Revised Newborn Jaundice Guidance Risks Preventable Harm

This is a response to the American Academy of Pediatrics’ August 2022 “Clinical Practice Guideline Revision: Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation,” published by Alex R. Kemper, MD, MPH, MS, FAAP; Thomas B. Newman, MD, MPH, FAAP; Jonathan L. Slaughter, MD, MPH, FAAP; M. Jeffrey Maisels, MB BCh, DSc, FAAP; Jon F. Watchko, MD, FAAP; Stephen M. Downs, MD, MS; Randall W. Grout, MD, MS, FAAP; David G. Bundy, MD, MPH, FAAP; Ann R. Stark, MD, FAAP; Debra L. Bogen, MD, FAAP; Alison Volpe Holmes, MD, MPH, FAAP; Lori B. Feldman-Winter, MD, MPH, FAAP; Vinod K. Bhutani, MD; Steven R. Brown, MD, FAAFP; Gabriela M. Maradiaga Panayotti, MD, FAAP; Kymika Okechukwu, MPA; Peter D. Rappo, MD, FAAP; Terri L. Russell, DNP, APN, NNP-BC in the journal Pediatrics.

New guidance from the American Academy of Pediatricians on managing jaundice in newborns normalizes dangerous complications of accidental starvation from breastfeeding, appears not to consider numerous possible iatrogenic harms from phototherapy, and does not compare the relative benefits and risks of the simplest strategies for treating neonatal jaundice and preventing its progression — namely, supplemental formula feeding before and during phototherapy. 

Starvation is the root cause of modal neonatal jaundice. Underfeeding worsens jaundice of all origins. Jaundice severity, in turn, increases risks including death and permanent brain injury. Preventing and treating starvation jaundice is literally as easy as giving a bottle.

Modern misconceptions about “exclusive breastfeeding” — a modern, Western intervention introduced without safety monitoring —commonly lead to insufficient milk intake in the days before mothers’ milk usually comes in, days or weeks before supply is established, and whenever insufficient milk persists or presents. This is a frequent occurrence and the cause of common, fully preventable harm. Current consensus normalizes signs of complications from resultant starvation including the appearance of pink uric acid crystals, excessive weight loss and crying, and jaundice. There is nothing normal or necessary about starving newborns.

The empirical literature links neonatal jaundice with possible substantial increases in neurodevelopmental harm including autism. It also links phototherapy with such risks. Of many jaundice-autism studies, the new AAP guidance authors cite only Wu et al 2016 — who estimate in line with other such studies that both jaundice-autism and phototherapy-autism effects may be quite substantial. This forms part of a body of evidence troubling the notion that phototherapy protects infants from harm, and suggesting that, rather, phototherapy may be associated with even more preventable harm than jaundice itself. This finding in the phototherapy-autism literature has been widely under-reported due to rampant misuse of statistical significance testing, a mistake denounced by leading methodologists

Before phototherapy, early modern healthcare providers advised breastfeeding moms to switch jaundiced babies to formula. The evidence still supports that treatment. Formula-fed newborns have greater bilirubin clearance than breastfed ones. Phototherapy efficacy hinges on excretion. Insufficient milk intake from breastfeeding likely first contributes to jaundice and its progression, and then compromises phototherapy efficacy. Phototherapy should be used as a second-line treatment after formula-feeding whenever possible, to minimize iatrogenic risks. Complementary formula supplementation should be standard with phototherapy.

Before breastfeeding’s modern resurgence in the mid-1970s, formula-feeding was the norm, and early modern societies lost generations of knowledge about safe breastfeeding. So reformers who brought breastfeeding back didn’t know what they didn’t know: All previous advanced civilizations had a safety infrastructure ensuring infants got enough to eat despite common breastfeeding insufficiencies. Prelacteal feeding traditions, shared nursing practices, and well-organized wetnursing professions were their common features. In most contemporary foraging societies today, newborns are breastfed by another lactating mother in the full 48 hours before their own mothers’ milk usually comes in. Starving newborns in the service of breastfeeding promotion is a well-intentioned but tragic, recent mistake. Treating jaundiced, breastfed babies with phototherapy may compound the permanent harm of this accidental neonatal starvation. It’s also not a humane response to hungry newborns.