newborn jaundice and formula supplementation

[newyorkmommy]

Hi everyone,

As I approach my fourth hospital birth, I'm feeling pretty stressed out about dealing with the doctors and nurses and in particular the issue of jaundice and formula supplementation.

With our first, I knew very little and didn't have much to say to fight the pediatrician's suggestion that we supplement our baby -- who had some jaundice and a little trouble breastfeeding but was not dehydrated or, in retrospect, very high on the bilirubin chart. The supplementing started us off on a really bad foot and contributed to some PPD for me and just was generally crappy, mostly because it so was not what I wanted. We got off it eventually but it took about 5 weeks (at which point my regular pediatrician even said, "Wow, I didn't think you could do it." Lovely.)

Anyway, with the next two births I was so paranoid about this that I basically made sure we got out of the hospital at the first sign of yellow baby so as not to be hassled. And, my milk came in a little sooner this time, so that helped, too.

But this next birth is going to be a scheduled csection, and at least 2 weeks early, both of which I know can influence jaundice in a baby. So -- stress .........

Sooooooooooooo, trying to be proactive, I went to meet with one of the pediatricians from the group who attends at the hospital yesterday, and while very "nice," I felt like he was just saying what he thought I wanted to hear. He said everything would be done "in partnership" with me, i.e. nothing behind my back, but also said one of the markers he looks for is weight loss and that generally anything over 10% is  when he might start thinking about supplementing.

Does anyone have any thoughts on this? Is this reasonable or unreasonable?

I can't wait to just get in and get out!

Thanks in advance.

[hildare]

ddcc- this is a concern for me too....\

you don't have to supplement with formula.  you can substitute with colostrum, your pumped milk, your pumped colostrum, or someone else's breastmilk.  do you have friends/relatives you would feel good about asking for this? 

also, jaundice and the weight loss are two separate issues.  you absolutely CAN refuse to let them supplement.  it will probably help if you don't let them take baby to the nursury, though with an early scheduled c-birth, that is more likely...  can your partner stay with the baby at all times?  if no partner, a doula/friend/ relative? 

you'd probably leave the hospital and go for another visit before the weight gain could be an issue.  and the baby wouldn't be available for anyone to give formula to, unless you chose to do so. 

are you able to have any leeway with the scheduling?  i know for some conditions it's actually medically necessary to schedule an early c-birth, but if you don't have an actual medical reason to do so, it's probably in your/baby's best interests to wait.  many hospitals now won't even schedule that early...  if you have to though, i wish you the best..  that's not easy. 

when i c-birthed dd in hospital, they gave formula, just a little, and she had jandice and was a HUGE baby.  i was out of it from the drugs and had put NO FORMULA in my birth plan; as soon as i realized what was happening, i got them to give me the pump, which they were very happy to do.  though i intend to do everything possible to prevent even that this time, as i think her stomach/colic problems were very much due to the formula, even that small amount.

does that hospital have a lactation nurse available?  could you speak with that person too, ahead of time, and explain your concerns and request, in your birth plan and otherwise that the lactation person attend you as soon as possible after the birth?  that should help immensely. 

good luck to you mama!!! 

[emmaegbert]

My first had jaundice but he was pretty large and my milk came in. Nobody said anything about supplementation (this was is a very BF-friendly hospital in California). But they kept him for phototherapy and observation for 4 days. UGH. My second, I had her at home and didn't take her in, she also had jaundice. I avoided the ped for 2+ weeks b/c of this and MWs supported that decision. My current MWs are also pretty clear on avoiding doc if baby is a little yellow. I would personally avoid supplementation for jaundice, unless the baby's behavior indicated that there was a problem and bilirubin levels were actually harmful (and in that case I would prefer using donated BM rather than formula but I realize a hospital is going to go for that). I really quizzed them on this with my first time and I wonder if that is part of why they never even mentioned supps to me. Maybe if you can stay really firm on insisting that they wait while bilirubin levels are high but not to the level to cause brain damage... can you research these numbers or ask your regular ped what those numbers are before hand so you know? There is a legitimate concern, but the numbers are much higher than those at which they generally start treating for jaundice.

FWIW my MWs recommended a FP who is based in lower manhattan (I think you are in Bkln so maybe that is not reasonable) who is very natural-health minded and does not recommend routine treatment of normal newborn jaundice. Dr Raymond Teets (Phillips Family Pracitce). I took my kids to him in June and he was great. Very hands off approach. You might look at having him lined up as your baby's PCP or looking for someone else similar? I just mention this specific doc since I know you are also in NYC.

[newyorkmommy]

Thanks, everyone.

hildare, I do really have to have a c this time. I had a scar separation (uterine rupture) with my last delivery, so even I don't want to chance that again -- and, everything I have read supports 38 weeks as being full term. My doctors have actually assured me that there's very little chance of the baby having to go to the NICU ... and we are doing an amnio the day before the surgery to test for lung maturity ... and, I'm told the baby does not even have to go to the nursery except perhaps once a day for routine nonsense (though of course we can fight that too), and during that time my DH can go with her, so she definitely will not be alone at any point. He has the same concerns and will be vigilant.

My main concern is that I will be bullied into it -- the old "it's for the health of the baby" routine -- and not have the medical knowledge to back up a different point of view, so I guess I need to do some research and just don't know quite where to turn, since of course there will be a study out there for every point of view. Maybe I'll start with AAP and/or ACOG, since the docs are most likely to respect those, and see what they say. And Dr. sears is reasonable, maybe he has some thoughts as well.

emmaegbert, thanks, I have a more relaxed FP in Brooklyn but she does not have privileges where I'm delivering (in Manhattan), so I won't see her immediately is what I'm guessing. Like I said, hoping I can just get in and then get out asap -- in my experience, usually 3 days with a c-section will do it, so hoping that is true this time as well.

[Dreamy]

Sorry you have to go through this, I'm terrified of having to have a c-section for similar reasons

If you want to try everything you can to avoid these issues and feel a later delivery date would help, these articles might help - there is a huge push out there to not schedule any c-section deliveries before 39 weeks:

http://www.marchofdimes.com/csection_lastweeks.html

The image at the end of this article provides a good visual summary of the systems that finally mature by 39 weeks: http://online.wsj.com/article/SB10001424052748704615504576172291331227676.html

As for supplementing, remember that hand expression is much more effective than the pump for obtaining colostrum. My son was a bit jaundiced, so I hand expressed into a teaspoon, then fed him via syringe - worked like a charm!

Good luck.

[Leiahs]

I was just reading something the other day about jaundice and supplementation.  Maybe it would be helpful for you, give you some more "ammo"?

http://www.drjen4kids.com/soap%20box/jaundice.htm

I hope you're able to avoid undue pressure.  I really feel for you, because I tend to be easily bullied into doing things I don't want to do, even when I feel like I've solidly researched it beforehand.  (Which has led to me having a pretty major doctor avoidance complex for anything that isn't major, ugh.) 

[corrabelle]

Originally Posted by Leiahs 

I was just reading something the other day about jaundice and supplementation.  Maybe it would be helpful for you, give you some more "ammo"?

http://www.drjen4kids.com/soap%20box/jaundice.htm

I hope you're able to avoid undue pressure.  I really feel for you, because I tend to be easily bullied into doing things I don't want to do, even when I feel like I've solidly researched it beforehand.  (Which has led to me having a pretty major doctor avoidance complex for anything that isn't major, ugh.) 

This! Also, I second having colostrum collected if at all possible, or milk from a friend? (If you're comfortable with that.) I don't know if you've tried pumping colostrum, but i've always found that hand expression works much better. I have about 2 oz collected just in case this happens, as both my other kids were jaundice and I too was forced to supplement. My first actually was dehydrated, so I don't regret supplementing, but I do wish that I had known to try to collect colostrum beforehand or use donated milk.

Also, if you do end up having to supplement (be it with formula or breastmilk) try to do it from a spoon or cup, rather than a bottle. They get used to the flow of that bottle and then have a hard time switching to the breast later.

I'm crossing my fingers for you-this is a worry of mine as well!

[not_telling]

Ohh...we went through this with DS.  He was a huge newborn (at least 95th percentile)...he didn't latch on until 8 hours after he was born and we had some breastfeeding issues the first 5-6 days.  He did end up losing 10% (or a little more?) of his body weight that first week and he was a little jaundiced.  I don't recall now if I knew numbers or not because I was unable to attend his ped appointments that week (I had severe SPD issues after delivery).  I worked with a lactation consultant who said I should pump when I wasn't trying to nurse and supplement that way...but she also was in agreement with our ped when our ped recommended supplementing with formula...I think more because of the weight loss.  The LC gave us this syringe...I think she said it was a dental syringe...plastic with a long skinny "snout."  Whenever we supplemented with colostrum/breastmilk or formula (which we did end up using a little bit for maybe 4-5 days), we gave it to the baby by placing the skinny tip of the syringe alongside one of our pinky fingers, then letting the baby suck the pinky finger and squirting just a little bit of milk/formula in when the baby made a sucking motion.  We supplemented only after DS had had a nursing session (successful or unsuccessful).  I really wasn't able to get much out of me via pumping, and I was worried about weight loss...though maybe, with such a big baby, I shouldn't have been...?  DS had no problem returning exclusively to breastmilk in his second week and no problem with returning exclusively to breast a little while after that.

[emmaegbert]

nymommy, could you at least call your FP if a discussion of supplementing is coming up? Maybe she would consult with the hospital docs? I don't know. I remember that you have worries about how you will handle pressure from the hospital staff.

Here is to hoping its NOT an issue. Its just the jaundice is so normal- a quarter of babies get it. And the vast majority of the time- as you well know- it resolves on its own. Just knowing that may help you go into this asking more questions. One tactic I have when I am feeling nervous with HCP is to just really quiz them. Sometimes showing that you are really knowledgable and interested in the details helps them see you as a different kind of patient. Also it sometimes buys me time to get some confidence.

[Jane]

I would concentrate on getting your milk in ASAP. Babies need both their liver to work properly to excrete the bilirubin, and they need to poop. The liver thing is ALL up to the baby, but you can help with the pooping by getting more milk/colostrum into the baby.
There is usually a greater delay in milk arriving after a c-section, but you will be avoiding the labor part, so that helps A LOT. Also, not your first child, so that helps in getting milk quick.
You could consider adding in a pumping session per day to add additional stimulation. Also, something like a more milk plus tincture, or just plain fenugreek to hurry milk a long. I have had one client start Dom just hours after birth due to a previous low milk supply issue. She ended up with massive milk on day 2. I'm not sure that was helpful long term, but it was her choice with her physician to do so.
If you want to be totally belt-and-suspenders about it, get some donor milk. 1-2 ounce portions are not suspicious. Just 10 ounces of donated milk is probably enough to supplement a medium jaundiced child until your milk arrives.

[NicaG]

Here's my experience.  I'm in a little different situation because I have gestational diabetes, which puts my babies at risk for jaundice.  My first ds had to be hospitalized a few days after birth, and I wanted to avoid hospitalization at all costs for my dd.  I am also a huge advocate of breastfeeding and nursed both my kids until they were around 2.5.  But here's what I've done:

With ds, I was a first-time mother and I didn't quite realize the gravity of the situation after we took ds home.  He was very sleepy and not much interested in nursing (this is common for jaundiced babies).  I took him in to the pediatrician for a routine checkup after he had been home for about 2 days.  My milk had not come in yet.  The pedi wasn't much concerned....until she got the results of the bilirubin test, at which point we had to go directly to the hospital and start light treatment, etc. because his levels were very very high.  He was also very dehydrated. I was a wreck.  They immediately started feeding him formula, but they told me I could bring in my breast milk as soon as it came in.  He had to be in the hospital for maybe 3 nights.  My milk came in on the second day he was in the hospital, and I learned fast how to pump.  Ds was fine after a couple days, but the whole experience was awful.

Three years later, I desperately wanted to avoid hospitalization for dd when she was born.  She was also very jaundiced, but she was more eager to nurse and latched on immediately after she was born and latched on well every time I tried nursing her at the hospital.  After a day, my milk still hadn't come in, so I started supplementing with formula.  The pediatrician actually thought this was unnecessary, but I wanted to flush the bilirubin out of her system and get her home as soon as possible, rather than risk having to admit her to the nicu.  With the formula, her numbers were borderline but they let me take her home, though I did have to take her back to the hospital every day for a few days to test her levels.  I kept trying to nurse, but she wasn't getting much. In retrospect, I think she was probably more alert and interested in nursing because she was getting some formula--if her numbers had just been rising and rising, she might have been too sleepy to nurse.  Eventually my milk came in and we phased out the formula.  She was a good nurser, so we never had any issues with nipple confusion etc. We never used formula again with her and it didn't disrupt breastfeeding for us at all.  I'm just glad she stayed out of the hospital. The doctors never pushed formula or doubted my ability/intent to breastfeed after that.

I will probably supplement with formula for the first few days with this baby too, to keep him out of the hospital.  I fully plan to breastfeed, but I feel it's more important that ds is with us and not at the hospital, so I don't mind using formula to make that happen.  If we weren't at such high risk of jaundice, I might feel differently.  Good luck!

[corrabelle]

a bit of a spin off...those of you who had really jaundice babes, did your babies get the vitamin k shot? Apparently that's a huge factor in jaundice.
Just curious.
Mine both did, we're doing the oral drops this time, if necessary, but I haven't really decided yet. I'm also taking alfalfa to boost my own k levels, which will transfer some in breastmilk too. (Also, post partum bleeding for the mama is supposed to be a lot less if you take alfalfa. sounds like a win win!)

[newyorkmommy]

Hm ... where did you read that about the Vitamin K?

Not sure I'll have a choice, but it's a thought.

I'm sure mine have always had the shot. The best I could do was to delay it an hour or two.

[corrabelle]

I have some links saved, I just have to find them. I'll post them once I do. (But for now, try googling vitamin k+newborn+jaundice...I think there are quite a few mentions out there.)

[~pi]

Originally Posted by newyorkmommy 
Sooooooooooooo, trying to be proactive, I went to meet with one of the pediatricians from the group who attends at the hospital yesterday, and while very "nice," I felt like he was just saying what he thought I wanted to hear. He said everything would be done "in partnership" with me, i.e. nothing behind my back, but also said one of the markers he looks for is weight loss and that generally anything over 10% is  when he might start thinking about supplementing.

Does anyone have any thoughts on this? Is this reasonable or unreasonable?

This has evidence behind it. Without having been there for the discussion, he sounds reasonable about it, and probably open to discussion.

A good source for up to date, evidence-based recommendations related to breastfeeding is here: Academy of Breastfeeding Medicine protocols. Jaundice is in the list (scroll down to #22.)

If you aren't happy with what they are recommending, I've always had a lot success coming to consensus using the following kind of phrasing, "OK, I understand the rationale for doing XYZ, and I certainly don't want to put my baby at unnecessary risk. Exclusive breastfeeding is really important to me and my family, so I'm wondering if there are any other steps that could be reasonable to try before we move up to that level."

The bit highlighted in red are magic words when talking to good health care providers. They will really go out of their way to take that into account. (If they aren't very good HCPs, then you're out of luck and that won't work. But if this guy was talking about working in partnership with you, that's code for being open to these kinds of statements.)