Study says: Breastfeeding problems aren’t serious. And are probably your fault, anyway.

One of the most interesting interviews I did in my research for Bottled Up was with a physician who had studied breastfeeding-related neonatal hypernatremia (severe dehydration leading to electrolyte imbalance). We discussed the fact that these days, this condition is typically caught early and can be treated successfully. But the doctor also cautioned that while the prognosis wasn’t usually dire in terms of long-term health (thanks to modern medicine), we shouldn’t forget about the emotional and financial effects on the parents. He worried about a first time mom, trying to do the best for her child, who ends up seeing that baby hospitalized – sometimes for weeks- due to what she might perceive as her own failure to nourish him adequately.

I’ve been thinking about this interview since I read several articles yesterday, detailing a new study about the same condition. According to the Guardian (“Breastfeeding problems rarely lead to serious illness, study says“), a new paper on neonatal hypernatraemia found that “Very few babies become dehydrated and seriously ill because they are not getting enough milk from breastfeeding…Dr Sam Oddie and colleagues found only 62 cases from May 2009 to June 2010, a prevalence of seven in every 100,000 live births… the babies were admitted to hospital, mostly because of weight loss, and some were intravenously fed…However, all were discharged within two days to two weeks having gained weight and none had long-term damage.”

Seem like good news, right? Put on the Def Leopard, because we’re about to start headbanging.

Source: http://www.yaindie.com/2012/12/banging-your-head-against-wall-is-it.html

Banging-my-head-against-the-wall Problem #1: 

Okay. So, correct me if I’m wrong, but having a 2-week-old newborn in the hospital hooked up to an IV for a week or two isn’t considered serious? And as for long-term effects – these babies were born between 2009-2010. The study is not available online, so I don’t know what the details are in terms of how the researchers followed up with the subjects… but considering studies on breastfeeding and intelligence have tested kids at the age of 8, I think one could fairly say the jury is still out on this sample of 4 and 5-year-old kids. And how were they assessed in terms of long-term effects? Psychological? Emotional? Physical?

With all the focus on mother-child interaction in the first days, and the effect of fatty acids on brain development, the superiority of breastmilk in the first weeks… doesn’t it seem a little ironic that we’re so quick to dismiss a condition which a) separates parents from babies through NICU stays and b) starves/dehydrates a child in those same “fundamental” weeks?

I understand that we’re talking small numbers here – 7 in every 100, 000 is admittedly a reassuring statistic. But while we’re talking about that figure… what exactly does it mean?

Banging-my-head-against-the-wall Problem #2:

First, without access to the study, I can’t tell you if this statistic means 7 in 100,000 of ALL LIVE BIRTHS – meaning EBF, formula-fed and mixed-fed infants, inclusive. The UK has lower breastfeeding rates than many countries, so if this was the number of babies in all live births, it doesn’t mean anything substantial. What we need to know is the number of babies admitted who were exclusively breastfed before we can start making statements about breastfeeding, milk supply, and what needs to happen to avoid this risk.

Banging-my-head-against-the-wall Problem #3: 

Even if this study did look only at EBF babies, there are major limitations in what we can fairly assess from the data.  We can’t know how many women can adequately produce milk so that their babies aren’t at risk, because most people would supplement before it got to the point of hospitalization. What the researchers did discover is that the babies hospitalized could nearly all breastfeed successfully:

Almost every baby is capable of breastfeeding, Oddie said. “In only a few cases were there special features of the baby that made it likely that there would be a severe feeding problem. [One of the babies, for instance, was found to have a cleft palate.] Normally all babies can get established with breastfeeding with the right support.”

Again, I’m a little confused. If there were only a few cases of this condition, what exactly is a “few” of a few? Of the seven babies hospitalized in a group of 100,000, does that mean one of them had a “special feature” which created a feeding problem? Was it a statistically significant number?

Then, the Deputy Manager of UNICEF’s Baby Friendly Initiative weighed in:

Anne Woods, deputy programme manager for Unicef’s Baby Friendly Initiative (BFI)…said the number of babies who could not feed was negligible and only a very small percentage – about 1% – of women would struggle to make enough milk. “The numbers who breastfeed in this country do not reflect the numbers who could breastfeed if they had effective support,” she said.

Where there are problems, she added, “it fundamentally boils down to the fact that the baby is not attached to the breast effectively. The whole of the baby’s mouth has to make contact and draw the breast tissue into the mouth.”

But because we have a bottle-feeding culture in the UK, she said, some women do not realise this and “try to bottle-feed with their breast”, so the baby takes only the nipple and does not get enough milk.

The other problem is when babies do not feed often enough. After a difficult labour or pain relief, the baby may be sleepy. There is also an expectation she said, that a baby will feed and then sleep.

Ah, right. It’s the mom’s fault. Who cares that this study proves – hell, even suggests – nothing about the true incidence of physiological lactation failure. The researchers are talking about the baby’s ability to feed, not the mother’s ability to produce milk. That doesn’t stop Anne Woods from hurling the 1% (the lowest number bandied about regarding lactation failure, by the way – she could’ve at least given us a break and used the higher end of the oft-cited 1-5% assumption figure) statistic at moms who’re already feeling like failures for landing their babies in the hospital. And of course, the mom probably can’t be bothered to feed as frequently as needed – not that it’s entirely her fault, since the formula companies have convinced her that her breast is actually…wait for it… a bottle!

Banging-my-head-against-the-wall Problem #4: 

I know, I’m being snarky. And I do appreciate that the lead researcher of this study, Sam Oddie, emphasized the need for better breastfeeding management and support. I’m fully on board with that. But I’m also concerned about what Dr. Oddie was saying back in 2009, when he embarked on his study:

Dr Sam Oddie, a consultant in the neonatal unit at Bradford Royal Infirmary, who is leading the study, said: ‘Once we understand the scale of the problem we can work out what to do about it – how to spot it, and how to act on it. But as far as I’m concerned the answer isn’t more formula feeding, but increased support for breastfeeding from the outset in the form of counsellors.” (Marie Claire, 2009).

I don’t disagree with him, necessarily, but going in to a study on hypernatraemia with a strong desire to avoid formula supplementation – even if that ended up being the best course of treatment – implies a certain degree of bias.

One could argue that there’s no harm in a study like this making the news; it will bring attention to those experiencing early breastfeeding problems and perhaps make medical professionals take them more seriously. But as we’ve seen so many times, these studies have a way of creeping into the breastfeeding canon and being misused as “truth” to back up future claims. I can already see Dr. Oddie’s quotes as being taken out of context, being used as “proof” that “all babies can breastfeed” and that the risk of inadequate feeding isn’t all that serious (so there’s never a need to supplement, even if your formula-pushing pediatrician tells you that there is).

Still think I’m overreacting? Here are the headlines from the other two major news sources covering the study:

Most mothers who struggle to breastfeed WILL be providing enough milk for their babies, say experts (The Daily Mail)

Dehydration risks from breastfeeding are ‘negligible’, study finds (The Telegraph)

Would you like me to move over and make a little space for you on the wall? Come on over. Bring some Metallica, and wear a helmet.

 

Read more about neonatal hypernatraemia:

http://fn.bmj.com/content/87/3/F158.full http://pediatrics.aappublications.org/content/116/3/e343.full

 

 

Formula feeding education, or lack thereof

Reading through my Google alerts, I almost squealed with excitement when I saw a link entitled “Health Tip: Preparing Baby Formula” from none other than U.S. News and World Report. A major news outlet! Formula feeding education! Squee!

Well, turns out the article was less “squee” and more “eh”.

According to the esteemed publication, the formula-related health tip that was so vital that it necessitated being “called out” (publishing world lingo for highlighting a fact or quote) was the following:

Wash Your Hands.

The rest of the tips have to do with general hygiene- cleaning surfaces, sterilizing bottles, etc. I’m probably being unnecessarily snarky, because this is important information; it is important to keep things as clean and sterile as possible when making up an infant’s bottle. They also throw in one useful tip about keeping boiled water covered while cooling (great advice). But most of this is certainly not new information, and in many ways, I think it’s a waste of newsprint.

Why? First, I expect most parents know they are supposed to wash their hands and clean their bottles. What they may not know is why. There is no mention of the risk of bacterial infection here, so it just comes of sounding like vague, somewhat stodgy advice, like something your mother-in-law tells you in that tone. (You know the one.) The kind of advice that gets filed in the “I know I should do it, but come on, what’s the harm” portion of your conscience, alongside “floss twice a day” and “never jaywalk” (unless you are in Los Angeles. Then you probably take the jaywalking thing seriously, as the LAPD will ticket your ass for crossing where you shouldn’t). I think an acknowledgement that these precautions will help you avoid potentially deadly bacterial infections would make the advice seem a tad more topical.

But also, this is standard food prep protocol. There are other intricacies to formula feeding that may not be as intuitive- safety precautions like mixing the proper amounts of water to formula; not diluting the formula; using the right type of water; discarding formula after specific amounts of time; opting for ready-to-feed for newborns. Or what about other tips which might help avoid other formula-related health problems? Like a run down of the different types of formulas so that parents can choose the right type for their babies. Advice for understanding hunger cues. A bit of education on growth spurts; what’s normal when it comes to formula-fed babies and spit-up and elimination (both pee and poop); a quick description of how to feed a baby holding the bottle at a good angle?

I get that this was merely a half-column filler, not an 800-word feature. I understand that U.S. News & World Report isn’t in the business of imparting feeding advice to parents (and in fact, the article in question was syndicated, from Health Day) . And I seriously do appreciate the effort to give a bit of valuable info to formula feeding parents. Yet, I can’t help but wish that this half-column was put to better use. A short paragraph on when (and just as importantly, why) formula should be discarded would have been infinitely more interesting and useful.

There are a few reasons why formula feeding education is as hard to come by as a good house under half a million in the greater Los Angeles area (I’m bitter about real estate at the moment). Many people think it’s unnecessary; formula feeding is seen as the “easy way out”, and assumed to be as simple as scoop and shake. Some breastfeeding advocates believe that prenatal formula education/preparation is counterproductive to breastfeeding promotion – the theory being that if you discuss it, it will be taken as an endorsement, when formula should only be used in an all-else-has-failed scenario. (The World Health Organization’s “WHO Code” basically forbids health workers from even uttering the words “infant formula” until it becomes clear that there is no other option.)

What is puzzling to me about this situation is that breastfeeding, while definitely a lost art in our bottle-heavy society, does have an intuitive aspect to it. Or at least it is portrayed that way – something so natural, so instinctual, shouldn’t require training. Assistance, yes. Support, most definitely. Protection, you bet your bottom dollar. But instruction/education? That seems rather – well, quite literally, counterintuitive.

Formula feeding, on the other hand, is something which has always been a man-made, lab created, medically-approved (at least up until recent events) form of infant feeding. It does require instruction; you don’t see our primate cousins giving birth and popping open a can of Similac (although I am quite sure they could be trained to do so, considering how smart they are. I’ve seen Rise of the Planet of the Apes. Scared the bejesus out of me). Yet parents leave their prenatal classes and hospital stays with plenty of info on birthing and baby care and breastfeeding, but little to no instruction on how to make a damn bottle.

The vast majority of babies will have some formula in their first year. Heck, by the time they are 6 months old, it’s a safe bet to assume most of them are partially, if not exclusively, formula fed. We can’t sell infant feeding as the number one predictor of infant health and development and simultaneously ignore the primary way our nation’s babies are being fed.  It’s bogus, and irresponsible.

This is not to imply that parents are putting their babies in dire jeopardy because they leave a bottle out too long, or forget to scrub their hands like Lady MacBeth before mixing formula. Heck, I committed almost every formula feeding sin and my kids are pretty normal. (Except for Fearlette’s suspicious fear of police helicopters, but I blame that on her past life.) But until we ensure that parents are properly educated on formula feeding – something that could be done with one quality, AAP-endorsed pamphlet, or a few minutes of discussion in a hospital baby care class – we can’t possibly get a clear idea of the real risks of formula feeding (I bet we’d see an even smaller difference in breastfed versus formula fed if all formula feeding parents were doing it correctly), or feel confident that all of our babies are getting the best version of whatever feeding method their parents have chosen.

For now, I’d suggest checking out Bottle Babies – a great non-profit organization run by some friends of mine. They’ve put together some excellent, research-based information on a myriad of bottle-related issues. Or feel free to click on the link to the FFF Quick-and-Dirty Guide. And I hate to say it, but for the moment, the formula companies are probably the best resource for formula feeding parents. At least they give a crap about their customer base, even if this is rooted in a desire for customer loyalty and a fear of litigation.

And, ya know, remember to wash your hands.

FFF Friday: “All of our decisions were made with an eye towards ensuring breastfeeding success.”

Welcome to Fearless Formula Feeder Fridays, a weekly guest post feature that strives to build a supportive community of parents united through our common experiences, open minds, and frustration with the breast-vs-bottle bullying and bullcrap.

Please note, these stories are for the most part unedited, and do not necessarily represent the FFF’s opinions. They also are not political statements – this is an arena for people to share their thoughts and feelings, and I hope we can all give them the space to do so.

Of all the misconceptions and untruths running rampant in the parenting community regarding breastfeeding, one bothers me more than any other. It’s the “you just didn’t try hard enough” sentiment, often heard alongside it’s ugly stepsister, “Nearly everyone can breastfeed if they just are willing to put in the work.” 

My analysis of these insulting adages? They usually come from a) people who have never breastfed themselves, b) women who had some minor breastfeeding issues and were able to work through them or c) women who breastfed effortlessly. When I encounter such attitudes, I always feel like screaming the immortal words of MTV’s Diary- you think you know, but you have NO idea.

Amanda’s story gives us yet another example of an intelligent, educated, dedicated breastfeeder who ended up turning to formula. She did everything right, and was still made to feel as if she did something fundamentally wrong. What’s even more ridiculous is that Amanda is still pumping (at least as of her submission date to FFF), trying her damndest to give her baby the “best”, and yet it’s still not considered breastfeeding “success.”

Well, that buck stops here, folks. Let’s take back the word “best”. Best is subjective. Best means your personal best; how best is defined for your family; what is best for your particular child. Your “best” is…well….best. (FFF Desiree Johnson came up with that one a few weeks ago on the Facebook page, and I think it’s pretty spot-on. )

I’ll be back with my own posts next week… focusing on the book promotion crap at the moment, but I don’t want it to be at the expense of the blog…so I promise to kick my butt in gear soon.

Happy Friday, fearless ones…

The FFF

***

Amanda’s Story

From the moment my wife and I decided to start trying to conceive, I just knew I would breastfeed.  First, we generally fall on the attachment-parenting-hippie-crunchy end of the parenting spectrum, and breastfeeding seemed like a natural fit with that.  Second, we live in a community where breastfeeding is very common, and breastfeeding support is truly first rate. Third, we are frugal people…throughout my pregnancy, we referred to my breasts as “the best coupons ever”.  I honestly never considered any other options.

I have PCOS (we’ll call that “warning sign #1”) so we guessed that getting pregnant would be a bit of a challenge for me, but 12 days after our very first IUI we got our positive pregnancy test. I was still hesitant to relax – my progesterone was low (warning #2), and miscarriage rates are incredibly high in women with PCOS.  When the first trimester ended, I breathed a gigantic sigh of relief…I’d overcome my big PCOS hurdle, or so I thought!  My pregnancy was mostly uneventful – a bit of nausea once or twice, some body aches, but nothing to write home about.

All of our major decisions were made with an eye toward ensuring BF success.  I chose my OB/midwife practice because they delivered at a birth center inside a Baby-Friendly hospital, and we hired an amazing doula so we could stay home as long as possible, because I was determined to avoid epidurals or a C-section.  The pediatrician we chose is married to an IBCLC and is incredibly pro-BF.  We took our childbirth classes and breastfeeding classes, and I read just about every major pro-breastfeeding, pro-unmedicated-childbirth book that I could lay my hands on.  I told my wife I wanted to donate all of our formula samples before the baby arrived –I wouldn’t need them, after all, and research showed that if I even had them in the house, I’d be jeopardizing my BF chances (she, wisely, said “Well, let’s keep them, just in case”).  I had my breastfeeding pillows, lanolin, breast pads, and a pump all ready to go, along with multiple boxes of milk storage bags for my soon-to-be-overflowing freezer supply. Meanwhile, my breasts had gotten a bit fuller, but not nearly as much as I’d expected(warning sign #3).

After 5 days of prodromal labor, things picked up in earnest.  We had an active labor at home.  I ended up arriving at the hospital at 9.5 cm, and they just managed to get the tub filled when he was ready to be born.  His birth got a little hairy – first the cord was around his neck, then his shoulders were stuck for about a minute and a half and he was born “stunned”, so had to be taken immediately to the warmer (he was just fine, we were both just a bit worn out from the ordeal). Then, probably because of the 5 days of prodroming, I hemorrhaged (warning sign #4).  My 8 lb, 4 oz son was put to my breast and immediately latched on, which was great, because it helped to control the bleeding.

All of the nurses at the hospital had lactation training, and they all commented on what naturals we were.  My doula said that I had “perfect” nipples for breastfeeding, and the IBCLC told me that our latch was great.  I kept waiting for painful fullness (that’s #5), but eventually we ate the cabbage that I’d bought anticipating engorgement…it just never materialized.  Our son fed CONSTANTLY, but didn’t appear to be dirtying diapers nearly as much as was expected (#6). The advice nurse told us that as long as he was wetting diapers, we were still fine. At our first post-discharge appointment, the baby had lost 7 ounces, but the doctor said he wouldn’t worry unless he was still losing at the two week appointment.  Nevertheless, he continued to poop less than expected, nurse for hours on end, and be hard to rouse for and during feedings (#7) – we resorted to rubbing him with cold washcloths, to try to keep him sucking for more than a minute or two at a time.

At his two-week appointment, he had lost 5 more ounces, and the pediatrician was officially concerned.  He suggested that I buy a Supplemental Nursing System to give him a little formula until we got my supply up, and asked us to come in for a re-weigh in 3 days.  I cried my eyes out all the way to the specialty mom and baby store, cried in the car while I made my wife go in to buy a short-term SNS and an expensive herbal tincture to increase production, cried on the ride home, cried while I mixed up the formula, and cried while I struggled to tape on the SNS.  My son ate like he was starving (which, you know, he was) and then fell fast asleep while I called the pediatrian’s  IBCLC wife.  She gave us a ton of suggestions on increasing supply, all of which I followed – water, hours of skin-to-skin, using the SNS, pumping every two hours or after every feed, whichever was more frequent, enough Fenugreek that I smelled constantly of maple curry, Goat’s Rue, and a prescription of domperidone at a dose that cost us roughly $5 a day.  With that, he was still drinking about 20 ounces a day of formula, so we think I was producing maybe 5 ounces total per day.

With the formula supplements, he started gaining right away, and became a totally different, much more alert, much happier baby.  I, however, was becoming exhausted and depressed.  We were completely tied to the house – even if I could somehow bring the pump, SNS, tape, and formula out with me, I was so mortified to be “failing” at breastfeeding that I refused to feed him in public, or even in my living room if anyone was there other than my wife. I began to dread the sound of him waking up, knowing that each time he cried from hunger, it would start an hour plus session of feeding, pumping, and washing all of the bottles and pump parts. He was super-alert and playful right after his feedings, but of course I missed all that, having handed him off to my wife to hold and play with while I pumped.  9 times of 10, he was asleep again before I was done.  I found myself yelling at him and getting angry and frustrated when he’d spit out the tube in the middle of the night, knowing it was going to be a battle to get him re-latched onto the finicky, leaky SNS.

And then there were the judgments. I posted on a few message boards about my troubles, and got a whole lot of “well, you gave into the pressure to give him formula, so his gut bacteria are already ruined, and it’s no wonder your supply tanked after you supplemented” and “before formula existed, people found a way, so there’s no reason you can’t make it work if you want to”.  Once, a woman who spotted my can of formula in my shopping cart told me that she “just feels so bad for children whose parents are too lazy to feed them properly.”

We slowly accepted that this was not going to be quickly resolved and bought a new, permanent SNS. I resigned myself to rashes on my breasts from taping on the tubes, cracked nipples from the pump, and allowing my wife all of the bonding time with my son, still convinced that my supply would increase and we’d eventually be able to have a “normal” nursing relationship.  Several times, I put him to my breast, only to have him scream and cry when almost nothing came out…which of course made me cry more.  I kept trying, convinced that if I just did everything right, things would all work out. At my 4 week follow-up with my midwife, I cried when I saw the “It’s Easy to Make Plenty of Milk” poster hanging in her office, and felt the need to explain to her all of the things I had tried, afraid she was going to judge me for my failings (she didn’t, and was awesome, as were the lactation consultants.  All of the medical professionals in my life were much kinder to me than I was).

With all of this, after 4 more weeks, my production was up to maybe 12 ounces a day.  One night, in a haze of exhaustion, I accidentally put part of the SNS down the garbage disposal.  My wife exploded about how much my breastfeeding failure was costing us in supplements, Canadian drugs, formula, and expensive nursing systems, I cried for 2 hours, and we eventually decided that paying another $70 to replace it just didn’t make sense.  I resigned myself to pumping and giving my son whatever I could make.

Funnily enough, once we dropped the SNS and I let myself accept that I wasn’t going to ever breastfeed him as I’d imagined, my supply jumped (I think the stress of the whole SNS/pump/wash cycle, combined with the worry over whether my supply was increasing or decreasing, playing a big role).  We got a car adapter for the pump so we could leave the house, I started timing my pumping so that I could spend time with the baby while he was awake and alert, and I started to really enjoy feeding times, where all I had to do was focus on him, instead of on whether the SNS was leaking, whether the tube was in his mouth right, or how long it would be before I could be done feeding and pumping, because I only had 2 hours before I had to be up for work.    And I slowly started “coming out” as a partial formula feeder, talking about my experience with a few other new moms, always starting with a long diatribe of all of the things I’d tried to make feeding work.

I still combination-feed my son, who is now 3 months old, with about half of his diet coming from formula, and the other half coming from what I pump.  I work from home, so I am able to pump whenever necessary, and for another, my wife is staying home with our son, so I have extra hands to help me with feedings that take longer than normal…otherwise, I have no illusions about whether we’d be able to continue this way.  For us, this is what works best.  But I am still working through my phobia of giving him bottles in public.  Today, I gave him a bottle in the middle of our Farmer’s Market…baby steps!  I am so incredibly grateful to FFF and other websites providing support for women who are feeding formula, wholly or partially – I truly believe that this site was a big part of me regaining my sanity around feeding my son.

***

Tell the world why your best was best. Send me your story for an upcoming FFF Friday – formulafeeders@gmail.com.

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

Guest Post: The Day I Championed Formula With My Whole Soul

My in-laws are coming in today and I need to clean the damn house, so I have to rely on a guest post today. Luckily for me, I had a great one lying in wait.


I received this story from a wonderful, positive lactivist who has a popular blog; she asked to remain anonymous for reasons that will become obvious. Still, I hope she is reads this – because I want her to know how much I admire her for being able to step back from her activism and recognize that in some cases, common sense has to supersede advocacy.

***

The Day I Championed Formula With My Whole Soul
by “Sharon”
My name is Sharon*, I am  a young and passionate activist for breastfeeding. I want to tell a story that to this day weighs on my mind and heart to such an extent, it makes my blood boil when I think to what extremes some women will go to in the “name of breastfeeding”. Let me first explain a little about my experience with breastfeeding and what has made me a compassionate and open minded advocate for breastfeeding.
I became a mother at the age of 18 to a beautiful 8 pound daughter. I went through hell the first weeks with cracked nipples and the whole shebang. I was fortunate to have had help, ambivalent familial support and a tremendous desire to breastfeed, so, I continued and eventually we fixed the problem. I fell in love with breastfeeding and this is what subsequently drove me to become an outspoken activist for the cause. I breastfed my daughter for a little over a year and I look forward to it the second time around.
Because of my tumultuous start with breastfeeding, I know what it’s like to be near that point of giving up. I know what it’s like to have nipples that feel like shards of glass each time a nursing session comes up, and I know how it feels to want to reach for that can of formula and say “To hell with this!” These reactions are normal and I don’t judge them, or women who feel this way, whether they succumb to the thoughts or not. I don’t gain any personal glory from putting a woman down for turning to formula when she feels like the whole world is crumbling around her. It’s a choice, it’s her choice, it’s not the choice I would have made, but that’s because it was not mine to make. I grant (in my mind ) everyone this right. The right to choose.
Let me continue now to tell you of a story of a former friend of mine, someone so determined to breastfeed, so full of passion and perseverance that she nearly starved her first, and second child to death.
She was a woman who exuded confidence to the extent that it turned into sheer arrogance. She had a character that was an acquired taste. I like to compare it to iguanas and cacti. Not many animals can walk on cactus, it takes a certain type of animal to bear it, namely, an iguana. She was like a cactus and I did my best to be like an iguana for the sake of the friendship. She refused all breastfeeding or childbirth education classes, but she knew she wanted a home birth and breastfeeding experience. She was too good to go to any class because she was a self proclaimed “self-learner”. She ate those words pretty quickly.
Fast forward some months and she finally gives birth. A rather small but healthy baby named Lola. Lola was adored by her family and  was given extra attention because of being the first grandchild. At that time, my former friend, Tanira* was living at her mother’s home, along with her husband and siblings. Tanira was adamant about breastfeeding. She came from a long line of breastfeeders who nursed their children successfully so nothing less would suffice for her (in her mind).  Her rigid and exacting attitude made it difficult to correct her or suggest anything that she disagreed with. That would just welcome a fight. 
A breastfeeding counselor looked at the latch, watched the nursing sessions and deemed everything alright. Tanira breastfed day in and day out.  Mercilessly. But, as the weeks passed by and I saw Lola, she wasn’t getting bigger, she wasn’t getting fatter. I mean, come on, a baby at the breast that much should be a load of rolls . Another week passed, yet another, and each time I saw Lola, she looked worse. The skin hung off her bones, her body re-grew fuzzy hair all over it, and if she ever cried, she could only squeeze out a whimper. Something was terribly wrong and it didn’t take a rocket scientist to know that. 
I was quite unsure about how she would react if I approached  her about how her baby looked and what I could observe. I could barely sleep at night thinking about how gruesomely skinny Lola was getting. I finally decided that I could no longer take it. I contacted an LC and notified her, but asked her to check things out quietly (for fear Tanira found out it was me who said something) I didn’t want to hurt Tanira’s feelings but I couldn’t stand by and watch what was happening and remain silent. Tanira’s husband and mother stood by and watched little Lola for weeks dwindle and lose weight but never spoke up. They weren’t allowed to dare mention the word bottle or formula. 
By this time, I started to become increasingly disgusted with Tanira because of her unyielding attitude. I sensed that she knew something was gravely ill but didn’t want to face the music and be deemed a “failure” by the standards she touted. She skipped the weigh-ins of her baby, and this is when I became enraged. Another LC was contacted because we could not figure out the problem. Everything the baby did was right, the latch, the suckling, the shape of the mouth, the suck, the mom’s nipples were fine. We were stumped. 
Then, a term I’d never heard of before came in the mix. IGT, or Insufficient Glandular Tissue. When I started researching IGT, I kept finding more and more similarities of her situation. The failure to notice breast changes during and after pregnancy, the very slight to almost non-existent engorgement the day your milk comes in, and also, tubular breasts. She matched the description perfectly. With IGT, a condition affecting a small amount of women, the mother doesn’t develop enough of the mammary tissue during puberty, nor during pregnancy , that sustain complete lactation. So while she does produce some milk, the amount never suffices for a complete feeding. 
It was as if we had an epiphany, we finally found out what was happening and now we could help her and get this baby growing! Not once, had anyone around her criticize or demean her if she decided to opt for formula as a supplement or even full time. Quite the contrary, we were all scared out of our wits, never having dealt with such a situation and we wanted nothing more than to shove a bottle of good ole cow’s milk down that baby’s pallet just to get something in that baby.
When her condition was suspected, she was advised by three different breastfeeding experts to pump what she could, and supplement whatever she could not. She was not allowed to breastfeed, she was forbidden to breastfeed because the baby had become so sickly. What did she do? She continued to breastfeed. She refused to pump stating it was too much to handle, despite the fact that her mother was there to help her every step of the way. I became so upset that I immediately notified the LC to take action for fear this baby’s life was in the balance. The LC then called Lola’s doctors to call her in for an appointment immediately.
To our surprise, Tanira went, a bit reluctantly, but she went. When Lola’s doctors laid their eyes on her, their stomachs sank. They informed Tanira that her baby had gained so little weight, that Lola had become anorexic. She grew hair all over her body for warmth because she was so weak she could not stabilize her own temperature. How much weight had Lola gained in 6 weeks? 300 grams. A little bit more than what a breastfed baby should gain per week. We were all stupefied. How could this have gone so far? What would have happened had we not intervened? That baby was near starvation, and for what? For the sake of breastfeeding, for the sake of validating herself as a mother, proving to herself, her self-worth by means of the act of breastfeeding. 
I was so turned off by Tanira’s actions over the course of the weeks. Her selfish and egotistical attitude, her disregard for her baby’s failing health. How could you look at your baby grow weaker and weaker and not feel anything? How could even after finding out the cause, still deny it and push the limits f your child’s life? Why could she not have supplemented, with donor milk or formula for that matter? Hell, all of us was chanting her to do so. It was because it was not about her baby drinking human milk. It was not about giving her baby the optimal start in life by means of mother’s milk. Had this been the case, she could have easily obtained breast milk from another mother. No, this was not acceptable to her. Nothing less than her own milk, not even at the cost of her baby’s health.. Now, I don’t know about y’all but, I’m all for breastfeeding, but not to the detriment of the child.
She did eventually supplement with formula, and then the baby grew, finally Lola grew! She gained weight! And this story was quickly swept under the rug like a shameful family secret that no one dare utter.
Fast forward two years later and Tanira gives birth to her second child. Another girl, named Emily. I was so sure that she had woken up and knew from the very beginning how to proceed and still reap the benefits of partial breastfeeding at least. And then, the unthinkable happened. She exclusively breastfed the second one too. What happened, you ask? Did Emily grow and thrive on a copious production? No, Emily dropped 200 grams below birthweight. Emily  was still passing meconium after 10 days of life. Emily’s once full cheeks sank into her face. But this time around, it was more serious. We had proof, we had evidence. And this time the CPS was thrown into the mix. 
Classic Tanira style, she refused to go weigh the baby stating that meconium after 10 days of life was “normal” and that everything was fine and dandy. Clearly, it was not. She was notified that if she refused to weigh the baby and follow instructions, her baby would be taken into foster care. The result? Sadly, it took her to hear those words for her to go to the appointment, and start the journey of supplementation again. With what result? Emily is now gaining well.
What about Tanira’s husband you ask? He never uttered a word. He never spoke out against her, not just because she rules with an iron fist, but because (and I can personally attest to his disregard) he simply didn’t care about anything around him.
To this day I struggle to wrap my mind about how far one mother could go just to be able to say “I breastfed exclusively!”. This thought sickens me. As if this was some race, some competition. It’s not ladies. Get that through your mind.
The morale of the story? This is exactly the reason why I strive to be understanding and compassionate when a mother decides to formula feed. I don’t want to be the one who makes women feel so insecure, so demeaned that if they gave anything less than human milk to their babies, they are incompetent, unfit, mothers. Because it could cost a baby their life.
So think about it, fellow activists. The next time you feel the urge to judge another formula feeding mother for her (unintentional) choice to formula feed, think of Lola, think of Emily, and stop being such a bitch about it, it makes breastfeeding look bad.
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