“Mothers deserve better”: An interview with Dr. Christie Del Castillo-Hegyi

Dr. Christie Del Castillo-Hegyi, MD, is a mother – and a physician- on a mission. Since she began her blog and Facebook page a few months ago, she’s become a hero to over 10,000 parents who have experienced insufficient milk or delayed lactogenesis II (the process of breastmilk “coming in” after birth). She has been tirelessly advocating for better safeguards for breastfeeding mothers, and fighting against the dogma that insists that supplementation is detrimental to a baby’s health. 

I’m honored to bring you this interview with Dr. Del Castillo-Hegyi. Her opinions are controversial, and I really admire her bravery, and how she’s turned a negative personal experience into a plea for change. Before we make blanket recommendations that force women to weigh their gut instinct against the fear of recriminations from medical professionals and hospital staff, it’s essential that we look at ALL the research- without bias, without blinders, without fear. 

- The FFF

“Mothers Deserve Better”:

An Interview with Christie Del Castillo-Hegyi, MD.

FFF: Your blog and Facebook page are called “Insufficient Breastfeeding Dangers”. What are the dangers of insufficient feeding in a newborn, exactly?

CDCH: The known potential effects of insufficient feeding are dehydration, low glucose, elevated bilirubin (jaundice) and high sodium.  All in all, those laboratory markers make up the syndrome of starvation.  Dehydration, if extreme enough, can cause decreased circulating blood volume, low blood pressure, and decreased circulation to the brain.  This can cause brain injury and even death.  In animal studies, thirty minutes of loss of circulation to the brain can cause widespread brain cell death.

 

Extreme dehydration results in hypernatremia, or high sodium, because as a baby loses water, the sodium will become concentrated.  Their brains can experience contraction similar to dehydrated fruit, which upon re-expansion through rehydration, can result in brain swelling and irreversible brain injury.  It has been documented in the literature that hypernatremic dehydration can result in brain swelling, brain hemorrhage, seizures and even death.

 

It is not clear how long a child can tolerate exclusive colostrum-feeding before they develop hypoglycemia.  I have had one mother whose child seemed dissatisfied from exclusive colostrum-feeding for only one day and was found hypoglycemic by the second day.  It is difficult to know what the typical time to developing hypoglycemia of an average exclusively breastfeeding child because glucose is not routinely checked in babies without a diabetic mother or other traditional risk factors.  Hypoglycemia eventually happens to all babies if they do not receive enough milk through breastfeeding either due to poor supply or poor latch.  EVERY article in the known medical literature that has studied newborn hypoglycemia shows evidence of harm in the form of abnormal MRI findings and decreased long-term cognitive outcomes.  A low glucose is typically cited as a glucose level of less than 45, even though some newborns may exhibit few signs of distress even at this level.  Signs of a hypoglycemic newborn is agitation, frantic feeding, inconsolable crying or lethargy.

 

Lastly, insufficient feeding can result in a third dangerous condition, called hyperbilirubinemia or jaundice.  A bilirubin of greater than 15 is considered abnormal in the literature and has been associated in multiple studies around the world with a higher risk of autism relative to newborns who don’t experience high bilirubin levels.  One study refuted these findings and it came from the Kaiser system, which is a Baby-Friendly hospital, where exclusive breastfeeding from birth is encouraged.  They produced a study that was well-done but was thousands-fold smaller in size that the largest study, which showed a positive correlation, in Denmark, where they studied the ENTIRE newborn population over 10 years, which included over 700,000 newborns.  The Denmark study found a 67% higher risk of autism in jaundiced newborns.

 

That being said, I don’t want to worry every mom whose child had jaundice.  Not every jaundiced newborn has a level above 15.  Also, not every child who develops a level above 15 will develop autism.  Autism is still a genetic disease.  I believe babies who are born with a lot of autism genetics, as predicted by having lots of scientists, mathematicians and engineers in their families, who experience a physiologic insult, such as lack of oxygen to the brain and jaundice (both demonstrated in the literature to be associated with autism) may go on to have the disabling condition of autistic spectrum disorder.

FFF: What sparked your interest in this issue?

CDCH: My newborn son developed hypernatremic jaundice and dehydration because I was assured by the breastfeeding manuals that there is always enough milk in the breast as long as I keep breastfeeding.  I was told that, “he would be hungry” and that my “latch was perfect” by our lactation consultant the day we left the hospital.  No one ever told me it was possible for a child to become dehydrated and unconscious because there was not enough milk present.  We were told to count the diapers but how wet is a wet diaper?

 

My son lost 15% by the third day, the day after discharge and my pediatrician must not have calculated the percent lost because he gave us the option of continuing to breastfeed and to wait for the 4th or 5th day.  I realized when I was watching my son get an IV that what I did must be common and that other mothers must be experiencing this horror too.  I thought, “What must my son’s brain injury look like and why hadn’t I heard of this before?”  Three-and-a-half years later, I found out what his brain injury looked like.

 

What I saw with my own physician- and mother-eyes was the slow torture of a newborn child.  Babies who are asked to endure hours of frantic feeding without compensation of milk, otherwise known as “cluster feeding,” are experiencing agony.  No textbook, lactation consultant or physician will ever convince me otherwise.  To this day, the description of what I saw is embedded in every breastfeeding manual as normal and vital for the stimulation of milk production.  We are systematically telling new mothers to ignore their child’s hunger cues by telling them there is ALWAYS enough colostrum and by scaring them into withholding formula even when a newborn needs it.  THAT is why newborn dehydration will never go away with simply increasing breastfeeding support and follow-up appointments.  Unless a mother is given the knowledge about the potential harms of insufficient feeding and the right to feed her own baby, newborns will continue to experience these complications and be hospitalized for it every day.

FFF: When you began researching the topic, was there anything that surprised or shocked you?quotescover-JPG-66

CDCH: I began researching the topic shortly after receiving our son’s formal diagnosis of autism, which was February, 2014.  I first studied jaundice and autism and was surprised that there were so many studies that linked the two conditions, because I had never heard of the risk factor listed in the patient literature on autism.  I wondered why a modifiable risk factor would not be heavily attacked in the face of an epidemic.  I believe it is because it is linked to breastfeeding.

Breastfeeding has enjoyed an untouchable status in the medical community.  So much so that no part of it as outlined by the lactation community has been challenged by the physician community.  We assumed because it is associated with breastfeeding, what ever the guidelines are must be safe, despite evidence that many newborns on a daily basis get admitted for dehydration and jaundice from exclusive breastfeeding.  Unfortunately, any challenge is quickly met with an accusation that the individual is “anti-breastfeeding” or “pro-formula,” when in fact, perhaps it may simply be a challenge like mine, whose purpose is to keep the newborn safe from harm.  I am surprised by the lack of activism by the medical community to reduce or stop the incidence of a horrible, life-threatening and brain-threatening condition that can be prevented with informing mothers of these complications and a few bottles of formula to keep a child out of the hospital.

quotescover-JPG-42I was surprised to find out that we really haven’t exclusively breastfed from birth for millennia before the creation of formula.  If that were so, indigenous cultures that have no access to formula currently would be doing so nearly 100% of the time.  In fact, there is no evidence that we have widely exclusively breastfed from a single mother at all.  According to a review of the history of breastfeeding written by an IBCLC, lactation failure was first described in Egypt in 1550 B.C.  Wet nurses were often employed to feed newborns whose mother could not lactate.  There are modern day cultures where babies are breastfed by a community of mothers, not just one mother.  Also, the breastfeeding literature is rife with articles showing how problematically low exclusive breastfeeding from birth is all around the world because most cultures give what they call, “pre-lacteal feeds.”  These moms probably just call it “feeding.”  Moms all over the world recognize that their children may need more than what is coming out of the breast and they have populated their countries on the tenets of feeding their children what they need every day.  It wasn’t until the breastfeeding resurgence in the 1980’s and the codification of exclusive breastfeeding from birth through the Baby-Friendly Hospital Initiative of the World Health Organization written in 1992, that we started feeding newborns colostrum-only during the first days of life in the hospital.  This was written primarily to counteract the dangerous feeding of formula prepared with contaminated water to babies in the developing world, which was an important public health endeavor.  However, the guidelines to exclusively breastfeed for 6 months largely ignored the common possibility of insufficient milk production experienced by many mothers.  So feeding newborns without supplementation only began in the 1990’s.

Nurses who worked in the newborn nursery in the 1980’s account that newborns were supplemented from the first day of life with 2 ounces of formula.  Most newborns tolerated these feeds and did not vomit it as widely claimed by the lactation community.  I found that the newborn stomach at birth is not 5 cc, as claimed by the lactation community.  It is in fact roughly 20 cc’s or 2/3rds an ounce, as summarized by a review of 6 different articles looking at actual newborns.  This is also the static volume of a newborn stomach and may not account for peristalsis, which may allow a newborn to accommodate more.  I discovered that it is quite implausible that the stomach can grow 10 times its size in 2 days and that a one-day-old newborns can in fact drink 2 ounces in one meal without vomiting at all.

Many moms asked me, “How much weight CAN they lose?” and “What DOES my newborn need?”  I looked again to the literature looking for evidence showing the safety of weight loss in newborns and NOT A SINGLE ARTICLE showing that 10% weight loss over 10 days is safe in every newborn, which is the current standard of care.  This teaching has been accepted for decades now.  To answer the second question, I sought out what a one-day-old’s daily caloric requirement was and what the caloric content of colostrum is.  I found that a one-day-old’s caloric requirement is the same as that of a three-day-old’s, because they have the same organs and same activity all three days.  A one-day-old newborn needs 110 kcal/kg/day and colostrum has 60 kcal/100 mL.  I must have done this calculation by hand 20 times because I found that this resulted in a one-day-old needing 2.8 ounces of colostrum per pound per day .  A 7 lb child would need 19.6 oz of milk in one day.  I confirmed this finding because I gave my 5.5 lb twin girls free access to supplementation and they each took 2 oz every 3 hours on their first day, a total of 16 oz.  They only gained 1 oz! That leaves 15 oz going completely toward their metabolic activity.  For them, they required 2.7 oz/lb/day.

How much actual science and observation of actual babies and safety data was done to come up with the breastfeeding guidelines?  There are many articles that show that unlimited supplementation can reduce breastfeeding duration, which is why formula is withheld from babies, but none that showed this practice was safe for the baby’s brain in the long run.  We have no idea what threshold of weight loss is in fact safe for a baby’s brain, because it has not been studied.  While babies’ bodies can endure days of underfeeding, their brains cannot.  That is what I am asking the scientific community to study.

FFF: Do you think that medical professionals are afraid to say anything that could be construed as “anti-breastfeeding”? How have your peers responded to your work in this area?

CDCH: Yes, medical professionals are afraid to say anything contrary to what the lactation community accepts as true because they do not want to be perceived as “anti-breastfeeding” or “pro-formula.”  Being “pro-formula” or “formula-sponsored” is a common accusation that I receive despite all the “pro-breastfeeding” instruction that I provide.  People have assumed that if you are against any part of the breastfeeding prescription, you MUST be against breastfeeding.

I am absolutely pro-breastfeeding.  I am absolutely AGAINST starving a child to achieve it.  I have received quiet support from several of my peers, but mostly silence for the majority.  I believe colleagues who are silent are incredulous or shocked or afraid.  I can’t truly know.  I can understand it because I am a physician and we are taught to stick close to the pack.  I am literally running away from it.

Until there is data from a credible and impartial source like the CDC or the Joint Commission, I will not have the proof that the Baby-Friendly Hospital Initiative is causing long-lasting harm.  There is already plenty of harm that has resulted locked in the hearts of many mothers who experienced this trauma.  I hope moms from both our Facebook sites will be willing to help advocate for increased safety for newborns by submitting written and/or video testimony on how the BFHI harmed them and their child.

FFF: What sort of response have you received from publishing your blog and Facebook page? 

CDCH: Outrage from breastfeeding moms and opposition from most lactation consultants except for a loved few, two of which fully recognize the harms of insufficient feeding to baby’s and their moms.  However, the ones I live for are the responses from moms who say that this happened to them and their babies either were harmed, hospitalized or were luckily saved from harm by an independently minded mom, nurse or other individual that told them their baby was hungry and needed a bottle.  These moms write to thank me for validating what happened to them and for telling them that this was not their fault, that what they saw was real and that this should never happen to any mother and child.  I have received messages from moms experiencing what I describe in my letter in real time and I have helped those moms advocate for their child, even when their professionals were bullying them to keep withholding formula!  It’s crazy.  What are we doing to our newborns?

What I feel most disappointed about is the lack of response I have received from the Executive Committee of American Academy of Pediatrics who I have been trying to contact for at least 6 months.  No response from the organization that is supposed to protect our newborns.  So I decided to inform the public on my own.  At first I was afraid.  Now I am not.

FFF: Have you endured any personal or professional attacks due to asking these tough questions about our current protocol for early breastfeeding?

CDCH: Tons.  People on the internet can act with cruelty because they don’t have to suffer any consequences.  I try not to let it get to me because I know it comes from a place that is likely sincere like mine, a mother trying to protect her newborn from harm.  Some mothers perceive my ideas as harmful, likely because the thought of starving your child is so horrible, I get the most harsh messages from breastfeeding moms, often moms whose children developed pathological weight loss.  I haven’t received too many challenges from physicians though, interestingly enough.  At least among my colleagues on Facebook, I have received supportive messages.

FFF: In an ideal world, how do you think hospitals could alter their procedures to better protect babies and mothers from the dangers of insufficient breastfeeding?

CDCH: These are my core recommendations:

1) Instructional videos on manual expression to check for the presence of colostrum.  Mom should also be instructed on listening for swallows to detect transfer of milk.

 

2) Pre- and post-breastfeeding weights to ensure transfer of milk and identify newborns at risk for underfeeding.

 

3) Calculation of the 7% weight loss threshold at delivery so that a mother knows when supplementation may be needed, which can be posted in her room.  The most critical clinical data an exclusively breastfeeding mom needs to know is the percent weight loss of her child.

 

4) Universal informed consent and thorough counseling on the possibility of underfeeding and jaundice due to delayed or failed lactogenesis and giving mothers permission to supplement their child if they go under the weight limit at home using a baby scale. Mothers must know the signs of a newborn in distress including hours of feeding continuously, crying after unlatching, and not sleeping. Most of all, a mother should be advised to check her supply by hand-expression or pumping to ensure that her child is in fact getting fed.  If little milk is present, she should be given permission ahead of time to supplement by syringe with next-day follow-up with a pediatrician and lactation consultant to assess the effectiveness of technique and transfer of milk if such an event arises.

5) Uniform daily bilirubin (abnormal total bilirubin > 14) and glucose checks (abnormal glucose < 45) for exclusively breastfed infants who are losing weight or who have any degree of jaundice.  Both these values are critical to detect physiology that can cause brain injury.

6) Twice daily weight checks in the hospital and at home until lactogenesis and consistent milk transfer has been established with a mother-baby dyad.  These can be plotted before discharge to predict the expected weight loss the day after discharge if mother’s milk does not come in.  A mother can check the weight at home and supplement if the child reaches the weight loss threshold.

7) Detailed instructions on supplementation only after nursing to continue the stimulation needed for milk production.  Supplementation should be a choice and be accepted and supported by the medical community as a patient right.  A mother has the right to feed her child above all goals the medical community has for her.

8) A breastfeeding safety checklist to reduce medical error in the care of a mother and exclusively breastfed newborn.

 

Lastly, my advice for new mothers at home is to have an experienced parent around for the first week to help.  Parents need sleep and they don’t get much in the postpartum period.  Additionally, experienced parents know the look and sound of a child who is hungry or in distress.  The child’s wishes should be honored.  I believe in the human rights of a newborn to be fed what they need because following the alternative can lead to what my son experienced.

FFF: Your page grows in popularity every day. Have you been surprised at how many mothers have been affected by this issue?

CDCH: I am not surprised by how many mothers have experienced this issue.  Mothers have been experiencing this for 2 decades now since exclusive breastfeeding from birth has been the mandate.  This is the first that the experience is being made public because mothers have been uniformly shamed for having their child go through this.

Even now, people still post comments that blame me for not knowing, for not producing enough milk, for not seeking out enough help when the entire teaching by the lactation community prevents a mother from knowing this is possible and the standard of care does not detect what is coming out of a mother’s breast.  We have been taught to abandon responding to a baby’s cry in order to achieve exclusive breastfeeding and rely instead on weight checks and bilirubin levels to determine “medical necessity” for supplementation.

What are we doing with our newborns?  What are we doing to our mothers?  It breaks my heart every day the things mothers have told me about inadvertently starving their newborns.  They all sought help and all followed the instruction of their providers while seeing that there was something wrong with their child.  But they were told breastfeeding is always enough as long as your child is producing diapers.  What we are doing is NOT enough. These are the most well-intentioned and motivated mothers who do this. They read parenting books, attend classes and follow their doctor’s orders like I did.  I was in the hospital for a whole 48 hours while my son was receiving nothing for me!  Then I was at my pediatrician’s office the next day, at a lactation consultant’s office the day after and in the hospital by that evening.

Mothers are being led astray by the current breastfeeding dogma and being led to hospitalize their precious babies.  These mothers deserve better.

Vist Dr. Del Castillo-Hegyi’s Facebook page for more information: https://www.facebook.com/insufficientbreastfeedingdangers?fref=ts

 

 

Vital Signs: Ignoring postpartum depression and psychosis won’t make them go away

Another horror story. Another mom. Three beautiful girls who will never have another birthday, whose last memory will be terror at the hands of the person they trusted the most.

I don’t know the details. I don’t really want to know the details. I do know that this mother reached out, told her own mom she was “feeling crazy”. I do know that she had three babies in a row, and that the youngest was 2 months. I do know that there’s a strong chance that this was the result of postpartum psychosis.

And I know that this has got to stop.

Can we protect every family, prevent every case? Of course not. But postpartum mental health is taking a backseat when it should be sitting shotgun to every maternal and child health program. That’s a start, at least. We spend so much time worrying about a woman’s breasts, while we dismiss her mind. We worry about how hormones and birth practices affect lactation, while we disregard how they affect our emotions.

After we give birth, we are whisked off to the maternity ward. Our vital signs are monitored, but other vital signs are ignored. A mom who can’t seem to connect with her baby. Who is scared, and asking for help. Who is alone and voiceless. Her pulse may be steady, but her hands shake. Her breasts may leak colostrum, but her eyes may leak silent tears. And we ignore this.

GE-Healthcare-Dash-2500-v4-Vital-Signs-Monitor

OB/GYNs don’t see mothers until 4-6 weeks postpartum. In some cases, that will be too late.

Pediatricians see moms with their newborns several days postpartum, but they are focused on the infant. As they should be. We don’t expect a heart surgeon to be concerned with the diabetic foot of his cardiac patient’s wife.

When I see the role of lactation consultants and breastfeeding counselors growing, gaining more attention, more insurance coverage, I also see an opportunity. What if these professionals could be trained to screen for postpartum mental health issues, if they could recognize red flags and know how to refer families to the proper resources? What if they were trained to support families in their feeding journeys, with the goal being a happy, healthy family and not just a breastfeeding statistic?

With the state of our health care system, I don’t expect that an entirely new support staff can be instilled at every hospital, for the sole purpose of protecting maternal mental health. But when 1 in 7 mothers suffer from postpartum depression or anxiety, I think that constitutes just as much of a public health concern as the supposed risks of “sub-optimal breastfeeding practices” in developed countries. If we are going to focus so heavily on breastfeeding, could we at least give a little simultaneous attention to a mom’s mood while we inspect her breasts?

What happened to the Coronado family is sub-optimal. What passes as “support” for postpartum women is sub-optimal. There is no reason we can’t support breastfeeding while prioritizing maternal mental health. Both are important, but one has been systematically ignored, shoved under piles of paperwork, given lip service. We only seem to worry about postpartum depression in terms of how it affects breastfeeding “success”. There are so many things wrong with that sentence, with that mentality. It’s like worrying about prostate cancer only in terms of how it will affect sex and procreation. Biological norms are important, but support also means protecting those whose biology turns on them.

If we can only speak of maternal needs under the umbrella of lactation support, I can live with that. As long as those needs are met, I can live with that. As long as those needs are being met, maybe we can all live with that.

Survive with that.

Thrive with that.

 

 

Of nanny states and nonsense

This is why I hate politics.

Earlier today, Jennifer Doverspike’s scathing indictment of Latch On NYC popped up on the Federalist website. By this evening, Amanda Marcotte had written a similarly scathing indictment of Jennifer’s piece on Slate. Both talked about hospital policies, formula feeder paranoia, and boobs. But in the end, what should have been a smart point-counterpoint between two passionate, intelligent women turned into a steaming pile of another bodily substance.

Yep, I’m talking about shit. 

Look, guys, I’m sorry for the language, but I’m done being classy, at least for tonight. Tonight, my Boston-bred, townie self is coming out, because I. Have. Flipping. HAD IT.

 

Doverspike’s piece does veer into political territory, mostly from the use of the term “nanny state”, a phrase that is undoubtably evocative (and apparently intoxicating) in today’s partisan climate. There were portions of her article that made me (a self-proclaimed, sole member of the Turtle party – our platform is that we just hide our heads in our shells whenever political issues arise. Anyone’s welcome to join!) a little uncomfortable, mostly because I worried that her important message would get lost by those on the Left. But I naively thought (us Turtles are naive about such things, considering we start singing “Mary Had a Little Lamb” whenever someone brings up Congress and prefer to our news from the Colbert Report) that she’d covered these bases with her final paragraph:

 

There are, of course, many laws the government issues for our protection and those of our children. Seatbelt laws, child car seat booster requirements, bans on drop side cribs and helmet laws. Regardless of whether or not these encompass valid risks (many do, some don’t), they do not encroach on personal freedom the way laws regarding parenting methods do. And don’t get me wrong; this goes in all directions. Infant feeding, and the personal freedoms associated with it, is not a liberal or conservative issue.

 

Apparently, it is a liberal or conservative issue, at least according to Marcotte, whose response to Doverspike felt far nastier than necessary. Marcotte accuses Doverspike of not doing her homework regarding the implementation of the WHO Code, for example:

 

What Doverspike fails to mention is why the WHO wrote out these regulations in the first place, something a quick Google search reveals. As reported at the time by theNew York Times, researchers had discovered that poor parents were stretching out formula by watering it down, which was leading to malnutrition in infants. In addition, places that lack clean drinking water are places where formula feeding is downright dangerous. There are substantial benefits, particularly worldwide, to creating a culture where breast-feeding is the go-to way to feed children, and formula is only viewed as a supplement for cases where breast-feeding isn’t working. Of course, that does cut into formula company profits, so if that’s your priority, by all means, bash the WHO’s efforts to keep babies healthy some more.

 

Huh. See, that’s odd, because I clearly remember reading something in Doverspike’s piece about this very issue… let’s see… ah, right:

 

Unlike the city of New York, the WHO  has valid reasons to be concerned with breastfeeding rates worldwide. After all, in less developed countries not breastfeeding may mean instead using cow’s milk for infants. When formula is used, the risks of it being prepared incorrectly and using contaminated water is rather high…The WHO should focus being on how to educate and support women in developing countries regarding the dangers of cow’s milk, the benefits of breastfeeding, and the importance of correctly mixing formula. Unfortunately, the WHO Code saves most of its energy in marginalizing formula companies, requiring hospitals to under no circumstances allow formula advertising and requiring that product samples only be given for research at the institutional level — “In no case,” it stipulates, “should these samples be passed on to mothers.” The WHO is also requiring labels stating the superiority of breastfeeding and warning to not use the product until consulting with a health professional.

True, she didn’t delve into the issues surrounding formula use in developing nations as deeply as she could have, but Marcotte’s take on the subject wasn’t exactly accurate, either. The Nestle controversy which she alludes to involved corporate subterfuge (women dressed as nurses convincing new mothers to use formula; these “health workers” then packed up and left, abandoning the moms with no established milk supply, no resources to procure more formula, and dirty water to use for what formula they did have), and this was what drove well-meaning individuals to create the WHO Code… but the problems that exist which lead women in these same countries away from breastfeeding are so much more complex than our Western understanding of “unethical marketing”. And to compare the risks of not breastfeeding in these countries to the risks in countries which are debating baby-friendly initiatives isn’t fair nor useful. These are two entirely separate issues.

Marcotte also dismisses Doverspike’s concerns that under Latch On, formula ”must be guarded and distributed with roughly the same precautions as addictive and harmful narcotics” by citing a “sober-minded assessment” that she claims “shows that no such things are happening”. This “sober-minded assessment” is a CNN option piece from writer Taylor Newman, who repeatedly brings up her own breastfeeding experience in a hospital with piss-poor support. Newman engages in some of the most immature name-calling I’ve seen in a respected news source – those who disagree with her opinion of Latch On are “obnoxious”, “unhinged” they write “badly-written” posts that are just ‘kicking up dust”. (If this is sober-minded, hand over the vodka. This is mean-girl, bitchy, completely anti-feminist bullshit, is what it is. If a man called a fellow woman writer “unhinged” or accused her of being hysterical, I bet we’d see plenty of backlash from Slate. ) She also makes the fatal mistake so many reporters, pundits and advocates have made in this tiresome debate: she’s only seeing it through the lens of her own experience. It may not seem like a huge deal to someone who wanted to breastfeed (and ultimately did, successfully) that new moms will have to ask for formula each time a baby needs to eat, or that they will have to endure a lecture on the risks and intense questioning of their decision. But try living through that experience as, say, a single mom who was molested as a child. Imagine you don’t have anyone around to defend you, to demand that the nurses treat your decision not to use your body in a particular manner with respect. Imagine that you don’t feel like reliving your abuse and telling a total stranger – repeatedly – why the idea of letting a baby suck on your breasts makes you want to throw up.

I know I’m digressing here, and again, I’m sorry to be throwing my usual I-Support-You, let’s all hold hands and braid each other’s hair Pollyanna-esque, evolved FFF persona out the window. This is old school FFF, the angry one, the one whose claws come out when I see that women are being told their voices don’t matter, their concerns don’t matter, their choices don’t matter. The one who refuses to allow an important discussion – a women’s rights discussion, not a political one – get bogged down in right vs. left rhetoric.

Marquette’s choice of image to go along with her article is a baby holding a bottle with the caption “Freedom Fighters”. Again, I have to ask – really? Fine, be mad that the Libertarian Federalist invoked the Nanny State and beat up on poor old Bloomberg. Rage against that. But to belittle those of us who care about this issue is petty and cruel. And to ignore – once again – that what Latch On’s PR machine told the press was quite different from what was written in the actual materials used to implement the program; to ignore that no one has actually done a follow-up story since the initiative was announced which reports actual accounts from actual women who actually delivered in actual Latch On hospitals and used actual formula – this is just poor journalism.

Feminists, journalists, bloggers – I belong to all of your clubs, and I’m sure you’re about to revoke my membership, but I have to ask: Why are we rehashing the same arguments over and over, instead of discussing how we could come to a more beneficial, neutral ground? For example – couldn’t women be counseled on the benefits of breastfeeding before they enter the emotional sauna of the postpartum ward? Yes, I realize that not all women have access to prenatal care, but for those who do, this seems like a practical and  beneficial adjustment. If these issues are discussed beforehand, at least a mom who knows from the start that she doesn’t want to nurse can sign whatever documentation is necessary to tell the state s has been fully informed of the “risks” and “still insists” (Latch On’s term, not mine) on formula feeding. For those who change their minds while in the maternity ward – well, couldn’t we just agree that she gets one lecture on why it’s a bad decision, and then receives the education, support and materials she needs to feed her baby safely, rather than having to go through the whole rigamarole every time her infant begins rooting?

Or here’s another idea – take the hyperbole out of the initiative. Stop saying these things are “baby-friendly” or “progressive” or “empowering” because they aren’t necessarily so. And by saying that they are, you get people all riled up, politically. You start hearing terms like “nanny state” because some of us don’t want to be told how we should feel (or how our babies should feel, for that matter. If my mom couldn’t feed me and some nurses weren’t letting me access the next best thing, I’d be hella pissed, and that environment would become decidedly baby unfriendly. Especially when I punched the person refusing my mom the formula in the nose with my tiny baby fist). You start getting feminists shouting about second waves and third waves and whether women should feel empowered by their ladyparts or held down by them. It’s one big mess, is what I’m saying. So can we stop it, now? Can we start writing articles that are balanced reports rather than press releases for a particular administration or cause? Can we stop hurling insults at each other just because we don’t agree on what being a mother should mean?

Can we please, for the love of all things holy, just flipping stop?

Bad medicine: Why the AAP’s new statement on breastfeeding & medication is puzzling

“The benefits of breastfeeding outweigh the risk of exposure to most therapeutic agents via human milk. Although most drugs and therapeutic agents do not pose a risk to the mother or nursing infant, careful consideration of the in- dividual risk/benefit ratio is necessary for certain agents, particularly those that are concentrated in human milk or result in exposures in the infant that may be clinically significant on the basis of relative infant dose or detect- able serum concentrations. Caution is also advised for drugs and agents with unproven benefits, with long half-lives that may lead to drug accumulation, or with known toxicity to the mother or infant. In addition, specific infants may be more vulnerable to adverse events because of immature organ function (eg, preterm infants or neonates) or underlying medical conditions.”

 

- Source: The Transfer of Drugs and Therapeutics Into Human Breast Milk: An Update on Selected Topics Hari Cheryl Sachs and COMMITTEE ON DRUGS. Pediatrics; originally published online August 26, 2013; DOI: 10.1542/peds.2013-1985

The preceding is the conclusion to a new report released by the American Academy of Pediatrics, which has given birth to a number of ecstatic headlines – “Most medications safe for breastfeeding moms”. “Medications of nursing mothers do not harm babies”. “Top Pediatrician’s Group Assures Most Drugs Safe While Breastfeeding”. Reading these, one might assume that a plethora of new research had been released, provoking the AAP to make a blanket statement about risk and benefits.

One should read the actual report before one gets too excited.

Other than the introduction and conclusion, which basically explain that studies are limited on most medications and how they affect a nursing infant, but that the benefits of breastfeeding outweigh the risks, the report reads like one giant warning.

Let’s start with antidepressants:

“Previous statements from the AAP categorized the effect of psychoactive drugs on the nursing infant as “unknown but may be of concern.” Although new data have been published since 2001, information on the long-term effects of these compounds is still limited. Most publications regarding psychoactive drugs describe the pharmacokinetics in small numbers of lactating women with short-term observational studies of their infants. In addition, interpretation of the effects on the infant from the small number of longer-term studies is confounded by prenatal treatment or exposure to multiple therapies. For these reasons, the long-term effect on the developing infant is still largely unknown…Because of the long half-life of some of these compounds and/or their metabolites, coupled with an infant’s immature hepatic and renal function, nursing infants may have measurable amounts of the drug or its metabolites in plasma and potentially in neural tissue. Infant plasma concentrations that exceed 10% of therapeutic maternal plasma concentrations have been reported for a number of selective serotonin reuptake inhibitors…”

As stated in the first sentence of this section, the evidence hasn’t really changed from when the last AAP statement on drugs and human milk was released, circa 2001. But the conclusion sure has. In 2001, the authors advised that “(n)ursing mothers should be informed that if they take one of these drugs, the infant will be exposed to it. Because these drugs affect neurotransmitter function in the developing central nervous system, it may not be possible to predict long-term neurodevelopmental effects.” In 2013, the author states “Mothers who desire to breastfeed their infant(s) while taking these agents should be counseled about the benefits of breastfeeding as well as the potential risk that the infant may be exposed to clinically significant levels and that the long-term effects of this exposure are unknown.”(p. e799)

This is where I start getting nervous. The last thing I ever want to do is discourage someone who needs antidepressants or another lifesaving medication from breastfeeding – especially considering I personally chose to take the small risk and feed my newborn breastmilk while I was on Zoloft (one of the many SSRIs that are categorized in both reports as “Psychoactive Drugs With Infant Serum Concentrations Exceeding 10% of Maternal Plasma Concentrations”, meaning that the levels of the drug getting into a newborn via breastmilk are clinically significant and of potential concern for a growing neonate). These are the risk/benefit scenarios we often discuss here on FFF – decisions that parents need to make (and deserve to make), armed with solid information and free from paternalistic admonishments that don’t have real world meaning. But I don’t feel that the new AAP statement – or the way that the media is reporting it – is allowing for a truly informed decision.

Notice the emphasis of the newer AAP statement – the advice given is to counsel the mother on the benefits of breastfeeding first, and then inform her of the potential risks and unknowns of nursing on her medication. Anyone with a grade-school understanding of psychology can figure out what that would sound like. (“Breastfeeding is extremely important and will save your child from every ill imaginable! But I should warn you that if you choose to nurse while on Zoloft, we can’t confirm or deny that your baby may turn into a werewolf when he reaches puberty. Your choice!”)

Maybe I’m arguing semantics here, but why couldn’t they avoid the paternalism of both the 2001 and the 2013 statement and simply advise doctors to inform parents of the risks and benefits of both feeding options, as well as the risks of nursing on medications, in an accessible, understandable way? And then help them mitigate the risks, no matter what path they choose?

Moving on… painkillers. The AAP is now agreeing with what I freaked out about in Bottled Up – Vicodin and newly postpartum, breastfeeding women are not a match made in heaven. And before you post-C-section mamas beg for the Darvocet, that won’t fly, either. Turns out that infants whose mothers used these commonly prescribed drugs  for managing postpartum pain have popped up with cases of unexplained apnea, bradycardia, cyanosis, sedation, and hypotonia; one infant died from a Vicodin overdose after ingesting the drug through mother’s milk. But hey- you can take (moderate) doses of Tylenol and Advil to manage that post-surgical pain, so no worries.

Are you starting to see why “Medications of nursing moms do not harm babies” might not be the most accurate headline?

Ummm…. Herbal remedies! Those have to be okay, right? They’re natural, after all!

Not so fast, sugar.

“Despite the frequent use of herbal products in breastfeeding women (up to 43% of lactating mothers in a 2004 survey), reliable information on the safety of many herbal products is lacking…The use of several herbal products may be harmful, including kava and yohimbe. For example, the FDA has issued a warning that links kava supplementation to severe liver damage. Breastfeeding mothers should not use yohimbe because of reports of associated fatalities in children…Safety data are lacking for many herbs commonly used during breastfeeding, such as chamomile,black cohosh, blue cohosh, chastetree, echina- cea, ginseng, gingko, Hypericum (St John’s wort), and valerian. Adverse events have been reported in both breastfeeding infants and mothers. For example, St John’s wort may cause colic, drowsiness, or lethargy in the breastfed infant…Prolonged use of fenugreek may require monitoring of coagulation status and serum glucose concentrations. For these reasons, these aforementioned herbal products are not recommended for use by nursing women.”

Wait. It gets worse. You know those galactagogues you were prescribed to increase your milk supply? Flush them down the toilet, says the AAP. The safety of Domperidone, for example, “has not been established.”

“The FDA issued a warning in June 2004 regarding use of domperidone in breast- feeding women because of safety concerns based on published reports of arrhythmia, cardiac arrest, and sudden death associated with intravenous therapy. Furthermore, treatment with oral domperidone is associated with QT prolongation in children and infants.”

The authors aren’t overly enthusiastic about other galactagogues, either, and instead encourage moms struggling with supply to “use non-pharmacologic measures to increase milk supply, such as ensuring proper technique, using massage therapy, increasing the frequency of milk expression, prolonging the duration of pumping, and maximizing emotional support.”

I’ve read the report 10 times now, trying to see where they could possibly come to the conclusion that this is a game changer; that it is at all newsworthy; that this is what counts as progress. To my untrained eye, it appears to be little more than a re-framing of old information to fit in better with the “breast is best at all costs” mantra, rather than a landmark “update” of an antiquated policy paper. Based on this report, how are pediatricians supposed to tell patients, in good conscience, that there is adequate evidence that it’s safe to breastfeed on “nearly all” medications?

For most of the meds in question, it probably is safe- similarly to how the risks of infant formula are scary on paper and far less daunting in real life, I honestly believe that we’d be seeing a lot of seriously messed-up kids if your absolute risk of nursing while on antidepressants was high. Just like many of us have made carefully weighed decisions to formula feed, feeling the weight of misery in one hand and balancing that with an increased risk of ear infections in the other, so shall we handle questions of breastfeeding and medications. The problem is not with moms making choices based on the facts we have- the problem is when respected, policy-creating organizations create false narratives that render us unable to make those choices in a truly informed way.

The report leans heavily on the work of Thomas Hale and LactMed, fantastic resources for research on these issues. I’m grateful there are people dedicated to focusing on this research – research that matters so much more than yet another associative study attempting to show that breastfed babies are smarter than formula fed ones. We desperately need more research on how commonly prescribed medications affect breastfeeding infants, not so that we can “forbid” women from breastfeeding, but so that we can help them reach their breastfeeding goals. This might mean timing medications so that they are mostly metabolized prior to nursing, or pumping for some feeds, or even -god forbid- using a little formula or donor milk for the feeds that have a higher amount of the drug coming through milk (these are tough things to figure out, sometimes, as people metabolize differently, as do babies, but it’s a good goal to have on the horizon). Maybe it means finding better medications. Or it might just mean allowing parents to ponder their own risk/benefit scenarios and respecting their decisions, whatever those may be.

Before we can do that, though, someone has to remind the AAP that they are doctors first, breastfeeding advocates second. Let the science speak, not the zealotry, and maybe we can start helping parents make truly “informed” choices.

 

A slightly curmudgeonly rant about the drama over Save the Children’s “Superfood for Babies” campaign

The problem with writing a post which criticizes an organization which strives to help starving kids is that it makes you feel like the Grinch. Or Gargamel. I feel like I should be stroking an acrimonious cat and arching a pair of overgrown eyebrows inward.

Save the Children does a lot of wonderful things for children in dire straits, and I don’t want to come down on them too hard. And in many respects, I applaud their recently announced “Superfood for Babies” initiative. I do believe that breastfeeding is a hugely important part of improving childhood mortality in resource-poor nations, and the report supporting the program offers some excellent perspective on the challenges of raising exclusive breastfeeding rates in these areas.

In public health circles, there’s a lot of discussion on messaging – how to make PSAs culturally appropriate, sensitive, and effective. The thing is, this doesn’t only hold true for at-risk groups – it also applies to the middle-class factions of western nations. It’s just as ineffective (and inappropriate) to try and graft a message addressed to people living in tribal societies with problematic water sources onto a secretary in suburban Iowa as it would be to do the opposite. Yet, this is what happens – repeatedly – in our international discussions of breastfeeding. (Incidentally, this is at the root of my beef with Unicef and WHO, and why I feel it’s necessary to amend the Baby Friendly Hospital Initiative set forth by those organizations to be more culturally appropriate to developed, Western societies.)

This brings us to my scroogey analysis of the “Superfood for Babies” campaign.  I would encourage everyone to read the literature – it offers some truly excellent insight into the specific issues at play in a variety of developing nations, and makes it clear (whether or not it intends to) that formula is not the only barrier to encouraging exclusive breastfeeding. In some cultures, there are beliefs that breastfeeding for the first few days of a babies life is detrimental; in others, women feel pressured to produce as many babies as possible, thus making the fertility-restricting nature of breastfeeding a downside; and in others, it’s not formula which is used as a supplement but raw animal milks or concoctions of grains.

Save the Children (STC) did a lot right with this report. They addressed the need for social change; advised that governments subsidize breastfeeding women so that those in unstructured agricultural jobs (which don’t exactly come with a 401k or paid maternity leave) don’t need to return to work immediately, and have to choose between making a living and feeding their babies; and they press for better education and involvement from medical workers and midwives. I think their motives were great, and they did their homework.

Unfortunately, in their excitement, they lost perspective in three key areas…

1. They were (intentionally or unintentionally) vague about the research

Look, I would never argue that breastfeeding isn’t the best choice – by far – for babies in places where food is scarce, infection and disease runs rampant, medical care and antibiotics are severely limited, and the water source is questionable. Formula feeding is dangerous in these settings. But since breastfeeding advocates and orgs like WHO have made breastfeeding a global issue, we have a responsibility to be honest about what our body of research actually says. There are numerous instances in the STC report where claims are simply not held up by their citations. For example, this quote, on page vii of the report’s introduction:

It is not only through the ‘power of the first hour’ that breastfeeding is beneficial. If an infant is fed only breast milk for the first six months they are protected against major childhood diseases. A child who is not breastfed is 15 times more likely to die from pneumonia and 11 times more likely to die from diarrhoea[2]. Around one in eight of the young lives lost each year could be prevented through breastfeeding,[3] making it the most effective of all ways to prevent the diseases and malnutrition that can cause child deaths[4].

Let’s take a closer look at the citations. The first one, #2, is from a UNICEF report on diarrhea and pneumonia- not a study, but a report. So it took a bit of digging to see exactly where they were getting their data from. I *think* this figure comes from a table attributed to a Lancet piece, which “estimated”  that “Suboptimum breastfeeding was… responsible for 1·4 million child deaths and 44 million disability-adjusted life years”. I couldn’t get the full study on this one, but again – it was an estimate, most likely based on other studies – not hard data.

Citation #4 is the one that’s bothersome, however (#3 is just a footnote with the definition of “exclusive breastfeeding”). The sentence “making it the most effective of all ways to prevent the diseases and malnutrition that can cause child deaths” is most likely read as “breastfeeding is the most effective way to prevent child death”. That’s quite emotive. The citation leads you to a Lancet paper on child survival, which does have some dramatic data and charts regarding the interventions which would most reduce infant mortality in the developing world. Breastfeeding is shown to offer the most dramatic reduction in risk- but there’s one important point to consider: while this report focuses on death in children ages 0-5, the majority of these deaths occur in the first few months of life. Exclusive breastfeeding, as opposed to mixed feeding or exclusive feeding of substitutes including goat or buffalo milk, paps, or formula (important to note that in many of the countries STC is concerned about, traditions include feeding neonates animal milks or solids within hours of birth – so I think it’s arguable that the issue here is the risk of giving a baby anything but breastmilk via the breast, rather than breastfeeding being the “magic bullet” the report dubs it to be. Otherwise, we probably wouldn’t see consistently poor outcomes in mixed-fed kids, as a “magical” substance would compensate) is going to reduce the risk of infections that cause death in very young babies. In other words – if the most deaths are in newborns, and breastfeeding saves newborns more than any other interventions like vaccines, clean water, etc – then there will be a disproportionate representation of “babies saved by breastmilk” in the results. This is not to say that breastfeeding isn’t an incredibly worthwhile and effective solution to reduce infant mortality, but it’s a bit of a stretch to suggest that breastfeeding alone will be the most effective intervention for ALL childhood deaths, which is exactly what the STC report does.

2. They didn’t consider the societal implications of their recommendations, beyond the scope of infant health

I was taking notes as I read the STC report, and my heading for the section which included this quote was “OMGOMGOMG”:

Many women are not free to make their own decisions about whether they will breastfeed, or for how long. In Pakistan, a Save the Children survey revealed that only 44% of mothers considered themselves the prime decision-maker over how their children were fed. Instead it is often husbands or mothers-in-law who decide….

 

….To overcome harmful practices and tackle breastfeeding taboos, developing country governments must fund projects that focus on changing the power and gender dynamics in the community to empower young women to make their own decisions.

Changing the power and gender dynamics sounds like a fantastic idea, and I would support any program that attempted to do this. But STC has to realize that “empower(ing) young women (in developing countries) to make their own decisions is a complex and uphill battle that extends far beyond infant feeding. I fear that by placing an emphasis on UNICEF-lauded solutions like warning labels on formula cans/making formula prescription-only, and on educating fathers/elders on the importance of breastfeeding using the current overzealous and often misleading messages, in these countries – places where, all too often, females are already considered “property” and subjected to any manner of injustices – it will create an atmosphere where women who are physically unable to breastfeed will be ostracized, shamed, or penalized. I agree that we need to empower women, but I think that we also need to be verrrry careful about presenting “suboptimal breastfeeding” as a risky behavior in certain cultures.

In another section, the authors report that breastfeeding rates have gone up in Malawai despite poor legislation on maternity leave, breastfeeding rights, etc. – that these improvements are based solely on strict implementation of WHO Code. I’d like to be reassured that as women are being given no option other than breastfeeding without any of the protections which would make EBF feasible while working, this isn’t having a deleterious effect on their lives. It’s wonderful that breastfeeding rates are up, but what about correlating rates of employment, poverty, and maternal health?

3. They failed to differentiate between resource poor and resource rich countries

I’ve seen a wide range of opinions on the STC program online in the past few days. Most of the drama is over British media reports which mention putting large warning labels on all formula tins – not just the ones going to resource-poor countries. Some feel that these labels will cause unnecessary upset in the West; others argue that when it comes to saving starving/sick third-world babies, privileged mommy pundits should STFU. And others keep insisting that the STC report was misrepresented, and that the labeling stuff was a minor part of the larger plan and shouldn’t be harped on.

All of these arguments are valid, and yet all are missing the nuance necessary to have a productive conversation. We need to realize that not breastfeeding has quite different implications in certain parts of the world. We also need to acknowledge that a woman’s rights are important no matter how much money she has or where she lives, and that we all have a right to stand up for what we believe – it’s rather useless to play the “eat your dinner because children are starving in Africa” game, and rather un-PC as well.

But STC also needs to take responsibility, here. The fact is that the report does not really differentiate between resource-poor and resource-rich countries when it is discussing WHO Code and formula marketing.  For example, this passage on p. 45 describes laws which STC wants implemented worldwide:

Breast-milk substitute companies should adopt and implement a business code of conduct regarding their engagement with governments in relation to breast-milk substitutes legislation. Companies should include a public register on their website that outlines their membership of national or regional industry bodies or associations, any meetings where the WHO Code or breastfeeding is discussed, and details of any public affairs or public relations companies they have hired, alongside the nature of this work… Any associations (such as nutrition associations or working mothers’ associations) that receive funding from infant formula companies should be required to declare it publicly. In addition to this information being made publicly available on the websites of individual companies, the International Association of Infant Food Manufacturers should publish a consolidated record of this information, updated on a quarterly basis.

Personally, I think the money spent on a “governing association” in order to police this policy would be better spent on funding literacy programs to help parents read the labels we’re arguing about. Some of these countries have literacy rates of like 30% – which makes me wonder exactly who the labels are geared to, if not the Westerners for whom formula feeding is far, far less of a risky endeavor.

Don’t mistake me – the evidence given in this report about the shady practices of formula co’s is alarming. There needs to be something done about unethical marketing practices in parts of the world where information is limited, education is a true privilege, and options are a joke. Yet, in the STC report, there is ample (and quite good) evidence that the unethical efforts of formula companies are only one slice of a thick-crust, Chicago-style pizza. There’s a lot of gooey, barely distinguishable elements which all combine to make a rather heavy problem, and focusing so much on one of them will leave you with the policy equivalent of Domino’s.

Further, the situation with breastfeeding in the developing world is markedly different from what’s going on in Great Britain, the US, Canada, and so forth. The online arguments are proof of this. I’ve seen the same people who argue that breastfeeding is a global issue turn around and tell concerned Americans and Brits that they have no idea what’s appropriate in Peru or Ghana. This may be true, but so is the reverse. International groups like STC have to remember that when they release papers making global recommendations about infant feeding, that they are inviting commentary from a global audience. That’s why we can’t make blanket statements about infant feeding and child health, or try and implement the same rules in order to get the same results. We wouldn’t go into a rural village where families share a 300-square foot hut and start lecturing them about the dangers of co-sleeping, and yet we assume that the same one-size-fits-all public health messaging is fair game when it comes to infant feeding. Breastfeeding might indeed be a global issue, but the type of issue it is varies greatly depending on what part of the globe you’re on.

 

Related Posts Plugin for WordPress, Blogger...