Strength of recommendation (SOR)
- Good-quality patient-oriented evidence
- Inconsistent or limited-quality patient-oriented evidence
- Consensus, usual practice, opinion, disease-oriented evidence, case series
Baby M is a 12-hour-old 40-week gestation boy, without any risk factors, whom you delivered vaginally to a first-time mother last evening. The following morning, his mother tells you that while she intends to breastfeed exclusively, she was told by a staff member in the nursery to give the baby some formula “until your milk comes in, so he won’t be so cranky.” The child appears entirely well.
The next morning, at 36-hours-of-age, Baby M still appears well, except that he is jaundiced. His bilirubin level is 15—just above the level at which phototherapy should be started, but well below the level at which an exchange transfusion is required. You order a transfer to the nursery for phototherapy.
You order IV fluids to prevent dehydration and to enhance the excretion of bilirubin. To bring his bilirubin level down more quickly, you advise the mother to temporarily stop breastfeeding and feed him a standard infant formula. The nursing staff gives the mother a breast pump to use until breastfeeding is re-started.
Forty-eight hours later Baby M is ready for discharge, and the mother has questions about infant feeding practices. You and the nurse explain to the mother that “breast milk provides complete nutrition” for her baby and that the baby will need no other nutrition until he starts solid foods at around 4 to 6 months of age.
Routine care, but was it appropriate?
The care you provided to Baby M and the advice you offered his mother might seem pretty routine, but look again. Was it appropriate?
In fact, your care—and that of the nursing staff—diverged from the evidence in 4 ways:
- There was no need to give Baby M formula until his mother’s milk came in (Strength of Recommendation [SOR]: C).
- It was not necessary to use IV fluids to treat jaundice in this otherwise healthy term newborn (SOR: C). IV fluids do not bring down bilirubin levels, and even with mild dehydration, the best fluid therapy is breast milk or formula.
- There was no need to temporarily discontinue breastfeeding during phototherapy to bring Baby M’s bilirubin level down more quickly (SOR: C). While doing so may bring levels down a bit faster, it is not worth the risk that the mother may opt to discontinue breastfeeding entirely.
- You should not have told Baby M’s mother that “breast milk provides complete nutrition.” In fact, the American Academy of Pediatrics (AAP) recommends that all breast-fed newborns receive supplemental vitamin D (SOR: B).
12 common beliefs that require a second look
Medicine has a long history of promoting practices like the ones described here, which are either not based upon scientific evidence or are in direct contradiction to existing evidence. Often, we do not realize how much of our advice is based on misunderstandings passed down from our teachers and absorbed from the cultural milieu in which we were raised.
In this article, we will review the most current evidence regarding 12 commonly held beliefs regarding newborn care. These beliefs relate to breast milk, breastfeeding, pacifier use, emesis, umbilical cord care, and jaundice. We’ve included them because these beliefs give rise to many of the common practices we’ve seen in our combined 60 years in pediatrics.
In our effort to look at the evidence behind these beliefs, we encountered some limitations. For most of the recommendations we’ve put forth here, the best evidence that exists is category C—that is, recommendations based on consensus, usual practice, opinion, disease-oriented evidence, or case series for studies of diagnosis, treatment, prevention, or screening.
Though no randomized, controlled trials exist for most of the common practices reviewed here, we have included consensus statements from the best available sources, such as the Centers for Disease Control and Prevention and the AAP. Where appropriate, we also included clear, pathophysiologic reasoning to support each recommendation.
BELIEF 1: Breast milk is a complete nutritional source for a healthy term newborn
THE EVIDENCE: Breast milk is not a complete nutritional source for healthy term newborns. In fact, breast milk provides the ideal source of nutrition, and it is almost a complete and perfect source of nutrition—with one important exception. The AAP recommends that all breast-fed newborns receive 200 IU/day of vitamin D until they are getting at least 500 ml/day of Vitamin-D formula or milk (SOR: B).1,2