BREASTFEEDING MEDICINE

Volume 11, Number 4, 2016 Clinical Research

ª Mary Ann Liebert, Inc.
DOI: 10.1089/bfm.2015.0170

Phototherapy for the Treatment of Neonatal Jaundice

and Breastfeeding Duration and Exclusivity

Whitney M. Waite and James A. Taylor

Abstract

Introduction: Because neonatal jaundice remains one of the most commonly treated conditions of the newborn
infant, it is important to assess the unintended consequences of treatment with phototherapy. The objective of
this study was to evaluate whether treatment with phototherapy affects breastfeeding duration in newborns >35
weeks gestation.
Materials and Methods: We analyzed data from the Infant Feeding Practices Study II. The exposure of interest
was treatment of neonatal jaundice with phototherapy. The outcomes of interest were any breastfeeding through
12 months and exclusive breastfeeding through 4 months. Logistic regression models were developed to evalu-
ate the association between the exposure and outcomes of interest. All models were adjusted for maternal age,
race, education, household income, and gestational age, as well as for several potential markers of suboptimal
breastfeeding.
Results: Our study included 4,441 infants, of which 220 (5%) received phototherapy. We found no difference in
the likelihood of any breastfeeding through 9 months of age, however, by 12 months, infants exposed to
phototherapy were less likely to still be breastfed than those who were not exposed (adjusted odds ratio [aOR]
0.58, 95% confidence interval [95% CI] 0.37–0.92). Infants exposed to phototherapy were less likely to be
exclusively breastfed throughout the first 4 months of life.
Conclusion: Although phototherapy use did not substantially impact rates of any breastfeeding during the first
year, it was associated with decreased rates of exclusive breastfeeding in the first 4 months of life. This suggests
that we need to tailor messaging to mothers of infants receiving phototherapy to promote exclusive breastfeeding.

Introduction jaundice before hospital discharge. This recommendation is

T here is a solid body of evidence supporting the as-
sociation between breastfeeding and health benefits
in infancy, and evidence suggests these benefits are maxi-
mized when breastfeeding is exclusive.1–7 Experts from the
American Academy of Pediatrics (AAP) recommend that all
infants be exclusively breastfed for the first 4–6 months of
life with continued breastfeeding through at least the first
year.1 Although steady progress has been made over the last
decade in improving breastfeeding initiation rates, the ma-
jority of infants in the United States are not breastfed as long
as recommended.8 Increasing breastfeeding duration and
exclusivity have been prioritized in the Healthy People 2020
goals.9
Neonatal jaundice remains one of the most commonly
treated medical conditions of the otherwise well newborn
infant.10 In 2009, the AAP released a revised set of guidelines
recommending that all newborn infants be screened for
in an effort to prevent the rare but devastating consequence of
kernicterus.11 Several studies following the new 2009 AAP
guidelines have shown an increase in the number of infants
receiving phototherapy for the treatment of jaundice, with
one study finding that 7.6% of all infants receive photo-
therapy in the first few days of life. This has led to a de-
crease in the incidence of severe neonatal hyperbilirubinemia
(serum bilirubin >25 mg/dL); however, it is unclear whether
or not the increased screening and treatment of jaundice has
led to fewer cases of kernicterus.12–16
Because it is not clear that increased screening and use
of phototherapy are associated with a decreased incidence
of kernicterus, it may be important to reassess current rec-
ommendations.12,17,18 Little is known about the potential
harms associated with phototherapy. Nearly 30 years ago
Kemper et al. reported on unintended harms of phototherapy,
including decreased maternal–infant bonding, increased
maternal anxiety, increase in the vulnerable child syndrome,

Department of Pediatrics, University of Washington, Seattle, Washington.

This abstract has been published as part of the pediatric academic societies meeting in San Diego, CA, April 2015.

1
2 WAITE AND TAYLOR
and decreased rates of breastfeeding19–21 However, data
collected by Kemper et al. during the 1980s may not be
generalizable today. Since that time, national breastfeeding
rates as well as hospital practices supporting breastfeeding
have increased.8 The purpose of this study is to determine if
the association between treatment of jaundice with photo-
therapy and a shorter duration of breastfeeding continues to
exist in a more recent cohort of infants.
Materials and Methods
Subjects and data collection
We conducted a cohort study analyzing data collected for
the Infant Feeding Practices Study II (IFPS II). IFPS II was a
survey conducted by the Centers for Disease Control and
Prevention (CDC). Data from this survey are publicly
available for analysis.
The methodology for IFPS II has been previously pub-
lished.22 For the IFPS II, *4,000 pregnant women were
enrolled between May and December 2005. To maximize
participation, the women were selected from a consumer
opinion panel poll of roughly 500,000 US households with
oversampling of women with lower education levels, and
African American and Hispanic women. To continue in the
study postnatally, participants must have given birth to a
healthy, singleton infant of greater than 35 weeks gestation
weighing at least 2.2 kg.
After enrollment, questionnaires were mailed to partici-
pants prenatally and then approximately once per month for
the first 12 months of the infant’s life. Questions were asked
about breastfeeding intentions and practices, as well as infant
formula use.
Inclusion and exclusion criteria
All infants for whom there were data in the IFPS II were
evaluated for inclusion into our study. Infants were included
if their mothers ever initiated breastfeeding. This was de-
termined by those who answered ‘‘yes’’ to the question, ‘‘Did
you ever breastfeed or try to breastfeed your baby, either in
the hospital or birth center, or after you went home?’’ A small
group of infants were excluded who indicated ‘‘other’’
treatment for jaundice, which included switching completely
to infant formula.
Data collection
For the study, we abstracted information on maternal age,
race and ethnicity, education level, marital status, and
household income from the IFPS II. In addition, we obtained
data on gestational age at birth, birth weight, and breast-
feeding outcome at each study month. Maternal intention to
exclusively breastfeed was determined by a question on the
prenatal survey that asked, ‘‘What method do you plan to use
to feed the baby in the first few weeks?’’ Answer options
included ‘‘Breastfeed only (baby will not be given formula),’’
‘‘both breast and formula feed,’’ ‘‘don’t know yet,’’ and
‘‘formula feed only.’’ (There were a small percentage of
women who prenatally intended to formula feed only, then
initiated breastfeeding after the birth of their baby). This was
then classified as a dichotomous variable with those who
responded that they did not know yet which feeding method
they would choose or those who had intended to exclusively
formula feed considered as not having the intention to ex-
clusively breastfeed. We also included data to determine use
of supplemental infant formula on the first day of life and any
breastfeeding problems the mother had during the first 2
weeks. This information was obtained from questions on the
neonatal survey at *3 weeks of age. The first question asked
‘‘How old was your baby when he or she was first fed for-
mula?’’ Response options included ‘‘1 day of life or less.’’
Breastfeeding difficulties encountered by the mother were
determined from the question, ‘‘Did you have any of the
following problems breastfeeding your baby during the first 2
weeks of breastfeeding?’’ This was followed by a list of 16
common breastfeeding problems. If a mother checked any of
the responses, she was considered to have had a breastfeeding
problem in the first few weeks of life (Appendix A1).
Outcomes
The primary outcomes of our study were any breastfeeding
at 1, 2, 4, 6, 9, and 12 months of age. The secondary outcomes
included exclusive breastfeeding at 1, 2, and 4 months of age.
Exclusive breastfeeding at each month was determined based
on the response to a survey item that asked which foods or
drinks were given to the baby over the past 2 weeks. Data for
exclusive breastfeeding in the past 4 months were not ana-
lyzed because the rate of use of complementary foods in-
creased rapidly after this age.
Exposure
The main exposure of interest for our study was whether
the infant received phototherapy for the treatment of jaundice
in the newborn period. Exposure to phototherapy was de-
termined by parental report on the IFPS II survey when a
study infant was *3 weeks old. On this survey, parents were
asked if their infant was ever jaundiced during the newborn
period. If the answer was ‘‘yes,’’ the parent was asked to
indicate if any treatment was required for the jaundice. One
of the treatment options was phototherapy. All remaining
infants whose parents did not indicate receiving phototherapy
were considered unexposed.
Data on the presence of jaundice were missing for 42.2%
of newborns who were included in the analyses, therefore
making them ineligible to answer the question about photo-
therapy exposure. We assumed that virtually all mothers
whose newborns received phototherapy would recall that
their babies had been jaundiced when surveyed when the
newborn was 3 weeks old. Therefore, we classified all those
infants with missing information regarding the presence of
jaundice as unexposed to phototherapy. To evaluate the va-
lidity of this assumption, we reanalyzed our study data after
excluding newborns with missing information on the pres-
ence of jaundice.
Analysis
Logistic regression models were developed to evaluate the
association between the dichotomous outcomes for both any
breastfeeding and exclusive breastfeeding and exposure to
phototherapy at each time point. All models were adjusted for
the potential confounders of maternal age, race, maternal
education, household income, and gestational age at birth. In
addition, there are data to suggest that newborns who have
PHOTOTHERAPY EXPOSURE AND BREASTFEEDING DURATION
breastfeeding problems during the first few days of life are
more likely to develop significant hyperbilirubinemia than
those who breastfeed well.23,24 Thus, it is possible that any
decrease in subsequent breastfeeding after exposure to pho-
totherapy might be related, in part, to breastfeeding problems
before treatment rather than to the therapy itself. To ac-
count for this, we included markers of potentially suboptimal
breastfeeding, including the mother’s intention to exclusively
breastfeed before birth, use of supplemental formula on day
of life 1, and reported breastfeeding problems in the first 2
weeks of life in all of the regression models. Results were
considered to be statistically significant if the 95% confi-
dence interval (95% CI) around a calculated odds ratio (OR)
did not include 1.0, or the p-value was <0.05.
This study was approved by the Seattle Children’s Hospital
Institutional Review Board.
Results
The IFPS II had an overall sample size of 4,902 infants. We
excluded 461 infants because they were never breastfed. This
yielded a study sample size of 4,441 infants. Of these, 1,098
(25%) were reported to have some degree of jaundice by their
caregiver. A total of 220 (5%) study infants required photo-
therapy (Fig. 1). A further 205 infants were excluded from
analysis because they indicated ‘‘other’’ treatment for jaun-
dice. In our sample, 30% of women were still breastfeeding at
12 months of age and 27% were exclusively breastfeeding at
4 months. Table 1 outlines characteristics of the study pop-
ulation. Significant differences between the phototherapy
exposed and unexposed groups were observed with regard to
race, income, and level of maternal education. The infants in
the phototherapy exposed group were of a significantly
FIG. 1. Study numbers and
exposure categorization for
study participants.
3
younger gestational age, 38.7 weeks compared with those in
the phototherapy unexposed group, 39.4 weeks. Infants in the
phototherapy exposed group were also significantly more
likely to receive formula supplementation on day of life 1
than those in the phototherapy unexposed group, 25.5%
compared with 15.4%.
When evaluating any breastfeeding by month of age, there
were no significant differences in the rates of any breast-
feeding through 9 months of age among infants treated with
phototherapy for jaundice compared to infants not exposed
to phototherapy. At month 12, infants who were exposed to
phototherapy were less likely to still be breastfed than infants
who were not exposed to phototherapy (OR 0.58, 95% CI
0.38–0.87) (Table 2).
When evaluating exclusive breastfeeding by month, in-
fants exposed to phototherapy were significantly less likely to
be exclusively breastfed at all months than infants who were
not exposed to phototherapy (Table 2).
A secondary analysis was done excluding all 1,876 infants
who did not answer the question about whether neonatal
jaundice was present. Results from this analysis were not
substantially different from results obtained from including
these mother–infant pairs in the analysis.
Discussion
The results of this study indicate that, among women who
initiate breastfeeding, those whose infants received photo-
therapy were as likely to be receiving any breast milk through
9 months of age as those whose infants did not receive pho-
totherapy. Only by 12 months of age were they less likely to
be receiving any breast milk than their nonphototherapy ex-
posed counterparts. However, we did find that phototherapy
4 WAITE AND TAYLOR

Table 1. Characteristics of Infants Who Received Phototherapy and Those Who Did Not Receive
Phototherapy (Excluding Exclusively Formula-Fed Infants and Those Who Indicated
Other Treatment for Neonatal Jaundice)
Infants who received Infants who did not
phototherapy, N = 220 receive, N = 4,016
n (%) n (%) p
Maternal age (years) 28.8 28.1 0.06
Race
Non-Hispanic white 177 (80.5) 3,125 (77.9) 0.36
Non-Hispanic black 7 (3.2) 260 (6.5) 0.05
Hispanic of all races 9 (4.1) 292 (7.3) 0.07
Asian/Pacific Islander 11 (5.0) 115 (2.9) 0.07
Other 8 (3.6) 105 (2.6) 0.36
Missing 8 (3.6) 119 (3.0) 0.57
Annual income
<$40,000 90 (40.9) 1,935 (48.2) 0.04
$40,000–$59,999 50 (22.7) 912 (22.7) 0.99
$60,000–$99,999 60 (27.3) 869 (21.6) 0.05
>$100,000 20 (9.1) 300 (7.5) 0.38
Education
Less than college graduate 111 (50.4) 2,291 (57.1) 0.05
College graduate or more 87 (39.6) 1,206 (30.0) 0.002
Missing 22 (10) 519 (12.9) 0.21
Gestational age (weeks) 38.7 39.4 <0.001
Birth weight (kg) 3.5 3.5 0.4
Planning to exclusively breastfeed first few weeks 165 (75.0) 2,473 (61.6) <0.001
Formula given on first day of life 56 (25.5) 579 (15.4) <0.001
Any breastfeeding problem in first 2 weeks 191 (87.2) 1,889 (88.1) 0.70

treatment was associated with decreased rates of exclusive
breastfeeding throughout the first 4 months of life.
Our results are in contrast to the findings of Kemper et al.,
in which mothers of infants treated with phototherapy were
nearly twice as likely to stop breastfeeding by 1 month of
age.19 In our cohort of infants, those exposed to phototherapy
were as likely as those unexposed to be receiving breast milk
through most of the first year of life. It is unclear what the
significance is, if any, of the decreased breastfeeding ob-
served at 12 months of age and this finding may be a statis-
tical fluke. There are several possible explanations for why
we did not observe the early abandonment of breastfeeding
that Kemper et al. found. First, infants for the study by
Kemper et al. were recruited from a single hospital compared
to the national sample that we evaluated. There are significant
regional differences reported in breastfeeding rates as well
as hospital practices supporting breastfeeding.8 It is there-
fore conceivable that breastfeeding counseling practices and
even maternal motivation to continue breastfeeding could
have been different among this population than the more

Table 2. Rates of Any Breastfeeding and Exclusive Breastfeeding by Month

for Phototherapy Exposed and Phototherapy Unexposed Infants
Breastfeeding rate in Breastfeeding rate in
phototherapy exposed, N = 220 phototherapy unexposed, N = 4,016
n (%) n (%) OR (95% CI)
Any breastfeeding
Month 1 186 (86.1) 1,813 (85.4) 1.14 (0.71–1.81)
Month 2 137 (75.3) 1,360 (74.8) 1.18 (0.78–1.78)
Month 4 108 (65.1) 1,069 (67.2) 1.03 (0.70–1.53)
Month 6 85 (54.5) 889 (59.9) 0.88 (0.60–1.27)
Month 9 66 (43.7) 695 (49.9) 0.80 (0.56–1.15)
Month 12 29 (20.7) 406 (31.4) 0.58 (0.37–0.91)
Exclusive Breastfeeding
Month 1 81 (37.5) 1,022 (48.1) 0.69 (0.49–0.95)
Month 2 57 (31.3) 767 (42.2) 0.69 (0.48–0.99)
Month 4 29 (17.5) 462 (29.0) 0.57 (0.36–0.88)
ORs based on logistic regression adjusting for maternal age, race, maternal education, household income, gestational age, prenatal
intention to breastfeed, supplemental formula use on day of life 1, and breastfeeding problems in the first 2 weeks of life.
OR, odds ratio.
PHOTOTHERAPY EXPOSURE AND BREASTFEEDING DURATION
nationally representative population in our study. In the study
by Kemper et al., all phototherapy was done in an in-patient
setting. In our study, it was not possible to know if an infant
was treated with hospital-based or home-based phototherapy.
Prior studies have shown that home-based phototherapy ap-
pears to be less detrimental to duration of breastfeeding than
hospital-based phototherapy.25 The use of home photo-
therapy among participants in our study may have attenuated
any negative effects on breastfeeding rates. Last, the Kemper
et al. study was done nearly 30 years ago. It is likely that
much of the observed difference in study findings is due
to greater breastfeeding support and encouragement in our
newborn nurseries, hospitals, and in outpatient settings, as
well as the overall increase in breastfeeding rates, especially
marked in non-white populations, now than was practiced 30
years ago.26
We did find a significant decrease in rates of exclusive
breastfeeding among phototherapy exposed infants during
the first 4 months of life. This finding suggests that, although
the mothers of infants treated with phototherapy are offering
at least partial breast milk feeds at similar rates to mothers of
infants who do not require phototherapy, they are more likely
to be supplementing with formula through the early months
of life. This may be due to breastfeeding-related messaging
parents receive from healthcare professionals while their
infants undergo treatment for jaundice. Our speculation is
that mothers of jaundiced infants may internalize the message
from providers (either spoken or unspoken) that their breast
milk is not enough for the baby and either begin or continue to
supplement their infant with formula.
There are several limitations to this study. First, the data
are now several years old and were not collected for the
purpose of answering this question. However, there are no
more recent data of such a large sample of women that ad-
dress this issue that we are aware of. Also, all data obtained
rely on parental report. Although it is likely that parents
would remember whether or not their newborn required
phototherapy and how the infant was fed over the previous 1–
2 months, undoubtedly this recall is not perfect. We believe
the main limitation of this study is the difficulty in deter-
mining whether early cessation of breastfeeding, or the de-
crease in exclusivity of breastfeeding, was related more to
breastfeeding problems before, rather than caused by, pho-
totherapy. Prior studies have demonstrated an association
between inadequate breastfeeding and neonatal jaundice.23,24,27
In a study by Bertini et al., breastfed infants who required
formula supplementation for excessive weight loss were
significantly more likely to have an elevated serum bilirubin
level (>12.9 mg/dL) than either those infants who were ex-
clusively formula fed or exclusively breastfed.23 This led
the investigators to conclude that breastfeeding per se is not
associated with elevated serum bilirubin levels, but rather
inadequate breastfeeding with associated fasting and dehy-
dration. Our results also show that infants exposed to pho-
totherapy were of a younger gestational age than those who
were not. Because prematurity, or being born at an earlier
gestational age, is associated with both the need for photo-
therapy and breastfeeding problems, it is difficult to deter-
mine if exposure to phototherapy is what led to the
subsequent decrease in exclusive breastfeeding. We tried to
account for early breastfeeding inadequacy by assessing
possible markers of breastfeeding problems such as gesta-
5
tional age, formula supplementation, maternal report of early
breastfeeding problems, as well as the mother’s overall mo-
tivation for exclusive breastfeeding assessed before the birth
of her child. Given that the phototherapy group had greater
intention to breastfed, but also greater formula use in the first
24 hours of life, this could suggest there were early breast-
feeding difficulties that were not completely accounted for in
our models.
Conclusion
It is encouraging that increased vigilance about neonatal
jaundice, with the concomitant increase in phototherapy use,
does not seem to be leading to a significant decrease in the
duration of any breastfeeding. However, it is concerning that
the use of phototherapy was associated with a decrease in the
rate of exclusive breastfeeding through the first 4 months of
life, as there is evidence that the benefits of breastfeeding are
maximized when there is no use of infant formula.2,28,29 This
result suggests that communication related to exclusive
breastfeeding in a child receiving phototherapy may need to
be evaluated to ensure that, as much as possible, exclusive
breastfeeding is supported in newborns receiving photo-
therapy who are not in need of extra fluid for hydration,
thereby preserving a mother’s confidence in her ability to
exclusively breastfeed after treatment is completed.
Disclosure Statement
W.M.W. has no financial disclosures. Dr. Taylor is co-
owner of BiliCam, LLC, a company that is developing a
noninvasive method to measure bilirubin levels in newborns.
He currently derives no income from the company.
References
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e435–e439.
4. Duijts L, Jaddoe VW, Hofman A, et al. Prolonged and
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reduced risk of sudden infant death syndrome: A meta-
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6. Ip S, Chung M, Raman G, et al. Breastfeeding and maternal
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(accessed February 10, 2016).
6 WAITE AND TAYLOR
10. Watchko JF. Neonatal hyperbilirubinemia—what are the
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ubinemia in the newborn infant 35 or more weeks of ges-
tation. Pediatrics 2004;114:297–316.
12. Kuzniewicz MW, Escobar GJ, Newman TB. Impact of
universal bilirubin screening on severe hyperbilirubinemia
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diatrics 2006;117:e855–e862.
15. Newman TB, Liljestrand P, Jeremy R, et al. Outcomes
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16. Trikalinos TA, Chung M, Lau J, et al. Systematic review of
screening for bilirubin encephalopathy in neonates. Pe-
diatrics 2009;124:1162–1171.
17. Brooks JC, Fisher-Owens S, Wu Y, et al. Evidence suggests
there was not a ‘‘resurgence’’ of kernicterus in the 1990s.
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18. Johnson L, Bhutani VK Karp K, et al. Clinical report
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20. Usatin D, Liljestrand P, Kuzniewicz M, et al. Effect of
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Appendix A1. Possible Responses to Question About Problems Breastfeeding in the First 2 Weeks of Life
Did you have any of the following problems breastfeeding
your baby during your first 2 weeks of breastfeeding?
(PLEASE ‘‘X’’ ALL THAT APPLY) My baby had
trouble sucking or latching on.............
My baby choked...........................
......
My baby wouldn’t wake up to nurse regularly enough.....
My baby was not interested in nursing.............
....
My baby got distracted.......................
......
My baby nursed too often.....................
.....
It took too long for my milk to come in...........
.....
I had trouble getting the milk flow to start.........
....
My baby didn’t gain enough weight or lost too much
weight ......................
22. Fein SB, Labiner-Wolfe J, Shealy K, et al. Infant Feed-
ing Practices Study II: Study methods. Pediatrics 2008;
122(Suppl 2): S28–S35.
23. Bertini G, Dani C, Tronchin M, et al. Is breastfeeding really
favoring early neonatal jaundice? Pediatrics 2001;107:e41.
24. Yamauchi Y, Yamanouchi I. Breast-feeding frequency
during the first 24 hours after birth in full-term neonates.
Pediatrics 1990;86:171–175.
25. Eggert LD, Pollary R, Folland D, et al. Home photo-
therapy treatment of neonatal jaundice. Pediatrics 1985;
76:579–584.
26. Taveras EM, Li R, Grummer-Strawn L, et al. Opinions and
practices of clinicians associated with continuation of ex-
clusive breastfeeding. Pediatrics 2004;113:e283–e290.
27. Maisels MJ, Gifford K. Normal serum bilirubin levels in
the newborn and the effect of breast-feeding. Pediatrics
1986;78:837–843.
28. Quigley MA, Kelly YJ, Sacker A. Breastfeeding and hos-
pitalization for diarrheal and respiratory infection in the
United Kingdom Millennium Cohort Study. Pediatrics
2007;119:e837–e842.
29. Kramer MS, Kakuma R. Optimal duration of exclu-
sive breastfeeding. Cochrane Database Syst Rev 2012.
doi: 10.1002/14651858.
Address correspondence to:
Whitney M. Waite, MD MPH
Department of Pediatrics
University of Washington
P.O. Box 5371
Suite 400, M/S: CW8-6
Seattle, WA 98145
E-mail: wmillig@uw.edu
I didn’t have enough milk .............
...
My nipples were sore, cracked, or bleeding..
My breasts were overfull (engorged).........
I had a yeast infection of the breast........
I had a clogged milk duct.............
...
My breasts were infected or abscessed......
My breasts leaked too much...............
I had some other problem.................
I had no problems ....................