Should Milk Sharing Among Mothers Be Encouraged?

My guest poster today is Karleen Gribble, PhD, Adjunct Research Fellow in the School of Nursing and Midwifery at the University of Western Sydney in Australia.  She also serves as one of Lactnet's listmoms and is well-known worldwide for her research and writing on adoptive and long-term breastfeeding, the risks of formula-feeding, and infant feeding in emergencies.  Thank you, Karleen, for weighing in on this hot topic.

The recent launch of the peer-to-peer breastmilk sharing group Eats on Feets has brought the issue of women sharing human milk to the attention of health authorities. Due to safety concerns, organisations such as Health Canada and the U.S. Food and Drug Administration have warned mothers not to use another woman’s breastmilk unless it comes from a milk bank. Individuals associated with milk banking have gone so far as to describe peer-to-peer milk sharing as “very unsafe” and “dangerous”

The discussion about peer-to-peer milk sharing has much in common with the discourse that surrounds bed sharing. We know many mothers bring their baby into bed with them at night.¹ Bed sharing makes breastfeeding easier² and breastfeeding mothers get more  sleep.³  It also allows mother-baby interaction to continue throughout the night and may protect the infant against the long periods of deep sleep thought to contribute to SIDS.^4,5

However, we also know that bed sharing is not always safe. We know that if a mother smokes, if she has consumed alcohol or other sedatives, if the baby is formula fed, if the sleep surface is a sofa or water bed, or if the bed is also shared with other children that a baby sleeping with his or her mother is at heightened risk of SIDS or accidental death. Infant deaths that occurred as a result of bed sharing under these circumstances have resulted in health authorities such as the American Academy of Pediatrics recommending that parents not sleep with their infants.⁶  It is ironic that not only does blanket condemnation of bed sharing potentially make parenting unnecessarily more difficult for some mothers, it also has the unintended outcome of increasing deaths in places other than beds, such as sofas. This has occurred because due to fears of falling asleep while feeding in bed, some mothers have gotten up to feed on a sofa, fallen asleep there, and infants have died as a result.^7,8 Thus, it seems that bed sharing should not be promoted nor condemned.  Rather, parents should be given information about how to bed share safely as well as its risks so they can examine their individual circumstances and decide for themselves where their baby sleeps.

It’s much the same with milk sharing. There is a growing awareness of the importance of breastmilk to the normal health, growth and development of children and of the unavoidable risks associated with the use of infant formula. There are also women who are unable to provide their child with all the breastmilk they require because they have had breast reduction surgery or a double mastectomy or because they have insufficient glandular tissue or are extremely ill. These women have the choice of either obtaining breastmilk from peers or using infant formula. Health authorities who have condemned peer-to-peer milk sharing have told these mothers to obtain human milk from milk banks.  But banked donor milk is an extremely rare commodity available to only a tiny number of (usually hospitalised) infants.

The only real alternative to obtaining human milk from a peer is using infant formula, and the evidence for short- and long-term negative impacts on infants from exposure to infant formula is overwhelming.⁹ It is interesting that the same health authorities who condemn peer-to-peer milk sharing have not condemned the use of infant formula.  One wonders why the risks of formula are somehow more acceptable than the risks of milk sharing.  Is it because formula feeding is so entrenched in our cultures, while breastfeeding remains marginalised? It is ironic that nearly all of the risks Health Canada identified as applying to breastmilk from a peer (http://www.hc-sc.gc.ca/ahc-asc/media/advisories-avis/_2010/2010_202-eng.php) also apply to infant formula.  But a similar health advisory on the use of infant formula does not exist.

Milk sharing allows mothers to avoid the risks associated with formula feeding.  For some this may be particularly important, for example, those with a family history of diseases associated with formula feeding (diabetes or asthma), the death of a formula-fed baby from necrotising enterocolitis or SIDS, or a baby with formula intolerance.  In most cases, milk sharing is not something a woman does lightly or without good reason. For one mother’s story, click here. 

When mothers use human milk, they avoid the risks associated with infant formula.  However, they potentially expose their child to a whole different set of risks. Fortunately, most of these risks are manageable and some very easily eliminated altogether.  (Although very few diseases can be transmitted via breastmilk, one of them is HIV.  Fortunately, however, a simple home pasteurisation process destroys HIV.¹⁰) The Eats on Feets website provides extensive information on managing and minimising risks associated with peer-to-peer milk sharing.

As with bed-sharing, peer-to-peer milk sharing should not receive either a blanket endorsement or condemnation, because the safety of the practice depends very much on the situation.  An alternative to endorsing or condemning it is to acknowledge the reasons women want to milk share (banked donor milk unavailable, infant formula deficient), provide information on how to  manage the risks (recognising that the risks are manageable) and affirm that it’s the parents’ decision.  Just as with bed-sharing, as James McKenna noted:  “It remains the right of parents to make informed decisions, which requires access to unbiased information exchanged within an appropriately relaxed and non-judgmental educational venue.”⁵

1Rigda, R.S., I.C. McMillen, & Bucley, P.  Bed sharing patterns in a cohort of Australian infants during the first six months after birth. J Paediatr Child Health 2000; 36(2):117-121.

2Blair, P.S., J. Heron, & Fleming, P.J.  Relationship between bed sharing and breastfeeding: Longitudinal, population-based analysis. Pediatrics 2010; peds.2010-1277.

3Quillin, S.I.M. & Glenn,L.L. Interaction Between Feeding Method and Co-Sleeping on Maternal-Newborn Sleep. JOGNN 2004; 33(5): 580-88.

4McKenna, J.J. & Mosko, S.S. Sleep and arousal, synchrony and independence, among mothers and infants sleeping apart and together (same bed): an experiment in evolutionary medicine. Acta Paediatr Suppl  1994; 397:94-102.

5McKenna, J.J. & McDade,T. Why babies should never sleep alone: a review of the co-sleeping controversy in relation to SIDS, bedsharing and breast feeding. Paediatr Resp Rev 2005; 6(2): p. 134-152.

6Task Force on Sudden Infant Death Syndrome, The Changing Concept of Sudden Infant Death Syndrome: Diagnostic Coding Shifts, Controversies Regarding the Sleeping Environment, and New Variables to Consider in Reducing Risk. Pediatrics 2005; 116(5):1245-55.

7Blair, P.S., et al., Major epidemiological changes in sudden infant death syndrome: a 20-year population-based study in the UK.  Lancet 2006; 367(9507):314-319.

8UNICEF Baby Friendly, U.K., New research reveals a four fold increase in babies dying when co-sleeping on a sofa, in Baby Friendly News. 2006.

9Ip, S., et al., Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries, in Evidence Report/Technology Assessment No. 153. 2007, Agency for Healthcare Research and Quality: Rockville, MD.

10Jeffery, B.S., et al., Determination of the effectiveness of inactivation of human immunodeficiency virus by Pretoria pasteurization. J Trop Pediatr 2001; 47(6): p. 345-49.



Breastfeeding: A Postpartum Chill Pill

Some think that breastfeeding adds to postpartum stress.  But research has found that mothers who do not breastfeed are more stressed than those who do.  Two obvious reasons are the calming effects of skin-to-skin contact during breastfeeding and the release of the stress-relieving hormone oxytocin.  Swedish research has found that higher oxytocin blood levels decrease blood pressure and levels of cortisol, a stress hormone (Jonas et al., 2008).  In one U.S. study of 24 women who both breastfed and bottle-fed, researchers measured the study mothers’ mood before and after breastfeeding and before and after bottle-feeding (Mezzacappa, Guethlein, & Katkin, 2002).  They found that the mothers were calmer after breastfeeding than after bottle-feeding.  This study is noteworthy because it eliminated one of the main problems of comparing breastfeeding and non-breastfeeding women: the often major differences between women who choose one feeding method over the other.  Since the same mothers were studied after both breast and bottle, this possible confounding factor was eliminated. Breastfeeding’s effect on down-regulating stress is no doubt one reason research has linked longer breastfeeding duration to better cardiovascular health in mothers later in life (Schwarz et al., 2009).

But that is not all.  Another U.S. study of 181 mothers measured mothers’ reactions to stress, including its effect on the immune system (measured by blood cytokine balance) and their mood (Groer & Davis, 2006).  The researchers found that the immune systems of non-breastfeeding mothers were more depressed by life stressors, and these mothers developed more infections than the breastfeeding mothers.  The non-breastfeeding mothers also had higher levels of anxiety and fatigue.  The study authors suggest that higher levels of blood prolactin stimulated by breastfeeding was related to more positive mood, greater immunity to infection, and decreased stress.

References

Groer, M. W., & Davis, M. W. (2006). Cytokines, infections, stress, and dysphoric moods in breastfeeders and formula feeders. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 35(5), 599-607.

Jonas, W., Nissen, E., Ransjo-Arvidson, A. B., Wiklund, I., Henriksson, P., & Uvnas-Moberg, K. (2008). Short- and long-term decrease of blood pressure in women during breastfeeding. Breastfeeding Medicine, 3(2), 103-109.

Mezzacappa, E. S., Guethlein, W., & Katkin, E. S. (2002). Breast-feeding and maternal health in online mothers. Annals of Behavioral Medicine, 24(4), 299-309.

Schwarz, E. B., Ray, R. M., Stuebe, A. M., Allison, M. A., Ness, R. B., Freiberg, M. S., et al. (2009). Duration of lactation and risk factors for maternal cardiovascular disease. Obstetrics and Gynecology, 113(5), 974-982.

For More Sleep, Breastfeed

Fatigue is a fact of life for new parents no matter how their newborn is fed.  When sleep is at a premium, they may consider their alternatives.  If a new mother's partner takes over some night feedings, will she get more sleep?  Will giving formula at night make baby sleep longer?  According to research, neither of these strategies produces the desired results.  One U.S. study of 133 new mothers and fathers during the first three months postpartum found that mothers who exclusively breastfed averaged 40 to 45 minutes more sleep at night than those whose babies also received infant formula.  Why didn’t sharing night feedings help mothers sleep more?  Because the mothers’ sleep was significantly disrupted while the baby’s father fed the baby.  The researchers wrote:

“…formula feeding not only failed to improve parent sleep, but actually resulted in parents getting less sleep, even when fathers helped during the night with…feedings” (Doan, Gay & Lee, 2007, p. 204).

Exclusive breastfeeding leads to more sleep, and it also leads to better sleep.  Compared to non-breastfeeding mothers and formula-feeding mothers with babies the same age, Australian research found that breastfeeding mothers spent more time in deep sleep (Blyton, Sullivan, & Edwards, 2002).  The exclusively breastfeeding mothers had “a marked alteration in their sleep architecture,” giving them longer periods of slow-wave sleep, a type of deep sleep.  The researchers concluded that “enhanced SWS may be another important factor to support breastfeeding in the postnatal period” (Blyton et al., 2002, p. 297).

References

Blyton, D. M., Sullivan, C. E., & Edwards, N. (2002). Lactation is associated with an increase in slow-wave sleep in women. Journal of Sleep Research, 11(4), 297-303.

Doan, T., Gardiner, A., Gay, C. L., & Lee, K. A. (2007). Breast-feeding increases sleep duration of new parents. J Perinat Neonatal Nurs, 21(3), 200-206.

Breastfeeding: A Cost Analysis

When families decide not to breastfeed, it costs them and the US healthcare system a bundle and many babies lose their lives unnecessarily.  These were the conclusions of an online article published recently in  the medical journal Pediatrics. 

 The last breastfeeding cost analysis was published by the USDA in 2001.  In that report, Jon Weimer estimated that in 2001 U.S. dollars, $3.6 billion would be saved if breastfeeding rates increased by just 9%.  At that time, 64% of women giving birth breastfed.  This USDA estimate included the cost savings from just three health problems: ear infections, vomiting or diarrhea, and necrotizing enterocolitis (NEC), an often-fatal bowel disorder that very preterm babies can develop. 

Now, almost 10 years later, about 74% of mothers giving birth breastfeed.  We also know much more about how a lack of breastfeeding affects health.  In 2007, Tufts Medical Center published a meta-analysis of the research on breastfeeding, which included 9,000 studies and calculated babies’ increased risks of many health problems if not breastfed.. 

Using Tufts’ findings, in their recent article Melissa Bartick and Arnold Reinhold updated the costs to the US healthcare system and estimated the number of lives lost as a result.  Like the 2001 article, this one included the costs of ear infections, vomiting or diarrhea, and NEC.  But thanks to the Tufts’ data, it added many more health problems non-breastfed babies are more susceptible to, including lower respiratory tract infections, SIDS, childhood asthma, leukemia, obesity, and Type 1 diabetes. 

Based on the Tufts’ data, Bartick and Reinhold estimated that if 90% of US babies breastfed at all (for 5 diseases) or exclusively for 6 months (for 4 diseases), in 2007 dollars this would save $13 billion.  These authors also estimated that at this level of breastfeeding, 911 lives could be saved each year.

They concluded that due to the considerable costs of not breastfeeding, money spent by the US government on breastfeeding promotion would be cost effective.

References

Bartick, M. and Reinhold, A. The burden of suboptimal breastfeeding in the United States: A pediatric cost analysis. Pediatrics 2009: DOI: 10.1542/peds.2009-1616.

Ip, S., Chung, M., Raman, G., Chew, P., Magula, N., DeVine, D., et al. 2007. Breastfeeding and maternal and infant health outcomes in developed countries. Evidence Report - Technology Assessment (Full Report)(153), 1-186.

Weimer, J.  2001; The Economic Benefits of Breastfeeding: A Review and Analysis. Food and Rural Economics Division, Economic Research Service, U.S. Department of Agriculture. Food Assistance and Nutrition Research. Report No. 13.