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Is this recommendation from the World Health Organization (WHO) really out of date?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.2Babies 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.3So 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. 

Should All Breastfed Babies Have Above Average Weight Gains?

Just like in the fictional Minnesota town of Lake Wobegon, where “all the children are above average,” many parents believe there is something wrong if their breastfeeding baby’s weight isn’t above the 50th percentile.  While it is human to want our children to excel, the assumption that babies at a higher weight percentile are healthier or somehow “better” reflects a basic misunderstanding of growth charts and what they mean.

The purpose of a growth chart is to plot a baby’s growth on a series of percentiles, with the average baby at the 50th percentile.   What this really means in terms of weight is that out of 100 children, 49 will weigh less and 50 will weigh more. A weight that falls at a higher percentile is not “good” and a weight that falls at a lower percentile is not “bad.” By definition, there will be healthy children at every percentile.  Some will be chunky and some will be petite, but their percentile does not necessarily reflect their overall health or growth. 

A child at the 5th percentile is not necessarily growing poorly and the child at the 95th percentile is not necessarily growing well.  That’s because growth can only be evaluated over time.  For example, a preterm baby born very small will likely fall on a low percentile for weight at first, even when he is gaining weight well.  Also, if during pregnancy a mother had high blood sugar levels, gained a lot of weight, or received lots of IV fluids during labor, her baby’s birth weight may be unnaturally high.  In these situations, after birth a large baby may fall in percentiles to a weight closer to what his genes naturally dictate.1

But parents are not the only ones confused.  A U.K. study2 examined both mothers’ and healthcare providers’ perceptions of growth charts, and found that many mothers worried about their baby’s weight gain between checkups and that both mothers and healthcare providers erroneously considered the 50th percentile a goal to be achieved.  When babies fell below the 50th percentile, healthcare providers often recommended the mothers give their babies formula and solid foods to try to boost baby’s weight gain to reach this “desirable” percentile.  The researchers concluded that healthcare providers need more training on how to assess the growth of breastfeeding babies and how to support breastfeeding rather than undermine it.

Normal growth means a baby is gaining weight at a healthy pace and growing well in length and head circumference.  One point on a baby’s growth chart should never be considered in isolation but rather compared to other points.  It’s a baby’s growth pattern over days, weeks, and months that provides an accurate picture of how breastfeeding is going.  If a baby is growing consistently and well, his actual percentile is irrelevant. 

If over time, however, his weight-for-age percentile drops, first it’s important to determine whether the chart is based on breastfeeding norms, as many are not.  (Click here for the World Health Organization’s growth charts based on exclusively breastfed babies.)  If the chart is based on breastfed babies and the baby’s weight-for-age percentile has dropped, this is a red flag to take a closer look and see if breastfeeding dynamics can be improved.  

References

1Mohrbacher, N.  Breastfeeding Answers Made Simple: A Guide for Helping Mothers.  Amarillo, TX: Hale Publishing, 2010.

2Sachs, M., Dykes, F., & Carter, B. Feeding by numbers: an ethnographic study of how breastfeeding women understand their babies' weight charts.Int Breastfeed J 2006; 1:29.

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.

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.

Do Breastfeeding Babies Need Extra Iron at 4 Months?

Susan Burger, MHS, PhD, IBCLC, my guest poster today, maintains a private lactation practice in New York City.  She is one of my favorite scribes on Lactnet, our professional listserv.  Her doctorate in nutrition and her work with breastfeeding mothers and babies in developing areas of the world add weight to her insights into this controversial topic . 

Should exclusively breastfed babies be routinely supplemented with extra iron?  Yes, according to the Committee on Nutrition of the American Academy of Pediatrics (AAP) in its recently issued Clinical Report.It justifies this recommendation by citing its “concerns that iron deficiency anemia and iron deficiency without anemia can have long-lasting detrimental effects on neurodevelopment.”  

As a mother myself and as someone who worked for many years on large-scale public health nutrition programs for mothers and children in developing areas, I certainly want the AAP to fully investigate and make solid recommendations about the potential impact of iron deficiency on cognitive development. 

In the late 1980s when I did my doctoral studies in nutritional sciences at Cornell, it was common knowledge that much of the iron that is stored by the fetus occurs in the last trimester of pregnancy. The closer to 40 weeks of gestation, the better the iron stores at birth.  More recent evidence has been accumulating that clamping the umbilical cord sooner than 2 minutes after delivery may deprive infants of a last and relatively substantial contribution of iron from the placenta to the newborn’s iron stores. 

Over 20 years ago, we knew that the iron in human milk is easily absorbed and that the iron added to formula is not and that extra iron may even interfere with absorption of iron from mother’s milk.  From the evidence at that time, we generally accepted that healthy full-term babies did not need additional sources of iron until they were around 6 months old.  In fact, a 2009 study reinforces this assumption.  The prevalence of iron deficiency was only 3% among otherwise exclusively breastfed infants who were randomly assigned to receive a placebo between 1 and 6 months of age.

So, I was expecting the AAP Committee on Nutrition to recommend ways to reduce preterm deliveries and premature cord-clamping and to remove barriers to exclusive breastfeeding for the first 6 months. Instead, the Committee’s ONLY recommendation was to start supplementing term breastfed infants with iron at 4 months. 

In puzzlement, I thought perhaps the Committee was privy to some new information of which I was unaware.  So, I carefully read the rationale for the recommendation and was surprised to see that it cited one study.  Again puzzled, I thought perhaps this one study was so astoundingly thorough that it upended all the other evidence I had read.  So, I read its methods section carefully. 

My expectations were dashed.  The sample size was small; only 77 babies were randomly assigned to receive either an iron supplement or a placebo at the start of the study. The drop out rate was high; 43% of the infants had dropped out by the time that developmental tests were administered at 13 months of age.  Compliance was low; study babies received the iron or placebo only 56% of the time they were supposed to receive these.

Furthermore, the study subjects do not match the population considered by the AAP Committee on Nutrition. The study babies were not “exclusively breastfed” as mentioned by the Committee; the researchers classified these babies as “breastfed” even though a few were given up to a bottle of formula a day from the start of the study and most were drinking formula by 6 months of age. The study babies did not start iron supplementation at 4 months as recommended by the Committee; the researchers started iron supplements or placebos at 1 month of age and continued for another 5 months.  So we really don’t know if the results would hold up among a group of infants who were started on iron supplement at 4 months of age and otherwise receiving nothing but mother’s milk until 6 months of age.

Finally, the sample size was not nearly sufficient to evaluate some of the potential harmful effects of iron supplementation among babies with healthy iron levels that were found in other studies, such as increased risks of infection and slower linear growth.

To the authors’ credit, they did not extrapolate beyond the findings of their own study when they wrote that a “larger study that focuses on the long-term developmental outcomes is needed before recommendations can be considered regarding the whole population of breastfed infants.”  Yet, the Committee went ahead and made a blanket recommendation anyway. 

I thought perhaps I was alone in my thinking when I read the long list of committees and groups cited as contributing to the report.  Then, I looked at the e-letters responses and discovered that others actually had similar objections, including the Chairperson of the AAP Section on Breastfeeding, Dr. Richard Schanler who stated:

 “…. the authors acknowledge that this report was submitted for review to the Section on Breastfeeding of the [AAP]. It did not mention that we disagreed and provided our additional recommendations, 2 years ago. The manuscript infers that the Section, along with many other groups, endorsed this report. This is wrong and will mislead the medical community.  We would welcome a discussion of science and changes in recommendations that are evidence-based.  We do not have issues with screening at-risk populations. We further request that the section “Development of this Report,” be retracted and removed from publication.”

I agree with Dr. Schanler that a discussion of the science is important. In the meantime, I have far more confidence in the previous recommendations of the American Academy of Pediatrics that iron supplements should not be routine for exclusively breastfed babies before 6 months of age.  As solids are introduced, selecting an appropriate mix of foods that include those rich in iron may circumvent any need to use supplements even after 6 months of age.

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 she’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.

Unintended Consequences

What’s a breastfeeding mother to do?  Is it riskier to bedshare with her baby during the night or is it riskier not to?  That’s what a survey of 4789 U.S. mothers with babies under one year clarified.1

In the U.S. parents are admonished never to sleep with their babies.2 The Milwaukee, Wisconsin health department, for example, uses the image of an adult headboard transformed into a tombstone as a warning about the dangers of bedsharing. (Click here for a video on this campaign.) 

Bedsharing appears even more dangerous when—as often happens in the U.S.—infant deaths are blamed on it even when other more hazardous practices are present, such as adult alcohol intoxication and drug use and when the “bed” is actually a recliner, chair or sofa.  One Scottish study, for example, found that the risk of an infant dying was nearly 67 times higher on a sofa compared to an adult bed.3

According to the U.S. mothers surveyed, despite their awareness of these public campaigns, nearly 60% of their babies shared their beds for at least part of the night.  Among the mothers who attempted to follow the recommendations against bedsharing, 55% fed their babies at night in chairs, recliners, or sofas and 44% of these (25% of the total) reported falling asleep some of the time in these much more dangerous places.  In other words, their attempts to “follow the rules” often led to the unintended consequence of much riskier behaviors.

The authors of this survey concluded that safe-sleep campaigns should include information on safe bedsharing, because when this information is absent, parents will continue to bedshare in unsafe ways.  The Japanese experience confirms this.  As bedsharing as has become more common in Japan (it is now the cultural norm), rates of SIDS have decreased. 4What’s different there is that Japanese families bedshare safely.  Families sleep together on futons on the floor away from walls, so babies cannot fall far or get trapped.  Fluffy pillows and bedclothes are not used. 

To save more lives, U.S. safe-sleep campaigns should consider taking a page from the Japanese playbook.  By emphasizing how to create a safe sleeping environment—rather than trying to browbeat parents into avoiding bedsharing—more babies’ lives would be spared.  And as an extra plus, more families would also get a better night’s sleep.

For a brochure for parents on safe sleep, click here.

References

1Kendall-Tackett, K., Cong, Z., and Hale, T.W.  Mother-infant sleep locations and nighttime feeding behavior.  Clin Lact 2010; 1(1):27-30.

2American Academy of Pediatrics, Task Force on SIDS.  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; 116:1245-55.

3Tappin, D. et al.  Bedsharing, roomsharing, and sudden infant death syndrome in Scotland: A case-control study.  J Pediatr 2005; 147:32-37.

4McKenna, J., Ball, H., and Gettler, L.T.  Mother-infant cosleeping, breastfeeding and sudden infant death syndrome: What biological anthropology has discovered about normal infant sleep and pediatric sleep medicine.  Amer J Phys Anthropol, Suppl 2007; 45:133-61.

Doing It Right

Today my guest blogger is one of my favorite people in breastfeeding, Diane Wiessinger, coauthor of the new The Womanly Art of Breastfeedingand author of the seminal article “Watch Your Language,” which forever changed how we think about the “benefits” of breastfeeding. 

I took my young son to a Chinese restaurant for lunch years ago.  I asked our waiter to show us the right way to use chopsticks.  “Well,” he said, scanning a nearby table of Chinese waiters, all busy eating lunch, all with chopsticks, “None of them are doing it right.”

Whether we’re eating, walking, or putting on socks, we don’t have to do it “right”; we just have to do it so it works for us.  So why are there so many rules about breastfeeding?  And why don’t they work very well? 

More than 30 years ago, when my first child was born, there were no rules at all about how to make a baby take the breast (there was no such thing as The Latch).  All anyone knew was that if a baby’s cheek is touched when he’s hungry, he responds by turning his head with a wide, searching mouth.  It was the height of the natural childbirth movement, and many of us who were interested in breastfeeding also had medication-free births, which meant our babies were competent from the start.  Skin-to-skin was unheard of, our babies were kept in central nurseries, often they had a bottle before their first nursing… but most of them latched with little or no difficulty.  It didn’t occur to us that they might not.

Trouble is, we were sore, often for weeks.  So the field of Lactation Consultants began – not to help babies latch, but to figure out what caused the pain.  We LCs looked carefully at each tiny piece and realized that the pain was usually from holding the baby as if for bottle-feeding.  But we broke everything into tiny steps, created rules about how to do each step “right”… and the whole thing worked even less well.  Now we began seeing non-latching babies!  So we added more rules, and more, and mothers’ confidence eroded.

When a baby learns to walk, he’s pretty awkward.  He falls a lot, he wobbles, but no one says, “Oh dear, if you don’t take that baby to a specialist, he’ll never walk right.”  Everyone knows he has the basics built in, and just needs time.  Making him follow a detailed set of rules would probably drive him back to crawling! 

That’s what happened with breastfeeding.  We laid down rules for something that had never had any, and we left mothers feeling incompetent and babies feeling totally confused. 

So try this:   lean back comfortably, your baby’s whole front on you, and let gravity take care of the holding.  Your baby lies there with his cheek against your breast.  If he’s hungry, he turns toward his cheek, and there’s that wonderful nipple right nearby.  You’ve done nothing in particular (in fact, any fumbling that you do probably helps), and he chooses the moment that suits him best.  What a concept! 

Are you doing it right?  Well… if both of you are comfortable and the milk is flowing, what else could possibly matter?  Let the Lactation Consultants save their problem-solving for if you have a problem. 

London Memories

Life can include some incredible moments.  I experienced one in London on the 26^th of October, when I was privileged to speak at the Womb to World conference along with sleep researcher Helen Ball, author Me and Kathy Kendall-Tackett in LondonDeborah Jackson (Three in a Bed), and my coauthor and all-around marvel Kathleen Kendall-Tackett.  This was the first conference where the second edition of Kathy’s and my book for parents, Breastfeeding Made Simple: Seven Natural Laws for Nursing Mothers, was on hand. 

Being in London was fabulous.  Speaking with my coauthor at the same conference was also a rare treat.  But to have our book debut in such an exciting place with the two of us together made the event even more special.

The question I was asked most often that day was, “What’s new in the second edition?”  I was happy to report that lots had changed even in the five short years since the first edition was released.  It felt fitting to talk about these changes at this particular conference, as Suzanne Colson was the conference chair and it was sponsored by her organization The Nurturing Project.  It was Suzanne’s 2008 journal article that triggered a sea change in our understanding of breastfeeding dynamics, which is reflected in this second edition.  You can read more about these new perspectives by clicking on my blog history section “Laid-Back Breastfeeding.” 

In addition to her amazing insights into how mother’s body position can make early breastfeeding easier or more difficult, Suzanne’s research also inspired us to tweak our Natural Law #1.  Rather than reading “Babies Are Hardwired to Breastfeed,” as it did in the first edition, it now reads, “Babies and Mothers Are Hardwired to Breastfeed.” 

Over the last decade, we in lactation came to accept that human babies, like all other mammals, are born with reflexes that help them get them to their feeding source and feed.  Now—thanks to Suzanne’s research—we must seriously consider the possibility that mothers may also have breastfeeding Me. Deborah Jackson, Suzanne Colson, and Kathy Kendall-Tackett at the Womb to World Conferenceinstincts.  However, one drawback to being human—at least as far as breastfeeding is concerned—is that we have large brains, which makes it possible to overthink it.  Some of my most respected colleagues are beginning to suggest that despite our sincere desire to help, some breastfeeding interventions and instructions—including positioning and latch-on—may actually cause breastfeeding problems.  When mothers are convinced to let others guide them, this may short-circuit their instinctive breastfeeding behaviors and cause difficulties.   Stay tuned for more on this…

Today, I’m basking in the glow of my London memories and excited that my second new book of 2010 is finally out.  Kathy and I are very happy with our new-and-improved Breastfeeding Made Simple.  We hope you like it, too.

Process, Product, and Personal Growth

I write these words on my oldest child’s 30th birthday, a milestone that also marks the 30th anniversary of the day I became a mother.  In those 30 years, I have learned many life-changing lessons about breastfeeding and parenting.  To mark this occasion, I’d like to share a few.

Child-rearing is an incredible opportunity for personal growth.  When I was pregnant with my son, I imagined all sorts of things I could do to give him a better life.  What I couldn’t imagine was how my child would affect me.  In hindsight, I don’t think I really grew up until after I gave birth to him.  Round-the-clock breastfeeding was a part of that.  When it became clear that my baby knew what he needed and when he needed it, it also reinforced my understanding that my child’s needs were valid and deserving of respect, another step toward my own maturity.  From my child’s perspective, having his needs met demonstrated beyond words that they mattered, which helped him stay in tune with his own inner voice—a dynamic that increased his resistance to peer pressure during his teen years. 

What about parenting “experts” who encourage mothers to remain in control by scheduling their babies’ routines by the clock?  As I wrote in my post “Fear and Surrender,” my decision to surrender to my baby’s individual feeding rhythm not only gave me abundant milk but was also instrumental in achieving a life-changing intimacy with him.  Had I tried to control the process, I have no doubt our relationship would have been different.  One of my early lessons came after several days of heeding the voices around me and letting him cry at night.  I was dismayed to find that I began to care less when he cried during the day.  Because this was not the kind of parent I wanted to be, I decided to go my own way and never looked back, convinced that these cry-it-out methods could distance me from my baby.  Unfortunately, many new parents embrace rigid methods that feed into their fear of change and the unknown, and their chance to experience this growth may be stunted.

Process trumps products and people trump things.  BC (before children) I was a Type A, check-it-off-my-list kind of person.  When my son was born, it was a big adjustment for me to put my list away and focus on him.  In the evening, we both looked the same as we did in the morning, which at first was hard to accept.  It slowly dawned on me, though, that rather than having a finished product to show for all my hard work each day, what I had instead was a thriving, happy baby.  I began to realize that my new job as a mother was more about the process rather than the product, and that was okay. 

This product-versus-process struggle can also spill over to breastfeeding.  Some mothers become overfocused on the milk, which is of course important.  But perhaps even more important is the process of breastfeeding.  As the months and years passed, breastfeeding became much more than a way to feed my son.  It morphed into an all-purpose mothering tool and a significant source of comfort for us both.  I found myself calmed by breastfeeding at family funerals and saw my toddler son’s tantrums short-circuited by the breast.  I began to see the milk as a nice “value add,” while the bond we shared at the breast as the real deal.

On this special day, I say: Happy birthday, Carl!  Thank you for everything you have taught me and have given me.

Some Ins and Outs of Laid-Back Breastfeeding

In an earlier post I explained why it’s time to change the way we teach breastfeeding.  I described research findings indicating that early breastfeeding is easier when mothers lean back with their babies’ weight resting on their body.1  (See my new Blog History category “Laid-Back Breastfeeding” in the right column for a link to all my posts on this subject.)  These laid-back positions not only make breastfeeding less work for mothers, they also make it easier for babies to take the breast deeply, especially during the early weeks.  That’s because in these positions gravity helps rather than hinders babies’ inborn feeding reflexes, which can make a huge difference when babies are at their most uncoordinated. 

After decades of teaching mothers to breastfeed sitting upright or lying on their sides, many have difficulty visualizing this new approach.  One common question I am often asked is whether these positions are practical after a cesarean birth.  The answer is most definitely yes.

A number of adjustments can be made to help a mother customize laid-back breastfeeding (also known as “Biological Nurturing”) to her body type and situation.  As you can see from these line drawings, one adjustment is changing the direction of the baby’s “lie” on her body.  In all laid-back positions, baby lies tummy down on mother, but this can be accomplished in many ways.  The baby can lie vertically below mother’s breast (as on this website’s banner), diagonally below the breasts, across her breasts, at her side, even over her shoulder.  As Suzanne Colson explains in her DVD, “Biological Nurturing: Laid-Back Breastfeeding,” the breast is a circle, and the baby can approach it from any of its 360 degrees, except for positions in which the baby’s body covers mother’s face.  So after a cesarean birth a mother can use many laid-back positions without baby resting on her incision.

Another possible adjustment is the mother’s angle of recline, or how far the mother leans back. In laid-back positions, the mother leans back far enough so that her baby rests comfortably on her body without needing to support her baby with her arms but is upright enough so she and her baby can easily maintain eye contact.   Because most hospital beds are adjustable, finding their best angle of recline is especially easy during the hospital stay.  At home, I suggest mothers imagine the positions they use to watch their favorite television show.  Most of us lean back on a sofa, chair, or bed, using cushions or pillows so we can relax our shoulders, head, and arms.  Colson says the best laid-back breastfeeding positions are those that mothers can easily and comfortably maintain for up to an hour.

When using laid-back breastfeeding, ideally each mother finds her own best variations by trial and error.  In light of these insights, I think the time has come for us to stop naming and teaching specific breastfeeding “holds.”  (After all, no one teaches bottle-feeding mothers how to hold their babies during feedings!)  That way, mothers will no longer waste their time trying to duplicate feeding positions taught in classes or pictured in books that may not be right for them or--even worse--may even make early breastfeeding more difficult. Instead, each mother’s focus will stay exactly where it belongs: on her and her baby.

Reference

1 Colson, S. D., Meek, J. H., & Hawdon, J. M. Optimal positions for the release of primitive neonatal reflexes stimulating breastfeeding. Early Human Development 2008; 84(7):441-449.

Fear and Surrender

Many cultures consider the first 40 days after birth a distinct time in a woman’s life.  Referred to as “la cuarentena” in many Hispanic cultures, and the “lying-in” period during America’s past, nursing couples are kept together and cared for in isolation, with others doing their household chores and taking care of older children. 

Somehow in modern America, this concept and practice—once key to establishing healthy milk production—have been lost.  Rather than planning to spend the early weeks recovering from childbirth and focusing on feeding the newborn, many parents in the U.S. today feel social pressure to “get back to normal” as quickly as possible. 

This relatively new attitude has wreaked havoc on lactation and no doubt contributes significantly to the steep drop in early nursing rates.  Once well-understood, most parents now give birth with no inkling that nursing involves intense, sometimes constant feeding.  As part of the natural order of things, newborns use these feeding frenzies to boost their nursing parent’s milk production from 1 ounce (30 mL) on Day 1 to 25-35 ounces (750-1050 mL) per day by about Day 40, when most reach full milk production.  

If new parents don’t understand or expect this intense early nursing, they may assume there’s something terribly wrong.  They may be fearful they aren’t making enough milk or decide that nursing is just too much work.  They may wean or start supplementing with no idea of what they stand to gain by simply responding to the baby’s feeding cues and surrendering to the experience.   

By about Day 40, surrendering to the reality of early nursing usually results in full milk production.  But there is more.  The baby who once fed for 30 minutes may now be done in 15.  The baby who fed 12 times each day may now feed only 8.  Over time, nursing usually becomes much less time-consuming than the alternative.  Intense early nursing is an investment that pays back many times over. 

But parents who surrender to early nursing enjoy another, often unexpected reward: the amazing emotional experience of getting in sync with their newborn.  Many describe this as the greatest intimacy they’ve ever known, an experience that can influence parenting for a lifetime.  Research has found, for example, that when older babies start solid foods, mealtime battles are less common in nursing families because these parents learned to trust their babies to know what they need and when they need it.1 The trust and sensitivity that nursing fosters enhances early attachment, which is the oil that greases the wheels of parenting for decades to come. 

Why are many parents afraid of surrendering to the intensity of early nursing?  Ignorance and social pressure are two reasons.  Popular but misguided authors warn that letting baby “use them like a pacifier” (see my post on that HERE) will produce children lacking in discipline or at risk for drug addiction.  Health professionals unaware of nursing norms may recommend formula as a remedy for frequent nursing.  But when—out of fear and ignorance—parents sacrifice or attempt to take control of nursing, they may lose much more.  

One mother I spoke with yesterday shared with me her unhappy odyssey through early breastfeeding, which included frequent milk expression so her partner could feed the baby.  The extra work of pumping convinced her that breastfeeding was just too hard and she began regularly feeding formula.  Now at 4 months, her baby was mostly formula fed and she spent much of her time alone with her baby while her partner traveled for work.  She felt regret at this state of things and wondered if she could somehow reclaim breastfeeding.  I talked to her about normal feeding patterns in the beginning and afterward and she began to realize that many of her choices made her life more complicated.  Because she began our conversation by describing her need as a mostly single parent to simplify her routine, I suggested rather than continuing with regular pumping—which she was still doing even with her partner gone—to just breastfeed more often.  As we discussed the resiliency of breastfeeding, I assured her that it was not too late.  She told me, “You’ve made me realize I need to rethink some things.”  

These moments of insight are not only satisfying, they’re key to becoming a breastfeeding-friendly culture.  It’s a good day when we can serve as an antidote to the fear, ignorance, and social pressure that plague new parents.  By dispelling the myths and conveying the realities of nursing, we can make it easier for parents to surrender to the experience and enjoy the profound rewards that they and their babies can enjoy. 

References

1Farrow, C., & Blissett, J. Breast-feeding, maternal feeding practices and mealtime negativity at one year. Appetite 2006; 46(1):49-56.

Changing How We Teach Breastfeeding

We are experiencing a sea change in breastfeeding.  But how quickly can we change our approach?  At a breastfeeding conference last weekend, I summarized breastfeeding teaching strategies since 1980, how our understanding has evolved, and how this affects the way we help mothers. 

In 1980, I was told to breastfeed my first baby by holding him in my arms with his tummy facing the ceiling, which I realize now was a bottle-feeding position.  Over time, these instructions changed.  Instead, we recommended mothers hold their babies “tummy to tummy.” To make latching easier, we suggested breast support using the “C” hold and “U hold.”  We incorporated a variety of techniques for helping babies achieve an asymmetrical—or off-center—latch.  

However, in 2008, U.K. researcher and midwife Suzanne Colson published an article indicating that some of our fundamental assumptions had been wrong.  Not surprisingly, our “latching” or “attachment” instructions had been influenced by what we grew up seeing.  Generations of bottle-feeding had convinced us that mothers needed to sit upright or lie on their sides to breastfeed their babies.  

What changed?  In her research, Colson identified 20 inborn reflexes that help babies breastfeed.  And surprise!  Like baby piglets and other newborn mammals, Colson found that these reflexes work best when our babies feed on their tummies.  It turns out that all those years of teaching upright and side-lying breastfeeding positions may have been wrong-headed.  Although our tried-and-true methods make sense in some situations, rather than using them sparingly, we taught all new mothers to breastfeed this way.  As a result, gravity pulled babies away from their mothers’ bodies and made breastfeeding more challenging.  Colson noted that as “positioning and attachment” techniques became more widely taught in the U.K., more new mothers gave up on breastfeeding early. 

Colson’s research demonstrated that when mothers simply lean back and rest their babies tummy down on their semi-reclined bodies, most of our complicated latching instructions are no longer needed.  In “laid-back” positions, gravity keeps mothers and babies touching and helps rather than hinders breastfeeding. 

Last week I spoke to a mother with a 5-day-old baby who at first had decided to formula feed because her baby wouldn’t take one breast and breastfeeding was just too hard.  But then she felt her milk increase and decided to give it another try.  Her goal was to do some breastfeeding and some formula-feeding.  I told her about laid-back breastfeeding positions and steered her to http://www.biologicalnurturing.com/ to watch Suzanne Colson’s video clips.  When we spoke again yesterday, her 10-day-old baby was now exclusively breastfeeding and she told me how much easier laid-back breastfeeding had been for her. 

After my conference talk, many of my listeners—most of whom work with breastfeeding mothers every day—struggled to accept this new approach.  Clearly much thought and reflection was needed before many could translate this knowledge into practice.  Major paradigm shifts are never easy.  But for the sake of mothers and babies, here’s hoping this one doesn’t take too long! 

For more on laid-back breastfeeding, see my earlier post: /blog/2010/7/18/laid-back-breastfeeding.html

Reference

Colson, S. D., J. H. Meek, et al.  Optimal positions for the release of primitive neonatal reflexes stimulating breastfeeding. Early Hum Dev 2008; 84(7): 441-9.

Nipple Shield: Friend or Foe?

Last week, I spoke to a mother whose 1-month-old baby was born 4 weeks preterm.  She was breastfeeding with a nipple shield, which she was given in the hospital, and she was confused by conflicting advice.  Should she pump after feedings?  Was her baby getting enough milk?  How should she wean from the shield?  This was her sixth breastfeeding baby but her first preterm baby and first time using a shield.  She was emotional and unsure of herself.  My answers below were based on the research described in my book, Breastfeeding Answers Made Simple. 

Express milk after breastfeeding?  As long as her baby was gaining weight normally (which she was), there was no reason to pump after feedings.  A study of 54 mothers and babies compared babies breastfeeding with a nipple shield to those breastfeeding without it and found no difference in weight gain during the first 2 months of life. 1 Although one 1980 study found babies took 22% less milk at the breast with a shield, 2 these mothers used thicker, rubber shields.  As long as the baby is suckling effective, today’s thin, silicone shields do not appear to decrease milk intake during breastfeeding.

How to gauge baby’s milk intake.  Weight gain is the best way to know a breastfeeding baby is getting enough milk.  This baby was gaining well, so adequate milk intake was guaranteed. After feedings, other signs of milk intake include reduced feelings of breast fullness and milk seen in the tip of the shield.

Weaning off the shield.  A hospital nurse told this mother to wean her baby from the shield by gradually cutting it away.  This strategy made sense with rubber shields, but cutting silicone shields produces sharp edges that could irritate the baby’s mouth.  A better strategy is to start the baby feeding with the shield and when the mother hears swallowing to quickly slip off the shield and slip in the breast. But I told this mother to be patient.  Her preterm baby may not be ready to wean from the shield.  One study found nipple shields increased milk intake in preterm babies having trouble suckling actively and staying on the breast.3  While not all preterm babies need to use a shield, I told this mother that for now her preterm baby may breastfeed better with it.  The baby’s readiness to wean from the shield is as important as the mother’s readiness.

In general, should nipple shields be considered “friend” or “foe”?  It depends.  As 88% of the mothers in one study reported,4 when used appropriately, nipple shields can help preserve breastfeeding.  Or—like any breastfeeding tool—they can be misused and undermine it.  In some cases, weaning off the shield may be the right thing to do.  In others, a mother should be patient and wean from the shield later rather than decrease her baby’s breastfeeding effectiveness or turn the breast into a battleground.

References

1Chertok, I. Reexamination of ultra-thin nipple shield use, infant growth and maternal satisfaction. J Clin Nurs 2009;18(21):2949-2955.

2Woolridge, M. et al. Effect of a traditional and of a new nipple shield on sucking patterns and milk flow.  Early Hum Dev 1980; 4(4):357-364.

3 Powers, D., & Tapia, V. B. Women's experiences using a nipple shield. J Hum Lact 2004; 20(3):327-334.

4 Meier, P. et al. Nipple shields for preterm infants: effect on milk transfer and duration of breastfeeding. J Hum Lact 2000; 16(2):106-114.

Too Late to Transition to Direct Nursing?

In my last post I wrote about a mother I spoke with who had been pumping and bottle-feeding for 3 weeks.  She was convinced that breastfeeding was no longer possible for her and her baby.

Many parents think there’s no turning back once they stop nursing.  But because babies are hardwired to breastfeed, it’s always possible to nurse later.  In Australia, for example, babies cannot be adopted until they are 6 to 12 months old, but even so, many adoptive parents report successfully transitioning their babies to nursing, even after a year or more of bottle-feeding.  This makes sense if you think of nursing as a survival skill nature builds into babies. (Click HERE to read one mother’s story of transitioning her 20-month-old adopted son to nursing when he joined their family.)

I remember one mother I worked with during my 10 years in private practice whose 5-month-old experienced neurological damage during what should have been routine surgery.  This mother was pumping her milk in the months since the surgery and produced ample milk.  She scheduled a home visit with me to help her bring her baby back to direct nursing.  She decided that in addition to the therapy her baby was receiving, he needed the comfort and physical stimulation only nursing could provide.  I pulled out my bag of tricks and—to her joy—before long her baby was fully nursing again.

What tricks did I use?  Latch attempts while he was in light sleep (eyes moving under eyelids) provided the first breakthrough.  When a baby accepts the breast during sleep, this can be repeated at every nap and night feeding to lower resistance to nursing during waking hours.  Whether awake or asleep, lying the baby tummy down on his semi-reclined parent’s chest releases the feeding reflexes that spur babies to nurse. (Click HERE for examples of these positions.)  These simple approaches can work wonders, as long as the parent’s chest remains a happy place and baby does not feel pressured to feed there.

If you’re a parent wondering if it is “too late” for nursing or if you work with new parents in this situation, don’t despair.  No matter how difficult nursing once was and no matter how long it has been since the baby latched and fed, it is almost always possible to make nursing work.  A healthy milk production helps but is not absolutely necessary.  I often remind parents that babies eagerly accept pacifiers (aka dummies), which provide no milk at all.  The parent’s body provides a place to suckle and so much more!

Anxiety and Breastfeeding

As part of my day job, I talk to mothers by phone about breastfeeding.  At its essence, the main reason most mothers call the pump company where I work boils down to anxiety. 

When breastfeeding matters to a mother, it’s natural for her to worry.  But the more anxious a mother feels about breastfeeding, the more likely it is that her anxiety will undermine it.  If her worry centers around her baby’s milk intake, she may try to relieve her anxiety by feeding some formula, which may temporarily make her feel better.  However, if her baby seems more satisfied for longer periods—which is common with formula—it may confirm her worries and increase her anxiety about breastfeeding, leading to more formula use and less milk produced.   

Or she might decide to express her milk and feed it to her baby in a bottle.  Seeing how much her baby consumes may temporarily reduce her anxiety, but trying to keep up with a grueling pumping schedule may increase it again.  A routine of pumping, feeding, and cleaning can take two to three times the effort of direct breastfeeding.  One study found, not surprisingly, that among mothers of preterm babies, 72% of those whose babies made the transition to the breast were still going strong at 4 months, whereas only 10% of those 4-month-olds whose mother pumped and bottle-fed were still receiving mother’s milk.1 It’s difficult to make pumping and bottle-feeding work long term.

Today I spoke to a mother who described her intense emotional upheavals during the first week of breastfeeding.  Her baby was struggling at the breast and the visiting nurse told her that her baby seemed to feed better from the bottle, which convinced this mother to stop breastfeeding.  By the time we spoke, she had been pumping and bottle-feeding for 3 weeks and was convinced that breastfeeding was impossible for her baby.  I explained to her that babies are hardwired to breastfeed and that even babies adopted between 6 to 12 months of age successfully transition to the breast.  I told her that there’s a world of difference between a 1-week-old and a 4-week-old and that although breastfeeding had been traumatic before, it didn’t have to be traumatic now.  I described laid-back breastfeeding positions and encouraged her to help her baby to the breast while in light sleep.  And I described how direct breastfeeding could make her life easier.

Many have rightfully referred to breastfeeding as a “confidence game.”  Encouraging a mother one-on-one can help boost her confidence and decrease anxiety.  Another great confidence booster is experiencing the oxytocin-rich zone of a breastfeeding support group.  Being with other breastfeeding mothers, hearing their stories, and seeing first hand thriving breastfeeding babies have helped many mothers take a deep breath and just keep breastfeeding.

Reference

1 Smith, M. M., Durkin, M., Hinton, V. J., Bellinger, D., & Kuhn, L.  Initiation of breastfeeding among mothers of very low birth weight infants. Pediatrics 2003;111(6 Pt 1), 1337-1342.

Ouch! What If Pumping Hurts?

Some families assume pumping should be painful.  Not so!  “No pain, no gain” does not apply here.  Painful pumping means something needs to be adjusted. 

Pump Suction Set Too High.  The highest suction setting does not always pump the most milk. In fact, too-high suction can actually slow your milk flow.  Set your pump at the highest suction that feels comfortable during and after pumping…and no higher. (If you’re gritting your teeth, it’s too high!)

Pumping milk is not like sucking a drink through a straw. With a straw, the stronger you suck, the more liquid you get. When pumping, most milk comes only when a let-down, or milk release, happens. Without a milk release, most milk stays in the breast.

What is a milk release?  Hormones cause muscles in the breast to squeeze and milk ducts to widen, pushing the milk out. When this happens, some mothers feel tingling. Others feel nothing.  A milk release can happen with a touch at the breast, hearing a baby cry, or even by thinking about your baby. Feelings of anger or upset can block milk release.

While breastfeeding, most mothers have three or four milk releases, often without knowing it. To get more milk with your pump, you need more milk releases, not stronger suction.  For a free, downloadable handout on pumping that includes tips for triggering more milk releases, click HERE.

Fit Issues.  Many nursing parents pump comfortably with the standard diameter nipple tunnel that comes with their pump. But if pumping hurts even on low suction, you most likely need another size. (You may even need different sizes for each nipple.) If the standard nipple tunnel size is too small or too large, a better-fitting one will feel more comfortable and may also pump more milk. To check your nipple-tunnel fit, click HERE. 

Breast or Nipple Issues can also cause pain during pumping.  If your pain is not due to too-high suction or too-small or too-large nipple tunnels, it is time to consider these questions.  Do you have nipple trauma?  If you had nipple trauma in the past, could you have a bacterial infection of the nipple?  Do you have an overgrowth of yeast (also known as thrush or candida)?  Is mastitis a possibility?  Does your nipple turn white, red, or blue after pumping?  If so, see your lactation consultant or other health-care provider to rule out Raynaud’s Phenomenon and other causes related to breast and nipple health.   Thankfully, in nearly all cases, pain during pumping is a solvable problem. and scroll down

Guest Post: The Importance of Support

My guest blogger today is Laura, whose comments on my post "Milk Paranoia" seemed so fitting, I wanted to highlight them.  They reinforce the importance of Step 10 of the Baby-Friendly Hospital Initiative. which involves referring mothers to breastfeeding support groups after hospital discharge. Without ongoing support, long-term breastfeeding is an elusive goal for many. --Nancy

I suspect most women don`t even realize what qualifies as having an oversupply to begin with. I didn`t realize I was in that category until just recently. Although I am quite blessed to have more milk than I need for my monster-sized 29 inch, 22 pound, 6-month-old baby, I often worry whether pumping and working will affect my supply at some point and I won`t be able to keep up. Never mind that I successfully nursed my oldest for 3.5 years without issues.

It`s hard not to find breastfeeding horror stories out there. All one has to do is read a breastfeeding forum to hear the tales of lost milk supply and madly switching to formula, which baby promptly refuses. For myself I wouldn`t dream of posting on these forums about my oversupply and ability to produce milk at the drop of a hat.

I guess the point is that whether I trust my body or not it`s quite easy to fall into the trap of worrying about supply. It`s not like I can just run to Walmart and pick up some breastmilk if I run out. Not only is breastfeeding about trusting one`s body, it`s also about having the right information and surrounding oneself with people that are confident in their breastfeeding ability. This can be difficult to do. The breastfeeding horror stories are everywhere and so is the misinformation.