My honest reaction to The Honest Company’s new formula

So there’s a new formula on the market.

Honest-Company-Formula-DHA

This should be good news, right? Especially as this particular formula brand (The Honest Company) is trying to corner the organic, natural-minded formula feeder market, which is steadily growing. I’ve heard from many FFFs who import a British organic formula because it’s the only one that suits their needs; this is certainly not cost-effective or efficient, and it’s spectacular that these parents now have a Stateside option.

Unfortunately, most of the formula feeding community (including me) learned of this new product via an article on PopSugar which only served to infuriate a good deal of its target audience.

“When you’re trying to feed your baby, you’re riddled with emotion, shame, judgement . . . all these extra layers,” Christopher Gavigan, the company’s cofounder and the creator of the formula, told us. “We acknowledge that breast milk is the most nutritious form of food on Earth, but if you look at the research, the majority of moms will end up doing some combination of feeding, whether it’s a choice or because they have to. It’s a growing reality around the world. And in that reality, parents have to be able to choose something.”

Um, I’m no marketing genius, but since when has “well, we know you feel really shitty about using this – and you SHOULD – but since you have to do it, you may as well choose us” been an effective marketing strategy?

One could argue that for moms who just need to supplement a little, or who are still feeling awful about their “failure” to breastfeed, this self-flagellating attitude might be welcomed. But that doesn’t mean it’s helpful. I wonder about the impact of this language on moms who already worry enough about nutrition to shell out $30/can for formula.

This product launch is also causing drama because Gavigan implies that other widely-used commercial formulas are sub-par:

What he came up with was a formula carefully modeled after breast milk, nutritionally complete, easy to digest, and meticulously blended using ingredients sourced from trusted organic farms. It’s free of gluten, GMOs, flavorings, steroids, growth hormones, and pesticides. And it’s the only formula on the market that has chosen to leave out hexane-extracted DHA (while the fatty acid is known to help with baby’s brain development, the synthetic forms don’t meet safety standards).

While there are many who don’t feel comfortable with hexane-extracted DHA (and I’m thrilled they have a new option, because all parents deserve to feel comfortable with what they are feeding their babies), it’s patently false that the forms used in other formulas don’t meet safety standards. They may not meet Gavigan’s safety standards, or the Cornucopia Institute’s standards, or European standards, or YOUR safety standards, but they do meet the safety standards formula companies must adhere to. Speaking of which, I highly doubt this formula’s ingredients closely resemble breastmilk any more so than Good Start’s. Every formula company wants to get as close to breastmilk as possible. That’s sort of the end-goal. If Honest Company has cracked the code, I think we’d be seeing articles in the Wall Street Journal, not PopSugar.  (Also, for the record, Baby’s Only also has a hexane-free option, although they market it as a “toddler formula” because they believe babies should be primarily breastfed for the first year. But it really is an infant formula. Which is weird. But whatever.)

That said, it is plausible that they have sourced all their ingredients from trusted organic farms. That’s probably where the hefty price tag comes from.

Yet, while Gavigan’s quotes in the Pop Sugar article left a lot to be desired, whoever designed the company’s website is a genius. In the introduction to their feeding section, they state:

No breast versus bottle, no right or wrong: We believe how parents choose to feed their babies is a personal process based on the needs of their families. We know it can be quite an emotional decision. That’s why we’re here not to judge, but rather to support parents with a range of researched information and safe, premium products that empower every family to make the best choices given their unique circumstances.
We’re aware that breast is best, but we also understand that families may choose or require other options. No parent should have to feel guilty for choosing to feed her or his baby one way or another. Parents have been nourishing their children in all kinds of ways since the beginning of time as we know it. With Honest Feeding, The Honest Company hopes to represent the next step in the evolution of nourishment as we help you lay the foundation for a safe, healthy and happy future.

 

Freaking amazing, isn’t it? And even better, they have a section called “Transparency” where they take you through the ingredients in their formula, where they are sourced, etc. The old guard formula companies could learn a lot from this approach. It’s beautiful.

Problem is, I don’t know if what’s on the site is merely lip service, and the “persona” of Honest as a formula company will be closer to the PopSugar representation. I really, really hope that Gavigan was just misquoted.

Regardless, when I posted about this new formula on the FFF Facebook page, all hell broke loose. Some echoed Gavigan’s feelings about currently available commercial formulas, saying that what was available was “garbage”. Others understandably balked at this suggestion. Feelings were hurt, insults were hurled, and I ended up turning off the computer and watching Law & Order SVU because it was less frightening.

(**This is what we’ve come to. We’re so reactive, because we’ve been forced to live in fear, under this heavy, smelly cloud of judgment. It puts us in bad moods, makes us jumpy and defensive, and who can blame us? You spend too much time under a smelly cloud, and you start to kind of stink, too. I know I do.** )

So where do I stand on this new product? First, it doesn’t matter what I think. It’s not my baby. It’s yours. And what mattered to me when I was choosing formula doesn’t have anything to do with what matters to you. My kids couldn’t tolerate anything but expensive hypoallergenics, and I was so relieved to have a way to feed them that allowed them not to starve or bleed from their GI tract that I wouldn’t have cared if the ingredients came from the seventh layer of hell. If organic, hexane-free formula is important to parents, then I damn well want to see organic, hexane-free formulas on the market. We should have more options, overall. That doesn’t mean formulas differ in how they will nourish your baby – they all meet the same nutritional standards and your baby will grow well on all of them, unless s/he has a special need/allergy/intolerance that necessitates a specialty formula. But there’s enough “noise” out there when it comes to our food (not that I condone or agree with this noise, but that’s not really here nor there) to make any new parent anxious, and when you’re already feeling anxious about not breastfeeding, the last thing you need is more anxiety.

One more thing I want to address, in this convoluted post: On Twitter, a lot of pediatricians I respect and who have fair, balanced perspective on formula use, surprised me with their reaction to this new formula. I share their skepticism on the marketing claims, but I worry about this attitude of “no formula will ever match breastmilk, so why even try?” That’s fatalist and scientifically pessimistic. There is always room for improvement. This may mean more options, better safety protocols, more transparency from the formula companies  And yeah, someday, it might mean making a formula that is even closer to breastmilk, at least in terms of certain specific aspects of human milk that we could potentially recreate in a lab. It’s not outside the realm of possibility.

Sometimes, I think that our desire to promote breastfeeding denies us the opportunity to do better for our population as a whole. As Gavigan rightly points out, many parents use formula. That will not change, at least not in our lifetimes. Throughout history, babies have been fed with drinks and foods other than breastmilk, much earlier than the currently advised 6-month mark. Providing the healthiest alternative possible should be a major goal. Dismissing formulas as “all the same” translates to “all junk” in the hyper-alert minds of loving parents. That’s not the message we should be sending, and more importantly, it’s not true.

Here is what it comes down to: No formula is “better” than another, nor is any parent “better” than another. We make choices; sometimes those choices are made for us, for financial or health reasons. The beauty of having options is that we feel we can exert some control over our babies’ health. The downside of having options is that we feel pressured to make choices that can exert control over our babies’ health.  And it gets even more complicated, because no one can agree on what is “healthy” half the time. Depending on whether you read Food Babe or Grounded Parents, your definition will vary.

But here’s what it also comes down to: We can’t confuse innovation, marketing and development within an industry with the politics of infant feeding at large. It’s the difference between arguing whether parabens should be in skin care products, and proclaiming that no one should be using anything but water and olive oil to clean their faces in the first place. It’s telling a car company that they shouldn’t be talking about their safety ratings, but rather encouraging people to walk.

It’s good to talk about these things. And no one should feel they have to sugarcoat or keep mum about issues that concern them. But if we could all just be realistic, be wary, and be kind, it would make for a much more palatable and productive discussion.

Honestly. It’s that easy.

A World Breastfeeding Week Plea: Stop celebrating, start collaborating

Usually, I’m all over the place this week. Getting quoted in the requisite “it may be breastfeeding week but gosh darnit some women still find exclusive breastfeeding super hard” articles. Posting my own stuff here on the blog, or over on HuffPo. Talking about #ISupportYou and pissing off hundreds of people in the process, because they see it as a veiled attempt to “steal the thunder” from World Breastfeeding Week.

But this year, I’m all but invisible.

Part of this was unintentional. I’ve been going through some stressful career-change mishigas, dealing with the inevitable gaps in childcare that occur between camp and school, entertaining a ridiculous number of visiting extended family members. I’ve been too exhausted to blog, or talk to media sources, or self-promote (because let’s be honest – that’s a part of what all of us parenting bloggers do. Even the most altruistic of us. Even those of us who don’t depend on hits or advertising or who never make a cent off their blogs. We write because we want to be heard; we pray for bigger audiences, book deals, evidence that we’ve made some sort of impact. I happen to be rather shitty at this, which is why I don’t blog much anymore. I don’t have the stomach for that part of the job).

Another part of my conspicuous silence has been intentional, however. Probably more than I care to admit. See, I’ve been focusing my efforts on the supportive stuff. Reaching across the aisle, trying to understand all facets of this debate, and hoping that by creating better resources for all moms, I can help stop all the guilt/anger/resentment/confusion/hurt. I know that breastfeeding is important to many, many women. I want those women to succeed, and feel happy and proud and supported. So this year, I wanted to try and stay out of World Breastfeeding Week drama like I try and stay out of my kids’ sibling squabbles.

Yeah. Because that works so well with my kids.

The problem is, I also want formula feeding mothers to feel happy and proud and supported. And for some reason, it’s not okay to want both of these things. It’s ok to pay lip service to it, to claim #ISupportYou and tell formula feeding moms that celebrating breastfeeding isn’t about them. But if you actually do the work you need to do to ensure that non-breastfeeding parents are supported, you are violating WHO Code. You are taking attention away from the women who “need it”. You are stealing…. what? Resources? Sympathy? One-up(wo)manship?

I tried to stay out of it. I really did. I held my newly-minted CLC certification close to my non-lactating chest and bit my tongue.

And then the articles came, and came, and came. And so many this year were not about the benefits of breastfeeding, but rather how hard it was. Or how hard it was NOT to breastfeed. How this mom felt like she was poisoning her baby, or this one felt like she’d be booted from the “mom club” because she didn’t wear the EBF badge.

So much guilt/anger/resentment/confusion/hurt. None of it is stopping. There’s more this year than ever before.

Then this happened.

https://www.yahoo.com/health/olivia-wildes-breastfeeding-photo-causes-a-stir-93893024387.html

https://www.yahoo.com/health/olivia-wildes-breastfeeding-photo-causes-a-stir-93893024387.html

And I heard my community inwardly wince. Not for the reasons you might think. Not because they didn’t think it was a beautiful image, and not because it glamorized something that had been messy and painful for most of them, although those certainly were thoughts that some of us had to squash down into that endless pit of mother-guilt. No, it was because it was yet another image of a breastfeeding celebrity, with headlines and stories that spoke of her bravery for normalizing nursing, and comments all over the place about how breastfeeding was finally being celebrated.

I think, for many of us, it was the “finally” that did it. For many of us, it would seem far braver for a celebrity to do a shoot with her bottle-feeding her kid with a can of formula in the background. We have only seen breastfeeding being celebrated. There’s so much partying going on, and we feel like the crotchety old neighbors calling the cops with a noise complaint. But you know, it’s late, the music is loud, and we’re tired.

Now, just to be clear – I’m talking about breastfeeding being “celebrated” That celebration doesn’t do us much good. It does not mean that it is easy for moms to nurse in public. Obviously, it isn’t. Or that lactation services are plentiful and accessible to all. Obviously, they aren’t. Breastfeeding is celebrated, but that doesn’t stop it from being difficult for the new mom in the hospital, whose birth didn’t go as planned. Or the one who has to go back to work 2 weeks postpartum. Or the one with a job not conducive to pumping. Breastfeeding is celebrated, but not when you’re overweight. Or when you’re nursing a toddler.

Idealized images in the media of what breastfeeding looks like do not normalize nursing. In fact, I’d argue it fetishizes it – not for men, so much, but for women. Now, we don’t just have to feel inadequate for not fitting into size 2 jeans a month after giving birth, but we need to feel inadequate if we don’t meet the feeding norm and make it look gorgeous and natural and easy.

Please do not misread what I’m saying here – talking about breastfeeding, supporting breastfeeding, and implementing changes to make breastfeeding easier for those who want to do it are important, admirable, and necessary goals, as far as I’m concerned. But the comments I saw coming from my community after this photo hit the news were not about any of these things. They were from women feeling totally drained, frustrated, and alienated after a nearly a week of hearing how inferior their feeding method was, who were sick of being told they were defensive or that they feel guilty if they tried to stand up for themselves. This story was the last straw. It’s weird, when you think about it – it wasn’t the piece on the risks of formula, or the memes about the superiority of breastfed babies – what broke the camel’s back was a seemingly innocuous spread of a gorgeous, confident actress proudly nursing her baby.

This is what perpetuates the cycle of guilt/anger/resentment/confusion/hurt: our lived experiences are so damn different, that it’s like we’re constantly talking at cross-purposes. The nursing mom who is the only one in her small town not using a bottle sees a photo spread like this as thrilling, victorious, self-affirming – as she should. The formula feeding mom living in Park Slope who carries her formula-filled diaper bag like a modern-day hairshirt sees the same spread as just another celebrity being held up as a pioneer, when she’s only doing what’s expected of a woman of her stature – as she should. Both are right. Because both are personal, emotionally-driven responses.

Earlier this week, I said that deciding how to feed your baby is just one of a myriad of important parenting decisions. But somehow, it’s become the most important one. We cannot expect formula feeding moms to support their breastfeeding sisters when they don’t receive the same support. We just can’t. It’s not fair, and it’s not realistic. I feel like that’s what I’ve been asking of all of you, and somehow I just woke up to that fact.

Why are there still articles talking about how shitty we feel for not breastfeeding, instead of articles talking about what’s being done to change this? Where is the news story about the doctors who are saying enough is enough (because I know they are out there – many of them contact me, and I appreciate these emails, but I wish they were able to say these things publicly without fear of career suicide)? Where’s the NPR program about ways we can improve breastmilk substitutes so those who cannot or choose not to nurse aren’t left hanging? Where’s the Today Show, The View, The Katie Show, doing segments on why women are REALLY not meeting breastfeeding recommendations, instead of segment after segment on how brave so-and-so is for posing nursing their newborn on Instagram, or talking to dumbasses on the street about the “appropriate” age for weaning?

When we stop “celebrating” and start normalizing and supporting and being realistic about how different life can be even just a street away, maybe World Breastfeeding Week can have it’s proper due. Maybe we can actually talk about ways to help women in the most dire straits feed their babies as safely as possible – clean water, free breast pumps, free refrigeration, access to donor milk.

I want to be able to be silent during World Breastfeeding Week. It shouldn’t have to be “overshadowed” by emotional, personal pieces about breastfeeding “failure”. It shouldn’t be a time for articles about not making formula feeding moms feel “guilty”. These words shouldn’t even be part of our infant feeding lexicon, for godsakes. Failure? Guilt? For what?

This year, I want us to stop celebrating, and start having some calm, productive conversations with people outside your social circle. For many of us, the celebration feels exactly like high school, when the popular kids had parties and we sat home watching Sixteen Candles for the thirty-fifth time. That’s not to say breastfeeding isn’t worth celebrating, but the end goal should not be one group feeling triumphant and the other feeling downtrodden. Formula feeding was celebrated for decades too – and that celebration made the current atmosphere of breastfeeding promotion necessary. Please, let’s learn from our mistakes. Let’s move on. Rip down the streamers, put away the keg, and open the doors to the outsiders looking in. You never know – they could end up being the best friends you’ve ever had.

 

Win-win or lose-lose: Study suggests breast may not “beat” bottle in multiple long-term outcomes

Every morning, I receive Google alerts for several terms: breastfeeding, formula feeding, infant formula, breastmilk, etc. And every morning, I brace myself, waiting for the inevitable headline that will cause panic among bottle feeding moms, or re-ignite the incessant argument between breastfeeding advocates and formula feeding parents (as if it ever needs reigniting – it’s like one of those trick birthday candles, always sparking back to life even after you’ve wasted all your breath), or force me to take some semblance of a “position” on an issue that is hardly ever black and white.

One might expect that this morning, I would’ve broken out in that annoying Lego Movie song. You know, ’cause everything is awesome!!!!!

Source: connectedprincipals.com

Source: connectedprincipals.com

News broke that a study out of Ohio State, which examined sibling pairs where one child was breastfed and the other formula fed, had found that there was no statistically significant advantage to breastfeeding for 11 outcomes. These outcomes included things like obesity, asthma, and various measures of childhood intelligence and behavior. As the study explains:

“Breastfeeding rates in the U.S. are socially patterned. Previous research has documented startling racial and socioeconomic disparities in infant feeding practices. However, much of the empirical evidence regarding the effects of breastfeeding on long-term child health and wellbeing does not adequately address the high degree of selection into breastfeeding. To address this important shortcoming, we employ sibling comparisons in conjunction with 25 years of panel data from the National Longitudinal Survey of Youth (NLSY) to approximate a natural experiment and more accurately estimate what a particular child’s outcome would be if he/she had been differently fed during infancy…

 

Results from between-family comparisons suggest that both breastfeeding status and duration are associated with beneficial long-term child outcomes. This trend was evident for 10 out of the 11 outcomes examined here. When we more fully account for unobserved heterogeneity between children who are breastfed and those who are not, we are forced to reconsider the notion that breastfeeding unequivocally results in improved childhood health and wellbeing. In fact, our findings provide preliminary evidence to the contrary. When comparing results from between- to within-family estimates, coefficients for 10 of the 11 outcomes are substantially attenuated toward zero and none reach statistical significance (p < 0.05). Moreover, the signs of some of the regression coefficients actually change direction suggesting that, for some outcomes, breastfed children may actually be worse off than children who were not breastfed.”

 

Source: Colen and Ramey, Is Breast Truly Best? Estimating the Effects of Breastfeeding on Long-term Child Health and Wellbeing in the United States Using Sibling ComparisonsSocial Science & Medicine, Available online 29 January 2014

I will admit that the comments made in several news outlets by the lead author of this study, Cynthia G. Colen, have made me want to run through the streets, acting as a one-woman ticker-tape parade in her honor. (Case in point: “I’m not saying breast-feeding is not beneficial, especially for boosting nutrition and immunity in newborns. But if we really want to improve maternal and child health in this country, let’s also focus on things that can really do that in the long term – like subsidized day care, better maternity leave policies and more employment opportunities for low-income mothers that pay a living wage, for example.”) But I’m not celebrating the results of this study, any more than I’d celebrate one that said formula feeding caused children to sprout green hair from their chiny-chin-chins and opt to live under bridges.

Why? Because this shouldn’t be a freaking contest.

The backlash that comes out of studies like these feels more like if someone came out with research that claimed fried Oreos were just as healthy as raw kale. Instead, we should be approaching it as if someone came up with a way to make a vitamin supplement that would offer similar benefits to kale, for those who hated the taste. One is natural, one is synthetic; one is manufactured, one exists organically. But for those of us who don’t or can’t eat raw kale on a daily basis, a good substitute is a godsend. (And maybe helps us justify those fried Oreos. A girl can dream.) Now, a study showing comparable effects of the supplement to the organic kale would not negate the fact that kale, grown in your own garden, is a nutritious, amazing thing – and tastes quite delicious to those of us who have a palate for it. If we started telling the kale aficionados that the supplement was better in some way, that would be a problem. But if the people who loved kale insisted that the supplement wasn’t a valid option and was somehow morally wrong, that would be a problem, too. Chances are, if we were really talking about kale, nobody would care all that much. The people who liked kale would eat it, and those who didn’t, might opt for the supplement – feeling confident due to the research that suggested the supplement was a viable option.

But we’re not talking about kale. We’re talking about breastmilk. And that, apparently, is where we all fall apart, and are rendered completely incapable of rational, measured discussion.

What the Golen/Ramsey study shows should not be controversial. The results should be reassuring- evidence that formula feeding does not condemn a child to a life of obesity, poor health, and lackluster intelligence; proof that whether a woman chooses, or is capable of, feeding a baby from her breast is not what defines her as a mother.

Imagine, for a minute, if we didn’t compare breast and bottle, but rather celebrated BOTH as valid, safe, healthy options for mothers and babies. Accepting that formula has legitimacy – that there is a reason it was invented (out of a need and a desire for a safe breastmilk substitute), and a reason why a woman may decide that a substitute is preferable – should not threaten those of us who celebrate breastfeeding. Yes, we should continue to rage against predatory formula marketing, especially in the developing world. Yes, we should speak up and speak out when companies (hello, Delta) retreat to 1953 when they express their breastfeeding policies. (For that matter, we shouldn’t need breastfeeding policies – if children are allowed, breastfeeding should be allowed. End of story.) Yes, we should ensure that women are entitled to adequate pumping breaks, and given solid breastfeeding assistance, and are supported by solid research regarding medications and breastmilk and best practices from pediatric professionals. But none of that means formula has to be Public Enemy No. 1. None of that means parents who formula feed should be left floundering due to an embarrassing lack of support and education. And for the love of god, none of that means we should be smugly celebrating when formula fed babies are shown to fare poorly, or gleefully rejoicing when and if the opposite occurs.

This is one study, with its own set of limitations and biases, like any other study in the modern canon of infant feeding research. But it’s a good study, artfully designed, and one that raises some extremely important questions about how the emphasis on feeding babies might be distracting us from the real work of supporting better maternal and childhood outcomes. Because speaking of retreating to 1953, it’s awfully easy to shove the responsibility for future generations onto women’s chests, rather than addressing true social inequities that can impact children’s lives. Maybe if we stopped wasting energy trying to prove how evil formula is, and just accepted it as part of life – not a slap in the face to our mammary glands, or an excuse for idiots to treat nursing mothers as horribly as they do now – we would have more energy to understand and destroy these inequities.

Or, you know, we could do what we always do and spend time looking for vague connections to the formula industry to discredit the study authors. Because that’s a really great way of helping families thrive.

 

 

 

Newborn jaundice: To supplement or not to supplement, that is the question…

Most of us come into the world red, wrinkly, and hairless. From a purely aesthetic point of view, it’s not a great look – and yet parents usually think their offspring are gorgeous. I don’t know about you, but I sometimes look at newborn photos of my kids and think they had more than a slight resemblance to Benjamin Button (not the hot Brad Pitt version, but the weird old-man baby in the beginning). And I clearly remember thinking both of them were the cutest newborns ever born.
This baby grows up to be Brad Pitt, so it’s all good.
At my daughter’s recent 15-month Well Baby visit, I was utterly shocked to find out that she’d dropped from the 25th to the 10th percentile for weight. I’d actually been joking about how adorably chubby she’d been getting… but as soon as I saw the number on the scale, it was like my eyes refocused; I suddenly thought she looked so scrawny.

When it comes to judging how our kids are doing purely by looking at them, I don’t think parents are really hardwired to be objective.

I’ve been thinking about this the past few days as I’ve researched the topic of neonatal jaundice. Jaundice is a relatively common problem in babies, and therefore is a frequent discussion point in the online parenting world. The other day, I read an online discussion where someone spoke of a baby who sounded pretty darn dehydrated and jaundiced. The advice given was mainly to handle the problem at home or through consulting peer breastfeeding counselors; there were warning about unnecessary interventions which would harm the new breastfeeding relationship. The fear of formula supplementation was palpable. I’m a strong believer in mommy gut and standing up for your parenting philosophies, so on many levels, I understand where these women were coming from.  There are a fair number of overloaded, poorly read-up, and even downright crappy medical professionals out there, and it’s likely that many women are pushed into supplementation when there are other methods which would ultimately achieve the same result. 

However, taking matters into your own hands, or downplaying the seriousness of jaundice, is not the answer. I don’t think a newly postpartum, first-time mom who is already struggling with a poorly-feeding, jaundiced baby is in a position to ascertain her child’s medical status, merely based on appearances. (I don’t recall thinking my son was particularly yellow; in fact, my daughter, who wasn’t jaundiced, looked far more mustard-hued than her brother ever did.) Nor is it fair or noble of us to expect that of her, considering the misinformation and bias running rampant in parenting media. 

Jaundice is a problem which pops up in a number of FFF Friday stories, so I decided it was relevant and necessary to discuss it on this blog, even though it is primarily a breastfeeding mom-related problem (mostly because formula feeding is one of the most common, and most controversial., therapies used to treat it; if you’re already bottle feeding, chances are you’re not freaking out about supplementation). But I know there are some pregnant women and prospective moms who frequent the blog, and you never know who’s going to stumble upon this post in the middle of a frantic newborn night… so this one’s for you. Oh yeah – I figure it’s pretty obvious, but just in case – please note that I am in no way, shape, or form a medical professional (although my dad’s a doctor, so if medical knowledge is passed down genetically I may have an edge up in that respect). The following piece is merely what I’ve gleaned from about 4 days of research and reading, mixed with a little personal knowledge and a hefty dose of opinion – so do with it what you will.

There’s a wide range of opinions on how best to treat jaundice, and much of the debate centers on how affected babies should be fed. But we’ll get to that in a moment – first, let’s define what we’re talking about.

Um, what is frock is “jaundice”?

Newborn jaundice typically comes in one or some combination of three forms – breastfeeding jaundice, breast milk jaundice, and Type ABO jaundice. In the most general sense, newborn jaundice occurs when your infant has high levels of bilirubin (the substance which is created during the process of blood cell “turnover”) in the blood. The body usually gets rid of the excess bilirubin, but in newborns, this function doesn’t always operate smoothly. That’s because the placenta handles the job while in utero, and once your baby is of the “outside” varietal,  his body might not have completely figured out how to handle this process.  Hence, the mildly yellowish hue so fashionable in the under 48-hours-old set.  Newborn jaundice (also called physiological jaundice) usually resolves in a few days, but sometimes it can be exacerbated by other problems.

One of these problems is a blood type incompatibility between mother and infant, called Type ABO jaundice. My son suffered from this type of jaundice; I am blood Type O, and he’s Type A. When our different types of blood merged during the birth process, my body basically created antibodies against his blood type, which caused a break down of his red blood that made extra bilirubin build up in system. He grew jaundiced. It sucked and I cried… but I digress.

Jaundice also occurs in a different form called “breast milk jaundice“, which MedLine Plus defines as “long-term jaundice in an otherwise healthy, breast-fed baby. It develops after the first week of life and continues up to the sixth week of life… It is probably caused by factors in the breast milk that block certain proteins in the liver that break down bilirubin.” This type of jaundice is typically harmless, and shouldn’t be confused with breastfeeding jaundice, which is caused by insufficient feeding, usually due to poor latching or supply issues, or as some sites somberly state, due to spacing out feedings too far apart or not co-sleeping. The body needs to flush out bilirubin, and it can’t do so if there is inadequate waste output. If a baby isn’t properly hydrated or fed, she can’t poop or pee. So in the case of bilirubin, the saying is actually want not, waste more.

I don’t recall being told much about jaundice in my prenatal classes; it certainly was not discussed in its relation to breastfeeding. This is odd, considering physicians have noted an increase in jaundice since the early 90’s, and severe jaundice is also suspected to be on the rise.


How do I help my baby stop looking like an Oompa Loompa?

Jaundice is treated one of three ways: formula supplementation, phototherapy (having the baby hang out underneath a special kind of light or biliblanket) and exchange transfusions (usually reserved for the most severe cases). The old-school approach to handling newborn jaundice was to supplement with formula; this is one of the quickest and easiest ways to help rid the body of excess bilirubin. You can also use donor milk (just not sugar water or other rehydration substances, which were historically also used as a means of hydration and jaundice therapy), and administer it through a supplemental nursing system (SNS), so “supplementation” doesn’t have to mean formula or bottles. But the new protocol for newborn jaundice is to take more of a wait-and-see approach; the AAP’s position is that breastfeeding should not be interrupted unless absolutely necessary, and that phototherapy be used as a curative measure:


In breastfed infants who require phototherapy, the AAP recommends that, if possible, breastfeeding should be continued (evidence quality C: benefits exceed harms). It is also an option to interrupt temporarily breastfeeding and substitute formula. This can reduce bilirubin levels and/or enhance the efficacy of phototherapy (evidence quality B: benefits exceed harms). In breastfed infants receiving phototherapy, supplementation with expressed breast milk or formula is appropriate if the infant’s intake seems inadequate, weight loss is excessive, or the infant seems dehydrated.
Many internet parenting and breastfeeding sites reassure parents that formula supplementation is hardly ever necessary, and this is probably true in a literal sense; most cases of jaundice will resolve with little intervention, and for those that don’t, there are other treatment options besides formula. But it’s important to know that these other treatments also carry risks, as this review article published on Medscape explains:


Phototherapy is not without disadvantages.. Under fluorescent tubes infants must wear eye protection and are usually separated from the mother in the nursery. Phototherapy may take days to exert the desired effect and, once the phototherapy lights are stopped, rebound hyperbilirubinemia may occur as bilirubin moves from the tissue into the blood. Risk of photooxidative damage to lipoprotein and red blood cell membranes is possible and data suggest that conventional phototherapy (with fluorescent tubes) may decrease postprandial mesenteric blood flow response that may adversely impact the neonatal GI tract.

The same paper also suggests that phototherapy “may not be as successful in decreasing serum bilirubin levels in breastfed infants due to increased enterohepatic circulation; supplementing with formula in addition to phototherapy may be more efficacious in these infants.” This is kind of scary, because is phototherapy doesn’t work… well, that leads me to the next question.


Why do I have to care about jaundice? Maybe I like the color yellow.



The problem with jaundice is that it isn’t a serious problem until it is. Explains the AAP:

Most jaundice is benign, but because of the potential toxicity of bilirubin, newborn infants must be monitored to identify those who might develop severe hyperbilirubinemia and, in rare cases, acute bilirubin encephalopathy or kernicterus. The focus… is to reduce the incidence of severe hyperbilirubinemia and bilirubin encephalopathy while minimizing the risks of unintended harm such as maternal anxiety, decreased breastfeeding, and unnecessary costs or treatment…

Pretty much the only presenting sign of jaundice is a slight yellowing of the skin and eyes. The other symptoms appear when bilirubin levels get dangerously high, putting your baby at risk for brain damage and other serious medical problems. WebMD tell us that the symptoms of jaundice-which-has- gone-too-far (the medical terms for this are “kerincterus” or “acute bilirubin encephalopathy”) include fever, sluggishness, poor feeding, irritability, shrill crying, and arching of the back. Which, except the fever, sounds like how almost every FFF Friday contributor has described her newborn when feeding problems were present. It might be hard to differentiate actual medical risk from normal newborn craziness or other feeding-related issues, and this complicates matters further.


According to the AAP“immediate exchange transfusion is recommended in any infant who is jaundiced and manifests the signs of the intermediate to advanced stages of acute bilirubin encephalopathy (hypertonia, arching, retrocollis, opisthotonos, fever, high-pitched cry) even if the TSB is falling.” TSB is total serum bilirubin, used to determine the severity of jaundice; this means that even if the levels are falling, if your baby is exhibiting these symptoms, doctors may recommend an exchange transfusion. Exchange transfusion is basically a blood transfusion; it can be lifesaving when jaundice becomes dangerous, but it also carries the risk of anemia, air embolism…and even death. These are rare side effects, and even getting to the point that you need an exchange transfusion is relatively rare. But on the other hand, a 2009 study out of the Netherlands found that “all healthy newborns are at potential risk of kernicterus if their newborn jaundice is unmonitored and/or managed inappropriately…we have estimated that 1 in 700 well newborns can develop extreme hyperbilirubinemia; these infants can be at major risk for kernicterus if there are no failsafe, system-based protocols.”

Okay, okay. Say I don’t want an oompaloompa baby. What’s my best plan of action?

First of all, know your risks. The AAP states that “infants at less than 38 weeks’ gestation, particularly those who are breastfed, are at higher risk of developing hyperbilirubinemia and require closer surveillance and monitoring.” This risk increases significantly if you are having feeding problems. A 2009 study published in BMC Pediatrics found that “significant weight loss increase(s) approximately 4 times the risk to develop severe non-hemolytic hyperbilirubinemia in breastfed term infants and it seems to be worst when the cut point to define significant weight loss is higher (infants with a weight loss of 10% have odds 4.2 times higher). Both hyperbilirubinemia and feeding problems persist worldwide despite well-intentioned guidelines for care…” And, if you’re blood type O, you also are at higher risk for Type ABO jaundice. 

Now, here’s the controversial bit: while it’s true that the major medical organizations are no longer recommending formula supplementation as the first line of treatment, you also have a right to know that providing formula or donated milk does improve jaundice.  If your baby is feeding well, it’s probably not necessary to supplement; the phototherapy will most likely do the trick. But if things are not going well with breastfeeding, supplementing – in some way, shape or form – can help.  

I fully comprehend why breastfeeding experts frown on supplementation. Interrupting the breastfeeding relationship in its literal infancy is not a great idea. Let’s look at this another way for a minute, though:

1. If the jaundice is caused or exacerbated by feeding issues, the breastfeeding relationship is already in jeopardy. A hungry, dehydrated, frustrated baby is often not a patient or energetic baby; how would you feel if you had fasted for 2-3 days? (Impressionable Fearless Husband has talked me into juice fasts a few times and I was certainly no fun to be around, nor did I have the “focused energy” all those diet plans promised…) I have yet to meet a woman whose baby wasn’t latching or whose milk didn’t come in, and had the situation spontaneously turn around without first ensuring that the baby was fed. I have, on the other hand, met several women who did supplement, and with some work and a good lactation consultant, got the baby to latch, improved their milk supply, and went on to exclusively breastfeed.

2. Having your baby end up in the hospital under the phototherapy lights, being monitored for a significant amount of time, is counterproductive to a struggling breastfeeding relationship, too. Phototherapy (as well as jaundice) can make a baby too tired to suck efficiently, and having a newly postpartum, stressed out mom is never a good thing, either.  Phototherapy and hospitalization is a necessary evil for many of us, but if the medical authorities admit that supplementation (especially with a hypoallergenic formula, interestingly) will hasten the process, we have a right to know this. Some may still choose to stay away from formula, and I get that – as a vegetarian, I personally would do whatever I could to avoid giving my child a steak. (Although to be honest, if his life depended on it, I would be shoving veal cutlets down his throat. I love baby cows, but I love my son more.) But for those of us who don’t see a little formula as the be-all, end-all to child health, it is important to have this knowledge.

3. I have to wonder if the current recommendations regarding jaundice and supplementation have more to do with the demonization of formula  than actual evidence. As a purely medical issue, we have a cure with no real, quantifiable risks – even if you believe that the risks of formula are 100% proven without a doubt, a small amount of the stuff administered as a one-shot deal hasn’t been proven to cause physiological harm (except for that whole virgin gut theory, about which I’ve yet to see any quality evidence). The breastfeeding relationship has been shown in studies to be affected by early bottle feeding, but this research is also somewhat questionable – the concept of nipple confusion has been questioned by breastfeeding guru Marianne Neifert herself. 

4. There is so much conflicting advice regarding jaundice, and I worry that parents are seeing jaundice prevention/treatment and breastfeeding protection/promotion as competing entities. This is not true, and it is detrimental to all parties involved to think this way. A passage from a physician-penned article about the clinical presentation of jaundice explains the relationship between the two rationally and clearly:

Identifying the infants who become dehydrated secondary to inadequate breastfeeding is also important. These babies need to be identified early and given breastfeeding support and formula supplementation as necessary. Depending on serum bilirubin concentration, neonates with hyperbilirubinemia may become sleepy and feed poorly… The most rapid way to reduce the bilirubin level is to interrupt breastfeeding for 24 hours, feed with formula, and use phototherapy; however, in most infants, interrupting breastfeeding is not necessary or advisable… Detailed history and physical examination showing that the infant is thriving and that lactation is well established are key elements to diagnosis. Breastfed babies should have 3-4 transitional stools and 6-7 wet diapers per day and should have regained birth weight by the end of the second week of life or demonstrate a weight gain of 1 oz/d.




In summary, newborn jaundice is not a serious problem for most babies, which is why all those breastfeeding sites tell you that supplementing isn’t necessary. Some even suggest that breastmilk jaundice is biologically normal, and we just don’t realize it because no one has been breastfeeding much for the past 50 years. But jaundice can become serious, and you might not be able to distinguish serious jaundice from feeding issues or fussy-newborn-ness, so please don’t shy away from medical observation because you’re scared they might make you supplement. Your best bet is to find a breastfeeding-friendly pediatrician prior to giving birth; this way, you’ll know you can trust that the two of you have the same goals in mind. Lactation consultants are not experts in jaundice (unless of course your LC is a really well-trained, thoroughly-researched RN or an MD, which luckily some are), so it’s probably not safe to rely on them or your postpartum doula to judge whether your baby needs medical intervention. 

Chances are no one will force you to supplement, but since you may have the ball thrown into your court,  make sure you are able to weigh your options without misinformation or subtle pressure in any direction. Opting against supplementation is probably not going to lead to terrible medical consequences, unless you’re in a very specific, very serious situation.  On the other hand, a few bottles of formula given in the span of a day or two is not going to put the kibosh on your breastfeeding relationship, and it may get rid of the jaundice faster and with less extreme interventions – which will allow you to get back to forging not only a breastfeeding relationship with your newborn, but a relationship, plain and simple.



Sources

http://www.nlm.nih.gov/medlineplus/ency/article/000995.htm

http://pediatrics.aappublications.org/content/114/1/297.full: 

http://emedicine.medscape.com/article/973629-overview#a0199

http://archpedi.ama-assn.org/cgi/content/abstract/153/2/184 –

http://www.bestforbabes.org/fast-facts-how-to-deal-with-common-breastfeeding-issues

http://www.nejm.org/doi/full/10.1056/NEJMct0708376

http://www.medscape.com/viewarticle/497028_6

http://www.indianpediatrics.net/jan2007/jan-32-36.htm

http://www.biomedcentral.com/1471-2431/9/82

http://www.nature.com/jp/journal/v20/n7/abs/720041

http://onlinelibrary.wiley.com/doi/10.1111/j.1651-2227.2009.01230.x/abstract;jsessionid=B04E9CEFBDE7EFE1F2EEA02364908DDE.d01t01?systemMessage=Wiley+Online+Library+will+be+disrupted+24+March+from+10-14+GMT+%2806-10+EDT%29+for+essential+maintenance

http://www.clinchem.org/content/50/3/477.long

Dirty Milk

FFF Sarah, who is currently trying to induce lactation for her upcoming adoption, emailed me this afternoon with an interesting question:

So, I’m pumping all of this crap into my body in an attempt to see if I’m able to lactate.

Today, I was telling my husband why I buy x-type of dairy milk (b/c it doesn’t have rBGH)…I read him this tidbit from the dairy’s page:

rBGH is “recombinant bovine growth hormone” and also known as recombinant bovine somatotropin (rBST). Developed by Monsanto Corporation, rBGH is an artificial hormone that causes cows to artificially increase milk production.

We love our cows and believe that pure, natural milk tastes best and is healthiest for you. Here at Brown’s, our cows are not treated with artificial growth hormones like rBGH.

He said…”um…isn’t that what you’re doing? Taking stuff to artificially increase milk production? How is that good for a kid then?” I said I thought the ingredients were better, but honestly…I don’t know. Is it better? Do we know the danger of Reglan or Domperidone or Fenugreek or Blessed Thistle or any of the other crap we take in order to make milk or more milk for our babies?

Honestly, I had no idea how to answer this; however, I thought it was one of the most interesting questions I’d ever been asked. Even the mere concept of rBGH-free milk is worth talking about, and I can’t believe I’ve never thought about it before. Of course, we’ve discussed the fact that breastmilk can be a veritable smorgasboard of chemicals; in fact, scientists use this particular bodily substance for bio-monitoring (a way of measuring how many toxins are being stored in the human body). Typically, this concern is squashed by folks telling us not to worry, breastmilk is so amazing that it counteracts or cancels out all the bad stuff, or yelling at us not to peek at the man behind the curtain, like the titular dude in Wizard of Oz. (Read this article from Mothering.com to gain a frustrating, bang-your-head-against-the-wall understanding of why some breastfeeding advocates are fighting the trend of using breastmilk in bio-monitoring.)

So, isn’t it kind of funny that everyone is so concerned with the mercury in fish; the hormones in beef and milk… and not the food our own bodies produce?

There is ample proof that what we eat, breathe and absorb goes through our breastmilk. In fact, the NRDC has an entire website dedicated to the chemicals present in breastmilk, and they admit that “infant formula contains far lower quantities of dioxins, PCBs and organochlorine pesticides than breastmilk”. Of course, they go on to assure mothers that “formula has serious drawbacks that tip the scale against it”, and then list all the “risks” we have discussed on this blog, time and time again. The chemical contamination dangers they cite pertaining to formula are “contamination with substances such as broken glass, fragments of metal and salmonella and other bacteria. The fungal toxin aflatoxin has also been detected in some commercial formulas. Although detected levels were very low, this toxin is known to cause cancer and is not present in breast milk. Infant formulas also may contain excessive levels of metals, including aluminum, manganese, cadmium and lead.” However, many of these contaminants are avoidable if we could improve manufacturing processes; the first few listed, when discovered, led to recalls.

The important message here should not be choose formula over breastmilk, or vice versa. It should be, let’s all become more aware of the chemicals our babies are exposed to. Formula is a product; if we want to discuss the chemical contaminants in formula, we can address manufacturing processes, corporate responsibility, quality assurances, ingredient sources, etc. If we want to discuss the chemical contaminants in breastmilk… well, chances are we won’t be discussing that, because its tantamount to yelling fire in a crowded movie theater. Us girls are, like, panicky and hysterical, dontcha know?

Back to the original question which spawned this post, though. It’s one thing to worry about chemicals we have no real control over; quite another to discuss intentionally ingesting something potentially harmful to increase milk supply or induce lactation in the name of Liquid Gold. But could Reglan, Domperidone, Fenugreek, or Blessed Thistle really be harmful? Doctors prescribe them for nursing women all the time, and these folks would never prescribe something that they don’t know 100% for certain won’t harm a baby, right?

(Pause for diabolical laughter…)

Fenugreek and Blessed Thistle are probably the least concerning of these substances, as they are herbal remedies. However, while NIH’s Medline Plus cites “increasing breastmilk quantities” as one of Blessed Thistle’s uses, they also warn, “Don’t take blessed thistle by mouth if you are pregnant. There is some evidence that it might not be safe during pregnancy. It’s also best to avoid blessed thistle if you are breast-feeding. Not enough is known about the safety of this product” and list “irritat(ion of) the stomach and intestines” as a possible side effect. As for Fenugreek, Kellymom warns that while “(m)ost of the time, baby is unaffected by mom’s use of fenugreek (except that more milk is usually available)”, sometimes “baby will smell like maple syrup…some moms have noticed that baby is fussy and/or has green, watery stools when mom is taking fenugreek and the symptoms go away when mom discontinues the fenugreek. Fenugreek can cause GI symptoms in mom (upset stomach, diarrhea), so it’s possible for it to cause GI symptoms in baby too.” A search on WebMD’s database found that “(s)ome reports have linked fenugreek tea to loss of consciousness in children”.

(I feel I should interject here to remind everybody that just like everything else we discuss on here, we should look at these warnings in terms of relative risk. If you read the possible side effects on a bottle of Children’s Advil, it’s a hell of a lot scarier. I’m merely trying to illustrate a point, so bear with me, please, and don’t panic if you’ve been binge-drinking Fenugreek tea.)

Reglan and Domperidone carry more severe warnings. Reglan is one of those drugs that repeatedly come up on litigator’s websites (never a comforting sign), and it has been suggested that it can cause a condition called Tardive Dyskinesia. As one of the litigators explains, “Before Reglan was released, the FDA only approved its use for 12 weeks at a time, which means that women who are breastfeeding are at an even higher risk for developing TD because of the timeframe spent breastfeeding.” (Ironically, I found a really great opinion piece about the relative risks of Reglan on another of these lawyer sites. Go figure.) Perhaps a more real-world concern – and definitely one that worries me a great deal, what with PPD being such a real threat to new moms – Reglan is also linked with depression.

Domperidone, a drug typically used for cancer patients or those with gastrointestinal issues, does seem to be a safer bet, although on a UK site detailing the prescription use of Domperidone, it clearly states that “this medicine passes into breast milk in very small amounts that are not expected to be harmful to a nursing infant. However, the medicine is not recommended for use in women who are breastfeeding unless the potential benefit to the mother outweighs any risks to the nursing infant. Seek medical advice from your doctor.” If that doctor happens to be breastfeeding guru Jack Newman, you’ll be reassured that it is indeed safe (“Worldwide experience with domperidone over at least two decades suggests that long-term side effects also are rare. Some of the mothers in our clinic, breastfeeding adopted babies, have been on the medication for 18 months without any apparent side effects…patients using domperidone for stomach disorders may be on it for many years. I hope you won’t need domperidone for very long, but if it’s necessary and helpful, stay on it,” he breezily suggests, adding links to back him up (nearly all of which are dead links, btw, save for one study which simply proves that Domperidone increases milk supply. Sort of a moot point, don’t you think?)

If a mom needed to take either of these drugs for a medical condition, I would think the benefits absolutely outweigh the risks. Aside from the depression risk, neither seems to be that scary, especially when you consider Reglan was discussed as a potential therapy when my infant daughter was suspected to have delayed gastric emptying (so one would hope it isn’t all that toxic to babies).

But we’re talking about selectively consuming these drugs in order to do something which is often marketed to women as the “natural” choice, the “biological norm”. If a woman wants to breastfeed, I would totally understand her desire to try these drugs, and more power to her. If a woman feels like she has to breastfeed, and has to take these medications in order to fulfill her biological and maternal responsibilities, that’s another story. And regardless, let’s stop the hypocrisy and ignorance so prevalent in the way we view and discuss breastmilk. If it is full of chemicals, the answer is obviously not to discourage breastfeeding, but shouldn’t it also be obvious that we can’t ignore the problem? Likewise, if someone has to take medication in order to breastfeed, we need to support her in her goals in whatever way we can, but we also need to ensure that she has adequate research on her side that proves she is not putting herself or her baby at risk.

Breastmilk, left to its own devices, is one of the most amazing and purest foods in the universe. Unfortunately, we live in a time when pretty much nothing has been left to its own devices. Nobody is saying that breastfeeding isn’t worth it, but in the world we currently inhabit, I don’t think we should view breastmilk as unadulterated, absolute perfection. It can be corrupted, like any biological substance.

So, FFF Sarah’s husband… I’m not sure what the answer to your question is, exactly. But I can tell you that while writing this, this image kept running through my head of one of those “Not treated with rBST!” messages stamped on a nursing bra. Thanks for that, buddy.

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