When tongue-tie interferes with feeding
Tongue-tie—or ankyloglossia, an atypically short or thick lingual frenulum—is present in 3% to 16% of all births. The condition can make breastfeeding difficult; result in poor neonatal weight gain; and cause sore nipples in 25% to 44% of cases.30 Once tongue-tie is noted, the physician should talk to the mother about the history of feeding success, including whether her nipples are sore and whether the newborn is having difficulty feeding (ie, transferring milk). The Hazelbaker Assessment Tool for Lingual Frenulum Function and the simpler Bristol Tongue Assessment Tool can be used to assess the severity of tongue-tie.30-35
When tongue-tie interferes with feeding, a physician who is not trained in treatment can refer the mother and infant to a specialist in the community. Frenotomy has been used for many years as a treatment for tongue-tie; improvement in nipple pain and the mother-reported breastfeeding score have been reported postoperatively in several studies.30-33
Ensure proper vitamin D intake through supplementation
Newborns should consume 400 IU/d of supplemental vitamin D to prevent deficiency and its clinical manifestation, rickets, or other associated abnormalities of calcium metabolism. Deficiency of vitamin D has also been linked to a number of other conditions, including developmental delay and, possibly, type 1 diabetes mellitus in childhood and cardiovascular disease later in life.36
In the first months of life, few infants who are solely formula-fed will consume a full liter daily; for them, supplementation of vitamin D for at least one month should be prescribed.35 For breastfed infants, high-dosage maternal vitamin D supplementation may be effective, precluding infant oral vitamin D supplementation36; however, neither the AAFP nor the AAP has issued guidance promoting maternal supplementation in lieu of direct oral infant supplementation.37
Jaundice prevention—and recognition
An elevated bilirubin level is seen in most newborns in the first days of life because of increased production and decreased clearance of bilirubin—a condition known as physiologic jaundice. Conditions that aggravate physiologic hyperbilirubinemia include inborn errors of metabolism, ABO blood-group incompatibility, hemoglobin variants, and inflammatory states such as sepsis. It is important to distinguish physiologic jaundice from exaggerated physiologic and pathologic forms of hyperbilirubinemia; the latter is a medical emergency. Before we get to that, a word about prevention.
Prevention. Because poor caloric intake and dehydration are associated with hyperbilirubinemia, physicians should advise breastfeeding mothers to feed their newborn at least 8 to 12 times daily during the first week of life. However, routine supplementation of liquids other than breast milk should be discouraged in newborns who are not dehydrated.38
All pregnant women should be tested for ABO and Rh (D) blood types and undergo serum screening for isoimmune antibodies. Randomized trials have demonstrated that the incidence of significant hyperbilirubinemia can be reduced if, for Rh-negative mothers and those who did not undergo prenatal blood-group testing, infant cord blood is tested for 1) ABO and Rh (D) types and 2) direct antibody (Coombs’ test).38,39
Screening and assessment. It is recommended that all newborns be screened for jaundice before discharge by 1) assessment of clinical risk factors or 2) testing of transcutaneous bilirubin (TcB) or total serum bilirubin (TSB). Furthermore, because evidence shows that treating clinical jaundice can improve outcomes and rehospitalization, TSB should be measured in every newborn who has clinical jaundice in the first 24 hours of life. Measurement of TcB or TSB should also be performed on all infants in whom there appears to be clinical jaundice that is excessive for age.38,39
During routine clinical care, TcB measurement provides a reasonable estimate of the TSB level in healthy newborns at levels less than 15 mg/dL,40 although TcB testing might not be available in the outpatient office. An AAP management algorithm can help determine when a newborn should be seen for outpatient follow-up based on risk of hyperbilirubinemia; higher-risk newborns should be reevaluated in 24 hours.9 Outpatient visual assessment of jaundice for cephalocaudal progression—in a well-lit room, with a fully undressed newborn—correlates well with TSB test results. However, visual assessment should not be used alone to screen for hyperbilirubinemia; recent studies have demonstrated that such assessment lacks clinical reliability.40
Laboratory assessment. All bilirubin levels should be interpreted based on the newborn’s age in hours. The need for phototherapy should be based on the zone (low, low-intermediate, high-intermediate, or high, as categorized in the AAP nomogram38 in which the TSB level falls. TABLE 438-40 provides recommendations for laboratory studies based on risk factors. Standard curves for risk stratification have been developed by the AAP.37,38
Treatment. Decisions to initiate treatment should be based on the AAP algorithm.38 When initiating phototherapy, precautions include ensuring adequate fluid intake, patching eyes, and monitoring temperature. Phototherapy can generally be stopped when the TSB level falls by 5 mg/dL or below 14 mg/dL. Home phototherapy, using a fiberoptic blanket, for uncomplicated jaundice (in carefully selected newborns with reliable parents) allows continued breastfeeding and bonding with the family, and can significantly decrease the rate of rehospitalization for infants older than 34 weeks.41
Breastfeeding is often associated with a higher bilirubin level than is seen in infants fed formula exclusively; increasing the frequency of feeding usually reduces the bilirubin level. So-called breast-milk jaundice is a delayed, but common, form of jaundice that is usually diagnosed in the second week of life and peaks by the end of the second week, resolving gradually over one to 4 months. If evaluation reveals no pathologic source, breastfeeding can generally be continued. Temporary discontinuation of breastfeeding to consider a diagnosis of breast-milk jaundice or other reasons for an elevated bilirubin level increases the risk of breastfeeding failure and is usually unnecessary.12,37,39