The impact of the maternal experience with a jaundiced newborn on the breastfeeding relationship

Neonatal jaundice is the most common condition for which newborns are tested, treated, and often rehospitalized, resulting in millions of dollars of annual expenditure.^1-3 Two types of jaundice are associated with breastfeeding⁴: early jaundice, or breastfeeding jaundice, caused by the infant receiving insufficient breast milk^5,6; and breast milk jaundice, which develops later in a thriving breastfed infant and is thought to be caused by a substance in the breast milk.^7,8

Diagnosis and treatment of jaundice can begin within the first few days after birth, while the breastfeeding relationship is being established. Despite the ongoing debate on the appropriate protocol for jaundice management^9-11 and a wide variance in physician practice,^12,13 little research has examined the effect of the jaundice experience on the newborn’s mother. The few studies to directly examine the influence of jaundice management on breastfeeding show that protocols such as maternal-infant separation for phototherapy or temporarily suspending breastfeeding are associated with a shorter duration of breastfeeding.^14-16

What remains unclear is how jaundice management affects breastfeeding. Our study adds to existing knowledge by exploring the process by which the maternal experience with a jaundiced newborn affects the mother and her breastfeeding decisions. Qualitative methods, guided by grounded theory, were used because of the paucity of information on this topic and the study’s focus on process.^17-19

Methods

Settings

Two distinct sites in Chicago were chosen to increase the heterogeneity of experiences: a community hospital serving a mixed-income and ethnically diverse population, and an urban teaching hospital serving primarily low-income Latino and African American patients. Breastfeeding initiation rates, tracked by the University of Illinois at Chicago breastfeeding task force, were 70% and 40%, respectively. Institutional Review Board approval was obtained from both sites.

Sample

Two purposeful sampling strategies were employed.²⁰ Criterion sampling was used to recruit mothers, identified through medical record abstraction of all jaundiced infants, who met the following criteria: Spanish or English speaking; exclusively or partially breastfeeding at postpartum discharge; and mother of an otherwise healthy term newborn who had a serum bilirubin level of =10 mg/dL within the first month of life and received care through a study site in 1 or more of the following settings: newborn nursery, outpatient clinic, hospital ward, or home. Maximum variation sampling, which seeks heterogeneity within the sample to permit examination of common themes, was applied to achieve variation in ethnicity, language, age, parity, and jaundice treatment. Eligible mothers were invited by phone to participate in an interview. Sampling continued until data from new interviews confirmed earlier data, signifying that theoretical saturation was achieved.¹⁸

Data collection

Using the literature on hyperbilirubinemia and breastfeeding, an interview guideline was developed addressing the topics in Table 1.²¹ Three female ethnographers (including authors S.K.W. and P.R.H.) conducted in-depth, semi-structured interviews in women’s homes. The interviews were approximately 60 minutes in length given in either Spanish or English. Women were encouraged to lead the conversation, with ethnographers using prompts to guide the discussion toward any topics not addressed and probes to elicit detailed descriptions of the women’s experiences. Audiotaped interviews were transcribed verbatim, and edited by the ethnographer to ensure accuracy and include field notes. Spanish-language interviews were translated into English. Participants received no financial incentives.