Breastfeeding Medicine

Physicians blogging about breastfeeding

Watch your baby, not the clock

with 8 comments

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 Farber noted in the introduction, “I have heard it said that half of what we practice now will be out-of-date in 10 years, but the trick is to know which half.”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 Unfortunately, one of the tips in that edition is out-of-date and could be counterproductive.

2

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.

Written by jymeek

March 29, 2016 at 4:32 pm

8 Responses

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  1. I think it’s inexcusable, sorry, that someone purporting to offer info to clinicians on breastfeeding is recommending timing and limiting breastfeeding in this way – in 2016. 2016!!!!! This is indeed damaging to breastfeeding and prevents mothers building up their own confidence in their ability to meet their babies’ needs. In fact, the clock is the least helpful ‘tool’ in the box. Joan – could the journal not print a correction?

    Heather Welford

    March 29, 2016 at 5:33 pm

  2. As a nurse and breastfeeding mother myself, I can tell you that medical professionals get very little training in breastfeeding if any and that goes for medical doctors as well. It is a shame but people like you are spreading the word to more and more women, so thank you.

    Mimi Mandrake

    March 29, 2016 at 10:09 pm

  3. […] via Watch your baby, not the clock — Breastfeeding Medicine […]

  4. I am so pleased Dr Meek wrote this response to the Farber Pearls publication. When I read this I was alarmed at the advice he was giving since it definitely is outdated. I felt compelled to wrote an editorial to Contemporary Peds myself but Dr Meek beat me to it. Thank you Joan for such an elegant rebuttal.

    Amy E Evans,MD,FABM,FAAP

    Amy Evans

    March 30, 2016 at 9:52 am

    • Was this rebuttal sent to Contemporary Pediatrics? Was it published? It is tragic when an eminent professional supports such dangerous myths.

      Nan Jolly

      March 30, 2016 at 10:55 am

      • I have now sent a response to Contemporary Pediatrics, as well.

        jymeek

        March 30, 2016 at 11:00 am

  5. […] State University College of Medicine and member of the Academy of Breastfeeding Medicine wrote a fantastic blog this week about provider knowledge of breastfeeding care and management.  Dr. Meek states, “The […]

  6. With my first, I followed the advice to “finish one side,” and he would happily stay latched on to that one side all day, falling asleep. It was never explained to me what “finish” really meant. When his weight started to drop in percentiles, some more targeted googling led me to learn the signs of satiety you mention — falling asleep, listening for actual swallowing, etc. His weight started to bounce back up. He needed both sides, but I didn’t know what signs to look for to signal when it was time to switch him.

    While putting a 10 minute time limit per side is not helpful to all women, neither is the vague advice to “finish one side,” “wait for the hind milk,” (as if I know when my milk magically turns fattier), “wait for a let down” (not all women feel the let down sensation; I certainly didn’t with my first), etc.

    Paying attention to your baby, checking for signs of satiety and breast emptiness, and knowing what swallowing sounds like, are important pieces of the puzzle and are inadequately communicated to women. It is not information easily imparted without help or generational knowledge. I can see how it is easy for healthcare practitioners to use a simple time limit as a communication tool instead. It would have helped me as a first time mom who didn’t know what she was doing and had to figure it out with google. My son probably would have gained more weight if I switched him after 10 minutes. I am a biologist and it took me a few months to figure out; others might switch to formula in the meantime.

    Rebecca

    June 14, 2016 at 8:41 am


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