Lifelong Impact? The Effect of Phototherapy Admission on Future Breastfeeding Free

Breastfeeding is the physiologic normal method of infant feeding and has been found to have potential lifelong infectious, allergic, and oncologic impact.^1,2  Readmission of infants for treatment of hyperbilirubinemia with phototherapy is common. Although there is some research on the effect of birth hospitalization phototherapy on future breastfeeding,³  very little is known about the impact that readmission may have on provision of breast milk after discharge. Although there are standardized recommendations for the management of breastfeeding during the birth hospitalization (operationalized through the Baby Friendly Hospital Initiative⁴ ), there is not a program for standardized breastfeeding support in the pediatric inpatient setting outside of the birth hospitalization. Support varies widely depending on aspects of the inpatient setting.

The authors in this month’s Hospital Pediatrics⁵  conducted a retrospective cohort study using electronic health records over a 4-year period at 16 hospitals. A large cohort of infants (7729) was included with 26.5% readmitted for phototherapy (bilirubin levels between 1 point below and 2.9 points above phototherapy threshold per the AAP guidelines and <15 days of age). They then assessed infants at 2 months of age for any versus exclusive breastfeeding, compared to infants in a comparable cohort that were not readmitted. Phototherapy readmission was associated with a lower adjusted risk of exclusive breast milk feeding at 2 months (relative risk: 0.9; 95% confidence interval 0.84–0.96). There was no significant difference in any breast milk feeding. Age, first outpatient total serum bilirubin (within 1.0 mg/dL), sex, gestational age, delivery mode, maternal age, average number of formula feedings per day at birth hospitalization, time of birth, and race or ethnicity were controlled between groups.

This study could have been strengthened by the addition of information on maternal factors which may impact both risk for readmission for hyperbilirubinemia and risk for formula supplementation at 2 months. Maternal obesity⁶  and gestational diabetes^7,8  can impact successful establishment of lactation and mature milk supply which could result both in readmission and need for formula supplementation at 2 months. This is especially important during the age groups of patients in this study, because maternal milk supply is still being established within the first 2 weeks of life. There was also limited information on specific lactation support available during the hospitalization, and whether this could have varied according to site. However, the authors did acknowledge that the medical system studied has a strong commitment to supporting the breastfeeding dyad. An additional limitation in this study was the lack of discussion of socioeconomic status (SES) among the admitted versus not readmitted groups. Maternal education, socioeconomic status, and partner occupation can affect breastfeeding rates.⁹  SES impacts access to both outpatient lactation support and availability of resources including frequent home visits.¹⁰  Although the authors discussed frequency of formula use during the birth hospitalization, formula use during readmission was not reported. In some cases, physicians may recommend temporary cessation of breast milk feeding or supplementation with formula to help lower bilirubin. Although this may not have been as common at the bilirubin levels studied, it would be helpful to know if provider recommendations for formula use was correlated with decreased breast milk intake at 2 months of age.

Need for readmission to the hospital for treatment of hyperbilirubinemia can take a toll on maternal confidence and stress, which can affect breastfeeding dyads both at the time of admission, and presumably several weeks after. Mothers frequently feel pressure to provide for their child’s every need, and the need for readmission for phototherapy can imply that they are failing to meet the infant’s needs. In addition, hospital admissions for any reason are stressful, and this stress can further decrease maternal milk supply.¹¹  Hospital visitor restrictions can unintentionally limit mother and baby’s support system, and a mother recovering from birth needs her basic needs met to be able to produce breast milk for her baby. This has been highlighted during the coronavirus disease 2019 pandemic. Therefore, although readmission for treatment of hyperbilirubinemia can potentially lead to decreased breast milk consumption because of maternal confidence and physician recommendation for supplementation, infant readmission for any reason may impact the ability to exclusively breastfeed because of maternal stress and access to lactation support. More research is needed to understand whether the observed decrease in exclusive breast milk feeding is because of readmission for hyperbilirubinemia specifically or would be associated with infant readmission for any reason.

There is little research about how to adequately support the breastfeeding dyad through a readmission, but protocols are available to provide practical support. As hospitalists, it is a frequent occurrence that we care for breastfeeding neonates admitted both for hyperbilirubinemia, and other reasons. Therefore, it is imperative that we understand how to support the breastfeeding dyad both during the hospitalization and after discharge. The Academy of Breastfeeding Medicine (ABM) has protocols publicly available pertaining to infants admitted for hyperbilirubinemia and infants and mothers admitted for other reasons.^12,13  In the event of readmission of mother or infant, the ABM recommends room sharing and allowing the infant to have unlimited access to their mother, whose nutritional and physical needs are supported. Mothers should also have access to lactation support and a breast pump, ideally a hospital grade double electric pump, if the baby has decreased intake or is not able to directly breastfeed. The ABM recommends early and frequent breastfeeding, and skin to skin to help establish maternal milk supply. Increased breastfeeding frequency in the first few days of life is associated with lower total serum bilirubin.¹⁴  When phototherapy is indicated, home phototherapy is preferred to admission to the hospital. When admission is necessary, routine intravenous fluids are discouraged in the absence of clinical dehydration or electrolyte abnormalities. With significantly high serum bilirubin, supplementation with additional milk may be recommended to facilitate decreasing the bilirubin level, especially if phototherapy is not readily available. In these cases, pumped maternal breast milk is preferred to formula. In limited cases, supplementation with formula can be considered to avoid reaching light level, or as an adjuvant to phototherapy.

Further research is needed to understand factors that may predispose an infant to both readmission for hyperbilirubinemia, and inability to exclusively breastfeed after admission. However, in the meantime, it is important that hospitalists help support breastfeeding dyads in any way feasible during hospitalization for hyperbilirubinemia or other indications. Ideally, hospitals should develop protocols to encourage lactating mothers to have unlimited access to their infants, optimizing lactation support and availability of breast pumps, encouraging frequent breastfeeding or pumping to maintain milk supply, and supporting mother’s needs to decrease the stress of hospitalization to whatever extent possible. For infants admitted for hyperbilirubinemia, hospitalists should encourage supplementation with pumped breast milk if supplementation is necessary for rehydration. The hospitalist is in a unique position to assure support for the breastfeeding mother or infant who may be readmitted after the birth hospitalization. Implementation of hospital guidelines around management of breastfeeding during the admission have the potential to impact breastfeeding during hospitalization and for the duration of the breastfeeding relationship.