to formula, they are preferred.
Supplementation can be started when the serum bilirubin concentration is the same
as that recommended for initiation of phototherapy (figure 2), with appropriate risk
adjustments as one would for phototherapy. Frequent monitoring of bilirubin levels
with serum or transcutaneous measurements should be undertaken. If
supplementation fails to reduce bilirubin levels or the levels continue to rise, other
methods of treatment must be considered.
Supplementation of breastfeeding can be achieved by administering one ounce
of formula by cup or use of a nursing supplementer device simultaneously with
each breastfeeding. Excessive amounts of formula should be avoided so as to
maintain frequent breastfeeding and preserve maternal milk production at a high
level. If the mother is not producing adequate milk or the diagnosis is starvation
jaundice, then larger quantities of formula should be offered to insure adequate
Jaundice in Breastfed Infant
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L. M. Gartner, M.D.
caloric intake. Supplementation can be discontinued when bilirubin levels have
declined to approximately 5 mg/dl below the serum bilirubin concentration
indication for phototherapy (figure 2).
2. Temporary Interruption of Breastfeeding: Interruption of
breastfeeding for 24 to 48 hours with full formula feeding will generally lower
serum bilirubin concentrations more rapidly than supplementation, especially in the
rare case with extreme exaggeration of breastmilk jaundice. A decline to one-half
of the serum bilirubin concentration is not unusual in this period of time, especially
in infants more than five days of age with classic breastmilk jaundice.6 In infants
less than 5 days of age, interruption of breastfeeding with substitution of formula
may not be as effective as the use of phototherapy.42 As with supplementation, the
guidelines for initiation of phototherapy (Figure 2) should be used to determine the
level of bilirubin for the start of temporary interruption of breastfeeding. Risk
factor adjustments of serum bilirubin concentrations for the start of this therapy
should be used as they would be for phototherapy. The use of protein hydrolyzed
formula is recommended for its greater efficacy.41 With temporary interruption of
breastfeeding it is even more important to maintain maternal milk production by
teaching mother to effectively and frequently express milk manually or by pump.
The infant needs to return to a good supply of milk when breastfeeding resumes or
starvation will result in a return of higher serum bilirubin concentrations. If
temporary interruption fails to promptly reduce bilirubin concentrations or bilirubin
levels continue to rise, then phototherapy and exchange transfusion need to be
considered.
3. Phototherapy: Phototherapy can be used while continuing full
breastfeeding or it can be combined with either supplementation or temporary
interruption of breastfeeding.3,43 The guidelines for initiation and application of
phototherapy are clearly defined, along with risk category adjustments in Figure 2.
When serum bilirubin concentrations have already exceeded the phototherapy
indication level, especially when rising rapidly, it is best to start phototherapy and
not rely only on supplementation or temporary interruption of breastfeeding alone,
since these will be slower in achieving the desired reduction.42 Phototherapy is best
done in the hospital and in the mother’s room so that breastfeeding can be
continued. Interruption of phototherapy for durations of up to 30 minutes to permit
breastfeeding without eye patches does not alter the effectiveness of the treatment.
Although phototherapy increases insensible water loss to a small degree,
breastfeeding and formula-feeding infants under phototherapy do not require
intravenous fluids unless the infant is clinically dehydrated, hypernatremic or
unable to ingest adequate milk. Unneeded intravenous fluids may inhibit thirst and
diminish oral intake.
Breastfeeding infants who require readmission for phototherapy are best
admitted to a hospital unit in which the mother can also reside so that breastfeeding
can continue without interruption, if that is the desired treatment.
Home phototherapy is possible, but discouraged, especially for infants with risk
factors.3 Home phototherapy may be appropriate for the rare infant with breastmilk
Jaundice in Breastfed Infant
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L. M. Gartner, M.D.
jaundice who requires phototherapy in the second or third weeks of life.
Phototherapy can be discontinued when the serum bilirubin concentration has
declined to one-half of the indication level for exchange transfusion, which for most
otherwise normal breastfed infants more than 96 hours old is 12.5 mg/dl.
4. Exchange Transfusion: If any of the three previous treatments fail to
keep the total serum bilirubin concentration below the exchange transfusion
indication levels (Figure 3), exchange transfusion should be instituted as rapidly as
possible.3 In addition, any infant with signs of impending or developing bilirubin
toxicity, regardless of serum bilirubin concentration, requires immediate exchange
transfusion.3 These signs include high pitched cry, rigidity of extremities, fever,
opisthotonic posture, and seizures. Every minute counts in reducing the serum
bilirubin concentration if permanent disabilities are to be avoided or minimized.
Breastfeeding need not be interrupted in advance of the start of exchange
transfusions because the volume of milk remaining in the stomach is very small due
to rapid emptying of human milk.44 Breastfeeding can be resumed immediately
after the conclusion of the exchange transfusion.
D. Post-Treatment Follow-up and Evaluation: Infants who have had any of the
above treatments for excessive hyperbilirubinemia need to be carefully followed with
repeat serum bilirubin determinations and support of breastfeeding since suboptimal
breastmilk intake may result in recurrence of starvation hyperbilirubinemia.
Encouragement to continue breastfeeding is of the greatest importance since most
of the parents of these infants will be fearful that continued breastfeeding may result in
more jaundice or other problems. They can be reassured that this not the case. Even the
rare infants with breastmilk jaundice who required treatment will not have sufficient rise
in bilirubin with continued breastfeeding to require further intervention.6
Summary and Conclusions
Jaundice and hyperbilirubinemia are normal and expected aspects of newborn
development. Breastfeeding is also a normal and expected aspect of infancy and
childhood. Managing the confluence of jaundice and breastfeeding in a physiologic and
supportive manner to ensure optimal health, growth and development of the infant is the
responsibility of all health care providers. A complete understanding of normal and
abnormal states of both bilirubin and breastfeeding is essential if optimal care is to be
provided and the best outcome achieved for the child. These guidelines provide a
template for this management, but it remains with the health care providers to use these
guidelines with judgment and to adjust the guidelines to the individual needs of each
child.
References:
1
Gartner LM, Herschel M. Jaundice and breastfeeding. Ped Clin North Amer 2001;48:389-399.
Gartner, LM. Hyperbilirubinemia and Breastfeeding. In Hartmann PE, Hale TW, editors. Textbook on
Lactation. Pharmasoft Publishing, Amarillo, Texas, 2007.
2
Jaundice in Breastfed Infant
3
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L. M. Gartner, M.D.
American Academy of Pediatrics, Clinical Practice Guideline. Management of hyperbilirubinemia in the
newborn infant 35 or more week of gestation. Pediatrics 2004;114:297-316.
4
Gartner LM, Lee KS, Vaisman S et al. Development of bilirubin transport and metabolism in the newborn
rhesus monkey. J Pediatr 1977;90:513-531.
5
Bertini, G,Dani C,Trochin M,Rubaltelli F. Is breastfeeding really favoring early neonatal jaundice?
Pediatrics 2001;107:www.pediatrics.org/cgi/content/full/107/3/e41.
6
Engle WD, Jackson, GL, Sendelbach D, et al. Assessment of a transcutaneous device in the evaluation of
neonatal hyperbilirubinemia in a primarily Hispanic population. Pediatrics 2002;110:61-67.
7
Gartner LM, Arias IM. Studies of prolonged neonatal jaundice in the breastfed infant. J Pediatr
1966;68:54-66.
8
Alonso EM, Whitington PF, Whitington SH et al. Enterohepatic circulation of nonconjugated bilirubin in
rats fed with human milk. J Pediatr 1991;118:425-430.
9
Dahms, B., Krausse, A., Gartner, L.M., Klain, D., Soodalter, J. and Auld, P. Breast Feeding and Bilirubin
During the First Four Days of Life. J Pediatr 1973;.83:1049-1054.
10
Bloomer JR, Barrett PV, Rodkey FL et al. Studies of the mechanism of fasting hyperbilirubinemia.
Gastroenterology 1971;61:479-.
11
White GL jr., Nelson JA, Pedersen DM et al. Fasting and gender (and altitude?) influence reference
intervals for serum bilirubin in healthy adults. Clin Chem 1981;27:1140-2.
12
Whiter DI, Gollan JL. Mechanisms and significance of fasting and dietary hyperbilirubinemia. Semin
Liver Dis 1983;3:42-51.
13
De Carvalho M, Klauis MH, Merkatz RB. Frequency of breast-feeding and serum bilirubin
concentration. Am J Dis Child 1982;136:737-8
14
Yamauchi Y, Yamanouchi I. Breast-feeding frequency during the first 24 hours after birth in full-term
neonates. Pediatrics 1990;86:171-5.
15
Wu PYK, Hodgman JE, Kirkpatrick BV et al. Metabolic Aspects of Phototherapy. NICHD Randomized,
Controlled Trial of Phototherapy for Neonatal Hyperbilirubinemia. Pediatrics 1985;75:427-433.
16
Maisels MJ, Gifford K. Normal serum bilirubin levels in the newborn and the effect of breast-feeding.
Pediatrics 1986;78:837-43.
17
Brodersen R, Hermann IS. Intestinal reabsorption of unconjugated bilirubin: A possible contributing
factor in neonatal jaundice. Lancet 1963;1:1242,
18
Volpe JJ. Neurology of the Newborn. 4th Ed. Philadelphia: WB Saudners 2001.
19
Van Praagh R. Diagnosis of kernicterus in the neonatal period. Pediatrics 1961;28:870-6
20
Harris M, Bernbaum J, Polin J et al. Developmental follow-up of breastfed term and near-term infants
with marked hyperbilirubinemia. Pediatrics 2001;107:1075-80
21
Cashore WJ. Kernicterus and bilirubin encephalopathy. Sem Liver Dis 1988;8:163-7.
22
Brodersen R. Bilirubin transport in the newborn infant, reviewed with relation to kernicterus. J Pediatr
1980;96:349-56.
23
Wennberg RP, Hance AJ. Experimental bilirubin encephalopathy: importance of total bilirubin, protein
binding and blood-brain barrier. Ped Res 1986;20:789-92.
24
Maisels MJ, Newman TB. Kernicterus in otherwise halthy breast-fed term newborns. Pediatrics
1995;96:730-733.
25
Righard L, Alade MO. Effect of delivery room routine on success of first breast-feed. Lancet
1990;336:1105-1107
26
Mikiel-Kostyra K, Mazur J, Boltruszko I. Effect of early skin-to-skin contact after delivery on duration
of breastfeeding: a prospective cohort study. Acta Paediatr 2002;91:1301-1306.
27
Riordan J, Bibb D, Miller M, et al. Predicting breastfeeding duration using the LATCH breastfeeding
assessment tool. J Hum Lact 2001;17:20-23.
28
Hall RT, Mercer AM, Teasley SL et al. A breast-feeding assessment score to evaluate the risk for
cessation of breast-feeding by 7 to 10 days of age. J Pediatr 2002;141:659-664.
29
Gunther M. Instinct and the nursing couple. Lancet 1955;1:575-578.
30
Klaus MH. The frequency of suckling. A neglected but essential ingredient of breast-feeding. Obstet
Gyncol Clin North Amer 1987;14:623-633.
31
DeCarvalho M, Holl M, Harvey D. Effects of water supplementation on physiologic jaundice in breastfed infants. Arch Dis Child 1981;56:568-569
Jaundice in Breastfed Infant
32
9
L. M. Gartner, M.D.
Nicoll A, Ginsburg R, Tripp JH. Supplementary feeding and jaundice in newborns. Acta Paediatr Scand
1982;71:759-761
33
Ahn CH, MacLean WC Jr. Growth of the exclusively breast-fed infant. Am J Clin Nutr 1980:33:183192.
34
Brown KH, Dewey KG, Allen LH. Complementary feeding of young children in developing countries:
A review of current scientific knowledge. Publication No. WHO/NUT/98.1. Geneva, Switzerland: World
Health Organization; 1998.
35
Heinig MJ, Nommensen LA, Peterson JM, et al. Intake and growth of breast-fed and formula-fed infants
in relation to the timing of introduction of complementary foods: the DARLING study. Davis Areas
Research on Lactation. Infant Nutrition and Growth. Acta Pediatr 1993;82:999-1006.
36
Butte NF, Lopez-Alarcon MG, Garza C. Nutrient adequacy of exclusive breastfeeding for the term infant
during the first six months of life. Geneva, Switzerland: World Health Organization 2002.
37
Academy of Breastfeeding Medicine, Clinical Protocol Number 3: Hospital Guidelines for the Use of
Supplementary Feedings in the Healthy Term Breastfed Neonate. http://www.bfmed.org/acefiles/protocol/supplementation.pdf
38
Powers NG, Slusser W. Breastfeeding update. 2: Clinical lactation management. Pediatrics in Review
1997;147-161.
39
American Academy of Pediatrics. Breastfeeding and the Use of Human Milk. Pediatr 2005;115:496506.
40
Gartner LM, Lee KS, Moscioni AD. Effect of milk feeding on intestinal bilirubin absorption in the rat. J
Pediatr 1983;103:464-471.
41
Gourley GR, Kreamer B, Arend R. The effect of diet on feces and jaundice during the first 3 weeks of
life. Gastroenter 1992;103:660-7.
42
Martinez, JC, Maisels, MJ, Otheguy, L et al. Hyperbilirubinemia in the breast-fed newborn: A controlled
trial of four interventions. Pediatrics 1993;91:470-473.
43
Gartner LM, Lee KS. Jaundice in the breastfed infant. Clinics in Perinatol 1999;26:431-445
44
Newell SJ. Enteral feeding of the micropremie. Clinics in Perinatology 2000;27:221-34