Breastfeeding Medicine

Physicians blogging about breastfeeding

Author Archive

I #March4Nutrition to make #breastfeeding a right, not a privilege

with one comment

I #March4Nutrition because breastfeeding is a powerful predictor of health and wellbeing for mothers and infants — and yet, too many families face barriers that prevent them from achieving their own breastfeeding goals.

Families who want to breastfeed navigate a veritable minefield of “Booby Traps.” Many maternity providers have minimal training in lactation support, and providers may not ask about breastfeeding during prenatal care — or spend only seconds on the topic — missing the opportunity to address concerns and provide guidance.  Parents are inundated with misleading materials from infant formula manufacturers, promising that their product is “designed to be like breast milk” or will magically convince fussy babies to sleep through the night. Indeed, in a study, mothers looking at formula advertisements voiced concerns that their milk didn’t have added vitamins, so perhaps it would be healthier to formula feed.

At birth, too few families receive evidence-based maternity care that gets infant feeding off to an optimal start. For example, putting a baby skin-to-skin for the first hour of life increases breastfeeding duration by as much as 6 weeks — yet 28% of US hospitals do not provide such care to most women.  Skin-to-skin is one of the World Health Organization Ten Steps to Successful Breastfeeding. Hospitals that implement all ten can be designated as “Baby Friendly” – but currently, only 11.5% of US maternity centers meet that standard. It’s worth noting that we are making progress — just 2.9% of hospitals were Baby Friendly in 2007 — but 88% of families are still hobbled at the starting gates when they start their breastfeeding journey.

Read the rest of this entry »

Written by astuebe

March 19, 2015 at 7:08 pm

What if we realized that food security is homeland security?

with 25 comments

I’m waiting for my flight home from the 1,000 Days U.S. Leadership Roundtable, a spectacular meeting that was held today at the Gates Foundation in Washington, DC. Stakeholders in nutrition and maternal-child health gathered to discuss how we can galvanize support for nutrition during the 1,000 days from conception to age 2. This is the time when our youngest citizens build their bodies and brains, laying the foundation for long-term health. Investing in optimal nutrition during these crucial days improves health and productivity across a lifetime.

For too many of our children, however, this foundation is fractured. Poverty, food insecurity, and commercial pressures prevent moms and babies from achieving their full potential. During the meeting, 1,000 Days executive director Lucy Sullivan shared daunting statistics about the challenges facing children in America. One in eight infants and toddlers in the US lives in deep poverty, defined as less than half the poverty line. Food insecurity affects 20% of families with children under 6. One in 20 children – 5% — experience very low food security, defined as multiple indications of disrupted eating patterns and reduced food intake. This food insecurity has lasting consequences, leading to chronic diseases, impaired school performance, and, paradoxically, increased risk of obesity.

Breastfeeding is one of the single best preventive health measures for mothers and children, Sullivan said, but families in poverty are less likely to initiate or sustain breastfeeding. The barrier is not lack of information – it is lack of support and policies that enable mothers to initiate and sustain breastfeeding, especially in areas with high rates of poverty and racial disparities.

How can this be, in one of the wealthiest nations in the world? As one roundtable participant noted, we don’t think of food insecurity as a problem in America, and certainly not as a threat to our nation’s future. Read the rest of this entry »

Written by astuebe

April 7, 2014 at 9:07 pm

Posted in In the news, policy

How often does breastfeeding come undone?

with 45 comments

One afternoon in my lactation clinic, I saw two mothers who came to see me because they couldn’t make milk. One was pregnant with her second child, and the other was considering a third pregnancy. Each described how they had looked forward to breastfeeding, taken classes, put their babies skin-to-skin and birth, offered the breast on demand, and then waited, for days, and then weeks, for milk that never came in. As the second mother came to the end of her story, she said, “No one ever told me this could happen. Have you ever heard of a woman not being able to make milk?”

“Yes,” I said. “There’s one in the very next room.”

The dogma is that inability to breastfeed is rare – “like unicorns,” one blogger wrote – but I was seeing an awful lot of unicorns in my clinic. I couldn’t help but wonder – how often does breastfeeding come undone? Read the rest of this entry »

Written by astuebe

March 27, 2014 at 4:23 pm

Shame, guilt and the search for common ground

with 48 comments

In the fallout from the breastfeeding sibling study, I’ve been struck by the intensity of conversations about shame and guilt. A colleague and friend posted on Facebook:

This study is for my patients who have taken every tea, herb and drug to raise their milk supply, and are afraid to be seen in public giving their babies formula. They shun the social support they need from other mothers because bottle feeding has become so stigmatized. I see such relief on their faces when I tell them that they are outstanding mothers raising healthy babies, and am glad to have some evidence behind that.

A father commented on the ABM Blog:

I sat in pre-natal class with my wife as a bunch of women were given the implicit message that they were not real women or good mothers if they did anything but breast feed. And a lot of these women; young women, bought into that message wholeheartedly. I was appalled.

Others attacked the paper — and the conversations around it — for sugar coating the truth for mothers who formula feed:

Breast is best no matter what, now I understand there are mothers who have tried and fail. For medical reasons or another.But the truth is there is not that many. A lot of mommies make the choice to do formula over breastfeeding. But why should the breastfeeding community sugar coat the truth to spare a formula feeding mothers feelings by not saying the whole truth breastmilk benefits and nutrients far out way formula hands down. Except it firmuka mommies and companies we need to support mothers who can’t keep doing it find other options like donor milk from a fellow friend or a breast sister to keep this poison out of our babies bellies. I mean do you see cigarette companies saying smoking doesn’t really kill it just makes you sick. No they have to say smoking is harmful and we as adults have to make an informed choice. Which is what the breastfeeding community wants women to do. Do not just give formula because you hear it is the same as breastmilk because it is not even on the same playing field. It us like comparing apples to oranges IMO.

The study in question doesn’t actually speak to any of these concerns— Bimla Schwarz and I have blogged about the limitations of the analysis and its implications. Yet these issues of shame, guilt, autonomy and informed consent are crucial to understand and address if we want to improve health and wellbeing for mothers and infants.  There is tremendous anger and angst that poisons conversations about breastfeeding and prevents us from finding common ground. Read the rest of this entry »

Written by astuebe

March 4, 2014 at 2:40 pm

Reports on breastfeeding sibling study are vastly overstated

with 39 comments

A recent analysis of breastfeeding’s effects on child health is making headlines that some of the benefits of breastfeeding have been overstated.

The authors examined behavioral assessments of children born between 1978 and 2006. When they compared breastfed children with formula-fed children, they found that the breastfed kids were healthier and smarter, as many other studies have previously reported. However, they then looked at families in which only some of the children had been breastfed, and they found that whether or not siblings were breastfed did not significantly affect their health outcomes. The authors argue that this proves that a child’s family – not infant feeding – is what really determines long-term child health, and breastfeeding doesn’t really matter.

The biggest problem with this conclusion is that the study ignored anything that happened in these families before their children reached the age of 4, disregarding well-established links between ear infections, pneumonia, vomiting and diarrhea and the amount of human milk a baby receives. There’s strong biological evidence for these relationships, because formula lacks the antibodies and other immune factors in breast milk that block bacteria from binding to the infant gut and airway. For preterm infants, formula exposure raises rates of necrotizing enterocolitis, a devastating and often deadline complication of prematurity. And evidence continues to mount that formula feeding increases risk of Sudden Infant Death Syndrome. Furthermore, mothers who don’t breastfeed face higher rates of breast cancer, ovarian cancer, diabetes, high blood pressure and heart attacks. None of these outcomes were addressed by the recent sibling study. The paper’s authors note they were interested in longer-term outcomes in childhood, but that’s been lost in the news coverage, which has effectively thrown out the breastfeeding mom and baby with the bath water.

Read the rest of this entry »

Written by astuebe

March 1, 2014 at 2:25 pm

Online milk sales, beyond “buyer beware”

with 39 comments

A new study in Pediatrics has spawned provocative headlines, contrasting images of human milk as “a nourishing elixir, or a bacterial brew.”   Researchers anonymously bought breast milk from 102 online sellers. Milk orders were often packaged poorly, arrived well above freezing, and — as one might expect with milk unrefrigerated for days — were rife with bacteria.

But that’s really not the whole story. First, consider who participated in the study.  By design, the authors communicated with sellers only by email, and cut off the conversation if the sellers asked about the recipient infant or wanted to talk by phone or in person. Milk was shipped to a rented mailbox to make the process anonymous. Of the 495 sellers the authors contacted, 191 sellers never responded, 41 stopped corresponding before making a sale, and 57 were excluded because they wanted to communicate by phone or asked about the recipient baby. Another 105 did not complete a transaction, leaving 102 of the original 495 sellers approached who actually shipped milk. Of these, half the samples took more than 2 days to ship, and 19% had no cooling agent in the package.

It’s highly plausible that milk sent with no questions asked, via 2 day or longer shipment, and (in 1 and 5 cases) without any cooling whatsoever, was collected with less attention to basic hygienic precautions.  The bacterial load in study milk samples therefore doesn’t tell us about the relative safety of milk obtained following a conversation between buyer and seller about the recipient baby and then shipped overnight on dry ice in a laboratory-quality cooler.  Indeed, when the authors compared online milk purchases with samples donated to a milk bank after a screening and selection process, they found much lower rates of bacterial contamination.  The authors acknowledge this limitation in the study, but that subtlety has been lost in the media coverage. Read the rest of this entry »

Written by astuebe

October 21, 2013 at 5:38 pm

Breastfeeding and depression: It’s complicated

with 38 comments

A recent Facebook post by Jack Newman has elicited passionate discussion about the relationship between breastfeeding and postpartum depression. Dr. Newman posted an email he’d received yesterday:

My baby is 3 months old and breastfeeding has been “bliss” for me so far. We both enjoy our relationship and it is very important for me as I have postpartum depression and right now breastfeeding is the only thing that works as I would have hoped and planned. (My comment: Many mothers tell me that they are told to stop breastfeeding for medication for postpartum depression and say that they are so upset because “breastfeeding is the only thing in their life that is working”. Do doctors ever think of this?).

I’m happy to report that I’m a doctor, and I do think of this — in fact, at UNC, we’re starting a 5-year NIH-funded study to try to understand the relationship between breastfeeding, postpartum depression, and infant attachment.  Our pilot data suggest that this relationship is complicated. We recruited 52 women who were intending to breastfeed and either did or did not have a history depression and/or anxiety. During pregnancy, mothers provided baseline blood samples, completed questionnaires, and had a standardized psychiatric interview to assess their history. Mothers came to our lab with their babies at 2 and 8 weeks postpartum, and we measured hormone levels while they breastfed their babies.

During pregnancy, we found that mothers who had higher levels of the hormone oxytocin had lower scores on the EPDS, a standard measure of depression, consistent with another recent study of oxytocin and mood symptoms.  When mothers returned at 2 weeks, we did not find any relationship between mood and hormone levels during breastfeeding, but at 8 weeks, the mothers with higher depression and/or anxiety had lower levels of oxytocin during breastfeeding (see figure). They were also less happy, and more stressed, depressed, irritated and overwhelmed, during the entire feeding visit than mothers who were not anxious or depressed.

Screen Shot 2013-05-30 at 10.54.15 AM

Maternal neuroendocrine response to feeding 8 weeks among women with depression/anxiety symptoms (dashed line) or without mood symptoms (solid line).

These results raise some interesting questions about the conventional wisdom that breastfeeding prevents depression. It could be that mothers who have lower oxytocin levels have trouble with breastfeeding and also feel more anxious and depressed. Or it could be that, for mothers whose baseline oxytocin is lower, breastfeeding gives them a boost that’s essential for them to feel connected to their babies. Read the rest of this entry »

Written by astuebe

May 30, 2013 at 11:31 am

Posted in Breastfeeding, research

Early, limited data for early, limited formula use

with 38 comments

A small study published in Pediatrics suggests that supplementing newborns with small quantities of formula may improve long-term breastfeeding rates. The results challenge both dogma and data linking supplementation with early weaning, call into question the Joint Commission’s exclusive breastfeeding quality metric, and will no doubt inspire intimations of a formula-industry conspiracy. Before we use this study to transform clinical practice, I think it’s worth taking a careful look at what the authors actually found.

First, I think it’s very important to be clear about what the authors meant by “early limited formula.” The authors used 2 teaspoons of hypo-allergenic formula, given via a syringe, as a bridge for mothers whose infants had lost > 5% of their birthweight and mom’s milk had not yet come in. At UNC, we use donor milk in a similar way, offering supplemental breast milk via a syringe as a bridge until mom’s milk production increases. Read the rest of this entry »

Written by astuebe

May 13, 2013 at 6:27 am

Establishing the Fourth Trimester

with 21 comments

Lisa Selvin’s provocative article, “Is the Medical Community Failing Breastfeeding Moms?” has elicited a wide range of reactions from the breastfeeding community. Some have argued that the piece, which focuses on unmet needs of mothers who encounter physiologic problems with breastfeeding, “sensationalizes” breastfeeding, making it sound so treacherous and difficult that mothers should avoid it altogether.

I would argue that there’s a very fine line between “sensationalizing” and “truth in advertising.” Reproductive biology is imperfect — some couples can’t conceive, and some pregnancies end in miscarriage or stillbirth. The silence around these losses and the isolation that women have historically experienced has probably worsened the suffering for many women. On the other hand, emphasizing these risks and creating a culture of fear harms the majority of mothers who will have successful pregnancies and births. Read the rest of this entry »

Written by astuebe

January 4, 2013 at 12:45 pm

Building a breastfeeding culture

with 9 comments

Breastfeeding take a village. For me, the star of the team is my husband, who stayed at home with our baby and brought him to visit on long weekend shifts.

I started my internship in Ob/Gyn the day my first child turned three months old, walking down Brookline Avenue to Brigham and Women’s Hospital with a Pump-in-Style slung on my back and a vague determination to breastfeed. The first day of orientation, I went hunting for the lactation room I’d been told was on the 15th floor of the hospital, only to learn that it had been closed months ago. Some merciful nurses let me into their break room, and I pumped hunched in a corner, contemplating this inauspicious beginning to working motherhood.

After a few days, I found the actual lactation room (on the 9th floor of a different building), and I settled into a routine of blending clinical work with every-three-hour breaks. This was before hands-free pumping bras, and I gradually mastered the art of balancing bottles on my knees while answering pages and reviewing patient charts. By the time I had my first overnight call, I’d learned to pre-assemble my pump parts, screwing the flanges onto the bottles at home and covering them with sandwich bags so I could save a few precious seconds.  That first night, I forgot to pack tops for the bottles, and found myself in the newborn nursery and Mass General, where more merciful nurses borrowed tops from sterile water bottles so I could take my milk home.

Another call shift, after an increasingly excruciating six hours of catching babies and writing progress notes, I staggered into the storage closet / pumping room to discover that I had the wrong pump attachment. The midwife on call came to my rescue, tracking down the right tubing and bringing me a tangy cranberry-juice-and-Shasta-ginger-ale cocktail.

Like every mother who juggles pumping and working, I could go on and on– the pumping in airplane bathrooms on long haul flights, the Fed Ex’ing of 100 ounces of pumped milk on dry ice to my in laws when my husband took our son to visit them, and the sweet, sweet comfort of putting my baby to breast after a 36-hour shift.

Most of all, I am grateful – grateful to a confluence of people and circumstances that made it possible for me to continue breastfeeding through my child’s first year and beyond. Eleven years later, I realize that there was not “one thing” that made it possible – in fact, there were multiple factors that helped me succeed. And if we want to build a breastfeeding culture, we need to build multiple influences into every mother’s experience so that she has the best chance of succeeding. Read the rest of this entry »

Written by astuebe

November 16, 2012 at 1:28 pm

Posted in Breastfeeding, policy