Should Solid Foods Be Started Earlier Than 6 Months?

Many breastfeeding advocates were startled by the worldwide press given to an article that appeared last week in the British Medical Journal.  Its authors suggested that the evidence for exclusive breastfeeding for the first 6 months of life is less than compelling.  And they shared data that caused them to question whether starting solids between 4 and 6 months of age might be a healthier alternative for families in affluent countries. 

Is this recommendation from the World Health Organization (WHO) really out of date?  Should it be revisited?  In response, Randa Saadeh of the Department of Health and Development at WHO headquarters in Geneva, Switzerland released the following statement:

"WHO's global public health recommendation is for infants to be exclusively breastfed for the first 6 months of life to achieve optimal growth, development and health. Thereafter, infants should be given nutritious complementary foods and continue breastfeeding up to the age of 2 years or beyond.
 
"WHO closely follows new research findings in this area and has a process for periodically re-examining recommendations. Systematic reviews accompanied by an assessment of the quality of evidence are used to review guidelines in a process that is designed to ensure that the recommendations are based on the best available evidence and free from conflicts of interest.
 
"The paper in this week's BMJ is not the result of a systematic review. The latest systematic review on this issue available in the Cochrane Library was published in 2009 ("Optimal duration of exclusive breastfeeding (Review)", Kramer MS, Kakuma R. The Cochrane Library 2009, Issue 4). It included studies in developed and developing countries and its findings are supportive of the current WHO recommendations. It found that the results of two controlled trials and 18 other studies suggest that exclusive breastfeeding (which means that the infant should have only breast milk, and no other foods or liquids) for 6 months has several advantages over exclusive breastfeeding for 3-4 months followed by mixed breastfeeding. These advantages include a lower risk of gastrointestinal infection for the baby, more rapid maternal weight loss after birth, and delayed return of menstrual periods. No reduced risks of other infections or of allergic diseases have been demonstrated. No adverse effects on growth have been documented with exclusive breastfeeding for 6 months, but a reduced level of iron has been observed in developing-country settings."
 
Reference

Fewtrell, M., Wilson, D.C., Booth, I. Parsons, L., and Lucas, A.  Six month of exclusive breast feeding: How good is the evidence?  BMJ 342:c5955 doi:10.1136/bmj.c5955.



Where Do Milk Banks Fit In?

During my early years in breastfeeding, I found the idea of milk banks intriguing but less than exciting. To me, the rubber gloves, the lab equipment, and the rest of their high-tech gadgetry were positively off-putting.  All that changed when I attended a conference of the Human Milk Banking Association of North America.  There I finally understood the bigger picture and realized that milk banks play a vital role in a breastfeeding culture. 

To better grasp this role, it helps to know the World Health Organization’s ranking of infant feeding options from healthiest to least healthy.  Healthiest is, of course, direct breastfeeding.  Second is mother’s own expressed milk. Third is donor human milk.  And fourth is infant formula.  

Donor milk can make the difference between life and death, especially among preterm and ill babies.  Although many mothers work hard to try to provide their at-risk babies with their milk, research has found that more than half of mothers expressing milk for preterm babies have inadequate milk production by Week 6.¹ 

This is a problem because very preterm babies are at risk of acquiring a serious condition called necrotizing enterocolitis, NEC for short, and feeding infant formula increases this risk.  When a baby acquires NEC, part of his digestive tract becomes inflamed and dies.   About 1 in 5 babies who acquire NEC die from it.  According to the Centers for Disease Control and Prevention, in the U.S. NEC is the cause of nearly 2% of all infant deaths.  Babies with NEC suffer horribly and the cost of treating it is astronomical.²  Babies whose NEC is severe enough to require surgery are also at risk of long-term growth delays and neurodevelopmental problems, which can affect a family and a society for a lifetime.

This is where milk banks come to the rescue.  Research has found that only 1.5% of babies fed mostly human milk acquire NEC, as compared with 10-17% of babies fed exclusively formula.³  So as the Swedes have already learned, the answer to this terrible scourge is to feed preterm babies only human milk during their hospital stay.  In Sweden, no hospitalized preterm baby receives infant formula before discharge.  If a mother cannot express enough milk for her baby, donor milk is given.

Milk banks provide a safety net for mothers unable to express all the milk their babies need. While direct breastfeeding is best and mother’s own expressed milk is second best, donor milk can be a lifesaver for babies whose only other option is infant formula. 

This ray of hope is why I became a member of the leadership team of the group pictured here, which hales from Illinois and Wisconsin and is working hard to establish the Mothers’ Milk Bank of the Western Great Lakes.  Our plan is to move heaven and earth to begin providing donor milk to babies in our states, where no milk bank currently exists.  An important role of this—and any—milk bank will be to educate hospitals about human milk as the standard of care.  Even with research backing, changing practice always takes time.  But it will be well worth the effort.  Our new website will be premiering soon and I’ll post a link when it’s ready.  Please wish us luck!

References

¹ Hill, P. et al.  Comparison of milk output between mothers of preterm and term infants: The first 6 weeks after birth.  J Hum Lact 2005; 21(1):22-30.

²Bisquera, J. A., Cooper, T. R., & Berseth, C. L.  Impact of necrotizing enterocolitis on length of stay and hospital charges in very low birth weight infants. Pediatrics 2002; 109(3): 423-28.

³Sisk, P. M., et al. Early human milk feeding is associated with a lower risk of necrotizing enterocolitis in very low birth weight infants. J Perinatol 2007; 27(7), 428-33.

Responses to 'Rethinking Swaddling'

My December 3 post, “Rethinking Swaddling,” attracted more than 7,000 hits—a new record—and triggered many strong reactions.  For some, this post met a need; for others, it struck a nerve.  After reviewing the research, its central question was:  Does swaddling really calm babies, or does it stress them to the point of shutting down?

Readers responded with more than 50 comments here and on Facebook.  One wrote: “My paradigms are shifting at an alarming rate!”  Many understood the concern: “As a hospital lactation consultant, about 50% of my time is spent unswaddling and derobing babies and placing them on their mothers’ bare chests…Parents marvel at how I supposedly got a baby to latch who wouldn’t before.”  “I would like to see the readouts of blood pressure, brain patterns, heart rate, temperature, etc.” And: “I remember a professor telling me she used a certain DVD to teach what ‘shut down’ looked like in a newborn.”

Many disagreed strongly.  Some believed—despite the research findings—that because swaddling appears to calm babies that babies “like” or “prefer” it.  “It’s not me who insists on the swaddle, but it is really my baby who wants it.”  “Some [babies] prefer swaddling, others prefer to be free to move.” Many referred to swaddling as a way to “make babies happy.”  But returning to the question: Are swaddled babies really “happy” or are they shut down?  One thoughtful writer suggested: “it might be a great experiment to swaddle newborn puppies and kittens and see what happens, but probably animal rights activists would have my hide!”

Although avoiding swaddling right after birth made sense to most, some discounted the findings that swaddled newborns lost more weight and had lower temperatures.  They believed that because their swaddled newborns breastfed without problems or because the baby they didn’t swaddle lost more weight initially than the one they did swaddle, the research must be “wrong.”  Of course, there are many factors at work, and swaddling is just one of them.  It takes many more than one or two babies to accurately measure the effects of any practice.

Some were concerned about “the consequences of not swaddling.”  Without it, one wrote, “we would be seeing infants who are fussier, sleep less, and wear parents out more in the weeks following birth.  Temptation will be to put them onto their tummies to sleep, increasing their risk for SIDS significantly.”  Another wrote:  “My guess is that swaddling has saved many infants from shaken baby syndrome (after extended crying bouts) and also allowed babies who have never been willing to sleep on their backs before to accept this practice (if they are not co-sleeping and bedsharing families).”

Swaddling and sleep was the subject of many comments.  Several who were not bedsharing said their babies “needed to be swaddled to go to sleep.” One wrote that the biggest benefit of swaddling was “to encourage a baby to sleep on their back as per the AAP’s recommendation.  It is unfair to me to give parents a recommendation for safety, and then not offer them tools to help them follow those instructions.” Another wrote: “If parents didn’t have unreal expectations or believe infants are meant to sleep all night in their own space at a few weeks old…they would cope much better.” 

One wrote: “Swaddling helped immensely with putting him down to sleep after his needs had been met.”  Biologically speaking, though, body contact is not just an optional “nice to have.” Like milk, it is one of a baby’s needs.  Breastfeeding Made Simple explains that of the four categories of mammals, humans are considered “carry mammals.”  Like the other carry mammals—such as the great apes and marsupials—constant holding and feeding during the early months are the biological expectations of our young.  Has swaddling become a culturally acceptable substitute for the body contact our babies expect?  One writer suggested that swaddling can be okay if parents are alert to their baby’s cues, but another responded: “Swaddling suppresses the baby’s cues...so no amount of responsive monitoring can see cues that aren’t there.”  Or as one so succinctly put it:  “Humans are meant to be close to mum, not at arms length being shushed at.”

One considered the article a “blanket statement against swaddling” and an “all or nothing” approach “based on opinion and not actual facts.”  Another thought the post attempted to “take away a tool that many parents find so helpful and needed.” She contended that most parents only use swaddling as last resort after trying many other things first.  However, more than a few popular books and DVDs suggest swaddling as a first strategy to calm a fussy baby. 

Most would agree with the comment “We need to empower parents to read the research second and to read their babies and their own intuition first.”  However, if parents are told repeatedly that swaddling makes their baby “happy,” this colors their interpretation of their baby’s response.  Shouldn’t parents know that swaddling may be stressful for their baby?  Anything less than full disclosure is patronizing.  Only by hearing both sides can they make informed choices about this practice.

Another writer defended the post, noting “I don’t think the purpose of the article was to say swaddling should be thrown out altogether….It reads, ‘when babies get fussy, it may be best to limit swaddling and suggest instead parents consider alternatives, such as skin-to-skin contact and baby carriers.’”  This seems like a logical approach until we learn more about swaddling’s effects on babies.

Finally, a writer cautioned against limiting swaddling because it is an “age-old practice” that has been “used for centuries.”  However, the same could be said of discarding colostrum as “dirty,” an age-old practice in many cultures. We have since learned better.  And if we discover with further research that rather than calming babies, swaddling actually does stress them, we may need to rethink this practice as well as many of our own assumptions about it. 

Rethinking Swaddling

There’s no doubt that babies seem calmer and sleep more when swaddled.  But is this a positive or a negative?  The research provides some surprising answers, starting with the first days after birth.

Swaddled babies arouse less and sleep longer.¹ That may sound good, but in the early hours and days after birth this can lead to less breastfeeding, which is associated with greater weight loss, more jaundice, and a delay in milk production.² 

Swaddling delays the first breastfeeding and leads to less effective suckling.  In a study of 21 babies after a vaginal birth,³ researchers divided them into two groups.  One group was laid skin-to-skin on mother’s body, examined briefly, then returned to skin-to-skin contact for two hours.  The other group was shown to the mother, examined, and swaddled with hands free and then returned to mother.  The swaddled group showed delayed feeding behaviors, suckled less competently at their first breastfeeding, and established effective breastfeeding later.

When swaddling is added to other newborn stressors, it appears to worsen their negative effects.  Researchers compared outcomes among 176 mothers and babies, who were divided into 4 groups: 

1. Kept in skin-to-skin contact with mother for 30 to 120 minutes after birth
2. Held in mother’s arms wearing clothes
3. Separated from mother at birth and returned to her after two hours
4. Taken to the hospital nursery at birth and returned to mother for breastfeeding seven times each day at regular intervals

In each group, some babies were swaddled and some wore clothes.  The researchers reported that skin-to-skin contact reduced “the stress of being born” and found the babies kept skin-to-skin after birth had the highest body temperatures.⁴

Swaddled babies separated during their first two hours lost more weight.  Among the babies in Group 3 above, the swaddled babies had a significantly greater weight loss on their third and fifth days.⁵

Swaddled babies kept in the nursery were colder and consumed less milk.  Among the babies in Group 4 above, those who were swaddled had the lowest foot temperature of any of the babies in any of the study groups.  Newborns who were both separated and swaddled consumed less mother’s milk overall than those who were separated but not swaddled.  Their mothers also produced less milk on the fourth day and they had a shorter duration of breastfeeding overall.⁵

Swaddled babies in the nursery lost more weight despite consuming more formula.⁵  Possible reasons for this that the researchers suggested include:

• Severely limiting baby’s movements is stressful, which burns more calories.
• Swaddled babies receive less touch, which can compromise growth in preterm babies.⁶

If there are reasons to be concerned about a newborn’s temperature, a more effective strategy than either swaddling or using an infant warmer is to keep baby on mother’s body, putting blankets over both mother and baby.^7,8,9 If the mother can’t provide skin-to-skin contact, the father is an excellent second choice.

But what about after hospital discharge?  Once a baby is breastfeeding well, is there any reason to avoid swaddling?  While swaddling may be helpful when used occasionally, routine swaddling during the first months associated with greater risk of: 

• Respiratory illness¹⁰ 
• Hip dysplasia¹¹
• SIDS in prone sleeping positions¹²
• Overheating¹³

Evidence is also growing that babies’ hand movements aid them in finding the breast and latching. ¹⁴ Swaddling during breastfeeding to restrict babies’ hands may contribute to breastfeeding problems.

After reading the research, my own opinion of swaddling has changed.  In most cases a mother’s body is her newborn’s best “baby warmer.”  When babies get fussy, it may be best to limit swaddling and suggest instead parents consider alternatives, such as skin-to-skin contact and baby carriers.

For a more detailed look at this subject, click here to read “Rethinking Swaddling,” my lead article in the September 2010 issue of the International Journal of Childbirth Education.

References

¹Franco, P., et al. Influence of swaddling on sleep and arousal characteristics of healthy infants. Pediatrics 2005; 115(5):1307-11. 

²Yamauchi, Y., & Yamanouchi, I. Breast-feeding frequency during the first 24 hours after birth in full-term neonates. Pediatrics 1990; 86(2):171-75. 

³Moore, E. R., & Anderson, G. C. Randomized controlled trial of very early mother-infant skin-to-skin contact and breastfeeding status. J Midwifery Womens Health 2007; 52(2):116-25.

⁴Bystrova, K., et al. Skin-to-skin contact may reduce negative consequences of "the stress of being born": a study on temperature in newborn infants, subjected to different ward routines in St. Petersburg. Acta Paediatr 2003; 92(3):320-26. 

⁵Bystrova, K., et al. The effect of Russian Maternity Home routines on breastfeeding and neonatal weight loss with special reference to swaddling. Early Hum Dev 2007; 83(1):29-39. 

⁶Ferber, S. G., et al. Massage therapy by mothers and trained professionals enhances weight gain in preterm infants. Early Hum Dev 2002; 67(1-2):37-45. 

⁷Galligan, M. Proposed guidelines for skin-to-skin treatment of neonatal hypothermia. MCN; Amer J Matern Child Nurs 2006; 31(5):298-304; quiz 305-296. 

⁸Ludington-Hoe, S. M., et al. Safe criteria and procedure for kangaroo care with intubated preterm infants. JOGNN 2003; 32(5):579-588.

⁹World Health Organization. Integrated management of pregnancy and childbirth: Pregnancy, childbirth, postpartum & newborn care. Geneva, Switzerland: WHO, 2003.

¹⁰Yurdakok, K., et al. Swaddling and acute respiratory infections. Amer J Pub Health 1990; 80(7):873-75. 

¹¹Sahin, F. et al.  Screening for developmental dysplasia of the hip: Results of a 7-year follow-up study.  Pediatr Int 2004; 46(2):162-66. 

¹²Ponsonby, A. L., Dwyer, T., Gibbons, L. E., Cochrane, J. A., & Wang, Y. G. (1993). Factors potentiating the risk of sudden infant death syndrome associated with the prone position. New Eng J Med 1993; 329(6):377-82. 

¹³van Gestel, J. P., et al. Risks of ancient practices in modern times. Pediatrics 2002; 110(6): e78.

¹⁴Genna, C.W. & Barak, D.  Facilitating autonomous infant hand use during breastfeeding.  Clin Lact 2010; 1(1):15-20.

Is Infant Feeding Really a Choice?

Many of us talk about breast or bottle as a choice.  I used to think that way, too.  But I’m beginning to see it differently. 

On November 1, I had the privilege of speaking to a group of amazing and inspiring British women who work with breastfeeding mothers as peer counselors.  The night before this talk in West Bromwich, England I stayed with Anne, one of the Training Coordinators of La Leche League of Great Britain’s Peer Counsellor Programme (LLLGB/PCP). 

Anne told me a story I will never forget.  It began when Anne’s son’s partner, Kelly, moved into her home while pregnant with her second child.  Kelly became involved with Anne’s son during this pregnancy, so her unborn baby was not Anne’s biological grandchild. 

Kelly had bottle-fed her first child and was planning to do the same again.  In preparation, she bought a sterilizer and an array of feeding bottles, which one day Anne came home to find covering her kitchen counter.  Knowing that many young mothers would be coming there for breastfeeding help, she asked Kelly to keep her purchases on a shelf out of view.  Anne was concerned about giving one message with her words and another with the obvious bottle-feeding paraphernalia.  Kelly did not really understand Anne’s concern (in Kelly’s mind babies, bottles, and sterilizers all just went together), but she agreed. 

After her baby was born, surprise!  Kelly gave birth in a Baby-Friendly hospital where after delivery all newborns are placed skin-to-skin with their mothers.  When this happened, Kelly’s baby crawled up and attached to her breast.  Kelly responded, “Well, I guess she’s breastfeeding after all.”  She went on to exclusively breastfeed and nursed her for several years.  No doubt her exposure to Anne and the breastfeeding mothers she met helped Kelly make breastfeeding a reality. 

When the baby was about a week old, Kelly said to Anne, “Why don’t they tell you about breastfeeding?  It’s easy, isn’t it?  If I’d known that, I would’ve done it before.”  She had only ever thought of breastfeeding as hard work and a source of problems.  Then Anne asked Kelly something Nancy illustrating a concept with a balloon in West Bromwich, Englandshe’d been wondering for a while: “Why did you choose to formula feed your first baby?”  Kelly’s response startled her: “I didn’t choose.  I just did what I thought you did to feed babies.  It was not a choice as such.  I didn’t think of it that way.” 

Kelly had only ever seen babies bottle-fed.  She didn’t know anyone who had breastfed and she knew nothing about it.  To Kelly, feeding babies by bottle was just how it’s done.   Asking her to consider breastfeeding would have felt to her like asking her to perform surgery or argue a legal case in court.  She knew some people did those things but definitely not her. 

Anne has a special interest in how a mother’s confidence in breastfeeding builds and often asks new mothers when they really began to feel like a breastfeeding mother.  According to Anne, some mothers raised in breastfeeding families see themselves as breastfeeding mothers even before becoming pregnant and giving birth.  In Kelly’s case, it took about a week.  For others it takes a few weeks or even months of breastfeeding.  Anne has noticed that once “breastfeeding mother” becomes part of a woman’s self-image, she is unlikely to let breastfeeding problems get her way.  Some term this phenomenon “breastfeeding self-efficacy,”¹ which is really just how much confidence a mother has that breastfeeding will work for her.   Not surprisingly, greater breastfeeding self-efficacy has been associated with longer duration of breastfeeding, even in cultures where fewer women breastfeed.²

What can we do to enhance mothers’ confidence in breastfeeding?  Physician Christina Smillie describes one way as “oozing confidence in the process.”  Most breastfeeding advocates do this naturally.  Showing mothers tricks that make breastfeeding easier is another. Contact with other breastfeeding mothers--either one-on-one or in support groups--is a big one.  Spending time with mothers who enjoy breastfeeding has a major impact, as does their encouragement.

The wonderful women I met in West Bromwich, England do this every day in their role as peer counselors.  It felt good to thank them personally for the important work they do.

References

¹Dennis, C.-L. Theoretical underpinnings of breastfeeding confidence: A self-efficacy framework.  J Hum Lact 1999; 15(3):195-201.

²McCarter-Spaulding, D. and Gore, R.  Breastfeeding self-efficacy in women of African descent.  JOGNN 2009; 38(2):230-43.