Section 3: Weight Loss Management, Supplementation, & Hyperbilirubinemia
The Academy of Breastfeeding Medicine’s Clinical Protocol #3, Hospital Guidelines for the Use of Supplementary Feedings in the Healthy Term Breastfed Neonate, Revised 2017 provides recommendations regarding early feedings, weight loss, and supplementation34:
- Small colostrum feedings are appropriate for the size of the newborn’s stomach. Eight to twelve feedings in a 24-hour period are sufficient to prevent hypoglycemia in the healthy, term, appropriate-for-gestational-age infant. Small feedings are easy to manage as the infant learns to coordinate sucking, swallowing, and breathing.
- Healthy term infants also have sufficient body water to meet their metabolic needs, even in hot climates. Fluid necessary to replace insensible fluid loss is adequately provided by breastmilk alone. Newborns lose weight because of a physiologic diuresis of extracellular fluid following transition to extrauterine life. The mean weight loss is 5.5% of birth weight in optimally exclusively breastfed infants and occurs between days 2 and 3 of life (48-72 hours after birth). A 10% weight loss is usually considered the high limit of what is acceptable.
- Optimally breastfed infants regain birth weight in an average of 8.3 days (95% confidence interval 7.7–8.9), with 97.5% having regained their birth weight by day 21.
- Percentage weight loss should be followed closely for outliers in this regard, but the majority of breastfed infants will not require supplementation.
Possible Indications for Supplementation in Term, Healthy Infants
Infant indications for supplementation
- Asymptomatic hypoglycemia documented by laboratory blood glucose measurement (not bedside screening methods) that is unresponsive to appropriate frequent breastfeeding.
- Symptomatic infants should be treated with intravenous glucose. (Please see ABM Hypoglycemia Protocol for more details.)
- Clinical and laboratory evidence of significant dehydration (e.g., 10% weight loss, high sodium, poor feeding, lethargy, etc.) that is not improved after skilled assessment and proper management of breastfeeding.
- Weight loss of 8–10% accompanied by delayed lactogenesis II (day 5 [120 hours] or later).
- Delayed bowel movements or continued meconium stools on day 5 (120 hours).
- Insufficient intake despite an adequate milk supply (poor milk transfer).
- Early, frequent, unrestricted breastfeeding helps to eliminate bilirubin from the baby’s body through stools. Since breastmilk has a laxative effective, frequent breastfeeders have more stools and lower bilirubin levels.
- Breastfeeding jaundice may occur in the first week of life in more than 1 in 10 breastfed infants. The cause is thought to be inadequate milk intake leading to dehydration, or low caloric intake. It is a type of physiologic or exaggerated physiologic jaundice.
- Breast milk jaundice is far less common and occurs in about 1 in 200 babies. Here the jaundice isn't usually visible until the baby is a week old. It often reaches its peak during the second or third week. Breast milk jaundice can be caused by substances in mom's milk that decrease the infant's liver's ability to deal with bilirubin. Breast milk jaundice rarely causes any problems whether it is treated or not. It is usually not a reason to stop nursing.35
- When macronutrient supplementation is indicated.
Maternal indications for supplementation34
- Delayed lactogenesis II (day 5 or later [72–120 hours] and inadequate intake by the infant.
- Retained placenta (lactogenesis probably will occur after placental fragments are removed)
- Sheehan’s syndrome (postpartum hemorrhage followed by absence of lactogenesis)
- Primary glandular insufficiency, which occurs in less than 5% of women (primary lactation failure), as evidenced by poor breast growth during pregnancy and minimal indications of lactogenesis
- Breast pathology or prior breast surgery resulting in poor milk production.
- Intolerable pain during feedings unrelieved by interventions.
Jaundice and some degree of hyperbilirubinemia are normal and expected aspects of newborn development. Data indicate that approximately 40% of healthy newborns have a total bilirubin of 5mg/dL at 24 hours and 7 mg/dL (120 µmol/L) by 36 hours of age. This normal elevation in unconjugated bilirubin is termed physiologic hyperbilirubinemia of the newborn.
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 healthcare providers. The Academy of Breastfeeding Medicine Protocol provides guidance in:
- Distinguishing those causes of jaundice in the newborn that are directly related to breastfeeding;
- Monitoring of jaundice and bilirubin concentrations and management of these conditions in order to preserve breastfeeding while protecting the infant from potential risks of toxicity from hyperbilirubinemia;
- Implementing a protocol for hospital and office procedures for optimal management of jaundice and hyperbilirubinemia in the breastfed newborn and young infant.
Inappropriate Reasons for Supplementation, Responses and Risks34
The Academy of Breastfeeding Medicine Clinical Protocol #3: Supplementary Feedings in the Healthy Term Breastfed Neonate, Revised 2017 provides guidance on supplementation. Refer to Table 1. Possible Indications for Supplementation in Healthy, Term Infants (37–41 6/7 Weeks Gestational Age) as well as Appendix “Inappropriate Reasons for Supplementation, Responses, and Risks" for more information.