Effects of water supplementation on physiological jaundice in breast-fed babies

Water consumption in 0-6-month-old healthy infants and effective factors: A systematic review

INTRODUCTION

Early introduction of fluids and water affects the duration of breastfeeding, the infant immune system, and possibly causes infants to consume less breast milk, which may, in turn, affect their nutritional and immune status.

OBJECTIVE

This study was carried out to determine water consumption in 0-6-month-old infants and the factors affecting this consumption.

MATERIALS AND METHODS

A literature review was conducted in seven electronic databases (Medline, Web of Science, PubMed, ScienceDirect, Scopus, Cochrane Library, and TÜBITAK) for studies published until April 25, 2022, using the keywords: drinking water, infant, and breastfeeding.

RESULTS

The systematic review included 13 studies. Five studies were crosssectional, three were descriptive and quasi-experimental, and the others were case-control and cohort studies. It was reported in the examined studies that 86.2% of the infants were around 6 weeks old, 44 % of the infants were 1 month old, 77% were 3 months old, 2.5% were 4 months old, and 2.5 to 85% of the infants were around 6 months old when they first consumed water. The prominent reasons for making the infants drink water are the thought that they need it and cultural reasons.

CONCLUSIONS

The exclusive breastfeeding of 0-6-month-old infants is the recommendation of reliable health authorities. Nurses play a key role in implementing this practice. In this systematic review, it was seen that families gave their infants water at varying rates in the 0-6-month period, and the factors affecting this situation were revealed. If nurses determine which factors affect families in terms of the early introduction of fluids, they could be able to plan the necessary education and interventions.

Impact of Saccharomyces boulardii on jaundice in premature infants undergoing phototherapy

OBJECTIVES

To evaluate the therapeutic effect of Saccharomyces boulardii supplementation on jaundice in premature infants undergoing phototherapy.

METHODS

In this article, the authors reviewed 100 hospitalized jaundiced premature infants under 35 weeks of gestational age. All infants were assigned to a control group (n = 45) and a treatment group (n = 55) randomly. The infants in the treatment group received S. boulardii supplementation by undergoing phototherapy and the infants in the control group were only treated by phototherapy. The total serum bilirubin levels were detected before and at the end of phototherapy, and transcutaneous bilirubin levels were measured on the 1st, 4th, 8th and 15th day of treatment. The duration of jaundice resolution and phototherapy, stool frequency, and characteristics were compared after phototherapy.

RESULTS

The duration of jaundice resolution and phototherapy were shortened. Total serum bilirubin level was lower than the control group at the end of phototherapy (p < 0.05). Transcutaneous bilirubin levels decreased more significantly on the 8th and 15th day of treatment (p < 0.05), while there were no significant differences on the post-treatment 1st and 4th day (p > 0.05). In addition, bowel movements including stool frequency and Bristol Stool Form Scale ratings of stools also improved after treatment.

CONCLUSIONS

S. boulardii in combination with phototherapy is effective and safe in reducing bilirubin levels and duration of phototherapy, accelerating jaundice resolution in premature infants with jaundice. The procedure also provided an ideal therapeutic effect of diarrhea induced by phototherapy to promote compliance and maternal-infant bonding.

Breastfeeding Insufficiencies: Common and Preventable Harm to Neonates

Insufficient milk intake in breastfed neonates is common, frequently missed, and causes preventable hospitalizations for jaundice/hyperbilirubinemia, hypernatremia/dehydration, and hypoglycemia - accounting for most U.S. neonatal readmissions. These and other consequences of neonatal starvation and deprivation may substantially contribute to fully preventable morbidity and mortality in previously healthy neonates worldwide. Previous advanced civilizations recognized this problem of breastfeeding insufficiencies and had an infrastructure to solve it: Wetnursing, shared nursing, and prelacteal feeding traditions used to be well-organized and widespread. Modern societies accidentally destroyed that infrastructure. Then, modern reformers missing a few generations of direct knowledge transmission about safe breastfeeding invented a new, historically anomalous conception of breastfeeding defined in terms of exclusivity. As that new intervention has become increasingly widespread, so too have researchers widely reported associated possible harms of the longer neonatal starvation/deprivation and later infant under-nutrition periods that it creates when breastfeeding is insufficient. Early insufficient nutrition/hydration has possible long-term effects including neurodevelopmental consequences such as attention deficit hyperactivity disorder, autism, cerebral palsy, cognitive and developmental delay, epilepsy, hearing impairment, kernicterus, language disorder, mood disorders, lower IQ, and specific learning disorder. Current early infant feeding guidelines conflict with the available evidence. Recent reform efforts have tended to focus on using more technology and measurement to harm fewer neonates instead of proposing the indicated paradigm shift in early infant feeding to prevent more harm. The scientific evidence is already sufficient to mandate application of the precautionary principle to feed neonates early, adequate, and often milk before mothers' milk comes in and whenever signs of hunger persist, mitigating possible risks including death or disability. In most contexts, the formula is the best supplementary milk for infants at risk from breastfeeding insufficiencies. National-level reviews of scientific evidence, health policy, and research methods and ethics are needed to initiate the early infant feeding paradigm shift that the data already support. Policy experiments and related legislative initiatives might also contribute to the shift, as insurers might decline or be required by law to decline reimbursing hospitals for costs of this type of preventable hospitalization, which otherwise generates profit.

Turkish Neonatal Society guideline to the approach, follow-up, and treatment of neonatal jaundice

Jaundice is one of the most common problems in the newborn. It is generally accepted as a physiologic condition; most cases are benign and transient. However, in a small portion of jaundiced newborn infants, serum bilirubin concentrations increase to a level at which irreversible brain damage can occur. The timely diagnosis and management of severe hyperbilirubinemia is essential to prevent acute bilirubin encephalopathy and kernicterus. Kernicterus still occurs although it is almost always preventable. The focus of this guideline is to reduce the incidence of severe hyperbilirubinemia and bilirubin encephalopathy. Therefore, a system-based approach using the recommendations of this guideline should be implemented in all birthing facilities and continued in ambulatory care of the newborn infants.

Fluid supplementation for neonatal unconjugated hyperbilirubinaemia

BACKGROUND

Neonatal hyperbilirubinaemia is a common problem which carries a risk of neurotoxicity. Certain infants who have hyperbilirubinaemia develop bilirubin encephalopathy and kernicterus which may lead to long-term disability. Phototherapy is currently the mainstay of treatment for neonatal hyperbilirubinaemia. Among the adjunctive measures to compliment the effects of phototherapy, fluid supplementation has been proposed to reduce serum bilirubin levels. The mechanism of action proposed includes direct dilutional effects of intravenous (IV) fluids, or enhancement of peristalsis to reduce enterohepatic circulation by oral fluid supplementation.

OBJECTIVES

To assess the risks and benefits of fluid supplementation compared to standard fluid management in term and preterm newborn infants with unconjugated hyperbilirubinaemia who require phototherapy.

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 5), MEDLINE via PubMed (1966 to 7 June 2017), Embase (1980 to 7 June 2017), and CINAHL (1982 to 7 June 2017). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.

SELECTION CRITERIA

We included randomised controlled trials that compared fluid supplementation against no fluid supplementation, or one form of fluid supplementation against another.

DATA COLLECTION AND ANALYSIS

We extracted data using the standard methods of the Cochrane Neonatal Review Group using the Covidence platform. Two review authors independently assessed the eligibility and risk of bias of the retrieved records. We expressed our results using mean difference (MD), risk difference (RD), and risk ratio (RR) with 95% confidence intervals (CIs).

MAIN RESULTS

Out of 1449 articles screened, seven studies were included. Three articles were awaiting classification, among them, two completed trials identified from the trial registry appeared to be unpublished so far.There were two major comparisons: IV fluid supplementation versus no fluid supplementation (six studies) and IV fluid supplementation versus oral fluid supplementation (one study). A total of 494 term, healthy newborn infants with unconjugated hyperbilirubinaemia were evaluated. All studies were at high risk of bias for blinding of care personnel, five studies had unclear risk of bias for blinding of outcome assessors, and most studies had unclear risk of bias in allocation concealment. There was low- to moderate-quality evidence for all major outcomes.In the comparison between IV fluid supplementation and no supplementation, no infant in either group developed bilirubin encephalopathy in the one study that reported this outcome. Serum bilirubin was lower at four hours postintervention for infants who received IV fluid supplementation (MD -34.00 μmol/L (-1.99 mg/dL), 95% CI -52.29 (3.06) to -15.71 (0.92); participants = 67, study = 1) (low quality of evidence, downgraded one level for indirectness and one level for suspected publication bias). Beyond eight hours postintervention, serum bilirubin was similar between the two groups. Duration of phototherapy was significantly shorter for fluid-supplemented infants, but the estimate was affected by heterogeneity which was not clearly explained (MD -10.70 hours, 95% CI -15.55 to -5.85; participants = 218; studies = 3; I² = 67%). Fluid-supplemented infants were less likely to require exchange transfusion (RR 0.39, 95% CI 0.21 to 0.71; RD -0.01, 95% CI -0.04 to 0.02; participants = 462; studies = 6; I² = 72%) (low quality of evidence, downgraded one level due to inconsistency, and another level due to suspected publication bias), and the estimate was similarly affected by unexplained heterogeneity. The frequencies of breastfeeding were similar between the fluid-supplemented and non-supplemented infants in days one to three based on one study (estimate on day three: MD 0.90 feeds, 95% CI -0.40 to 2.20; participants = 60) (moderate quality of evidence, downgraded one level for imprecision).One study contributed to all outcome data in the comparison of IV versus oral fluid supplementation. In this comparison, no infant in either group developed abnormal neurological signs. Serum bilirubin, as well as the rate of change of serum bilirubin, were similar between the two groups at four hours after phototherapy (serum bilirubin: MD 11.00 μmol/L (0.64 mg/dL), 95% CI -21.58 (-1.26) to 43.58 (2.55); rate of change of serum bilirubin: MD 0.80 μmol/L/hour (0.05 mg/dL/hour), 95% CI -2.55 (-0.15) to 4.15 (0.24); participants = 54 in both outcomes) (moderate quality of evidence for both outcomes, downgraded one level for indirectness). The number of infants who required exchange transfusion was similar between the two groups (RR 1.60, 95% CI 0.60 to 4.27; RD 0.11, 95% CI -0.12 to 0.34; participants = 54). No infant in either group developed adverse effects including vomiting or abdominal distension.

AUTHORS' CONCLUSIONS

There is no evidence that IV fluid supplementation affects important clinical outcomes such as bilirubin encephalopathy, kernicterus, or cerebral palsy in healthy, term newborn infants with unconjugated hyperbilirubinaemia requiring phototherapy. In this review, no infant developed these bilirubin-associated clinical complications. Low- to moderate-quality evidence shows that there are differences in total serum bilirubin levels between fluid-supplemented and control groups at some time points but not at others, the clinical significance of which is uncertain. There is no evidence of a difference between the effectiveness of IV and oral fluid supplementations in reducing serum bilirubin. Similarly, no infant developed adverse events or complications from fluid supplementation such as vomiting or abdominal distension. This suggests a need for future research to focus on different population groups with possibly higher baseline risks of bilirubin-related neurological complications, such as preterm or low birthweight infants, infants with haemolytic hyperbilirubinaemia, as well as infants with dehydration for comparison of different fluid supplementation regimen.

ABM Clinical Protocol #3: Supplementary Feedings in the Healthy Term Breastfed Neonate, Revised 2017

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Early additional food and fluids for healthy breastfed full-term infants

BACKGROUND

Health organisations recommend exclusive breastfeeding for six months. However, the addition of other fluids or foods before six months is common in many countries. Recently, research has suggested that introducing solid food at around four months of age while the baby continues to breastfeed is more protective against developing food allergies compared to exclusive breastfeeding for six months. Other studies have shown that the risks associated with non-exclusive breastfeeding are dependent on the type of additional food or fluid given. Given this background we felt it was important to update the previous version of this review to incorporate the latest findings from studies examining exclusive compared to non-exclusive breastfeeding.

OBJECTIVES

To assess the benefits and harms of additional food or fluid for full-term healthy breastfeeding infants and to examine the timing and type of additional food or fluid.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 March 2016) and reference lists of all relevant retrieved papers.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials in infants under six months of age comparing exclusive breastfeeding versus breastfeeding with any additional food or fluids.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Two review authors assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

We included 11 trials (2542 randomised infants/mothers). Nine trials (2226 analysed) provided data on outcomes of interest to this review. The variation in outcome measures and time points made it difficult to pool results from trials. Data could only be combined in a meta-analysis for one primary (breastfeeding duration) and one secondary (weight change) outcome. None of the trials reported on physiological jaundice. Infant mortality was only reported in one trial.For the majority of older trials, the description of study methods was inadequate to assess the risk of bias. Most studies that we could assess showed a high risk of other biases and over half were at high risk of selection bias.Providing breastfeeding infants with artifical milk, compared to exclusive breastfeeding, did not affect rates of breastfeeding at hospital discharge (risk ratio (RR) 1.02, 95% confidence interval (CI) 0.97 to 1.08; one trial, 100 infants; low-quality evidence). At three months, breastfeeding infants who were provided with artificial milk had higher rates of any breastfeeding compared to exclusively breastfeeding infants (RR 1.21, 95% CI 1.05 to 1.41; two trials, 137 infants; low-quality evidence). Infants who were given artifical milk in the first few days after birth before breastfeeding, had less "obvious or probable symptoms" of allergy compared to exclusively breastfeeding infants (RR 0.56, 95% CI 0.35 to 0.91; one trial, 207 infants; very low-quality evidence). No difference was found in maternal confidence when comparing non-exclusive breastfeeding infants who were provided with artificial milk with exclusive breastfeeding infants (mean difference (MD) 0.10, 95% CI -0.34 to 0.54; one study, 39 infants; low-quality evidence). Rates of breastfeeding were lower in the non-exclusive breastfeeding group compared to the exclusive breastfeeding group at four, eight, 12 (RR 0.68, 95% CI 0.53 to 0.87; one trial, 170 infants; low-quality evidence), 16 and 20 weeks.The addition of glucose water resulted in fewer episodes of hypoglycaemia (below 2.2 mmol/L) compared to the exclusive breastfeeding group, reported at 12 hours (RR 0.07, 95% CI 0.00 to 1.20; one trial, 170 infants; very low-quality evidence), but no significant difference at 24 hours (RR 1.57, 95% CI 0.27 to 9.17; one trial, 170 infants; very low-quality evidence). Weight loss was lower for infants who received additional glucose water (one trial, 170 infants) at six, 12, 24 and 48 hours of life (MD -32.50 g, 95% CI -52.09 to -12.91; low-quality evidence) compared to the exclusively breastfeeding infants but no difference between groups was observed at 72 hours of life (MD 3.00 g, 95% CI -20.83 to 26.83; very low-quality evidence). In another trial with the water and glucose water arms combined (one trial, 47 infants), we found no significant difference in weight loss between the additional fluid group and the exclusively breastfeeding group on either day three or day five (MD -1.03%, 95% CI -2.24 to 0.18; very low-quality evidence) and (MD -0.20%, 95% CI -0.86 to 0.46; very low-quality evidence).Infant mortality was reported in one trial with no deaths occurring in either group (1162 infants). The early introduction of potentially allergenic foods, compared to exclusively breastfeeding, did not reduce the risk of "food allergy" to one or more of these foods between one to three years of age (RR 0.80, 95% CI 0.51 to 1.25; 1162 children), visible eczema at 12 months stratified by visible eczema at enrolment (RR 0.86, 95% CI 0.51 to 1.44; 284 children), or food protein-induced enterocolitis syndrome reactions (RR 2.00, 95% CI 0.18 to 22.04; 1303 children) (all moderate-quality evidence). Breastfeeding infants receiving additional foods from four months showed no difference in infant weight gain (g) from 16 to 26 weeks compared to exclusive breastfeeding to six months (MD -39.48, 95% CI -128.43 to 49.48; two trials, 260 children; low-quality evidence) or weight z-scores (MD -0.01, 95% CI -0.15 to 0.13; one trial, 100 children; moderate-quality evidence).

AUTHORS' CONCLUSIONS

We found no evidence of benefit to newborn infants on the duration of breastfeeding from the brief use of additional water or glucose water. The quality of the evidence on formula supplementation was insufficient to suggest a change in practice away from exclusive breastfeeding. For infants at four to six months, we found no evidence of benefit from additional foods nor any risks related to morbidity or weight change. The majority of studies showed high risk of other bias and most outcomes were based on low-quality evidence which meant that we were unable to fully assess the benefits or harms of supplementation or to determine the impact from timing and type of supplementation. We found no evidence to disagree with the current international recommendation that healthy infants exclusively breastfeed for the first six months.

Early additional food and fluids for healthy breastfed full-term infants

BACKGROUND

Widespread recommendations from health organisations encourage exclusive breastfeeding for six months. However, the addition of other fluids or foods before six months is common in many countries and communities. This practice suggests perceived benefits of early supplementation or lack of awareness of the possible risks.

OBJECTIVES

To assess the benefits and harms of supplementation for full-term healthy breastfed infants and to examine the timing and type of supplementation.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (21 March 2014) and reference lists of all relevant retrieved papers.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials in infants under six months of age comparing exclusive breastfeeding versus breastfeeding with any additional food or fluids.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the trials, extracted data and assessed risk of bias.

MAIN RESULTS

We included eight trials (984 randomised infants/mothers). Six trials (n = 613 analysed) provided data on outcomes of interest to this review. The variation in outcome measures and time points made it difficult to pool results from trials. Data could only be combined in a meta-analysis for one secondary outcome (weight change). The trials that provided outcome data compared exclusively breastfed infants with breastfed infants who were allowed additional nutrients in the form of artificial milk, glucose, water or solid foods.In relation to the majority of the older trials, the description of study methods was inadequate to assess the risk of bias. The two more recent trials, were found to be at low risk of bias for selection and detection bias. The overall quality of the evidence for the main comparison was low.In one trial (170 infants) comparing exclusively breastfeeding infants with infants who were allowed additional glucose water, there was a significant difference favouring exclusive breastfeeding up to and including week 20 (risk ratio (RR) 1.45, 95% confidence interval (CI) 1.05 to 1.99), with more infants in the exclusive breastfed group still exclusively breastfeeding. Conversely in one small trial (39 infants) comparing exclusive breastfed infants with non-exclusive breastfed infants who were provided with artificial milk, fewer infants in the exclusive breastfed group were exclusively breastfeeding at one week (RR 0.58, 95% CI 0.37 to 0.92) and at three months (RR 0.44, 95% CI 0.26 to 0.76) and there was no significant difference in the proportion of infants continuing any breastfeeding at three months between groups (RR 0.76, 95% CI 0.56 to 1.03).For infant morbidity (six trials), one newborn trial (170 infants) found a statistically, but not clinically, significant difference in temperature at 72 hours (mean difference (MD) 0.10 degrees, 95% CI 0.01 to 0.19), and that serum glucose levels were higher in glucose supplemented infants in the first 24 hours, though not at 48 hours (MD -0.24 mmol/L, 95% CI -0.51 to 0.03). Weight loss was also higher (grams) in infants at six, 12, 24 and 48 hours of life in the exclusively breastfed infants compared to those who received additional glucose water (MD 7.00 g, 95% CI 0.76 to 13.24; MD 11.50 g, 95% CI 1.71 to 21.29; MD 13.40 g, 95% CI 0.43 to 26.37; MD 32.50 g, 95% CI 12.91 to 52.09), but no difference between groups was observed at 72 hours of life. In another trial (47 infants analysed), we found no significant difference in weight loss between the exclusively breastfeeding group and the group allowed either water or glucose water on either day three or day five (MD 1.03%, 95% CI -0.18 to 2.24) and (MD 0.20%, 95% CI -1.18 to 1.58).Three trials with four- to six-month-old infants provided no evidence to support any benefit from the addition of complementary foods at four months versus exclusive breastfeeding to six months nor any risks related either morbidity or weight change (or both).None of the trials reported on the remaining primary outcomes, infant mortality or physiological jaundice.

AUTHORS' CONCLUSIONS

We were unable to fully assess the benefits or harms of supplementation or to determine the impact from timing and type of supplementation. We found no evidence of benefit to newborn infants and possible negative effects on the duration of breastfeeding from the brief use of additional water or glucose water, and the quality of the evidence from a small pilot study on formula supplementation was insufficient to suggest a change in practice away from exclusive breastfeeding. For infants at four to six months, we found no evidence of benefit from additional foods nor any risks related to morbidity or weight change. Future studies should examine the longer-term effects on infants and mothers, though randomising infants to receive supplements without medical need may be problematic.We found no evidence for disagreement with the recommendation of international health associations that exclusive breastfeeding should be recommended for healthy infants for the first six months.

Glucose induces intestinal human UDP-glucuronosyltransferase (UGT) 1A1 to prevent neonatal hyperbilirubinemia

Inadequate calorie intake or starvation has been suggested as a cause of neonatal jaundice, which can further cause permanent brain damage, kernicterus. This study experimentally investigated whether additional glucose treatments induce the bilirubin-metabolizing enzyme – UDP-glucuronosyltransferase (UGT) 1A1 – to prevent the onset of neonatal hyperbilirubinemia. Neonatal humanized UGT1 (hUGT1) mice physiologically develop jaundice. In this study, UGT1A1 expression levels were determined in the liver and small intestine of neonatal hUGT1 mice that were orally treated with glucose. In the hUGT1 mice, glucose induced UGT1A1 in the small intestine, while it did not affect the expression of UGT1A1 in the liver. UGT1A1 was also induced in the human intestinal Caco-2 cells when the cells were cultured in the presence of glucose. Luciferase assays demonstrated that not only the proximal region (-1300/-7) of the UGT1A1 promoter, but also distal region (-6500/-4050) were responsible for the induction of UGT1A1 in the intestinal cells. Adequate calorie intake would lead to the sufficient expression of UGT1A1 in the small intestine to reduce serum bilirubin levels. Supplemental treatment of newborns with glucose solution can be a convenient and efficient method to treat neonatal jaundice while allowing continuous breastfeeding.

Early additional food and fluids for healthy breastfed full-term infants

BACKGROUND

Widespread recommendations from health organisations encourage exclusive breastfeeding for six months. However the addition of other fluids or foods before six months is common practice in many countries and communities. This practice suggests perceived benefits of early supplementation or lack of awareness of the possible risks.

OBJECTIVES

To assess the benefits and harms of supplementation for full-term healthy breastfed infants and to examine the timing and type of supplementation.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 March 2011) and reference lists of all relevant retrieved papers.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials in infants under six months of age comparing exclusive breastfeeding versus breastfeeding with any additional food or fluids.

DATA COLLECTION AND ANALYSIS

Two authors independently selected the trials; three extracted data and assessed risk of bias.

MAIN RESULTS

We included six trials (814 infants). Two trials in the early days after birth that reported data did not indicate that giving additional fluids was beneficial. For duration of breastfeeding, there was a significant difference favouring exclusive breastfeeding up to and including week 20 (risk ratio (RR) 1.45, 95% confidence interval (CI) 1.05 to 1.99), indicating that supplements may contribute to reducing the duration.For infant morbidity (three trials), one newborn trial found a statistically, but not clinically, significant difference in temperature at 72 hours (MD 0.10 degrees, 95% CI 0.01 to 0.19), and that serum glucose levels were higher in glucose supplemented infants in the first 24 hours, though not at 48 hours (MD -0.24mmol/l, 95% CI -0.51 to 0.03). Two trials with four- to six-month-old infants did not indicate any benefit to supplemented infants to 26 weeks nor any risks related to morbidity or weight change.None of the trials reported on the remaining primary outcomes, infant mortality or physiological jaundice.

AUTHORS' CONCLUSIONS

We were unable to fully assess the benefits or harms of supplementation or to determine the impact from timing and type of supplementation .We found no benefit to newborn infants and possible negative effects on the duration of breastfeeding from the brief use of additional water or glucose water. For infants at four to six months, we found no benefit from additional foods nor any risks related to morbidity or weight change. Future studies should examine the longer term effects on infants and mothers, though randomising infants to receive supplements without medical need may be considered unethical.We found no evidence for disagreement with the recommendation of international health associations that exclusive breastfeeding should be recommended for healthy infants for the first six months.

The Effect of Traditional Remedies (Camel's Thorn, Flixweed and Sugar Water) on Idiopathic Neonatal Jaundice

OBJECTIVE

Jaundice is the most common reason of newborn's admission to neonatal ward. Many Iranian families give traditional remedies like sugar water, camel's thorn and flixweed extracts to breast-fed babies for reducing jaundice. This study investigated the effect of traditional remedies on idiopathic neonatal jaundice.

METHODS

This prospective study has been performed on 336 babies with idiopathic jaundice in a four year period (2005-2009) at Ghaem hospital, Mashhad, Iran. The babies were divided into two groups. In case group (n=234) breast-fed babies received no remedy and in control group (n=102), traditional remedies were given additional to breast milk and the results recorded and compared.

FINDINGS

In the present study significant differences were observed between the two groups in age of admission (6.8±3.2 vs 9.2±3.7 day, P<0.001), serum bilirubin values (17.8 vs 21.3 mg/dl, P<0.001) and percent of weight loss (P<0.01). There were no significant differences between the two groups in birth weight, sex, gestational age and duration of hospitalization, age at jaundice remission, hematocrit value and maternal factors (age, gestational order, pregnancy and labor problems)(P>0.05).

CONCLUSION

Traditional remedies (camel's thorn, flixweed and sugar water) cause more weight loss and delayed reexamination of newborns leading to increased hyperbilirubinemia. These remedies may raise pseudo confidence in parents, which postpones reexamination and follow up of the newborns.

Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation

Jaundice occurs in most newborn infants. Most jaundice is benign, but because of the potential toxicity of bilirubin, newborn infants must be monitored to identify those who might develop severe hyperbilirubinemia and, in rare cases, acute bilirubin encephalopathy or kernicterus. The focus of this guideline is to reduce the incidence of severe hyperbilirubinemia and bilirubin encephalopathy while minimizing the risks of unintended harm such as maternal anxiety, decreased breastfeeding, and unnecessary costs or treatment. Although kernicterus should almost always be preventable, cases continue to occur. These guidelines provide a framework for the prevention and management of hyperbilirubinemia in newborn infants of 35 or more weeks of gestation. In every infant, we recommend that clinicians 1) promote and support successful breastfeeding; 2) perform a systematic assessment before discharge for the risk of severe hyperbilirubinemia; 3) provide early and focused follow-up based on the risk assessment; and 4) when indicated, treat newborns with phototherapy or exchange transfusion to prevent the development of severe hyperbilirubinemia and, possibly, bilirubin encephalopathy (kernicterus).

Randomized controlled trial of oral versus intravenous fluid supplementation on serum bilirubin level during phototherapy of term infants with severe hyperbilirubinaemia

OBJECTIVE

To compare the rates of decrease in serum bilirubin levels in severely jaundiced healthy term infants given oral or intravenous fluid supplementation during phototherapy.

METHODS

A randomized controlled study was carried out in the neonatal intensive care unit (NICU) of Hospital Universiti Kebangsaan Malaysia over a 12-month period. Fifty-four healthy term infants with severe hyperbilirubinemia were randomized to receive either solely enteral feeds (n = 27) or both enteral and intravenous (n = 27) fluid during phototherapy.

RESULTS

There were no significant differences in the mean birthweight, mean gestational age, ethnic distribution, gender distribution, modes of delivery and types of feeding between the two groups. Similarly, there was no significant difference in the mean indirect serum bilirubin (iSB) level at the time of admission to the NICU between the enteral (359 +/- 69 micromol/L [mean +/- SD]) and intravenous group (372 +/- 59 micromol/L; P = 0.4). The mean rates of decrease in iSB during the first 4 h of phototherapy were also not significantly different between the enteral group (10.4 +/- 4.9 micromol/L per h) and intravenous group (11.2 +/- 7.4 micromol/L per h; P = 0.6). There was no significant difference in the proportion of infants requiring exchange transfusion (P = 0.3) nor in the median duration of hospitalization (P = 0.7) between the two groups. No infant developed vomiting or abdominal distension during the study period.

CONCLUSION

Severely jaundiced healthy term infants had similar rates of decrease in iSB levels during the first 4 h of intensive phototherapy, irrespective of whether they received oral or intravenous fluid supplementation. However, using the oral route avoided the need for intravenous cannulae and their attendant complications.

Breast-feeding, neonatal jaundice and kernicterus

Despite the many advantages of breast-feeding, there is ample documentation of the strong association between breast-feeding and an increase in the risk of neonatal hyperbilirubinaemia. Breast-fed infants have higher bilirubin levels than formula-fed infants. Suggested mechanisms for these findings include poor fluid and caloric intake, inhibition of hepatic excretion of bilirubin, and intestinal absorption of bilirubin (enterohepatic circulation). On rare occasions, breast-fed infants without evidence of haemolysis have developed extreme hyperbilirubinaemia and kernicterus. Because almost all of the cases of kernicterus reported in the last 15 years have occurred in fully or partially breast-fed newborns, it is important that these infants be followed closely. Appropriate support and advice must be provided to the lactating mother so that successful breast-feeding can be established and the risk of severe hyperbilirubinaemia reduced.

Breastfeeding

A large and growing body of scientific evidence suggests that breastfeeding provides immediate and long-lasting health advantages for the mother and her infant. In the United States, breastfeeding rates currently are the highest recorded in 30 years, although premature weaning owing to the largely avoidable problems of breast pain and concern about adequate milk supply is still common. The advantages of breastfeeding will be more widely appreciated when all health care professionals acquire competence in evidence-based lactation management strategies. These strategies include helping women to position and attach their newborns correctly, encouraging frequent and effective feedings at the breast from birth onward, teaching new parents the signs of adequate milk intake, and providing the resources for promoting breastfeeding without the competition of commercial product promotion.

Common complaints in the first 30 days of life

Visits to the emergency department (ED) by neonates and their parents can cause anxiety for parents and the ED staff. Many of the presenting complaints are unique to the neonatal population, and an understanding of both common problems and true medical emergencies is paramount. This article discusses the complaints the EDs have seen more frequently as a result of earlier newborn discharges from hospitals.

Jaundice and breastfeeding

Optimal management of breastfeeding does not eliminate neonatal jaundice and elevated serum bilirubin concentrations. Rather, it leads to a pattern of hyperbilirubinemia that is normal and, possibly, beneficial to infants. Excessive frequency of exaggerated jaundice in a hospital or community population of breastfed infants may be a warning that breastfeeding policies and support are not ideal for the establishment of good breastfeeding practices. The challenge to clinicians is to differentiate normal patterns of jaundice and hyperbilirubinemia from those that indicate an abnormality or place an infant at risk.

High-technology breastfeeding

When there is interference with the natural process of breastfeeding, breastfeeding technology may be useful in supporting women to initiate and continue breastfeeding. Each breastfeeding mother has different technologic needs. By providing a range of choices and referrals, primary health care providers may facilitate the optimal decision for each lactating mother, which contributes to reaching the goals of the American Academy of Pediatrics for optimal infant feeding, that is, exclusive breastfeeding for the first 6 months of an infant's life, with continued breastfeeding for 1 year or more.

Neonatal jaundice, animal-induced injuries, and immunizations

The authors describe current investigation and most recent developments in three areas of pediatrics commonly faced by the office practitioner. The impetus of earlier newborn discharge places increased emphasis on pediatricians to accurately predict clinically significant jaundice. A better understanding of the pathophysiology of breastfeeding and breast milk jaundice, and the realization that Gilbert's syndrome may play a greater role in neonatal jaundice, only help confirm that the story of neonatal jaundice is still unfolding. Animal (particularly canine) bite injuries continue to be the most common animal-induced injuries, and a thorough review of appropriate antibiotic treatment and rabies prophylaxis guidelines are essential for the pediatric practitioner. During the past year, several major changes involving the use of rotavirus, pneumococcal, polio, meningococcal, and hepatitis A vaccines have taken place, which will have marked impact not only on pediatric office practice, but also on society as a whole.

Neonatal jaundice. Strategies to reduce bilirubin-induced complications

Neonatal hyperbilirubinemia is the most common reason for hospital readmission in the first 2 weeks of life. Kernicterus is still relatively uncommon but has been on the rise with the institution in the 1990's of aggressive early postnatal discharge policies. Bilirubin-induced complications can be prevented by instituting a neonatal jaundice protocol to identify infants at risk for significant hyperbilirubinemia, by ensuring adequate parental education and preparedness, and by implementing a good neonatal tracking system for follow-up care. Hyperbilirubinemia is easily treated with phototherapy, which can be administered at home in selected infants.

The effect of feeding glucose water to breastfeeding newborns on weight, body temperature, blood glucose, and breastfeeding duration

In order to determine the effect of feeding glucose water on breastfeeding newborns, we randomly distributed 180 normal newborns into two groups: a glucose water group (GW), fed 5% glucose solution during the first 3 days of life in addition to being breastfed; and an exclusively breastfed nonglucose water group (NGW). The following data were evaluated: weight at 6, 12, 24, 48, and 72 hours of life; temperature during the first 72 hours of life; serum glucose level at 6, 12, 24, and 48 hours; total duration of breastfeeding and age at introduction of infant formulas. In the NGW, there was a greater weight loss at 48 hours but not at 72 hours, temperatures higher than 37.5 degrees C were more frequent, and the mean serum glucose levels at 6, 12, and 24 hours were lower. This group also had more serum glucose level determinations under 2.2 mmol/l (40 mg/dL). However, no infants exhibited hypoglycemic symptoms. Infants in the GW received twice as many formulas during the first month and had a shorter duration of any breastfeeding. Our results suggest that the suppression of feedings with glucose water in the first days of life increases the probability of successful breastfeeding. However, infants who do not receive glucose water in the first few days of life may require greater supervision and close monitoring of blood glucose and body temperature, particularly in the first 24 hours of life.

Standing feeding orders in a well-baby nursery: "water, water everywhere..."

The objective of this study was to examine standing physician orders affecting healthy breastfeeding newborns for items not in concert with the "Ten Steps to Successful Breast-feeding." All order sets of physicians or physician groups (n = 22) at a mid-sized hospital in central New Jersey (USA) (approximately 1200 deliveries/year) were reviewed. Seventeen orders called for water to be offered routinely as the first feeding. Five order sets called for two or more such feeds. Twelve orders gave infants nothing by mouth (NPO) for more than 2 hours and six mandated 4-hour intervals between feedings. Practices that undermine successful breastfeeding are still ubiquitous. Physician orders, in addition to hospital policy, should be targeted for improvement.

Diurnal variation in serum bilirubin concentrations in infants with neonatal jaundice

We investigated whether there are independent intradaily changes in bilirubin levels in neonates. Healthy term newborn infants (n = 124) with neonatal jaundice bilirubin >/t171 mmol/L (10mg/dl) were studied for at least 3 consecutive days. Starting from the second day of life, consistent intradaily changes were observed in bilirubin levels (morning levels were greater than evening levels; p < 0.001), and body weight steadily increased. This diurnal variation in bilirubin levels should be considered in the follow-up and treatment of neonatal jaundice.

Clinical rounds in the well-baby nursery: treating jaundiced newborns

Ten pearls (and pitfalls) in the management of the jaundiced newborn: Remember to take a history. Ask about jaundice in previous siblings and check family ethnicity. Don't ignore jaundice in the first 24 hours--it is considered pathologic until proven otherwise. Some normal infants may appear jaundiced and have a bilirubin level of 5 mg/dL at 23 hours and 59 minutes. On the other hand, a bilirubin level of 5 mg/dL at 10 hours is almost certainly pathologic. Use your judgment. Don't treat 35 to 37 week gestation infants as if they were full-term infants. Although these babies are cared for in well-baby nurseries and are generally treated like full-term infants, they are not full term. They are not as vigorous and do not nurse as well as full-term infants. Infants at 37 weeks gestation are four times more likely to have a serum bilirubin level greater than 13 mg/dL than those at 40 weeks gestation. Don't send 35-week gestation infants home before 48 hours. Document your assessment, particularly if the infant is being discharged early. Document the presence or absence of jaundice and its severity. A late rising bilirubin is typical of G6PD deficiency. Think about the ethnic background: G6PD deficiency is much more likely to occur in families from Greece, Turkey, Sardinia, and Nigeria, and particularly in Sephardic Jews from Iraq, Iran, Syria, and Kurdistan. Your practice may not contain many such families but remember in today's world of travel and intermarriage, etc, these genes are ubiquitous and the diagnosis of G6PD deficiency should always be considered in a newborn child with a significant elevation of bilirubin, particularly if it is a male and the rise in bilirubin is of late onset. Don't use homeopathic doses of phototherapy. As with any drug, phototherapy should be provided in a therapeutic dose (see above), but with the light sources commonly used, it is impossible to overdose the patient. Don't ignore a failure of response to phototherapy. If the bilirubin rises despite adequate phototherapy, there must be a reason. Consider the possibility of an unrecognized hemolytic process. Provide timely follow-up. Infants discharged (as most are) before 48 hours should be seen by a health-care professional within 2 to 3 days of discharge. Don't ignore prolonged jaundice. About one in three normal breast-fed infants still will be clinically jaundiced when they are 2 weeks old (two thirds will be biochemically jaundiced). These infants all have indirect hyperbilirubinemia. Occasionally, however, an infant with prolonged jaundice has direct hyperbilirubinemia. In these infants, the diagnosis of biliary atresia or some other cause of cholestatic jaundice must be considered. If the infant is clinically jaundiced beyond age 2 weeks, you should: 1) check the newborn record to make sure that the metabolic screen for hypothyroidism is normal (congenital hypothyroidism is a cause of indirect hyperbilirubinemia), and 2) ask the mother about the color of the urine and stool. If the baby's stools are pale or the urine is dark yellow, you must get a direct bilirubin to rule out cholestasis. If there is direct hyperbilirubinemia, a urine dipstick will identify the presence of bile (bilirubin). If the color of the urine and stool are normal (by history), it is reasonable to follow the child for another week. However, any infant who is still jaundiced beyond age 3 weeks must have a measurement of direct bilirubin. Don't ignore severe jaundice. If the bilirubin is sufficiently elevated, kernicterus can occur in a healthy, breast-fed infant.

Supplementation of breastfeeding newborns: a flow chart for decision making

Although research clearly demonstrates that supplementation of healthy infants in the early neonatal period has many potentially negative effects on breastfeeding initiation and continuation, the practice persisted at a Level II hospital. This paper explores the process undertaken to decrease this practice. A flow chart designed to assist nursing staff with decision making regarding supplementation was developed and tested.

The effect of breast-feeding frequency on serum bilirubin levels

OBJECTIVE

Our purpose was to evaluate the effect of breast-feeding frequency on serum bilirubin levels in the first 3 days after birth.

STUDY DESIGN

Two hundred seventy-five infants were randomly assigned to a frequent or demand breast-feeding schedule.

RESULTS

Infants in the frequent group (n = 131) nursed nine (7.5 to 10.5) times per day (median and inner 80%), and the demand group (n = 143) fed 6.5 (5.5 to 8.0) times per day. The serum bilirubin level was measured in all infants between 48 and 80 hours (median 53 hours, inner 80% 48 to 68 hours) and was 7.4 (1.8 to 10.7) mg/dl in the frequent group and 8.0 (2.9 to 11.2) mg/dl in the demand group (p = 0.103). There was no correlation between the frequency of breast-feeding and the serum bilirubin level.

CONCLUSION

Within the range of the frequency of nursing observed in this study, we could not demonstrate a significant effect on serum bilirubin levels in the first 3 days after birth.

When Breast-feeding is not Contraindicated: Do you know when to stop breast-feeding?

As more mothers elect to breast-feed, more concomitant problems in mothers and babies are reported that are thought to contraindicate breast-feeding. Many frequently cited maternal and infant reasons for stopping breast-feeding are not valid. Breast-feeding can usually be maintained if the physician remembers that breast-feeding is important for the baby and mother and not simply another feeding method.

Supplementation of breastfeeding infants and weight loss in hospital

Charts were reviewed to determine the frequency of glucose water supplementation of breastfed babies during their hospital stay and to discover if glucose water supplementation affected weight loss. Babies who received glucose water supplementation lost more weight and stayed in hospital longer than babies who did not receive supplementation. These findings were statistically significant. Routine supplementation with glucose water is unnecessary and potentially harmful to the baby. Stopping this practice may increase the mother's milk supply, increase her confidence in the adequacy of her supply and decrease the length of hospital stay.

Breastfeeding fallacies: their relationship to understanding lactation

When inaccurate information is the basis for clinical decision making, patient care is likely to be incomplete, inappropriate, and potentially harmful. We identified 17 fallacies relating to lactation and breastfeeding that exist in the professional and lay literature and that continue to be perpetuated among care providers and shared with new mothers. The inappropriateness and inaccuracy of these beliefs, and how they influence attitudes about, and practices relating to, breastfeeding, are discussed. Alternatives to these fallacies exist, and their use may contribute to more relevant care and advice giving, and to successful breastfeeding.

Perinatal events and neonatal morbidity: an analysis of 5380 cases

The associations between perinatal events and neonatal morbidity were examined in a regional population of 5 380 newborns weighing 500 g or more. Perinatal mortality was 6.9%, and neonatal mortality was 3.0%. The low birth weight (less than 2500 g) rate was 3.8%. The incidence of prematurity (gestational age less than 37 weeks) was 6.6%. Respiratory distress syndrome was found in 0.9%, nonhaemolytic hyperbilirubinaemia in 16.5%, hypoglycaemia in 0.5%, septic infection in 0.8%, asphyxia in 4.0%, intracerebral haemorrhage in 0.3%, and cerebral symptoms in 0.7%. Maternal toxaemia, multiple pregnancy and maternal short stature were associated with spontaneous prematurity and a birthweight below the 10th percentile. Prematurity was associated with respiratory distress syndrome, hyperbilirubinaemia, hypoglycaemia, infection, low Apgar scores, asphyxia and intracerebral haemorrhage. Placental complications were associated with spontaneous prematurity, low Apgar scores and asphyxia. Premature rupture of the membranes was associated with spontaneous prematurity, infection, low Apgar scores and asphyxia.

Supporting the Breast-feeding Dyad

Although there has been a resurgence of breast-feeding in the last decade, 50% of women discontinue exclusive breast-feeding by the third month postpartum. Practices known to interfere with breast-feeding are often begun in hospital and continued at home. The physiology of lactation, the need for interaction between mother and infant during breast-feeding, and research findings indicate that scheduled feeds, feeds of limited duration, supplementation, and separation of mothers and infants interfere with the success of breast-feeding. Health care providers can promote breast-feeding duration by advising unlimited feeds, promoting 'rooming-in' at hospitals, and providing support and information.

Fecal bilirubin excretion and serum bilirubin concentrations in breast-fed and bottle-fed infants

To assess the rate of excretion of bilirubin in the stools and its effects on serum bilirubin concentrations, we studied 24 breast-fed and 13 bottle-fed infants during the first 3 days after birth. Bottle-fed infants passed significantly more stool (3-day totals, 82 vs 58 gm, P less than 0.001), excreted more bilirubin (3-day totals, 23.8 vs 15.7 mg, P less than 0.05), and had lower serum bilirubin values (day 3, 6.8 vs 9.5 mg/dl, P less than 0.02). Among the breast-fed infants, greater stool output was associated with greater fecal bilirubin excretion (r = 0.56, P less than 0.05) and lower serum bilirubin concentrations (r = 0.66, P less than 0.001). Our data suggest that hyperbilirubinemia in breast-fed infants may be related to a delay in bilirubin clearance resulting from low stool output.

Incidence of hyperbilirubinemia in breast- vs. formula-fed infants

A retrospective study of 233 consecutively born full-term infants was performed to determine the effect of several variables on the development of hyperbilirubinemia. Thirty-five (15%) of the infants developed peak bilirubin levels greater than 12 mg/dl in the first week of life. Step-wise multiple regression analysis revealed that breast-feeding was the most predictive of a group of eight variables for the development of hyperbilirubinemia greater than 12 mg/dl. The correlation between type of feeding and hyperbilirubinemia was significant (p less than 0.02). None of the other factors evaluated was significantly associated with hyperbilirubinemia. Breast-fed infants also were found to have a significantly higher incidence of hyperbilirubinemia greater than 15 mg/dl; 12 of 101 (12%) infants compared with 2 of 117 (2%) formula-fed infants (p less than 0.002). This group of infants accounted for the increased incidence of hyperbilirubinemia greater than 12 mg/dl in breast-fed infants. There was no significant correlation between weight loss and development of hyperbilirubinemia in the breast-fed infants.

Jaundice in full term healthy neonates--a population study

A geographically based population of 498 full term, appropriate for gestational age, healthy, singleton neonates was used to study the effect of obstetric and nursery practices on the occurrence of neonatal jaundice. At 3-4 days 56% of babies became visibly jaundiced (plasma bilirubin (PB) greater than 100 mumol/l) and 10% were hyperbilirubinaemic (PB greater than 200 mumol/l). Less mature babies, those slow to pass meconium and those who had lost weight at 4 and 7 days were more likely to be jaundiced. Obstetric practices, drugs given during labour, mother's or baby's blood group, natural illumination, plethora, extravasated blood or mode of feeding were found to have no effect. No benefit from giving supplementary milk or dextrose to breast fed babies was discovered. At 6-7 days at least 9% of babies, all but one of whom were breast fed, were visibly jaundiced. The frequency of prolonged jaundice (breast milk jaundice) was 3.8% of breast fed babies at 3 weeks and zero by 7 weeks. The proportion of babies receiving phototherapy was 2.2%.

Supplementary feeding and jaundice in newborns

In a survey it was found that the majority of full-term breast fed infants receive supplementary feeds of water, dextrose solution or infant formula during the first few days of life. Breast fed babies receiving water or dextrose supplements had higher plasma bilirubins on the sixth day of life than bottle fed infants. Supplementation with water or dextrose did not reduce the hyperbilirubinaemia of term, breast fed infants. Since it may prejudice the establishment of breast feeding, we suggest that the practice is abandoned.

Water supplementation in jaundiced babies

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Investigation and management of neonatal jaundice: a problem-orientated case record

A problem-orientated case record was used for the investigation and management of neonatal jaundice. Investigation of babies requiring phototherapy rarely showed any abnormality but we consider that such routine investigations are worth retaining. There were problems in the interpretation of moderately low plasma concentrations of thyroxine in small, preterm babies. There was biochemical evidence of hepatitis in 3 babies; in all 3 the biochemical abnormality was mild and had disappeared 6 months later in 2 of them. It may be that mild episodes of the neonatal hepatitis syndrome are more common than have been thought and that such infants have a fairly good prognosis.