Gs copier freon Sens AHRe Agency for Healthcare Research and Guality 4 Advani fxelene Heath cxe Digi Mears arity Guideline Summary NGC-7866 Guideline Title Guidelines for management of jaundice in the breastfeedi Bibliographic Source(s) ‘Academy of Breastfeeding Medicine Protocol Committee, ABM clinical protocol #22: guidelines for management of Jaundice In the breastfeeding infant equal to or greater than 35 weekS' gestation. breastfeed Med. 2010 Apr;s(2):87-93. [53 references] PubMed & nfant equal to or greater than 35 weeks' gestation. Guideline Status This is the current release of the guidaline. Academy of Braactfeading Medicine protocols expt five years from the date of publeaton. Evidence-based revisions are ‘made within five yeers or sooner if there are significant changes in evidence. Scope Disease /Condition(s) Newborv/infant jaundice Guideline Category Diagnosis Management Treatment Clinical Specialty Family Practice Nursing Nutrition Obstetrics and Gynecology Pediatrics Intended Users ‘Advanced Practice Nurses Allied Health Personnel Dictitians Hospitals Nurses Physician Assistants Physicians GuideSine Objectives) «To provide guidance in distinguishing those causes of Jaundice inthe newborn that are directly related to Treastfeeding from those that are not directly related to breastfeeding + Ta gulde monitoring of jaundice and bilirubin concentrations and management of these conditions in order to reserve breasteeding while protecting the Infant fom potenti risks of foxy from hyperbirubinemia ‘= To provide a protocol for hospital and office procedures for optimal management of Jaundice and hyperbilirubinemia in the breastfed newborn and young infantTarget Population ‘Nursing mothers and thelr newborn infants Interventions and Practices Considered 1. Prevention of potentially toxic serum bilirubin concentrations + Early Initiation of breastfeeding + Exclusive breastfeeding + Optimization of breastfeeding by provider trained in breastfeeding management. + Education on early feeding cues + Identification of at rik mothers and babies 2, Treatment. + Phototherapy + Temporary interruption of breastfeeding + Supplementation of breastfeeding 3. Follow-up with repeat serum bilirubin determinations Major Outcomes Considered + Toxicity from hyperbilrubinemla, including brain damage known as kernicterus or bilirubin encephalopathy + Preservation of breastfeeding Methodology Methods Used to Collect/Select the Evidence Searches of Electronic Databases Description of Methods Used to Collect/Select the Evidence ‘an initial search of relevant published articles written In English in the past 20 years in the fields of medicine, psychiatry, logy, and basic biological science Is undertaken for 9 particular topic. Once the articles are gathered, the papers bre evaliated far scientific accuracy and significance. Number of Source Documents Not stated Methods Used to Assess the Quality and Strength of the Evidence Expert Consensus (Committce) Welghting According to a Rating Scheme (Scheme Given) Rating Scheme for the Strength of the Evidence Levels of Evidence Evidence obtained from at least one properly randomized controlled trlal T-L Evidence obtained from well-designed controlled trials without randomization 19-2 Evidence obtined frm well-designed cohort or case-control analytic studies, preferably fom more than one center or research group 1-3 Evidence obtained from multiple time saries with or without the intervention. Dramatic results in uncontrolled experiments (suchas the results ofthe Introduction of pencil treatment inthe 1840s) could also be regarded as this type of evidence: III Opinions of respected authorities, based on clinical experience, descriptive studles and case reports; or reports of expert committees Methods Used to Analyze the Evidence ‘systematic Review with Evidence Tables Description of the Methods Used to Analyze the Evidence ‘an expert panel Is Identified and appointed to develop a draft protocol using evidence based methodology. An annotated bibliography (literature review), Inclading salient gape in the itsratore, 1s submitted by the expert panel Yo the brotocol Committee Methods Used to Formulate the Recommendations ‘Expert ConsensusDescription of Methods Used to Formulate the Recommendations. Not stated Rating Scheme for the Strength of the Recommendations ‘Not applicable Cost Analysis ‘A formal cost analysis was not performed and published cost analyses were not reviewed Method of Guideline Vatidation Extamal Peer Review Intemal Peer Review Description of Method of Guideline Validation Draft protocol Is peer reviewed by individuals outside of lead author/expert panel, including specific review for Inkaratonst spplicslity: Proto! Conmitiass sub-group of nernatonal pert racorimaris appropiate intemational reviewers. Chott (co-chaits) institutes and facitates process, Reviews submitted to committee Cat (eo-chaits)- Draft protocol Is submitted to, The Academy of Breastfeeding Madicine (ABM) Board for review and approval. Comments for rexsonvll be accepted or tree meets following submission. Ca (co-chaks} and protocol authors) amends motocl Following all revisions, protocol has final review by original author(s) to make final suagestions and ascertain whether to ‘maintain lead authorship. Final protocol is submitted to the Board of Directors of ABM for approval. Recommendations Major Recommendations: Management of Jaundice Prevention of Potentially Toxic Serum Bilirubin Concentrations: ‘Not all exaggerations of unconjugated hyperbilirubinemia in breastfed infants can be prevented, but close follow-up of the breastfeeding neonate to Insure against excessive weight loss from birth and adequate weight gain in the first month assutes the detection and intervention for potentially toxic serum bilirubin concentrations. (Nommsen-Rivers & Dewey, 2009; Harris et al., 2001; World Health Organization, 2009; Volpe, 2001; Maisels & Newmian, 1995) The following ‘measures ate recommended to keep serum bilirubin Concentzations in the normal, safe range while maintaining exclusive breastfeeding: 1. Early initiation ,_ Initiate breastfeeding as early a5 possible, preferably in the frst hour after birth. (Righard & Alade, 1990; Mixiel-Kostyra, Mazur, & Boltus2ko, 2002) Even with infants born by cesarean delivery, breastfeeding can be started In the first hour. 2. Exclusive breastfeeding should be encouraged. a, Its 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 breastigeding practices by the infant and delays establishment ff adequate milk production, increasing the risk of starvation and exaggerated hyperbilirubinemia, b. Breastfeeding infants should not be supplemented with water, glucose water, or formula. (See the section on {treatment of hyperbiirubinemia for use of supplementation in the infant with excessive serum bilirubin concentrations.) (de Carvaiho, Hall, & Harvey, 1981; Nicoll, Ginsburg, & Tripp, 1982; Ahn & MacLean, 1980; Brown, Dewey, & Allen, 198; Heinig at al’, 1983; Butte, Lopez-Alareon, & Gatza, 2002) Supplementation with expressed breastinilk, banked human milk, or formula (in that order of preference) should be limited to infants with at least Se athe lowing (Academy o Bresteeding Medicine (aBWH] Potocal Commitee, 200%; Powes Susser, 1997): |. A clear indication of inadequate intake as defined by weight loss in excess of 10% after attempts to correct breastfeeding problems. (Dewey et al., 2003; Nommsen-Rivers & Dewey, 2009) 1, Flue tn 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. li, 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.) 3. Optimize breastfeeding management from the beginning fa. Assure ideal position and latch from the outset by having a healthcare provider trained in breastfeedi Fanapement (ruts, lactation consultant, lactation educator, mie, or physician) evaluate position and atch (Riordan et al, 2001; Hall et al,, 2002) providing recommendations as necessary. 4. Education on early feeding cues. 2, Teach the mathe to respond tothe arlest cues of Infant hunger Including lip smacking, hand movements foward the mouth, restlessness, and vocalizing. (Gunther, 1955, Klaus, 1987). Infants should be put to the breastbefore tne onset of crying: Lying Is @ fate sign ot hunger and often results in a poor start to the breastreeaing pene yng. Crying) 9 rT Pe 0 5. Identification of at-risk mothers and bables. 2. ath matemal (2g. dabetes, Rh sencization) and lfant slated (a9. rulcng, prematurity, ABO diaase) health factors may Increase the likelhood of an infant developing signiticant hyperbilirubinemia, These factors can bbe additive with starvation Jaundice and/or breastmilk jaundice and produce even higher bilirubin levels than would otherwise be seen. When such risk factors are Identified tis prudent to seek lactation consultation in the ‘arly houts after delivery to assure optimal breastfeeding management. In certain instances (2.0., sleepy baby, bremature infant, motije-baby separation) motiers may benefit from interventions, such as early instructions in ‘manual oF pump stimulation of breasts to optimize mile supply and prevent delayed secretory activation of the’ Breasts (actogenests 11) b._Late preterm Infants ara at increased risk for severe hyperbilirubinemla because thelr greater tisk of breastfeeding difficulties (Meter, Furman, and Degenfiardt, 2007) often results in starvation jaundice In combination with higher levels 6f bilirubin because of the delay in the maturation of the liver’s capacity for bilirubin conjugation. If the 25-17 week premature infant manifests poor breastfeeding bshavior or Inadequate weight gain, consideration should be given to providing small amounts of expressed breastmilk, donor milk, or Supplerental formula after each breastfeeding until weight gain is established to avold starvation Jaundice in these infants, (ABM, 2005) Treatment of Excessive Hyperbiliubinemia ‘The reader is advised to carefully read and utilize the American Academy of Pedlatrics (AAP) Clinical Practice Guideline on Nonagament of typarbinubinamia inthe Newborn inant 2> o More Wecks f Gestion and the 2009 update to the guideline. (AAP Subcommittee on Hyperbilirubinemia, 2004; Matsels et al., 2009) ‘When efforts to prevent the rise of serum bilirubin concentrations into potentially toxic ranges in the breastfed infant Have faled, several treatment options ate avaliable, These management options may be combined. All modes of treatment re compatible with continuation of breastfeading, Recognizing that phototherapy for neonatal Inger blirubinemia, depending onthe care setting, may result in mother Infant Separation, pistons may opt to, inaitte supplementary feedings ot levels of bib omer thn those recommended for piototheropy inthe AAD Guideline. In other settings it may be possible to conduct phototherapy in the mother's room, and such therapy may be Jess disruptive to the breastfeeding process than supplemental feedings. Such dacisions shovid be individualized taking into account the specific clinieal setting and indleations for therapy with the goal ef keeping mother and baby together, reserving and optimizing breastiesding while delivering the reulred therapy to effectively treat the condition. Options Include photathe‘apy, temporary Supplementation with special formula, and temporary interruption of breastfeeding and replacement feeding with Infant special formula, ‘Because the parents may associate txeastfeeding with the development of joundica requiring special treatment or Fespitaieaton, they maybe econo continue beastecdng,Heafhcare provider should oe spec essence to these mothers to insure that they undercard the importance milk suppy if temporary Interruption is necessary. ‘The AAP Clinical Practice Guideline on Management of Hyperbilitubinemia in the Newbom Infant 35 or More Waeks of Gestation (see Figure 2 in the original guideline document) provides guidance about levels of total serum bilirubin (TSB) at which treatment fs recommended. (AAP Subcomrnittee on Hyperbiliubinemia, 2004; Maisels et al, 2009) Treatment leyels are adjusted for a number of fisk factors such as prematurity and hemolysis, The guidelines apply to the breastfed Infant 3& well as the formula fed infant. There is ne evidence to support allowing serum bilirubin levels In the broastied infant to rise above the fecommended limits, even when the apparent cause of the hypetbilirubinemia is either breastinilk jaundice or starvation, The reador Is Toferred to the AAP guideline (AAP Subcommittee on Hyporblirubinemla, 2004; Maisels et al.. 2009) for specific detailed information about bilirubin measurement by serum and transcutaneous methods and treatment including indications for exchange ransusion. (AAP Suivcommittee on Hyperlirubinemin, 2004; Matsels et al, 2009) The following information is meant to supplement the information offered in the AAP Guideline Treatment Options 41. Phototherapy. Phototherapy can be used while continuing full breastfeeding, ot it can be combined with either upplementation or temporary intemuption of breastfeeding with realacement feeding. (AP Subcommittee on Fiyperbiliubinemia, 2004; Malsels et al, 2009? Gartner & Lee, 1999) When serum Diffubin concentrations have alteady exceeded the phtotherapy indication level, especialy when rising rapidly ts best to start photatherapy and fot rely only on supplementation or temporary intefruption of breastfeeding alone because these will be slower In achieving the desired reduction. (Martinez et al., 1993) Phototherapy is best done in the hospltal and in the mother's oom or 2 pediatric room where mother and baby can stay together 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 some degree, infants under phototherapy do not routinely Fequira Intravenous fluids. They may be Indicated in cases of Infant dehydration, hypemnatemla, or inability to adequate milk, The routine provision of intravenous fluids is discouraged, however, as they may inhibit thirst ant diminish oral Intake. Breastfeeding infants who are readmitted from home for phototherapy should be admitted to a hospital unit in which ‘the mother can also reside so that breastfeeding can continue without interruption. Home phototherapy is possible, but discouraged, especialy for infants with risk factors. (AAP Subcommittee on Hyperbilinusinemia, 2004; Maissls et al, 2009) Home phototherapy may be appropriate for the rare infant with breastmilk joundica wha fequires phototherapy in the second or third weeks of Hfe if the serum bilieubin ts Tsing slowly or is stable and If there are no additional risk factors for kemicterus. 2. Alternatives to phototherapy. Phototherapy for neonatal hyperbiliubinemia may result in mother-infant separation ini some settings and thus adversely affect the establishment and ultimate long-term success of breastieeding, There Ig some uncertainty about exact levels at which treatment of hyperbiliubinemla is Justified, and clinicians must use their judgment as fo when to Institute a specific therapy taking into account the care setting, Individual maternal and Infant health Tactors, risks of the Infant developing sevare hyperbiliubinemia, and family preferences, When total ‘serum bilirubin (TSB) levels are close to AAP treatment tresholds (2-3 mg/dl or 34-51 pmol/L below) with ‘appropriate risk adjustments (see Figure 2 in the original guideline document), supplementation or replacement feeding with formula is reasonable in addition to or instead of phototherapy, if it can be done in @ way that is, ‘continuing breastfeeding and know how to maintain thelrportive of breastfeeding and the baby can be followed closely. Infants must be followed closely to ensure that the bilirubin levels are improving aporopriately with supplemental feedings, Bilirubin measurements should be undertaken ‘every 4-6 hours. Phototherapy should be Instituted if serum bilirubin levels reach AAP threshold levels adjusted for Fisk Factors and infant age. ‘3, Supplementation of breastfeeding. Con's milk-based formulas have been shown to inhibit the Intestinal absorption o binubin, Gartner, tee, a Mascon, 1983) Theafee, supplementation of breastfeeding with small mounts of Infant formula can fe uséd to lower serum billubin levels In breastfeeding Infants. (ABM Protocal Committee, 2009) Hydrolyzed protein formulas (elemental formulas) have been shown to be more effective than standard infant formulas in preventing intestinal absorption of bilirubin, (Gourley, Kreamer, & Arend, 1992) Hydrolyzed formulas ate preferred because they are less likely to Induce milk alleigy or Intolerance and may not be viewed by the patents as "switching to formula.” Excessive amounts of formula should be avoided so as to maintain frequent breastfeeding and preserve matemal milk production at 3 high level. If the mother fs not producing adequate milk or infant weiaht loss (=10%) or hyaiation indicate inadequate, lk production or mk trensfr tothe infant, then larger quantities of formula should be offered to insure adequate caloric Intake. Regards of whlch breastmilk substitute Is chosen, supplementation of breastfeeding should be achlevad by cup OF Use of @ supplemental nutsing device simultaneously with each breastfeeding. Nipples/teats and bottles should be avoided where possible. (ABM Protocol Committae, 2009) b, Temporary interruption of breastfeeding. Interruption of breastfeeding for 24-48 hours with full formula feeding will generally lower serum bilirubin concentrations more rapidly than supplementation, especially in the rare caso wwithextreme exaggeration of breastmilk jaundice. In infants luss than 9 days of age, interuption of breastfeeding ang replacement feeding wit formula may not be as effective as the use of phototherapy. (Martinez et a. 1993) Risk factor adjustments of serum bilirubin concentrations for the start of this therapy shauld be used as they would be for phototherapy. The use of hydrolyzed protein formula Is recommended for its greater efficacy. (Gourley, Kreamer, & Arend, 1002) With temporary interruption of breastfeeding, It is critical to maintain maternal ‘nilk production by teaching the mother to effectively and frequently express milk manually or by pump. The Infant, heeds to retun to 3 good supply of milk when breastfeeding resumes, or poor milk supply may result in a return of her serum bilirubin concentrations. If temporary interruption fails to promptly reduce bilirubin concentrations oF bilirubin levels continue to rise, then phototherapy needs to be considered. Post-treatment Follow-up and Evaluation Infants who have had any of the above treatments for excessive lirubinemia need to be carefully followed with repeat serum bilirubin determinations and support of breastfeeding because suboptimal breastmilk intake may result in recurrence of hyperbiliubinemia, Encouragement to continue breastfeeding Is of the greatest Importance since most of the parents of these infants will be {earl that continued breastfeeding may result n re jaundice o other problems, Thy can be (caesured tat this is pet the case, Even those infants with breastmilk jaundice who required treatment will not have sufficient rise in bilirubin with continued breastfeeding to require further Intervention. (Gartner & Arias, 1006) Clinical Algorithm(s) None provided Evidence Supporting the Recommendations References Supporting the Recommendations Academy of Breastfeeding Medicine Pratocal Committee. ABM clinical pratocal #2: haspital guidelines for the use of ‘supplementary feedings in the healthy term breastfed neonate, revised 2009. Breastfeed Med. 2009 Sep;4(3):175-82. PubMed Academy of Breastfeeding Medicine. Protocol #10: breastfeeding the near term infant (35 to 37 week gestation). New Rochelle (NY): Academy of Breastfeeding Medicine; 2005. ‘Ahn CH, MacLean WC Jr. Growth of the exclusively breast-fed infant. Am 3 Clin Nutr. 1980 Feb;33(2):183-92. PubNed ‘American Academy of Pediatrics Subcommittaa on Hyperbilirubinemia. Management of hyperbilirubinemia in the newborn {infant 35 of more weeks of gestation. Pediatrics. 2004 lul;114(1}:207-316. [28 references] PubMed = [Brown KH, Dewey KG, Allen LH. Complementary feeding of young children in developing countries: 2 review of current scientific knowledge. Publication no. WHO/NUT/98.1. Geneva: World Health Organization; 1938. Butte NF, Lopez-Alarcon MG, Garza C. Nutrient adequacy of exclusive breastfeeding for the term infant during the fst six ‘months of life. Geneva: World Health Organization; 2002. de Carvalho M, Hall M, Harvay D. Effects of water supplementation on physiological Jaundice in breast-fed babies. Arch Dis Child. 1984 1ul;56(7):568-9. Pubtted © Dewey KG, Nommsen-Rivers LA, Heinig MJ, Cohen RJ. Risk factors for suboptimal infant breastfesding behavior, delayed onset of lactation, and excess leonatal weight loss. Pediatrics. 2003 Sep;112(3 Pt 1):007-19. PubMed © Gartner LM, Arias IM. Studies of prolonged neonatal jaundice in the breast-fed infant. 3 Pediatr. 1966 Jan;68(1):54-66. PubMed © Gartner LM, Lee KS, Moscionl AD. Effect of milk feeding on intestinal bilirubin absorption in the rat. 3 Pediatr. 1983 ‘$e0:109(3):464-71, Publed eGartner LM, Lee KS. Jaundice in the breastfed infant. Clin Perinatol. 1999 2un;26(2):431-45, vl. [73 references] Pubmed # Gourley GR, Kreamer B, Arend R. The effect of diet on feces and jaundice during the frst 3 weeks of life Gastroenterology. 1992 Aug;103(2):660-7. PubMed w Gunther M, Instinct and the nursing couple. Lancet, 1955 Mar 19;268(6864):575-8. PubMed « Hall RT, Morcor AM, Toaslay SL, McPhorson DM, Simon SD, Santos SR, Meyers BM, Hipsh NE. A breast-feeding assessment score t6 evaluate the risk for cessation of breast-feeding by 7 to 10 days of age. J Pediatr. 2002 Nov;141(5)*659-64. PubMed & Harris MC, Bembaum 1C, Polin JR, Zimmerman R, Polin RA. Developmental follow-up of breastfed term and near-term Infants with marked hyperbilitubinemia, Pediatrés. 2001 May;107(5):1075-80, PubMed Heinig MJ, Nommsen LA, Peerson 3M, Lonnerdal B, Dewey KG. Intake and growth of breast-fed and formula-fed infants in relation to the timing of introduction of complementary foods: the DARLING study. Davis Area Research on Lactation, Infant Nutrition and Growth, Acta Paediatr. 1993 Dec;82(12)-999-1006, PubMed Klaus MH. The frequency of suckling. A neglected but essential ingredient of breast-feeding. Obstet Gynecol Clin North ‘Am. 1987 Sep; 4(3)-623-33. [21 references] PubMed & Maisels MJ, Bhutani VK, Bogen D, Newman TB, Stark AR, Watchko JF. Hyperbiliubinemia in the newborn infant > o weeks’ gestation: an update with clarifications, Pediatrics. 2009 Oct;124(4):1193-8. [20 references] PubMed © 35 \Maisels M0, Newman TB. Kemicterus In otherwise healthy, breast-fed term newborns. Pediatrics. 1995 Oct;96(4):730-3. PubMed Martinez JC, Maisels M2, Otheguy L, Garcia H, Savoranl M, Mogni B, Martinez 3C Jr. Hyperbiliubinemia in the breast-fed hewbom: a controlled tal of four interventions. Pediatrics. 1993 Feb;01(2):470-3. PubMed © Neer, Fuman LM Degenhordt M, Increased lactation sk for ate preterm infants and mothers: evidence and ‘managerhent strategies to protact breastfeeding. 1 Midwifery Womens Health. 2007 Nov-Dec;52(6):579-87. [58 references] PubMed IMikiel-Kostyra Ky Mazur , Boltruszko I. Effect of early skin-to-skin contact after delivery on duration of breastfeeding: 3 prospective cohort study. Acta Paediatr. 2002;91(12):1301-6. PubMed & ‘Nicoll, Ginsburg R, Tripp JH. Supplementary feeding and jaundice in newborns. Acta Paediatr Scand. 1982 $op;71 (5):759°61. PubMed’ ‘Nommsen-Rivers LA, Dewey KG. Growth of breastfed infants. Breastfeed Med. 2009 Oct;4 Suppl 1:545-9. PubMed & Powers NG, Slusser W. Breastfeeding update. 2: Clinical lactation management, Pediaty Rev. 1997 May;18(5):147-61. [9 references] PubMed i Righard L, Alade MO. Effect of delivery room routines on success of first breast-feed. Lancet. 1990 Nov 3;336 (8723):1105-7, Publied Riordan 2, Bibb D, Miller M, Rawlins T. Predicting breastfeeding duration using the LATCH breastfeeding assessment tool. J Hum Lact. 2001’ Feb;17(4):20-3. PubMed Volpe 31, Neurology of the newborn. 4th ed. Philadelphia (PA): W. B. Saunders; 2001. ‘World Health Organization. Welght velectty standards. Geneva (Switzerland): World Health Organization; 2009. Type of Evidence Supporting the Recommendations ‘The type of evidence supporting the recommendations is not specifically stated. The recommendations were based primarily on a comprehensive review of the existing literature, In cases where the literature does not appear conclusive, recommendations were based on the consensus opinion of the group of experts. Benefits/Harms of Implementing the Guideline Recommendations Potential Benefits ‘+ Appropriate management of jaundice in the newborn and young Infant = Preservation of breastfeeding Potential Harms ‘eqflthouah phototherapy inzeases insenible water ass to some degre Infants under phototherapy do nt routinety equire intravenous fluids. They may be indicated in cases of Infant dehyaration, hypematremia, ot Wak ingest agaeauate milk. The routine provision of intravenous fluids is cIscouraged, however, as ther may inhibit thst onsot tempore nterupton of breastfeeding, Wis etic te mantigatenal mil roduction by teachin the ‘Mik when bresstfeding restmes, Spoor milk supply many rest in's atu of higher serum blubincokcontek one Qualifying Statements Qualifying Statements coy f central goal ofthe Academy of Breastfeeding Medicine Is the development of clinical protocols fr ma 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 seive as standards of ‘medical care. Variations in treatment may be appropriate according to the needs of an individual patient. + A complete understanding of normal and abnormal states of both bilirubin and breastfeeding Is essential if optimal Gare is to be provided and the best outcome achieved for the child. These guidelines provide a template for this ‘management, but it remains wit) the healthcare providers to use these guidelines with judament and to adjust the ‘uidelines to'the individual needs of each infant. Implementation of the Guideline Description of Implementation Strateay ‘An implementation strategy was not provided. Institute of Medicine (IOM) National Healthcare Quality Report Categories 10M Care Need Getting Better Staying Healthy TOM Domain Effectiveness: Patient-centeredness Identifying Information and Availability ibographic Source(s) Academy of Breastfeeding Medicine Protocol Committee, ABM clinical protocol #22: guidelines for management of ‘SanSied in the brescteading tant caual to or reator than 98 mocks" gestation, Breasted Mad. 2010 Apr o(5) 87-93. [53 references] PubMed i ‘Adaptation ‘Not applicable: The guideline was not adapted from anather source, Date Released 2010 Apr Guideline Developer(s) ‘Academy of Breastfeeding Medicine Professional Association Source(s) of Funding ‘Academy of Breastfeeding Medicine ‘A rant from the Maternal Child Heslth Bureau, U.S. Department of Health and Human Services Guideline Committee Academy of Breastfeeding Medicine Protocol Committee Composition of Group That Authored the Guideline Gommitece Members: Maya Bunk, M.D. MSPH, FABH; Caroline J. Chant, M.D. FABM, Co-Chaipersan, Cynthia R Howard, M.0., MPH, FABM, Co-Chauperson; Ruth A. Lawrence, M.0., FABM; Kathleen A. Matinell, M.D, FABM, Com okeed gor; Lawrence ‘Noble, M.D., FABM, Translations Champersom; Nancy G. Powers, M.D., FABM; Julie Scott Taylor, Contributor: Lawrence Gartner, M.D. Financial Disdosures/Conflcts of InterestNot stated Guideline Status ‘This is the current release of the guideline ‘Academy of Braastfeading Medicine protocols expire five years from the date of publication. Evidence-based revisions are er ee eee Guideline Availabiity Electronic coples: Available in Portable Document Format (PDF) from the Academy of Bressttaeding Modicine Web site Print copies: Available from the Academy of Breastfeeding Medicine, 140 Huguenot Street, 3rd flor, New Rochelle, New York 10801. ‘Availabilty of Companion Documents The following Is avalabl + Procedure for protocol development and approval. Academy of Breastfeeding Medicine. 2007 Mar. 2 p. Print copies: Available from the Academy of Breastfeeding Medicine, 140 Huguenot Street, 31d floor, New Rochelle, New York 10801. Patient Resources None available NGC Status: This NGC summary was completed by ECRI Institute on October 18, 2010. 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