Trust and test weights

“Nobody seems to trust test weights in our unit.  What are we doing wrong?”

To “test weigh” a baby means to measure how much milk she has transferred by simply weighing her — clothing, diaper and all — before and after breastfeeding.  Test weights are often used in term infants using precise scales such as the Medela BabyWeigh.  A few studies have supported the utility of test weights in preterm infants: these include a Swedish study favorably comparing babies cared for in NICUs using test weights vs NICUs that did not (earlier attainment of exclusive breastfeeding and earlier discharge) as well as a small study from the illustrious LCs at my own institution describing the development of a technique for accurately performing test weights.

It still seems, though, that NICU providers and even parents have a tendency to distrust test weights in premies learning to breastfeed.  Some of this distrust, especially for the providers, is probably a residuum of earlier studies using less precise scales and/or less consistent, accurate weighing techniques.  (It is true that we NICU folks tend to love our numbers, and we prefer that they have as many significant digits as possible.) I suspect another large part of the distrust has to do with the fact that premies who are learning to feed don’t consistently transfer the same volume of milk even when their feeding quality seems to be subjectively “good.”  As with learning to walk or talk, learning to feed is an incremental and not a linear process… but when numbers-focused, pattern-seeking people see “inconsistency” in the amount transferred, we think “that can’t be right.” Finally — just perhaps — part of the distrust might be with breastfeeding itself.  If we can’t measure it or control it, we can’t trust it. And if parents hear us expressing distrust of breastfeeding, they are probably more likely to distrust it as well.

Day of Action: get out from under the influence of a lifetime of formula marketing

May 21, 2014 marks the 33rd anniversary of the World Health Organization’s adoption of the International Code of Marketing of Breast-Milk Substitutes (or “the Code”) in an effort to promote breastfeeding and limit formula companies’ influence over women’s infant feeding decisions.

Today more than 20 organizations and thousands of moms and citizens are participating in a day of action led by Public Citizen, directed at the largest formula makers in the U.S. and Canada – Mead Johnson (manufacturer of Enfamil), Abbott (Similac) and Nestle (Gerber Good Start — and aiming to end the unethical practice of promoting formula in health care facilities, particularly through the distribution of commercial discharge bags with formula samples – a longstanding violation of the code.  Efforts include the delivery of a petition with more than 17,000 signatures to Mead Johnson at its headquarters outside of Chicago as well as to Abbott and Nestle;  sending photos and messages to companies on Facebook, Twitter and other online platforms; and blogs such as this one.  The day of action is not meant to advocate against formula use in cases where it is necessary, but to focus on the need to give mothers unbiased information about infant feeding, information that hasn’t been influenced by formula companies.

In reflecting on the influence of formula companies, I realized that the history of my life  parallels the history of the Code:

 The 27th World Health Assembly in 1974 noted the general decline in breastfeeding related to different factors including the production of manufactured breast-milk substitutes and urged Member countries to review sales promotion activities on baby foods and to introduce appropriate remedial measures, including advertisement codes and legislation where necessary.

I was born a bit before this.   My mom says that she wanted to breastfeed me but that nobody, including hospital personnel, could tell her how.  My baby book contains the crib card with the formula company logo.

Re-visiting pacifiers and breastfeeding

A newly published study in Pediatrics  is receiving media attention due to its finding that “restricting pacifier distribution during the newborn hospitalization without also restricting access to formula was associated with decreased exclusive breastfeeding, increased supplemental formula feeding, and increased exclusive formula feeding.”

The study took place in a US hospital’s mother-baby-unit (MBU) before and after implementation of a new institutional policy restricting routine pacifier distribution as part of a breastfeeding support initiative.  (The four other breastfeeding support measures adopted by the MBU included breastfeeding in the first hour after birth, feeding only breast milk in the hospital, keeping infant in same room with mother in the hospital, and giving mother a telephone number to call for help with breastfeeding after discharge.)  Of note, pacifiers were stored in a locked supply management system as part of the new policy, but formula access was not limited in the same way.

The researchers retrospectively examined exclusive breastfeeding rates (as compared to breastfeeding plus supplemental formula, and exclusive formula feeding) before and after the change.   They saw a significant decrease in exclusive breastfeeding (from 79% to 68%) paralleled by significant increases in both formula-supplemented breastfeeding (18% to 28%) and exclusive formula feeding (1.8% to 3.4%).

While it is tempting to conclude “thus pacifier use is necessary in supporting exclusive breastfeeding”, it’s also important to note that the study in question states that “no specific script was instituted to verbally instruct parents on infant soothing techniques” either before or after restricting pacifier use.  Thus it is equally tempting  to conclude that desperate parents will resort to culturally familiar ways to soothe crying newborns — and in US culture, those include bottles and pacifiers.

It would be interesting to see a similar study conducted in a setting that emphasizes supporting parents in learning alternative ways to comfort their babies, such as skin-to-skin care and cue-based breastfeeding.  It might also be interesting to see weight loss at discharge,  and/or jaundice requiring phototherapy, as an outcome measure.

Kimberly Lee is a neonatologist and member of the Academy of Breastfeeding Medicine. She has previously written about pacifiers and breastfeeding in her blog post, “A sucker born every minute:” Pacifiers and breastfeeding.

Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.

Emotional (!) responses to breastfeeding promotion and formula marketing

Is anyone besides me endlessly fascinated by how emotional we all become about infant feeding?  It’s such a big part of mothering, & I would submit that we get emotional about our kids because they are so precious to us.  (As my 10-year-old would say, well, duh.)

In response to my rant about the formula company putting my name on their advertising rag last week,  a friend I hadn’t heard from in years sent me a lovely private message saying that the “tangle over breastfeeding” left adoptive moms feeling ignored and left out.  “(W)hen (my kids) were babies, I often felt badgered and belittled by the insistence that breast milk was best… We were, after all, feeding our kids.”

I tried to apologize for leaving adoptive moms out of the discussion.

I tried to sum up the public health perspective:  that human babies do best with human milk, and that, in the US at least, we feel we are still working to overcome  decades of cultural “belittling” of breastfeeding —  summed up by Jayne’s comment that  “(t)he only reason breastfeeding is seen as so much harder is because our culture and often our medical professionals totally undermine it.”.

And (rhetorically, perhaps) I asked whether there is a way for the public health community to avoid hurting feelings while still counteracting the cultural forces of formula marketing, back-to-work pressures, and just plain undervaluing women in general.

Perhaps there is some explanation, if not an actual answer, in the State of the World’s Mothers 2011 report.  (For those who haven’t already heard, the US comes in at #31 among 43 developed countries surveyed.)

And I think the US Surgeon General’s Call to Action to Support Breastfeeding (full statement here)  is an important start toward improving our situation in this country, beyond the simple repetitive  “breast is best” message that seems to have so hurt and angered my friend.

Happy Mother’s Day to all of us!   Love your kids, nurture them … feed them.  It’s what we do.

Kimberly Lee is a neonatologist and member of the Academy of Breastfeeding Medicine.

Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.

Do I laugh or cry?

I just sent the following email to a company called Remedy Health Media:

I was shocked today to find a magazine full of advertising sitting in the doctors’ lounge at (our community hospital) with my own name on the front (“Compliments of”).

The magazine contains, among other things, an article subtly undermining the health benefits of breastfeeding.

I don’t know where this came from, and especially how it acquired my name, but I respectfully request that it be stopped immediately.

I really don’t know whether to laugh or cry —  it is such an egregious thing to see my own name on a formula-advertising rag.

The article in question — “Choose Breast and Bottle Happily” —starts out with “both choices have pros and cons”, points out that “breastfed babies may be healthier”, outlines the AAP guidelines … & then goes on to say how stressful it is to breastfeed.

Of course it’s stressful to breastfeed — it’s stressful to have a new baby — and of course “nursing a baby requires a lot of energy, time, support and other resources that aren’t always available to new mothers.”

But does that mean that I’m going to personally advertise formula as a solution?

I don’t think so… but we’ll see if I get a say in the matter.

Kimberly Lee is a neonatologist and member of the Academy of Breastfeeding Medicine.

Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.

“A sucker born every minute”: pacifiers and breastfeeding

For new moms, deciding about whether to offer a pacifier to a newborn, like deciding whether to breastfeed, can be an emotionally loaded decision.  Newborns need to suck – for non-nutritive (comfort) as well as nutritive (food) reasons.  I can’t count the number of times I’ve heard “that baby is using [me/you/her mom] as a pacifier!” from parents and nursery nurses during the first hours of life.

When I hear that, I can’t help but to cringe and comment that pacifiers were invented as a substitute for moms, not vice versa.   The physiology of lactation requires frequent suckling and emptying of the breast to establish and maintain a mom’s milk supply.  So it makes sense that giving a pacifier to a newborn who wants to suckle, instead of letting him nurse, could adversely affect his mom’s milk supply as well as his own growth.  Thus physicians who want to support breastfeeding usually caution new parents about the use of pacifiers before breastfeeding is well established, usually about two weeks after birth. ( Avoidance of artificial teats or pacifiers is, in fact, one of the WHO/UNICEF Ten Steps to Successful Breastfeeding.)

However, it has been difficult to find definitive scientific evidence to support this advice.  And as a mom, I well remember the frustration of seemingly incessant newborn breastfeeding.  That’s why I was hopeful when I saw the abstract for a new Cochrane meta-analysis that suggests pacifiers need not be avoided.

How babies grow

The United States Centers for Disease Control (CDC) recently recommended a long-awaited change in the way we track babies’ growth.

For years, US pediatricians and family docs have used growth charts from the CDC for monitoring infants and children. These charts were based on cross-sections of small segments of the (largely formula-fed) US population. They are considered “references” rather than “standards”, even though it is easy for doctors and parents to assume there is something wrong if a baby’s growth doesn’t follow the expected curve. And because breastfeeding babies’ growth patterns differ from formula-fed babies, this situation made it possible for some babies to be given formula unnecessarily for “poor growth”.

Now an expert panel convened by the CDC, National Institutes of Health (NIH) and American Academy of Pediatrics (AAP) recommends that clinicians use World Health Organization (WHO) growth charts for infants up to two years of age. The WHO growth charts are based on consecutive measurements over time of healthy breastfeeding babies around the world (almost 19,000 measurements in more than 800 babies). These charts serve as a standard rather than a reference for growth, since these were carefully selected healthy infants and, as the CDC’s statement points out, breastfeeding is the optimal form of infant feeding. Because of the variation in babies’ growth and the lack of correlation with poor outcomes, care providers are advised to “accept” growth within 2 standard deviations from the norm, i.e., between approximately the 3rd and 97th percentiles rather than 5th and 10th.

The CDC statement takes care to point out that for babies whose growth deviates from the standard, “clinicians need to carefully assess general health issues and ensure appropriate management of lactation. Only if there is evidence of lactation inadequacy should they consider supplementation with formula.” It also reminds us, as always, to be mindful of environmental and social factors contributing to challenges in growth.

The bottom line: this is a welcome — some might say overdue — affirmation of breastfeeding as the standard for infant nutrition.

Kimberly Lee is a neonatologist and member of the Academy of Breastfeeding Medicine.

Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.

Formula marketing’s effect on the public purse

I just came across a fascinating recent report from the US Center on Budget and Policy Priorities detailing the effects of the formula industry on the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) budget.

Briefly, although there is no evidence that new “functional ingredients” (ie DHA, ARA, probiotics) in infant formula are beneficial for term infants, WIC appears to be spending more than 10 percent extra (more than $90 million per year) on these ingredients, based on a recent study by the US Department of Agriculture (USDA)’s Economic Research Service.

The problem is related to the fact that, while the US Food and Drug Administration (FDA) is responsible for determining safety of food products, it is not responsible for assessing the accuracy of claims of efficacy. And the USDA is the agency responsible for administering WIC, but at present decisions regarding which formula to offer are left to state WIC programs.

Current WIC reauthorization legislation (unanimously approved by the Senate Agriculture Committee last month) includes a provision clarifying that USDA has the authority to disallow foods with specific ingredients, based on scientific evidence of health or developmental benefits.

Not surprisingly, the formula industry opposes this legislation, since it could significantly restrict future profits on further “advances”: WIC purchases more than half of all infant formula sold in the United States.

Kimberly Lee is a neonatologist and member of the Academy of Breastfeeding Medicine.

Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.

Giving moms what they want?

I am sitting in my office just outside our community hospital’s special care nursery. One of the nurses just walked in and asked “would you (neonatologists) please reconsider giving out the formula company diaper bags? All the moms are asking for them, even the breastfeeding ones, and it’s embarrassing to just hand them a plastic trash bag from the hospital with our own breastfeeding handouts. All of us (nurses) want to be able to give the moms what they want.”

This is life in the trenches. The hospital wants to make the patients happy, and it definitely does not want to spend money on better/alternative diaper bags, or for that matter anything else (even decent newborn-sized stethoscopes for the special care babies — my pet peeve at the moment).

Here is the best solution I can think of (building on the approach a friend of mine uses in her pediatric practice):

Give them the bags they are asking for, but with the disclaimer (printed, spoken, or ideally both) that “evidence shows that moms whose physicians/hospitals give them formula company marketing materials are less likely to breastfeed successfully”.

And, of course, take out the formula company materials & substitute our hospital lactation service’s breastfeeding support information and phone number.

It’s not perfect, but neither is this world.

Thoughts?

Kimberly Lee is a neonatologist and member of the Academy of Breastfeeding Medicine.

Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.

Well said, Stephanie!

I just have to share this lovely defense of What Breasts are For by Stephanie Pearl-McPhee.

(By way of introduction, Stephanie is perhaps better known as the Yarn Harlot, a “knitting rock star” whose blog of the same title was the top-ranked blog in Canada in 2008. It is probably safe to say that she is the only knitting humorist to have made the New York Times best seller list, with her most recent title, Free-Range Knitter. She has also been, in her pre-celebrity days, a lactation consultant and doula.)

Last week some of the Harlot’s readers took issue with her story of a less than successful sweater project, because she used the terms “nipple” and “breast” in her description of the problems involved in the sweater’s fit.

Her defense (from a five-item list on “Really Random Friday“):

5. I also can’t believe that I got mail about saying nipple and breasts in my blog post yesterday. I’ve emailed back and forth with the people who sent mail, and everything is cool. I’ll tell you what I told them. Nipple is not a dirty word. They are present on (just about) every person on earth, and in mammals (and we are mammals) they serve a pretty good function. (Let me take that back by 50%. I’m not sure of the purpose they serve on men. I think nature can’t figure out how to get them off.) Nipple is no different a word than elbow. It cannot corrupt youth, get them pregnant or make them think about sex so much that they consider doing it. (Hint: Youth is already thinking about sex that much, even if you don’t say nipple.) Furthermore (and you can tell I really mean it when I start whipping out the furthermores) nipples, at least on women, are there for the purposes of nursing our young, and frankly, I think that maybe if we didn’t have them all caught up in the crazy sex thing to the point that we can’t even talk about them at all without feeling dirty or worried, then maybe women wouldn’t be so totally screwed about what to do with them when a baby comes along. From the perspective of someone who counseled breastfeeding women for years and years, I can tell you I really, really, really think it would have helped if the word nipple wasn’t coming up for the first time when we were trying to attach 7 pounds of starving humanity to it.

Nipple Nipple Nipple Breast.

(And yeah, I know what sort of spam that’s going to get me. I’ll live with it.)

I have a feeling she has reached more people with that message than we will with this one.

Thanks, Stephanie.

Kimberly Lee is a neonatologist and member of the Academy of Breastfeeding Medicine

Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole..