Category Archives: breastfeeding medicine

“Where is the mother in the discussion?” An interview with Walker Karraa on maternal mental health and infant feeding

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Some of you may know Walker Karraa from her comments on our Facebook community page, or from her fantastic posts on Science & Sensibility. But I doubt you’re aware of the full magnitude of her bravery and dedication to issues surrounding maternal mental health. I recently interviewed Walker for a short piece on formula feeding and postpartum adjustment, and was so blown away by her answers – I was only able to use a few of her wise words due to word count constraints, so I’m thrilled she’s agreed to let me post the interview in full here on FFF.

Walker is a doctoral candidate at Sofia University, where she is conducting a study on the transformational dimensions of postpartum depression. She was also the founding President of PATTCh, an organization founded by Penny Simkin dedicated to the prevention and treatment of traumatic childbirth, and is a perinatal mental health contributor for Lamaze International’s Science and Sensibility, Giving Birth With Confidence, and the American College of Nurse-Midwives (ACNM) Midwives Connection. Like that wasn’t enough on her plate, Walker also served as social media manager for the Integral Leadership Review, and has her own social media consulting business, On My High Horse, and is currently working toward co-authoring a book regarding PTSD following childbirth with Kathleen Kendall-Tackett, Ph.D., IBCLC, FAPA. 

I’m exhausted just reporting all of that. And did I mention she has two kids and is a breast cancer survivor? Yeah, she’s all that and a bag of reduced fat potato chips.

I hope you guys will appreciate the revolutionary nature of Walker’s discussion here – her opinions, while brilliant, probably seem uncontroversial to those who follow this blog, but they are quite “rogue” in the birth/maternal-child health community. I can’t thank her enough for being a dissenting voice and speaking up for the benefit of all women. 

FFF: Here on FFF, we see stories almost weekly which discuss how a perceived “failure” to breastfeed can lead to depression, anxiety, and self-esteem issues. Do you think the maternal mental health community has recognized how breastfeeding (or lack thereof) can affect the emotional state of new moms?

Walker Karraa

WK: I think that overall breastfeeding is very well addressed in the health psychology, and developmental psychology fields. What’s lacking is the reframe of the research to integrate more qualitative data, and methods, into the consideration of the full range of implications of breastfeeding from multiple perspectives—including the woman’s perspective.

In a 1985 Lancet article on maternal mortality, Allen Rosenfield asked the famous question, “Where is the ‘M’ in MCH (Maternal Child Health)? In the discussions of MCH, it is commonly assumed that what is good for the child is good for the mother.” (Rosenfield & Maine, 1985, p. 83). In many ways this is relevant in the discussion of breastfeeding and maternal mental health. Where is the mother in the discussion? And in what ways do we still assume what is good for the child is good for the mother? For me, this is all about reproductive rights and a deeper issue about our discomfort with women’s sovereignty over their reproductive, physical, and mental health.

The mental health community has responded to the growth in published data regarding infant health and breastfeeding. This has also been the funding stream for a large part of the last 20 years. But maternal mental health has yet to directly address a woman’s infant feeding choice as a part of her reproductive choice, rather than discrete periods of time that occur with as a continuum of events that are inextricably woven through reproductive events—none of which, taken by themselves, gives either the best data on mental health.

FFF: What do you feel needs to change in order for new mothers to be better supported in terms of mental health in general?

WK: I think one of the first calls to action must be for maternal care providers to get support in knowing that perinatal mood and anxiety disorders are common and create the conditions for morbidity and mortality for mother and children. This is starting to happen, but still very slow. I think new models of medical care such as Dr. Michael C Lu’s life course model, which places the woman at the center of care, not the doctor. And, she is treated across the lifespan, not merely when she is pregnant. This facilitates better reproductive health in preconception and interconception, and uses a reproductive life plan for women and families from an early age. At puberty, to have a conversation with medical, nutritional, mental health providers as to planning one’s reproduction (girls and boys) would be ideal.

FFF: Many women struggle with the decision of whether to treat postpartum or prenatal depression/anxiety with psycho-pharmaceuticals, especially when they are breastfeeding. Why is there such mixed information and messaging about what drugs are safe, and what the relative risks are (ie, breastfeeding without meds vs breastfeeding on meds vs formula feeding and taking the meds)?

WK: Not having good information is a barrier to care for everyone involved. The OB/GYN or midwife, the social worker, the woman, her partner and family—when we don’t have good information, we cannot make informed choices. And for women in poverty, the risk is twofold. Specifically regarding breastfeeding, but also education across the board regarding psychopharmacology, pregnancy, and lactation. With organizations such as OTIS (Organization of Teratology Information Specialists) and Motherisk, there really is no excuse for not having current evidence-based data regarding risk and benefit of untreated depression and anxiety, as well as risks and benefits of medications used to treat them.

Byatt et al. (2012) did a wonderful grounded theory study regarding community mental health provider reluctance to providing psycho-pharmacotherapy. 28 obstetric care providers (nurses, OB/Gyns, etc.) shared how they perceive community mental health practitioners as obstacles to psychopharmacology for perinatal women. The participants felt community mental health providers “99% of the time” discontinued a patients’ medication, and put women at risk of relapse. Secondly, Byatt et al., (2012) reported that participants perceived a lack of collaboration and communication between community mental health care providers and OB/Gyn providers, and that pharmacists also “further impede or delay depression treatment by not filling needed psychotropic prescriptions, often exacerbating women’s mental health symptoms” (p. 3).

FFF: Why do you think so many women express grief, guilt, and feelings of failure around the subject of infant feeding?

WK: Because that is their experience! And I attribute all of it to social constructs that are completely ingrained in medical, social, and mental health systems that have been made for and by men. The intentions of those men is not necessarily nefarious, and not really the point. It is that the constructs we have to measure ourselves (abilities and weaknesses) are made by men. We tell women from the get-go that they need us to be good mothers. They need our insight, knowledge, treatment, book, video, technique, services, product to be taught how to mother. This is so ironic, because so many of the birth movements have evolved from a call to empower women. But to empower, we have just made more systems of knowledge that mimic the ones we refute. That is not very popular to say, but it is true. The messages still given to women is that if they “know” something analytically, they are devoid of femininity, and if they “know” something inter-subjectively, they are devoid of ration.

Shame is a powerful force for women. And at no time in her life is a woman more susceptible to shame than early motherhood. If they are lucky enough to find a safe space to share their feelings without judgment, such as your blog, they are given the gift of voice. They can speak their truths.

FFF: Any tips for a mom who is having a tough time reconciling her use of formula?

WK: You know, when I was a doula, I had clients ask me to go buy formula for them so they wouldn’t be seen in public. When I was diagnosed with breast cancer shortly after the birth of my second, I underwent two mastectomies before she had turned one. I learned that my body parts have nothing to do with my inherent ability to love her. My breasts were gone—off of my body, one in one hospital and another at a hospital down the road. I fed, nurtured, attached with, loved, and parented without them…and still do! So my advice is to write down on a piece of paper: My breasts have nothing to do with my love for my child. And keep it where you can see it. Memorize it, know it.

A couples therapy session for Science and fed-up parents

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You know how I’m always harping on and on about how we could be doing studies that actually help us protect infant health, rather than guilt-tripping mothers? My fairy godmother must’ve been listening, because today I stumbled upon an interesting article, courtesy of Mammals Suck (maybe she is a fairy godmother? Scientists can be fairy godmothers, can’t they?)

Featured on Nature.com, the article described two findings about the sugars in breastmilk. The first discovery was that one of the human milk oligosaccharides (HMOs) – the sugar molecules present in breastmilk -  can actually increase the chance of mother-to-child HIV transmission.

The molecule, called 3′-sialyllactose (3′-SL), is found in varying concentrations in the milk of different women. In a study in Zambia, HIV-negative newborns breastfed by HIV-positive mothers are twice as likely to catch the virus during their first month of life if the mother’s milk has an above-average level of 3′-SL1.

Doesn’t sound like the most positive news, but wait: only certain women’s milk contains significant enough levels of the sugar to place their babies in danger. Plus, other sugars have a positive effect:

The same study in Zambia found that five more of the 150-odd complex sugars in breast milk seem to have a protective effect. HIV-negative infants who consumed these sugars had a better chance of reaching their second birthday than did HIV-negative babies who drank breast milk lacking those sugars irrespective of their mothers’ HIV status. (Once a baby had caught HIV, however, breast-milk sugars had no influence on survival.)

 

The second part of the article described research into why some babies are not able to fight off necrotizing enterocolitis (NEC), despite being fed human milk. Breastmilk contains oligosaccharides that fight off this deadly infection – but as it turns out, not all women produce these sugars:

 (A team) reported an association between a dangerous gut disease in babies called necrotizing enterocolitis (NEC) and the inability of affected infants to secrete a suite of oligosaccharides in their mucus. These babies are considered particularly likely to benefit from drinking the sugars via breast milk, but about 10% of European women cannot make them in their milk…

 

Okay, so this is where it gets really interesting. Both of these examples suggest that depending on the composition of a particular woman’s milk, the health benefits of breastfeeding may not be identical across populations. A researcher quoted in the article hypothesized that “(t)he often confusing literature on breast feeding’s impact on disease will be largely explained by this underestimation (of the variation in human milk).” The article also explains how “(s)everal labs are trying to identify how variation in the prevalence of the large sugar molecules in breast milk… influences infant health. Once clear links are established, clinical trials to test HMOs as health-boosting additives in infant formula milk can be drawn up.”

Say WHAAAAAAAAT??

Yep, you read it correctly, FFFs. And I think we can all take a moment for a collective sigh of relief. Not all researchers are so entrenched in their  public policy advocacy efforts that they forget to see the forest for the trees! Not all lactation scientists are lactation consultants! Some are – dare I say it – scientists.

I fear that this is the type of research that gets pushed under the rug, because it requires critical thinking. There isn’t an easy soundbite that can appeal to the masses – in the first example, the answer is not to tell HIV+ women in developing countries to use formula until they are tested for the specific HMO, because formula feeding in resource-poor countries with contaminated water is a high-risk activity. But perhaps more research could lead to some sort of treatment which would help these women lower their levels of 3′-SL and increase the beneficial HMOs.

Similarly, what if a preemie’s mom wanted to get her breastmilk tested to see if it contained the necessary HMOs to protect her baby? And if she found that she was part of the 10% who didn’t produce these beneficial sugars, perhaps that could allow her to make an informed decision about using donor milk, while either pumping to keep up her own supply, or deciding to switch to formula once the baby was older.

Research like this allows for progress. It allows us to understand exactly what it is about breastmilk that makes it so beneficial, which might lead to better, more biologically “equivalent” options for women who can’t or choose not to breastfeed. But even taking it away from the infant feeding choice powderkeg for a minute, I think it’s an interesting thing to ponder why certain people are so uncomfortable with the suggestion that not all breastmilk is perfect milk. I mean, I understand it – who the hell is science to tell a woman that her milk isn’t “good enough”?

But people – this is exactly why we can’t be wishy-washy about whether breastfeeding is a personal act or a monitored, medicalized event. If we are going to pitch it to women based on statistics, telling parents that science has proven the medical necessity of nursing our young, then we must accept the risk that science could turn around and say “erm, you know what? I messed up. That’s only true for some women. Some gals just produce inferior milk.” While we might want to say screw you, science, and the horse you rode in on, we can’t. Because we used science in some very dirty ways when it suited our needs, and now it is hanging around like a rebound boyfriend who just doesn’t take a hint.

On the other hand, if we don’t allow medical authorities to lay down moral indictments based on the way we feed our babies, then we can easily kick science to the curb when it tries to tell us that our milk may not be all it’s cracked up to be.

Personally, I don’t think either scenario is great. As that Facebook group with the funny memes says, I f**king love science. Because I don’t think it’s true science that is messing things up for women. I think it is zealotry dressed up as science – people who are so committed to a cause that they are unable to come into research with the open, curious mind so integral to the scientific process.

So, I think as women, as mothers, it is safe for us to applaud research like this. We have to trust that knowledge can be power, as long as it is handed to us free of extrapolation. It’s not scary to hear that formula fed babies aren’t protected from NEC if donor milk is made available to preemie parents, or if we know that good old science is doing its best to create a supplement that could offer our tiniest babies protection regardless of the quality or quantity of a new (and often highly stressed, given the circumstances) mother’s pumping efforts. It’s not guilt-inducing to hear that breastfed babies have a higher IQ if we know exactly why this is – if it is an association, or something about the physical closeness during the act of nursing (which could easily be recreated by a bottle-feeding parent using a bit of imagination and less clothing) or something specific in the milk (in certain milk? Do some women increase their baby’s intelligence, and some women decrease it? Who the heck knows until we look into it?).

We can’t be scared of science, and we can’t abuse it. And scientists can’t be scared of staying neutral, and can’t abuse their power. If we can give each other this mutual respect, maybe we can turn this into a beautiful relationship. Even if it did start out as a rebound…

 

 

WTF, AAP? The problem with the American Academy of Pediatrics’ newest statement on breastfeeding

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“Breastfeeding and human milk are the normative standards for infant feeding and nutrition. Given the documented short- and long-term medical and neurodevelopmental advantages of breastfeeding, infant nutrition should be considered a public health issue and not only a lifestyle choice.”

Thus begins the newest statement from the American Academy of Pediatrics regarding infant feeding. And consequently, thus begins the newest battle for FFFs anyone who cares about the freedom of women to choose how they feed their babies, and how they use their bodies.

The ghosts of statements past

It may seem like an overreaction, but the choice of words in this “official statement” from the preeminent child health organization of the United States, is deeply disturbing to me. To explain why, I think it may be helpful to look at the AAP’s past statements regarding breastfeeding, over the last 15 years.

Back in 1997,the AAP concluded its position paper on breastfeeding by stating that “Although economic, cultural, and political pressures often confound decisions about infant feeding, the AAP firmly adheres to the position that breastfeeding ensures the best possible health as well as the best developmental and psychosocial outcomes for the infant. Enthusiastic support and involvement of pediatricians in the promotion and practice of breastfeeding is essential to the achievement of optimal infant and child health, growth, and development.” This reads like a strong suggestion to breastfeed; a plea for pediatricians to support breastfeeding but at the same time acknowledging that sometimes there are complications which make the “preferred” choice a difficult one to carry out.

By 2005, an updated statement was released. This statement was relatively similar to the 1997 one, but contained some updated information (including an advisory statement about Vitamin D supplements in breastfed infants). The concluding statement was the same as that in the 1997 document.

Now, in 2012, we are presented with a document that’s opening paragraph puts the kibosh on personal autonomy for mothers. There is no longer any acknowledgment – however cursory – of external factors which might complicate the decision to breastfeed; the section on contraindications is worded in a way which suggests that even meth-addicted women are better off breastfeeding; and pediatricians are encouraged that their “role in advocating and supporting proper breastfeeding practices is essential and vital for the achievement of this preferred public health goal.” The concluding paragraph is in stark contrast to that of prior statements:

Research and practice in the 5 years since publication of the last AAP policy statement have reinforced the conclusion that breastfeeding and the use of human milk confer unique nutritional and nonnutritional benefits to the infant and the mother and, in turn, optimize infant, child, and adult health as well as child growth and development. Recently, published evidence-based studies have confirmed and quantitated the risks of not breastfeeding. Thus, infant feeding should not be considered as
a lifestyle choice but rather as a basic health issue. As such, the pediatrician’s role in advocating and supporting proper breastfeeding practices is essential and vital for the achievement of this preferred public health goal.

I am woman, hear me roar (unless it keeps me from breastfeeding, in which case I should shut up)


In this statement, pediatricians are called upon to visit an AAP website which will “provides a wealth of breastfeeding-related material and resources to assist and support pediatricians in their critical role as advocates of infant well-being.”

Labeling the intended audience of this paper as “advocates of infant well-being” is exactly right: pediatricians are advocates of infant well-being, not maternal well-being. Within a section on “maternal benefits” to breastfeeding, the authors claim that “a large prospective study on child abuse and neglect perpetuated by mothers found, after correcting for potential confounders, that the rate of abuse/neglect was significantly increased for mothers who did not breastfeed as opposed to those who did.” This study was the one we discussed here; if you go back and read that post, you’ll realize that this study did NOT control for the most important (and in my opinion, most obvious) confounder, which was that women who are most likely to be neglectful or abusive will not choose to breastfeed in the first place. This study was one of the weakest, most ridiculous pieces of drivel that I’ve read in the entire body of breastfeeding science, and that’s saying a lot. The fact that the AAP would stoop so low to add this to their official breastfeeding statement speaks volumes, in my opinion. (Although considering they later allude to the infamous Bartick study as an “evidence-based stud(y)” which has “confirmed and quantitated the risks of not breastfeeding”, I guess I shouldn’t be too surprised.) Insult is added to injury by their brief discussion of postpartum depression (“Prospective cohort studies have noted an increase in postpartum depression in mothers who do not breastfeed or who wean early…”).

It is one thing for pediatricians to write a strongly worded statement about the benefits of human milk to babies. If we’re going to talk about maternal benefits, I’d like to hear about that from a cancer specialist, a psychiatrist or clinical psychologist who specializes in maternal mental health, and maybe an OBGYN. Not my child’s pediatrician, who hasn’t focused on adult vaginas or brains since they graduated from medical school. “But FFF”, you’re probably saying, “it’s for the children! The children!!” Yes, it may well be. But if we’re going to discuss subjugating the needs of the mother for the needs of the child, then we are getting ourselves into a very controversial area, and one which I don’t think the AAP has the right – or the depth of knowledge – to tackle. And regardless of where you may personally stand on that issue, I fear that if we go down this path, it’s a short trek over to another road where they start sterilizing women over 40 because they have a higher risk of birth defects, or making certain reproductive technologies illegal because they aren’t the “normative standard” of how we are supposed to reproduce. Melodramatic? I sure hope so, but I don’t think it’s that far a stretch.

Redundant Redundancy

Here’s what I find interesting: the authors state that they are releasing this updated statement because “(r)ecently published research and systematic reviews have reinforced the conclusion that breastfeeding and human milk are the reference normative standards for infant feeding and nutrition. The current statement updates the evidence for this conclusion…” And yet, the main source of data is the AHRQ Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries, which is also the basis for the recent Surgeon General statement on breastfeeding. This document is actually a really good read, as nearly every benefit they cite is capped with a strong warning not to get over-excited over the findings as they are bogged down by study limitations, confounding factors, etc. If you haven’t read it, I strongly suggest that you do – it will make you feel a hell of a lot better about the foreboding statements made by our government and the AAP.

If you look at the references at the bottom of the newest AAP breastfeeding statement, you’ll see that quite a few of the cited studies are indeed from after 2005, when the last AAP statement was released. In that sense, a new statement is justified. But what do these studies really tell us that the older ones haven’t? None of the “rules” have changed; it’s more of the same type of evidence, which suggests a slight benefit after adjusting for confounders (which are usually not appropriately comprehensive). As usual, I feel I must state for the record that I am in NO WAY suggesting that these findings are fundamentally incorrect – I’m only trying to remind everyone that the methods used to obtain this data are inherently flawed. Breastfeeding may indeed be so far superior to formula that it makes breastfeeding look like Lindsay Lohan circa-Parent Trap, and formula feeding resemble post-jail Lohan. But so far, the body of evidence looks more like a comparison between chubby Renee Zellwegger and skinny Renee Zellweger. The body might be a bit different, but the face is cute regardless. (And hell, she won an Oscar for the film she did when she was chubby.)

Now, there have been some studies published since 2005 that would have been interesting to include – like this one, which argues that breastfeeding problems are strongly linked to PPD, which may explain away the data that they are using to promote breastfeeding as a maternal mental health advantage. Or how about this one, which counters the claim that breastfed children are smarter than their peers. Or this one, this one, or  this one, which found that breastfeeding has no correlation with future obesity risk? But no. The AAP cherry-picks the studies which support its ideologies, and ignores the ones which might offer some truly new insight. Now, whether or not we like to admit it, here on the interwebz and in scholarly debates, we all cherry-pick to some degree. (In fact, one could argue that I just did it now, by purposely finding 5 studies which supported my argument.) This is because we take sides; we fall victim to confirmation bias; or sometimes, we just don’t do our homework. But a major medical organization should be bipartisan. A major medical organization should be honest about the evidence, especially when there are conflicting studies. A major medical organization should not be cherry-picking.

The really nasty elephant in the room (or better yet, elephantitis, maybe of the testicles. It’s that disturbing.)

And lastly…Let’s pretend, for the sake of argument, that formula is so risky that it is a true health threat to our nation, and meriting this dramatic sort of action on the part of the government and the AAP. Then why the heck doesn’t anyone try to improve formula? We live in a time where we can clone sheep and create human life in a test tube – we really can’t come up with an adequate substitute for human milk? Why shouldn’t women have the ability to overcome their biology if they so desire? Whatever science has to say about modern infant formula as a product, the fact remains that sociology may see it in a different light. Formula feeding does allow a woman to choose to return to work immediately and allow a partner or caregiver – god forbid, even a male one – to care for her infant. Whether we agree or disagree with her choice, it is, and should remain, her right. If we are going to argue that not breastfeeding is as risky as other health concerns like smoking or drinking and driving, then why aren’t we rioting in the streets demanding better?

I don’t believe that the situation with formula is that dire; not be a long shot. I happen to think that formula does a pretty bang-up job of nourishing kids, and that loving, nurturing formula feeding parents do amazingly well at providing the “nonnutritive” advantages despite their lack of lactation. But I’m starting to realize that there is a hideous punchline to this debate: if people think that formula is so awful, why is the only solution to breastfeed exclusively? I believe that for most, breastfeeding would end up being the preferred way to go if all things were equal. Social inequities aside, however – there are women out there who may just not want to breastfeed. Just like there are women out there who don’t want to have a hospital birth. Or women who want to be single mothers by choice. Or pick any other choice which falls outside the “norm” or may not be accepted as kosher by mainstream society.

So, AAP, here’s what I have to say about your “amended statement”: please realize that by “advocating for children” in this manner, you are putting mothers – and fathers, for that matter – in a really stressful situation. You are doing so based on research which is no in many ways no better than it was 5, 10, or even 20 years ago. And you are certainly not helping children by aiding a system which is trying to take away a choice from their parents, a choice which has the ability to solve medical, marital, employment, and financial problems, thus making them better parents in the long term.

FAIL. Try again, please.

 

Caffeine and breastfeeding: Do we need to wake up and smell the coffee?

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I know it’s odd for the Fearless Formula Feeder to be discussing something that really only pertains to breastfeeding moms (except in one minute way, which we’ll get to), but I worry that a lot of studies which could be construed as “discouraging” to nursing moms are swept under the carpet like my son’s puzzles (don’t ask – I think he’s trying to protect them from his baby sister, who does have a criminal record for the capital offense of wrecking a 90-piece puzzle we worked on for a frustrating 2 hours; in any case, I find various and sundry puzzles hiding under the rug in our playroom on a daily basis). Plus, some of you are thinking of breastfeeding future children, or are combo feeding or pumping, and I think it’s really vital that we ALL get fully-informed about any form of infant feeding. We’re not children, nor Tom Cruise; we can handle the truth.

So, onward, fearless soldiers… Today’s post is about one of my favorite drugs: caffeine. I am currently maintaining a 4-cup-a-day habit with my coffee addiction; while I abstained during my first pregnancy, I held onto that 200-mg pregnancy “allowance” like it was a lifevest during my second. There was just no way to care for a 15-month-old who was still waking up several times a night, while suffering from pregnancy-induced exhaustion, without my faithful, beloved cup of joe. Or peppermint soy latte, depending on the day.

After I gave birth, one of the first thing I did was hit my local Coffee Bean. And I have to tell you, I think the ability to drink massive amounts of caffeine was as beneficial to my second postpartum experience as was my prescribed antidepressant. Alone with my new infant and a needy toddler, going on no sleep? No problem. I could even chug a Red Bull, if need be.

I know that I could have had a small cup of coffee every day that I was nursing (or pumping for) Fearless Child. But he was fussy; it would have been ridiculous for me to cut out dairy, soy, chocolate, green leafy veggies, and nuts if I was going to keep caffeine in my diet. So I abstained.

Perhaps I was being paranoid; my breastfeeding friends definitely drink caffeine, although probably in more moderate amounts than I typically consume. Most breastfeeding websites will tell you that caffeine is fine in moderation; that only a small amount passes through to the infant. However, breastfeeding mothers are counseled not to smoke due to low levels of nicotine passing through; how do those levels compare to that of caffeine in breastmilk? Is there a bias towards nicotine, because smokers are popularly vilified and coffee drinkers are not?

I came across an interesting interview with Ruth Lawrence, PhD,  an executive director of the Academy of Breastfeeding Medicine and the veritable grand dame of breastfeeding advocacy, which seems to suggest that this may indeed be the case. Published in the Journal of Caffeine Research, the discussion centers around how caffeine is passed to an infant during pregnancy and lactation, and how long-term – and especially early – exposure to the substance can affect development. “If caffeine is consumed by the mother, then a small amount of caffeine will get into the breast milk and, therefore, into the baby,” Dr. Lawrence explains. “This is probably not too important later on, but initially in the first week or so, babies do not metabolize and excrete caffeine very well. So, if a mother consumes a lot of caffeine, it accumulates and her baby can become quite symptomatic.” The interviewer then asks her if the 300 mg limit typically given to breastfeeding women is prudent. 


“I think that (300 mg/day is a) reasonable starting place. I think it varies from mother to mother and baby to baby. Probably one of the biggest problems is that women do not realize all the sources of caffeine… (and) it depends on whether the mother drank coffee during her pregnancy and whether the baby is already attuned to it and has begun to be able to metabolize it. There is going to be some variation.”



Lawrence goes on to ponder if babies who are diagnosed as colickly may actually be suffering from higher levels of caffeine exposure. She even cites an extreme example, where a baby was thought to be having seizures:


“Unfortunately a lot of things about breastfeeding are based on opinion, and I do not know that the ‘‘safe’’ amount of caffeine for daily use has been carefully measured. I know of case reports. We had a case here in which a child was brought in, thought to be having seizures, and was headed for the mil- lion-dollar workup, the EEG, the MRI, the works. And in the emergency room we drew a caffeine level. It was off the charts! And we spared that child an admission. Taking a history from the mother, she said, ‘‘Oh yeah, I drink coffee all the time. I have a cup ready for me all day long. Is that a problem?’’




It’s an interesting read, and I think this journal piece speaks to the real lack of truly evidence-based advice given to nursing moms. As Lawrence suggests, further research into this issue is warranted, and for the love of all things Java, I hope that someone will fund an infant caffeine study instead of yet another showing the superiority of breastmilk over formula. 

Even those who go straight to the bottle could learn something from this interview: part of the discussion focuses on caffeine withdrawal, and if babies who are exposed to significant amounts of caffeine in utero may go through withdrawal after birth. In this case, a breastfeeding mom who consumed a specific level of caffeine might actually help her baby slowly withdraw. For those not breastfeeding, this knowledge could give a little hope to those with fussy babies in the first few days: maybe Junior just needs an espresso shot.

The tale of the asshat pediatric GI

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Recently, the Academy of Breastfeeding Medicine held their annual conference. I followed the Twitter stream from the conference, and some of the soundbytes coming out of there were frightening, even more so because they were coming from the mouths of medical professionals. One speaker was quoted in numerous tweets for spouting this lovely tidbit: “I don’t say, ‘breastfeeding is so protective for mothers.’ I say, ‘Formula feeding is so dangerous.’” This came from a woman whose CV mentions an interest in the “responses of women to life stressors such as trauma.” Sounds about right; she can traumatize them with comments like that, and then study them to see the effect.
My main problem with this conference is that I think calling it the Academy of Breastfeeding MEDICINE is misleading. If it’s the Academy of Breastfeeding Medicine, let’s talk medicine. Presentations like “The Dermatology of the Breast” and “ Exclusively Human DIET (EHD) for Infants <1250 grams to Prevent Nectrotizing Enterocolitis (NEC)" sound perfectly suited to this event; "Effect of Delaying the Bath on Exclusive Breastfeeding Rates” and “ A Report from Japan: What We Learned from the 3.11 Disaster”? Not so much. 
Okay, quick irrelevant aside, because I just can’t let it go. According to the abstract, the “findings” of the latter report were:
The myth that the artificial milk was safe collapsed in the developed country such as Japan. Though the information that indicated the safety of breastfeeding at the time of a disaster was easily accepted, the assertion to be said not to receive liquid milk donated from foreign countries was hard to be understood not only by general public but journalists. The problem about nuclear accidents is now going on.
Maybe it’s a language barrier, but isn’t this stating that that the public and journalists were pissed off that UNICEF was discouraging formula donations – ready-to-feed formula donations, to be specific? Did they not see why people would be pissed? (And yes, I know the reasons why UNICEF has it’s protocol for infant feeding in disasters; I’m on the fence about it, actually. But it isn’t a totally black and white issue, either.) Am I reading too much into this abstract and the tweets coming from its presentation if I say these folks sounded mighty gleeful that the disaster “collapsed the myth” that formula was safe?
Anyway. Back to the reason this makes me so uppity…  I worry that by morphing together breastfeeding advocacy and breastfeeding science, we are coloring the judgment of those who should be treating us on a case-by-case, individual basis.
And speaking of case-by-case, here’s a case in point. A little story about the FFF in my  Fear-ful days, when I was a brand new mom; a floundering mess with a child who wouldn’t stop crying and a pump which wouldn’t stop screaming “YOUSUCKYOUSUCKYOUSUCK” every time I turned the blasted thing on.
Fearless Child had been miserable pretty much since the 4th hour of his life. First, he’d been starving; once we realized he’d never latch and resorted to exclusive pumping, he gained weight fast, but he never seemed healthy. He had a weird rash all over, never slept, screamed before, during and after feedings, and had mucous-filled diarrhea about 15 times a day. My doctor suggested cutting out milk, soy and nuts; I did so for two weeks, to no avail (actually, I’m about 90% vegan to start with, so there was little dairy in my diet to begin with. Soy was a lot harder for me to cut out.). The third or fourth time I visited our pediatrician about FC’s stomach issues, she looked at the poor little guy, still screaming his rashy head off; felt his tight, gurgly abdomen; and suggested that we see a pediatric gastroenterologist. As she wrote down the contact info for the referral, she told me she’d also give me a sample of a special, hypoallergenic formula, to try in the interim. “The guy we refer to will probably have you try this for 48 hours to see if there’s a difference, rather than putting FC through a lot of invasive testing. You might as well try it out while you’re waiting for an appointment – no need for him to suffer any more than he already has, and it’s worth a shot.”
Within twenty-four hours, we pretty much already had our diagnosis. The hypoallergenic formula stunk to high heaven, but FC lapped it up like it was chocolate milk. And after he finished the first bottle of the special formula, he slept for a record four hours. That night, although he still fussed a bit, like normal babies do, Fearless Husband and I were able to sit down and eat dinner for the first time in weeks. FC let us put him in his swing – practically unused, up until this point – and he stared up at the attached mobile, eyes clear and wide. We knew better than to declare victory. Instead, we held our breath and hoped, hoped, hoped.

 

We came close to cancelling our appointment with the specialist many times in the following week. FC was an entirely different baby, a smelly-and-expensive-formula-induced changeling. I began realizing why people would actually choose to be parents. It was kind of fun when the kid wasn’t miserable and wailing twenty-four hours a day. His rash cleared up and his diapers no longer scared us. It seemed that we had our answer, and it came in a purple can with a $30 per week price tag.
Still, we figured it couldn’t hurt to get a definitive diagnosis so we would know what the future held. What happened to dairy and soy intolerant kids when they were weaned off formula – were they sentenced to a life of rice milk and birthday cake deprivation?
After a two-hour wait, we were taken into a small room where FC was weighed and measured. It appeared that in the week since we’d seen the pediatrician, he had apparently shrunk an inch. When we asked the nurse about this, she just shrugged her shoulders and said that measurements could be off between offices.
A few moments later, a young woman entered the room and introduced herself as the doctor’s resident. She spent a half-an-hour obtaining a ridiculously detailed history of our son and his feeding issues, stopping several times to excitedly tell us that this was “classic” milk/soy protein intolerance behavior.  FC even added his two cents to the discussion in the form of a dirty diaper, which the resident encouraged us to hold onto for testing. Considering we’d been on the hypoallergenic formula for a week, and his system was free and clear of all offending foods, she wasn’t sure this would be an accurate diagnostic tool, but she wanted to doctor to have the option.
By the end of this warm-up act, we were even more geared up and anxious to hear from the illustrious doctor himself. The resident seemed pretty enthusiastic, too – she told us that it was clear our pediatrician had diagnosed this correctly, but she wanted the doctor to confirm and explain the condition to us in detail. She left the room to go over her notes with him, and promised to return, doctor in tow, in a few minutes.
My memory of what happened next is fuzzy. I know the doctor came into the room, and proceeded to school us on Baby Basics 101. He referred to what FC had as “colic”, suggesting that I “call my mom to come help me out if it’s too much for me”; when we explained we had no family in the area, he blithely quipped that we should “just hire someone.” (We could barely afford FC’s formula at this point, let alone a caregiver for a newborn.)  He refused to even look at the detailed history the resident had taken (she stood behind him, mouth agape, and sending apologetic glances in our direction); he threw out the diaper we’d kept for his inspection without even looking at its contents. I remember pleading our case, trying to get a logical answer as to why FC had rashes and mucousy diapers for so long, and recovered so remarkably once he was switched to hypoallergenic formula. “The peak of colic is about 6 weeks,” he responded, a condescending smile never budging from his lips. “It was probably just good timing.”
“So you’re saying that he went from a screaming, rashy mess to a calm, happy baby in one day by chance? And it had nothing to do with switching him to hypoallergenic formula?” I asked, the anger churning in my belly so powerfully that I probably needed my own visit with a gastroenterologist.
“Yes, that’s what I’m saying,” Everything out of his mouth sounded syrupy sweet, between his velvety accented English, and the icy smile that capped every sentence.
“You don’t even want to look at the history we just spent 30 minutes rehashing?” Fearless Husband piped in. The doctor shrugged his shoulders and opened the folder containing the resident’s careful, thorough notes. He scanned the first page – simply detailing FC’s height and weight stats – and conceded that there could indeed be a problem, although not the one we suspected.
“You’re overfeeding him,” he proclaimed. “He’s overweight. He’s in the seventy-fifth percentile for weight, but his height-to-weight percentile is closer to the ninety-fifth.  Do you know what that means? Only 5% of babies his height are fatter than him.”
“I think your nurse may have mismeasured him, actually,” my husband muttered. We both knew this was a lost cause. It was no use suggesting that FC may have been comfort eating for the entire time he was on pumped milk – a pattern that had ceased as soon as we’d switched to the hypoallergenic. Or that the poor kid had been growth restricted in the womb, and probably had been making up for lost time (or food, in this case) now that he was able.
Then came the kicker. “It’s a real shame you gave up on breastfeeding,” the doctor sighed. “It’s best for the baby, and so much easier on their stomachs.”
Next to me, I could feel my husband’s entire body tensing up. “That’s funny,” my husband retorted, coldly. “He was the most miserable on her breastmilk. And as we’ve tried to tell you about five different times, now that he’s on hypoallergenic formula, he’s doing great. I’m not sure what you don’t understand about that.”
“Well, I can only tell you what I think,” said the doctor, snapping the file closed.
 
Three years later, I can only tell you what I think. I think that guy was an asshat. But beyond that, I think this experience was what provoked me to start this blog, more than any mommy-war drama, more than any study I’ve seen misrepresented in the news. It was seeing how a doctor could immediately dismiss you, immediately judge you, simply because they were married to the party line regarding breastfeeding. 
And unfortunately, if the tweets from the ABM conference are any indication, there is an awful lot of dismissive judgment going on in the medical field. Unless you’re an exclusively breastfeeding, educated, white, middle-to-upper-class mother; then you’ll be given a gold star. 

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