Six years ago, I wrote a blog reflecting on Diane Wiessinger’s seminal essay, “Watch your language.” “There are no benefits of breastfeeding,” I wrote. “There are risks of formula feeding.”
That post remains the most-viewed piece I’ve ever written, with more than 74,000 views as of this writing. I’ve taken the lesson to heart. I’ve published a peer-reviewed study on the increased risk of hypertension among women with curtailed breastfeeding, and I’ve flipped odds ratios in teaching slides and review articles to frame associations as the “risk of not breastfeeding” or the “risk of formula,” rather than the “benefits of breastfeeding.”
Weissinger’s 1996 essay rests on the position that breastfeeding is the physiologic norm, against which all other feeding methods should be compared. Moreover, she notes, mothers who are facing difficulties will be more likely to seek help to avoid a risk than to achieve a benefit:
When we fail to describe the hazards of artificial feeding, we deprive mothers of crucial decision-making information. The mother having difficulty with breastfeeding may not seek help just to achieve a ‘special bonus;’ but she may clamor for help if she knows how much she and her baby stand to lose.
Thus, when we talk about risks of formula, we will motivate mothers to “clamor for help,” and thereby increase breastfeeding rates and improve the health of mothers and babies.
It’s a compelling logical argument. And yet, I’ve been unable to find empirical evidence that it is true. To generate that evidence, we’d need to compare outcomes among mothers and babies counseled that formula increase risk with outcomes among those told that breastfeeding improves health and wellbeing. To my knowledge – and please let me know if there is a peer-reviewed study out there! – such a study has not been done. Read the rest of this entry »
In the past few weeks, I’ve found myself thinking a lot about privilege and parenthood. At the Breastfeeding and Feminism International Conference and the Kellogg #FirstFoods16 forum, I heard testimony from men and women of color who described structural barriers, indifference and outright hostility from health care providers and community members. These two meetings bracketed House Bill 2, in which the North Carolina state government legalized discrimination against trans, gay and lesbian individuals, and prohibited local municipalities from instituting a living wage.
These events and discussions drove home for me the multiple levels of sex, race, and class privilege that undermine the health and wellness of our nation’s families.
With these experiences fresh in my mind, this morning, I picked up the New York Times Sunday Review and saw Nicholas Kristof’s column, “When Whites Just Don’t Get It, Revisited.” Kristof reviews the burgeoning evidence of discrimination against people of color, from disparities in the quality of public schools serving children of color to experiments demonstrating that a job applicant named “Brendan” is 50% more likely to get a callback that an applicant with the identical resume named “Jamal.”
I was nodding in vigorous agreement, as Kristof affirmed the testimony I’d heard at Breastfeeding and Feminism and at the First Food Forum – until I hit this paragraph:
Reasons for inequality involve not just institutions but also personal behaviors. These don’t all directly involve discrimination. For instance, black babies are less likely to be breast-fed than white babies, are more likely to grow up with a single parent and may be spoken to or read to less by their parents.
In this aside about infant feeding, Kristof misses the crucial role of structural barriers that prevent women from breastfeeding – barriers that affect all families, but are especially severe for women of color. Contrary to popular belief, breastfeeding is not simply a “personal behavior” – it is constrained by the life circumstances and support (or lack thereof) that a woman receives from her family, her community, her employer, and her health care providers. Read the rest of this entry »
Dr. Jon Matthew Farber published the final installment of pearls reflecting on his practice in the January 1, 2016 edition of Contemporary Pediatrics. (Farber, Pearls from the trenches: Part 4, Contemporary Pediatrics. ) As Dr. Farber noted in the introduction, “I have heard it said that half of what we practice now will be out-of-date in 10 years, but the trick is to know which half.” Many of his clinical observations are quite valid and helpful for the practitioner. Unfortunately, one of the tips in that edition is out-of-date and could be counterproductive.
Under “Words to Live By,” item #10 addresses breastfeeding routines and states that “After 10 minutes, if not sooner, a breast is mostly empty. Having a child feed for 20 to 30 minutes at the first breast will exhaust both the mother and the child (and can lead to very sore nipples). Particularly for newborns, I recommend 10 minutes at the first breast, switching breasts for another 10, and then “topping off” for another 5 to 10 minutes at each breast if the baby is still hungry.” This statement includes the Lancet reference. ( Lancet. 1979 Jul 14;2(8133):57-8. )
Indeed, as Dr. Farber has noted, in the more than 35 years since that publication, our understanding of breast milk production and transfer, as well as the composition of milk, has improved significantly. We also know that each baby is different, as he or she masters the skills of feeding from the breast with continued practice. While some babies may indeed consume a substantial volume of milk in 10 minutes, others, and especially newborns, may take significantly longer. (Breastfeed Med. 2013 Dec;8(6):469-73. )In addition, the greatest proportion of fat is consumed towards the end of a feeding. Frequent “switching” from side to side may result in relatively higher water and sugar intake, with proportionately less fat intake, tending to make babies more fussy and gassy, with frequent frothy, green stools. In some circumstances, these babies may suffer from growth faltering. (J Am Board Fam Med. 2016 Jan-Feb;29(1):139-42. ) Therefore, it is no longer recommended that parents follow the clock when feeding, but instead observe the baby for signs of satiety, such as, relaxing of the posture or falling asleep. A full feeding (no specific time, but noted by less frequent swallowing or the baby drifting off to sleep) on the first breast offered, followed by as much feeding as desired on the second breast, if requested by a baby, works well for most babies, especially during the newborn period. (Breastfeed Med. 2010 Aug;5(4):173-7.) The breast never completely empties, because production continues throughout the feeding. Soreness of nipples does not correlate with the time spent nursing, but with the adequacy of latch.
If the mother is experiencing sore nipples (J Obstet Gynecol Neonatal Nurs. 2005 Jul-Aug;34(4):428-37), the latch should be carefully evaluated by someone skilled in breastfeeding assessment, whether that be a doctor, nurse, lactation consultant, or other helping professional. Fellows, or members, of the Academy of Breastfeeding Medicine, an organization of physicians dedicated to the promotion, protection and support of breastfeeding and human lactation, are excellent resources. ( Academy of Breastfeeding Medicine) Good breastfeeding routines are especially important in the early days and weeks in order to establish and maintain a good milk supply. Timed feedings may actually increase the risk of insufficient milk supply, which can be challenging to resolve.
While the pearls gleaned from practical experience can be very useful in our clinical decision making tool kit, they must be combined with current knowledge of clinical practice. The majority of mothers initiate breastfeeding, however, 60% do not meet their own breastfeeding goals. (Pediatrics. 2012 Jul; 130(1): 54–60. )
. Evidence-based medicine combines careful review of the medical literature with clinical experience and judgment. In order to support breastfeeding families optimally and achieve the improved health outcomes for both mothers and children, it is critical that physicians and other health care providers communicate current information and recommendations to colleagues, instead of relying only on our own observations and dated references.
Joan Meek is a Associate Dean for Graduate Medical Education and Professor of Clinical Sciences
Florida State University College of Medicine. She has served as president of the Academy of Breastfeeding Medicine, Chair of the American Academy of Pediatrics Section on Breastfeeding, and Chair of the United States Breastfeeding Commitee.
Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.
This essay is reposted with permission from CHAMPSBreastfeed.org
Thirty years ago, every newborn infant born in a US hospital was separated from their parents at the time of birth. Rooming-in was not an available option. We know now that that this standard practice was not optimal for the mother or the infant. As a pediatrician, I am concerned by the implications of this article. The image used by Time Magazine depicts an “unsafe” practice: several newborns swaddled in basinets on their sides sleeping. This sleep position carries more the double the risk of SIDS compared to infants sleeping on their backs. In addition, the bassinets are positioned adjacent, in a row, which is a practice that is fraught with risk for nosocomial infections, and has implications for security, and privacy concerns, especially when viewed by the public as is often the case in US delivery hospitals.
Beyond the disturbing photo the subtitle is inaccurate. It is important to note that what is changing among maternity care hospitals is that mothers are now offered the opportunity to allow their newborn to share a room with them. This opportunity is not “forced” but protected, given that rooming-in not only does help breastfeeding, it is safer than sleeping separated from mom. In the past, mothers were forced to separate from their newborn infants and required to have their infants sleep separately in a nursery setting, where they were grouped with other infants. Rooming in is the recommended environment for all mothers regardless of chosen feeding method. The author repeatedly refers to rooming-in as unsafe but with appropriate guidance and monitoring it is not unsafe and is safer than sleeping in a nursery. Both mother and newborn continue to receive the same level of care and supervision. Rooming-in does not mean that the care of the newborn is delegated to the mother, however, rooming-in provides the mother the opportunity to participate in their own newborn’s care. This permits staff to do additional teaching and observation of parenting skills before discharge. Read the rest of this entry »
Fifteen years ago, a friend of mine had her first baby at a prestigious Boston hospital. She was a resident in Ob/Gyn at the time, and a long labor ultimately ended with a c-section, and a healthy newborn boy. That evening, when she, her baby, and her husband were in their postpartum room, the nurse entered.
“It’s time to take the baby to the nursery!” she said.
My friend looked confused. “We’re planning to keep him in the room with us tonight.”
The nurse frowned. “Well, who’s going to take care of him? You just had a c-section.”
My friend gestured to her husband, who was sitting on the couch.
The nurse frowned again. “Well, you know these c-section babies can get a little junky,” she said, alluding to the mucous that babies not born vaginally sometimes cough up.
My friend replied, with emphasis, “We are going to keep our baby in our room tonight.”
The nurse shrugged. “Well, you’re a doctor. I guess if he aspirates, you can resuscitate him.” And she walked out of the room, shaking her head.
My friend used to tell this story, laughing darkly, as she recalled how she thought perhaps she should ask for the code cart to be wheeled into the room, just in case.
For the record, baby spent an uneventful night in mom’s room. But the routine separation of moms and babies – as well as other practices that have been shown to make it harder for families to get started breastfeeding – remains the default in many maternity centers in the US. Less than half of US hospitals provide routine rooming in for healthy moms and babies.
That’s bad news for babies, and it’s bad news for mothers, because these out-of-date practices make it harder for women to achieve their own breastfeeding goals. A study of nearly 2000 US mothers found that among mothers who received six of six best practices for maternity care, 97% achieved their personal goal to breastfeeding for at least 6 weeks. Among mothers who received zero of six, nearly 30% failed to achieve their personal goals.
These practices – the World Health Organization Ten Steps to Successful Breastfeeding – have been shown to be effective in a randomized controlled trial, which is the gold standard for medical evidence. In the PROBIT study, researchers randomized 31 hospitals to the Ten Steps or to continuing usual care. The study enrolled 17,046 mother-infant pairs, all of whom intended to breastfeed. Dyads who received care in a Ten Steps hospital were more likely to be exclusively breastfeeding at 3 months (43.3 vs. 6.4%) and to be breastfeeding at 12 months (19.7 vs. 11.4%). Ten Steps care has a lasting impact on breastfeeding success. Read the rest of this entry »
The Lancet has boldly stepped onto center stage to launch its new publication, Breastfeeding in the 21st Century. They state that “every mother and child no matter their location or circumstance, benefits from optimal breastfeeding practices.” They hosted the launch on January 29, 2016 in the Barbara Jordan Conference Center in the Kaiser Family Foundation building in Washington, D.C. The Conference Center symbolically honors Barbara Jordan, first African-American woman member of the Texas State Senate and then congresswoman from Texas starting in 1972. She was committed to fairness and to legislation that protects the underserved and the underrepresented.
The Academy of Breastfeeding Medicine was invited, and Karla Shepard Rubinger was named. I, too, received an invitation to attend. Imagine going to Washington, staying overnight at a hotel to attend a two hour meeting! But I had to be there. I had to hear the discussion with my own ears and see the members of the program from the Bill and Melinda Gates Foundation, the World Health Organization, UNICEF, USAID, the Chicago Council on Global Affairs, to mention a few. Read the rest of this entry »
A heart-wrenching story has been circulating on social media about an exclusively breastfed baby who suffered brain damage after 4 days of ineffective feeding. The mother, Dr. Christie del Castillo-Heygi, is a physician, and she shares how she was reassured that all mothers can make milk, and did not realize until she engaged a lactation consultant at 96 hours postpartum that her child was profoundly dehydrated.
It’s a tragic story. Dr. del Castillo-Heygi is petitioning public health leaders to warn all parents about the risk of irreversible brain damage with exclusive breastfeeding. That warning would directly challenge efforts across the US, and around the world, to emphasize the value of exclusive breastfeeding and the risks of unnecessary supplemental feeding. This push for exclusive breastfeeding is part of efforts to implement the Baby Friendly Hospital Initiative, a set of quality improvement efforts that increase the likelihood that women achieve their personal breastfeeding goals. For healthy infants, supplementation can interrupt the demand-drives-supply physiology of breastfeeding, reduce a mother’s milk supply, confuse baby’s latch, and expose the infant’s gut to allergens that may impact lifelong health.
So who’s right? Well, it’s complicated – and my sense is that this debate reflects the challenges of ensuring that families have the knowledge and support they need to initiate and sustain breastfeeding in the early weeks after birth.
We might start by acknowledging, once and for all, that not all mother-baby dyads are able to breastfeed exclusively. Reproductive physiology is not infallible. 10.9% of women have difficulty getting pregnant or carrying a baby to term. 15 to 20% of pregnancies end in miscarriage, 10% of infants are born preterm, and 1 in 100 infants are stillborn. Similarly, less than 100% of women can exclusively breastfeed. Read the rest of this entry »