Breastfeeding Medicine

Physicians blogging about breastfeeding

Archive for the ‘research’ Category

Reports on breastfeeding sibling study are vastly overstated

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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.

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Written by astuebe

March 1, 2014 at 2:25 pm

Online milk sales, beyond “buyer beware”

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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

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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

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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

Re-visiting pacifiers and breastfeeding

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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.

Written by neobfmd

March 19, 2013 at 1:06 pm

The Breastfeeding and Obesity Controversy

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Fact or fiction: Is breastfeeding actually linked with a lower risk of childhood obesity? The common thinking for the past several years has been “yes,” based on comprehensive analyses from the US Agency for Healthcare Research and Quality and the World Health Organization. However, two recent articles have disputed these conclusions. Considerable media attention has surrounded new data from the Promotion of Breastfeeding Intervention Trial (PROBIT), published in the Journal of the American Medical Association (JAMA) on March 13, and in a January 31 article in the New England Journal of Medicine (NEJM) on obesity myths by Casazza et al. We discuss both articles’ conclusions, as the public tries to make sense of all the conflicting information. Read the rest of this entry »

Written by Melissa Bartick, MD, MSc, FABM

March 15, 2013 at 5:30 pm

How often does breastfeeding just not work?

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Jessica Isles posted a great question today on my blog, “When Lactation Doesn’t Work:”

I was wondering if any comparative studies have been done on the statistics of lactation failure in various cultures both developed and less developed. Please post if you are aware of any – or any statistics on how many women’s milk never comes in (in the US), with a healthy full term new born, in an environment supportive of breastfeeding. We need to help mothers who struggle with this.

That’s a great question – and a difficult one to answer. Marianne Neifert estimates that “as many as 5% of women may have primary insufficient lactation because of anatomic breast variations or medical illness that make them unable to produce a full milk supply despite heroic efforts.”   [Neifert MR (2001). “Prevention of breastfeeding tragedies.” Pediatr Clin North Am 48(2): 273-97.] Read the rest of this entry »

Written by astuebe

October 15, 2012 at 3:35 pm

Newest ABM Protocol Released from the International Meeting in Miami Today: Allergic Proctocolitis in the Exclusively Breastfed Infant

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We are here in sunny Miami at the 16th Annual International Meeting of the Academy of Breastfeeding Medicine–our “Sweet Sixteenth” birthday party!  What better way for me, a member of the Board of Directors and the Chair of the Protocol Committee to celebrate the accomplishments of our organization than to see the e-pub release today, live from the meeting, of our newest clinical protocol, #24: Allergic Proctocolitis in the Exclusively Breastfed Infant?
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Written by kmarinellimd

November 5, 2011 at 7:16 am

Highlights from Third Annual Summit on Breastfeeding: First Food–The Essential Role of Breastfeeding

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Riding home on the train from Washington DC Thursday night, I was utterly physically exhausted as my mind tumbled over everything I had heard during the past two days.  I was returning from the Third Annual Summit on Breastfeeding.  For those of you who aren’t familiar with this Summit, I am going to unapologetically copy from the announcement of this Summit, as they said it better than I can!

“The First Annual Summit, held in June 2009, marked the 25th anniversary of the Surgeon General’s Workshop on Breastfeeding and Human Lactation, a milestone event led by C. Everett Koop, MD in 1984. Dr. Koop also delivered opening remarks at this 21st century follow-up.

The Second Summit in June 2010 addressed the unmet health needs of underserved mothers and their vulnerable children associated with low rates of breastfeeding, working proactively toward reducing barriers to breastfeeding. The goal was to bring high-level visibility in order to generate timely and judicious policy recommendations for a national breastfeeding agenda under the new health reform plan.

The Third Annual Summit on Breastfeeding was just held June 29-30, 2011 to make sure that we continue our best efforts to guarantee support for First Food: The Essential Role of Breastfeeding.  The Summit again took place in Washington to ensure maximum visibility in the public policy arena.

With continued support from the Kellogg Foundation, key leaders in health and public policy, including high-level representatives from key federal agencies as well as hands-on grass roots administrators from important programs throughout the country and leaders from academic institutions, industry, nonprofits, and public agencies were invited.”

The significant accomplishments of the First Summit and the Second Summit are documented in special supplements of Breastfeeding Medicine.  The Third Summit will be published in detail in an upcoming issue of Breastfeeding Medicine—so be on the look-out for Volume 6 Issue 5 in October. Read the rest of this entry »

Written by kmarinellimd

July 4, 2011 at 8:30 am

Announcing our Newest Protocol: ABM Clinical Protocol #10: Breastfeeding the Late Preterm Infant (34 0/7 to 36 6/7 Weeks Gestation) (First Revision June 2011)

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I am pleased to announce our newest protocol has been published in Breastfeeding Medicine: ABM Clinical Protocol #10: Breastfeeding the Late Preterm Infant (34 0/7 to 36 6/7 Weeks Gestation) (First Revision June 2011).  This is a revision of the previously entitled ABM Clinical Protocol #10: ‘‘Breastfeeding the Near-Term Infant (35 to 37 Weeks Gestation)”.  As this protocol starts out explaining:

“At the time this protocol was first written ‘‘near-term’’ infant was commonly used to describe infants born in the few weeks before the 37th week of gestation. In July 2005 a panel of experts assembled by National Institute of Child Health and Human Development designated infants born between 34 0/7 to 36 6/7 weeks of gestation as late preterm to emphasize the fact they are really ‘‘preterm’’ and not ‘‘almost term’’ and establish a uniform designation for this group of infants.  This definition, however, includes infants born 1 week more premature (34 0/7–34 6/7 weeks) than the previous Academy of Breastfeeding Medicine protocol for the ‘‘near term infant’’ that encompassed infants born at 35 0/7 weeks to 36 6/7 weeks. In addition, infants born at 37 0/7–37 6/7 weeks may be at risk for breastfeeding problems and associated risks, and, therefore, the following guidelines may be applicable to these infants as well”.   Breastfeeding Medicine 2001; 6(3):151-156.

This protocol is the perfect example of what we as the Protocol Committee hope can happen as we update and revise our Clinical Protocols on a 5 year basis.  Unless the evidence has changed dramatically, the plan is to attempt to update the references and the data in such a way as to follow the general outline of the original protocol.  The reasoning is that those of you who are used to using a particular protocol will think everything is changed if you see a completely differenct document, when maybe only one or two things have actually been changed.  If the format remains generally the same, you will be able to easily see what has been updated and what has changed since the last version, and easily be able to update your own practice.  Sometimes this is not possible if either practice really has changed extensively, or author styles and interpretation of the data are so different that there is just no way around it.  But this protocol is an excellent example of how some of the evidence has changed, starting with the basic definition of the population, and there are many more references available ( 13 cited in 2004 versus 52 in 2011) but the basic outline has been followed, enhanced, and expanded to make an even better protocol than the original was.

As the ABM Protocol Chair, I speak for my Committee and for the ABM Board of Directors when I say we are very proud of these Clinical Protocols and our Statements, all of which can be found on our website.  The Clinical Protocols are also accepted and published by the National Guidelines Clearinghouse, sponsored by the Agency for Healthcare Research and Quality of the U.S. Department of Health & Human Services, which has very stringent requirements for acceptance to their website.

So please check out this newest protocol, and keep your eye open for our next one, the brand new Clinical Protocol #24: Allergic Proctocolitis in the Exclusively Breastfed Infant!

Kathleen Marinelli MD, IBCLC, FABM is a neonatologist a Board member of the Academy of Breastfeeding Medicine, and Chair of the ABM Protocol Committee.

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

Written by kmarinellimd

June 6, 2011 at 7:45 am