Saturday, August 10, 2013

Use of APNO in Treating Sore Nipples

I'm sure every breastfeeding mother has heard of the ubiquitous "APNO". Maybe it was recommended to you by an IBCLC, maybe you found it while trying to google solutions to your own sore nipples. All-purpose Nipple Ointment (or "APNO" as it is so endearingly abbreviated) is a mixture of various prescription creams, and was developed by Dr. Jack Newman. [1]

Mupirocin 2% ointment + Betamethasone 0.1% ointment + Miconazole powder to a final concentration of 2%

In laymen's terms, it's an Antibiotic + Steroid Cream + Anti-fungal. 

Because those ingredients are prescription only, APNO has to be obtained via prescription from a compounding pharmacy. Despite this, I continue to see APNO recommended with near-reckless abandon to all breastfeeding women, regardless of the cause of their sore nipples. Some have even taken the liberty of developing over-the-counter substitutes for APNO, such as bacitracin, polysporin, lamasil, nystatin, hydrocortison, miconazole, and all sorts of combinations/variations. 

Mupirocin/Antibiotic Ointment

Mothers with severe, persistent nipple pain are at a high risk of becoming infected with Staphylococcus aureus, a bacterial strain which can form biofilms, has methicillin-resistant strains, and has been isolated in cases of mastitis. [2],[3],[4] Staph. aureus has been found growing in the abrasions of severely damaged nipples, which has led to a strong correlation between cracked and bleeding nipples with Staph. aureus colonization. [5],[6]

However, colonization is not the same as infection. Colonization is just the presence of bacteria, but without any accompanying symptoms or illness. An infection, on the other hand, implies symptoms and illness. Colonization with Staph. aureus usually requires no treatment. In cases where severe nipple trauma is present, an antibiotic might be prescribed to prevent a Staph. aureus colonization from entering the bloodstream through the cuts and becoming an infection. The first ingredient in APNO, Mupirocin (trade name is bactroban), is known to be effective against strains of Staph. aureus, including MRSA.

That said, there are increasing reports of bacterial resistance to Mupirocin (used for nasal decolonization of MRSA), even being reported in up to 50% of community-acquired MRSA cases in some regions. [7],[8] Such resistance develops as a result of over-use of specific antibiotics, sometimes without cause. In accordance with Antibiotic Stewardship protocols, antibiotics should only be used when they are clinically indicated, in the lowest dose, for the shortest duration of time. [9] Recommending that women put Mupirocin on their nipples for cases of minor to moderate nipple pain with no accompanying abrasions is not good practice. Such practice may result in an increase in Mupirocin resistance, which may reduce the overall effectiveness of Mupirocin (or other antimicrobials) when treating true cases of Staph. aureus infection. 

In some cases, oral antibiotics have even been found to be more effective than topical Mupirocin in treating Staph. aureus colonization [16],[17], suggesting that true cases of Staph. aureus nipple infections require treatment outside the scope of APNO.

Betamethasone/Other Cortisone Creams

The inclusion of Betamethasone in APNO is specifically to target nipple soreness that is caused by atopic dermatitis, eczema, or general inflammation. As a steroid cream, it may help reduce redness and swelling and irritation in the early days of breastfeeding. 

That said, a double-blind study published in the Journal of Breastfeeding Medicine found no advantage to Betamethasone (in the form of APNO), versus pure lanolin. [10] When undergoing any treatment with medication, best practice indicates to always begin with the most basic treatment and work up. Therefore it stands to reason that mothers experiencing nipple soreness would be better off starting with pure lanolin rather than a prescription cortisone cream. Corticosteroid creams are not without risk, and their use needs to be monitored and kept within the shortest parameter's possible to prevent unwanted side effects. [11]

Another consideration with the use of Betamethasone ointment is the potential exposure of the infant to high levels of mineral paraffins. [12],[13] Most pharmaceutical ointment bases contain paraffin. Given that no significant benefit has been found for Betamethasone vs pure lanolin, most mothers would be better off using lanolin unless an actual case of atopic dermatitis has been identified. 

Miconazole/Anti-Fungals

Some cases of nipple pain may be traced back to an overgrowth of Candida. Candida is a fungus that is present in all humans, but in some cases it may grow to high levels, causing a condition known colloquially as thrush. Thrush can be difficult to get rid of, and is very strongly associated with recent antibiotic use. Antibiotics kill many of the good bacteria that compete with Candida for food. Destruction of this good bacteria can allow Candida fungus to grow.

Miconazole is an anti-fungal and although it is not the first choice of many doctors for treating nipple thrush, it has nonetheless been found to be effective. When used in conjunction with a topical antibiotic it could potentially prevent thrush from developing. But, when it comes to APNO, Mupirocin already has anti-fungal properties and therefore is unlikely to result in thrush. [14],[15]

When it come to "all purpose" nipple ointments, I have to wonder if we really need to be treating ALL the potentials. A mother who has a known case of thrush is not going to need an antibiotic. A mother who needs a topical antibiotic probably doesn't need a steroid cream. Even. Dr. Newman acknowledges that when it comes to medicine, it is best to go with the single "right" treatment for the "right" problem. Any time a case of nipple pain can be isolated to its roots, treatment should be tailored to that specific problem.

The justification for prescribing APNO is that mothers who are suffering from sore nipples "without known cause" may not have time to play a juggling game with treatments, trying to figure out which one works. Therefore prescribing an ointment designed to knock out all of the potentials may be prudent, particularly if weaning is being considered. That is where APNO has carved out a very valuable place in breastfeeding management. 


But it needs to be said that anytime a mother is experiencing such severe pain and trauma that she is considering weaning, she needs to be seen by an IBCLC. Such problems do not arise out of nothing, and it is critical to prolonged and sustained relief that the root cause be identified and corrected. I see many times where those in the breastfeeding community treat APNO as a substitute for proper lactation management, or they recommend it for mild to moderate transient pain, where pure lanolin would work just fine.  

Also concerning is the upsurge in "over-the counter" APNO's, made by mixing various store-bought topical creams together. The proportions of these creams may vary, and over the counter antibacterial ointments have also been increasingly linked to antibiotic resistance in the community. Antibiotics in particular need to be used very judiciously, and there is no scientific basis for applying antibiotic cream or ointment to nipples for just transient pain. Antibiotic ointments themselves do not get rid of pain; they inhibit bacterial growth. Therefore they only need to be used in cases where the pain is either a direct result of an infection, or else the mother has nipple wounds and is at risk of developing an infection. 

Whenever those in the breastfeeding community are dealing with sore nipples, start with the most effective treatment that also carries the fewest side effects. Unless a mother has sustained, severe pain and/or open nipple wounds, pure lanolin is most certainly the safest and best choice.

References: 

1. International Breastfeeding Centre. 2009. "All Purpose Nipple Ointment (APNO)"http://www.nbci.ca/index.php?option=com_content&id=76:all-purpose-nipple-ointment-apno&Itemid=17

2. Journal of Emerging Infectious Diseases. 2007. "Postpartum Mastitis and Community-acquired Methicillin-resistant Staphylococcus aureus."
 http://wwwnc.cdc.gov/eid/article/13/2/06-0989_article.htm

3. Journal of Obstetrics and Gynecology. 2008. "Community-acquired methicillin-resistant Staphylococcus aureus among patients with puerperal mastitis requiring hospitalization."
 http://www.ncbi.nlm.nih.gov/pubmed/18757649

4. International Breastfeeding Journal. 2008. "The role of bacteria in lactational mastitis and some considerations of the use of antibiotic treatment"
http://www.internationalbreastfeedingjournal.com/content/3/1/6

5. Journal of Human Lactation. 1999. "The treatment of Staphylococcus Aureus Infected Sore Nipples: A Randomized Comparative Study."  http://www.breastfeedingclinic.com/ckfinder/userfiles/files/TreatmentofStaphyloccocus.pdf

6. American Family Physician. 2008. "Management of Mastitis in Breastfeeding Women" http://www.aafp.org/afp/2008/0915/p727.html

7. Journal of Antimicrobial Agents and Chemotherapy. 2007. "Mupirocin-Resistant, Methicillin-Resistant Staphylococcus aureusStrains in Canadian Hospitals"
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2151460/

8. Journal of Clinical Infectious Diseases. 2009. "Mupirocin Resistance"
http://cid.oxfordjournals.org/content/49/6/935.long

9. The Nebraska Medical Center. "Antimicrobial Stewardship Program"
http://www.nebraskamed.com/careers/education-programs/asp

10. Journal of Breastfeeding Medicine. 2012. "An All-Purpose Nipple Ointment Versus Lanolin in Treating
Painful Damaged Nipples in Breastfeeding Women: A Randomized Controlled Trial"
http://online.liebertpub.com/doi/pdf/10.1089/bfm.2011.0121

11. Journal of Cutaneous Medicine and Surgery. 2004. "Nipple and Areolar Eczema in the
Breastfeeding Woman"
http://dermatologycentral.typepad.com/files/nipple-and-areolar-eczema-i.pdf

12. Journal of Regulatory Toxicology and Pharmacology. 2003. "Exposure of babies to C15-C45 mineral paraffins from human milk and breast salves."
http://www.ncbi.nlm.nih.gov/pubmed/14623482?dopt=Abstract

13. Drugs and Lactation Database
http://toxnet.nlm.nih.gov/cgi-bin/sis/search/f?./temp/~S8ICbU:2

14. The Journal of Antimicrobial Chemotherapy. 1999. "The antifungal activity of mupirocin."
http://www.ncbi.nlm.nih.gov/pubmed/10350391

15. International Journal of Dermatology. 1999. "Perianal candidosis--a comparative study with mupirocin and nystatin."
 http://www.ncbi.nlm.nih.gov/pubmed/10487455

16. University of Michegan: Department of Pediatrics. 2003. "Oral Antibiotics and Positioning Are Effective in Decreasing Morbidity in Breastfeeding Mothers"
http://www.med.umich.edu/pediatrics/ebm/cats/bfeed.htm

17. Journal of Human Lactation. 1999. "The treatment of Staphyloccocus aureus infected sore nipples: a randomized comparative study."
 http://www.ncbi.nlm.nih.gov/pubmed/10578803

Tuesday, August 6, 2013

Neonatal Hypoglycemia

Neonatal Hypoglycemia has received an upsurge in attention recently. As breastfeeding is pulled more and more in to the spot light, hospital interventions are being painted in a much more negative light. One such hospital intervention is the routine testing of infant blood sugar, which is used to justify formula supplementation of newborns.

Neonatal Physiology and Hypoglycemia

Glucose is the main source of energy for humans, and up to 90% of our total glucose is consumed by the brain. While in the womb, the neonate is attached to the umbilical cord, which supplies a constant infusion of glucose to the developing brain. Once born, that supply is cut off, and the infant's body must then change over to an enteral supply of glucose. During the 3rd trimester, the infant begins laying down liver glycogen stores. These glycogen stores will act as fuel until the mother's breast milk volume increases and breastfeeding is established. [1]

Within the first few hours of a newborn's life, it's is physiologically normal for there to be a drop in blood sugar. When you move from a constant supply to intermittent supply of glucose, there is going to be some fluctuation. Ideally, the infant begins metabolizing stored glycogen and that, combined with regular breastfeeding of colostrum and skin to skin contact with the mother, allows the infant to maintain his blood glucose levels on his own. The blood sugar levels will then begin to rise, normalizing around the 24 hour mark. [1],[2],[3]

When Hypoglycemia Becomes An Issue

Some infants are unable to maintain their blood sugar. Preterm infants are at a particularly high risk, since they oftentimes lack the liver glycogen stores that full-term, healthy newborns have. In some instances, delaying the first breastfeeding can also result in blood sugar levels that are too low. While there is no single cut-off point for determining when an infant is hypoglycemic, there are different levels of intervention that are implemented at different points in the first days of life, all of which have the ultimate goal of preventing full-blown hypoglycemia. [3]

During full-blown hypoglycemia, the brain experiences a decrease in the amount of glucose it has available for fuel. Without that fuel, neurological damage can result. Treating Neonatal Hypoglycemia in a timely manner is of utmost importance and involves maintaining blood sugar levels while they are within treatment thresholds, BEFORE they reach the level of neurological impairment. Since no one really knows at what level an infant is going to experience neurological impairment as a result of low blood sugar, the therapeutic threshold of <40 mg/dL has been established as the point at which therapy becomes necessary. That level is variable though, and depending on who is responsible for care of an infant, therapy may begin at a higher blood sugar level for sick or preterm infants, or may be allowed to go lower in infants who are otherwise asymptomatic. [4]

The American Academy of Pediatrics established guidelines in 2011 for the monitoring and treatment of Neonatal Hypoglycemia, with 45 mg/dL designated as the target glucose level. The AAP also recommends against the routine testing of blood glucose in full term, healthy newborns. Rather, the implementation of a glucose screening program should target those infants who are at risk. [12] The rationale for such a recommendation is that routine blood sugar testing usually results in aggressive supplementation of infants who would have otherwise been breastfed. Breastfed infants have higher levels of ketone bodies, which may provide protection against hypoglycemia-induced neurological impairment, since the brain is also able to use ketones for fuel. [5],[7]

Stage 1 Intervention

The first stage of intervention applies to all infants, regardless of blood sugar levels. FEED THE BABY. Breastfeeding should be initiated within the first 60 minutes of an infant's life. If the infant is separated from the mother, or the mother is unable to bring the baby to breast, or the baby will not latch, then she should begin to hand express by the end of that first hour. The expressed milk can then be given to the infant through an alternative device (syringe, cup, dropper, SNS, etc). Colostrum is the preferred food source for preventing hypoglycemia because it is high in amino acid precursors and fatty acids which prompt the newborn's body to undergo gluconeogenesis, while minimizing insulin secretion. [5]

Stage 2 Intervention

The second stage of intervention is once again to feed the baby. If an infant is presenting with blood sugar levels below 40 mg/dL, but it asymptomatic, then protocol is to simply continue to offer breastfeeds. In addition to offering breastfeeding, it may be necessary to offer a small supplement of expressed colostrum with a syringe. If expressed colostrum is not available, human donor milk or formula can be used. Blood glucose can then be re-measured 30-60 minutes later. [4],[6],[7]

Stage 3 Intervention

Stage 3 intervention is for infants who are asymptomatic with a sugar level < 25 mg/dL, infants who are symptomatic with a sugar level < 40 mg/dL, or infants who have a persistent hypoglycemia who do not improve by increased breast milk feeding. It is also for infants who are unable to tolerate oral feeds.

The third stage of intervention involves the administration of an IV bolus of dextrose, followed by an intravenous infusion. Once an intravenous infusion of dextrose has been started, it cannot be stopped without first titrating down the dose. Sudden cessation of IV dextrose can result in reactive hypoglycemia. Infants who are unable to maintain their blood sugars are usually referred to the Neonatal Intensive Care Unit. [4],[6],[7]

Use of Infant Formula in the Treatment of Neonatal Hypoglycemia

With an increased awareness of the hazards of not breastfeeding, supplementing infants with formula is almost always regarded with disdain, regardless of the reason for the supplementation. When it comes to treating Neonatal Hypoglycemia, the first choice of supplement is always going to be breast milk, first from the mother, then from another mother.

But in some instances, breast milk is not available. The mother may be recovering from a difficult delivery, the infant may be in the NICU for other reasons, the mother may not have any success hand expressing or using a pump, or donor milk may not be available at that hospital. In those instances, formula is the next option.

There are some breastfeeding supporters who advocate for the use of IV dextrose as a "non-formula" alternative to supplementation, but I feel that kind of management goes against not only evidence but also better judgement.

Treating Neonatal Hypoglycemia should always involve the stage of intervention that is the least aggressive, but is going to allow for the best possible neonatal outcome, as well as the greatest preservation of breastfeeding. In infants who are not symptomatic and who can tolerate oral feedings, supplementation with a clinically indicated amount of formula is preferable to an IV infusion of dextrose. [6] IV dextrose is a much larger intervention, oftentimes involving moving the infant to the NICU. Such maternal/infant separation does more to undermine breastfeeding than a one-time limited formula supplementation. Infants who are allowed to be orally supplemented with expressed milk or formula can remain skin-to-skin with the mother. This type of kangaroo care helps the infant to regulate his body temperature, which results in less caloric expenditure and thus greater glycemic management. Oral supplements can be given in a way that does not affect breastfeeding, such as using an at-breast supplementation device or a syringe. And the duration of hospital stay is shorter than an infant receiving an IV infusion.

The other downside to IV infusions of dextrose is aluminum content. Many IV medications, including dextrose, contain aluminum. [8],[9] Intravenous infusions of aluminum are associated with larger accumulations of aluminum in the body, and neurological delays. This is of particular concern with preterm infants, and studies on preterm infants who receive Total Paraenteral Nutrition have shown slight neurological delays as a result of the aluminum given in the infusions. [10],[11] Formula also contains aluminum, but orally obtained aluminum is much easier eliminated from the body and very little is absorbed and accumulated.

For that reason, lower-level interventions should always be preferred and used to prevent Neonatal Hypoglycemia from getting to the point where an IV infusion of dextrose is indicated. IV dextrose should not be used as an "alternative" to giving an infant formula. Proper management of breastfeeding with neonatal hypoglycemia should, in almost all cases, remove the need for formula in the first place, and there is no evidence to back of the "routine" supplementation of infants with formula. [2]

References:

1. American Academy of Pediatrics. 1999. "Neonatal Hypoglycemia"
http://pedsinreview.aappublications.org/content/20/7/e6.full

2. International Breastfeeding Center (Dr. Jack Newman). 2009. "Hypoglycaemia of the Newborn (Low Blood Sugar)"
http://www.nbci.ca/index.php?option=com_content&id=71:hypoglycaemia-of-the-newborn-low-blood-sugar&Itemid=17

3. World Health Organization. 1997. "Hypoglycaemia of the Newborn: Review of the Literature"
https://apps.who.int/chd/publications/imci/bf/hypoglyc/hypoclyc.htm

4. National Neonatology Forum. 2000-2013 "Management of Neonatal Hypoglycemia"
http://nnfpublication.org/Uploads/Articles/4c86270b-ac2d-4c04-b55b-abc5add3e623.pdf

5. Walker, Marsha. 2009. Breastfeeding Management for the Clinician: Using the Evidence

6. Academy of Breastfeeding Medicine. 2006. "ABM Clinical Protocol #1: Guidelines for Glucose Monitoring and Treatment of Hypoglycemia in Breastfed Neonates"
http://www.bfmed.org/Media/Files/Protocols/hypoglycemia.pdf

7. International Lactation Consultant Association. Marinelli, Kathleen. 2012. "Hypoglycemia and the Breastfeeding Newborn"
http://www.ilca.org/files/USLCA/Education_Resources/Webinar_Materials/11-8-12/Hypoglycemia%20Marinelli%20USLCA%202012.pdf

8. B. Braun Medical, Inc. 2008. "Dextrose Injection USP"
http://dailymed.nlm.nih.gov/dailymed/archives/fdaDrugInfo.cfm?archiveid=8218

9. Journal of Parenteral and Enteral Nutrition. 2010. "Aluminum content in intravenous solutions for administration to neonates: role of product preparation and administration methods."http://www.ncbi.nlm.nih.gov/pubmed/20467015

10. American Academy of Pediatrics. 2009. "Aluminum Exposure From Parenteral Nutrition in Preterm Infants: Bone Health at 15-Year Follow-up"http://pediatrics.aappublications.org/content/124/5/1372

11. Proceedings of the Nutrition Society. 2011. "Aluminium exposure from parenteral nutrition in preterm infants and later health outcomes during childhood and adolescence."http://www.ncbi.nlm.nih.gov/pubmed/21781356

12. American Academy of Pediatrics. 2011. "Postnatal Glucose Homeostasis in Late-Preterm and Term Infants"http://pediatrics.aappublications.org/content/127/3/575.full


Sunday, August 4, 2013

Early Limited Formula: Exclusive Breastfeeding?

On May 13, 2013 the American Academy of Pediatrics published a study in their journal Pediatrics looking at the effects of Early Limited Formula on the duration of exclusive breastfeeding. As many outraged bloggers and health professionals pointed out in the days following its publication, the sample size was small and can hardly represent a larger population of women outside of the San Francisco area.

But there are some very overlooked facets of the study that I feel warrant additional criticism. Per definition, any infant who receives ANY breast milk substitutes in the first 6 months of life can no longer be considered "exclusively" breastfeeding for research purposes. It does not matter if an infant gets 1 bottle and is exclusively breastfed afterwards. For the sake of research, that infant cannot be considered exclusively breastfed.

Therefore, Early Limited Formula (ELF) does not increase exclusive breastfeeding rates. It is, by its very existence, a detriment to exclusive breastfeeding. That doesn't mean that ELF doesn't have its place, and as demonstrated by this study most of the mothers who gave ELF went on to wean entirely off the supplement and breastfeed their infants without supplementation. [1]

Which brings me to my second criticism: Early Limited Formula. ELF is not the haphazard feeding of formula to neonates "just because". It is a strictly controlled method of delivering formula supplements to infants who have a clinical indication, in a way that does not undermine breastfeeding. The women in the supplementation group gave only 10 mL's of formula via a syringe after each breastfeed. Infants who were assigned to the study were those who had lost > 5% of their birth weight in the first 24 hours of life. Such dramatic weight loss is correlated with overall weight loss of  >10%. The formula supplements were discontinued at 3-5 days postpartum, when the mother's milk volume increased.

By their mere participation, the women in the supplementation group received additional education on the proper supplementation of a breastfed infant. By having strictly controlled formula amounts and a set timeline, these women were inadvertently educated on newborn stomach size as well as clinically indicated supplementation amounts. The ELF supplements were administered by a study nurse, who also educated them on how to supplement. That makes them much less likely to go home and try and give their baby a 2 ounce "top up" bottle of ready-to-feed (the most common form of formula given out to new moms as samples) .

This is education that the control group missed out on. In the study, the women in the control group were given education on an infant soothing technique.

This study shows that it's not the supplementation itself that benefits breastfeeding rates, but it's actually HOW you supplement. Many women stop exclusively breastfeeding because they perceive their supply to be low. They give overly large bottles, which results in the newborn's stomach stretching, flow preference developing, and breastfeeding becomes even more difficult.

Going off of 20 years of research, hospital supplementation of newborns is almost always correlated with reduced breastfeeding rates. This study has far too small of a sample size, with far too many clinical errors, to be considered groundbreaking. It does nothing to counter-act decades of research. [2],[3],[4]

Some other criticisms of the study:

1. Did the >5% weight loss in the first 24 hours control for women who received IV fluids? IV fluids given during labor pass through the placenta and over-inflate the newborn's birth weight. In the first 24 hours, the infant will urinate out much of that fluid, which results in a dramatic % weight loss. [6]

2. Not all of the women were on equal footing when it came to breastfeeding experience. The ELF group contained more multiparous women, and they even admitted that 78% of multiparous women were still breastfeeding at 3 months vs 33% of primaparous mothers.

3. Why formula and not donor milk? Pasteurized donor milk has been found to be a safe and effective supplement for newborns. [7],[8] This study has the side effect of promoting/justifying the use of infant formula, when really it was the supplementation method itself that had the effect and not the choice of supplement.

This study also brings up ethical concerns. Given that there are very real hazards associated with giving infants formula, the randomization of infants to receive either formula supplementation or exclusive breast milk is troubling. The criteria for including infants in the study only mentions that they had lost >5% of their birth weight. That alone should not be considered cause for supplementation. So by randomizing infants to receive possibly unnecessary formula supplements, this study has the potential to be considered unethical.

There are a number of "interventions" that have all been positively correlated with longer duration of breastfeeding:

1. Early initiation of breastfeeding. The sooner after birth a mother initiates breastfeeding, the more likely she is to continue breastfeeding after discharge. Higher rates of formula supplementation are associated with newborns born on the night shift, where access to IBCLC's and lactation support is more scant. [4]

2. Prenatal childbirth and breastfeeding education. Prenatal breastfeeding education is very positively correlated with greater breastfeeding initiation as well as longer breastfeeding duration. [4]

3. Staff support of breastfeeding, hospital policy, and home-based peer counseling. This includes things like formula samples, rooming-in, staff support of breastfeeding, and education of nursing staff on breastfeeding. Baby-Friendly Hospital Initiative is also positively associated with better breastfeeding outcomes, [5] as are peer-counseling programs.

References:

1. American Academy of Pediatrics. 2013. "Effect of Early Limited Formula on Exclusivity and Duration of Breastfeeding in At-Risk Infants"
 http://pediatrics.aappublications.org/content/early/2013/05/08/peds.2012-2809.abstract

2. American Academy of Pediatrics. 1991. "Early Formula Supplementation of Breastfeeding"
http://pediatrics.aappublications.org/content/early/2013/05/08/peds.2012-2809.abstract

3. American Academy of Pediatrics. 1985. "Effect of Formula Supplementation in the Hospital on the Duration of Breastfeeding."
http://pediatrics.aappublications.org/content/75/3/514.short

4. Journal of Human Lactation. 2005. "In-Hospital Formula Supplementation of Healthy Breastfeeding Newborns"
http://jhl.sagepub.com/content/21/4/397.short

5. American Academy of Pediatrics. 2001. "Baby-Friendly Hospital Initiative Improves Breastfeeding Initiation Rates in a US Hospital Setting"
http://www.pediatricsdigest.mobi/content/108/3/677.short

6. International Breastfeeding Journal. 2011. "An observational study of associations among maternal fluids during parturition, neonatal output, and breastfed newborn weight loss"http://www.internationalbreastfeedingjournal.com/content/6/1/9/abstract

7. Journal of Human Lactation. 2001. "Donor Milk: What's in It and What's Not?"
http://jhl.sagepub.com/content/17/2/152.short

8. American Academy of Pediatrics. 2012. "Breastfeeding and the Use of Human Milk"
http://pediatrics.aappublications.org/content/129/3/e827.full

Thursday, August 1, 2013

The fallacy of being Pro-"feed the baby"

Whenever a discussion begins about breastfeeding, it's not uncommon to find a subset of individuals who fall prey to the "feed the baby" fallacy:

"Oh, I'm not pro-breastfeeding or pro-formula. I'm just Pro-'feed the baby' "
"Some women can't breastfeed. It's not about breast or bottle, just feed the baby."

"It doesn't matter how an infant is fed, as long as the infant is just fed, period."

Fair enough. I used to be one of those people (in a day before children). But now I can see some glaring errors in that kind of argument.

1. Who is advocating for starving an infant?

No one in their right mind would ever support infants not being fed. EVERYONE is Pro-"feeding the baby".

The deeper issue with this argument is that it plays in to the misinformation about breastfeeding, namely that breastfeeding is not enough, that mothers do not have milk, and that a desire to breastfeed results in infants "starving" until a mother's milk "comes in."

Some women cannot breastfeed. About 3% of the US population have Primary Insufficient Milk Supply (IMS). It's the inability of a woman to make enough breast milk right out of the gate. Causes may include breast reduction or surgery (mastectomies, cyst removal, biopsy, etc), untreated hypothyroidism, breast hypoplasia, or other hormonal or endocrine disorders.

Then there is secondary IMS, which could be a result of a tongue tie, premature birth, clefts in the lip or palate, Down Syndrome, infant scheduling, formula supplementation, etc. Secondary IMS is low milk supply caused by conditions that are secondary to a woman's actual biology. These women do produce enough milk and have the potential to exclusively breastfeed, but other causes result in their supply lowering from insufficient milk removal.

When someone says that they are Pro-"feeding the baby", they are giving credence to the argument that breastfed mothers are somehow not going to produce enough and will starve their infants. There are all kinds of personal stories out there about mothers who did not have adequate lactation support and almost starved their infants trying to breastfeed.

It is not the goal of a Lactation Consultant (or educator, peer counselor, LLL leader, etc) to force women in to breastfeeding in situations where it would not be reasonable. The number one goal of a Lactation Consultant IS to feed the baby. A baby who is fed has more energy to maintain their body processes and reflexes to latch. This is why in some situations it is actually beneficial to supplement newborns with formula or donor milk. A baby who is fed is a baby who can then be guided back to breast

Any Lactation person who believes otherwise, who believes that exclusive breastfeeding is the only goal, is seriously missing the boat. When a newborn needs to be supplemented is widely variable, which is why proper breastfeeding support and follow-up is so direly needed.

2. Feeding a baby does not have to imply that you cannot have a preference for a food source.

As we can see, everyone is Pro-"feed the baby". But when you're working to make sure an infant is being fed, it is ignorant to assume that you're not allowed to have a preference for a food source.

Breast milk is the baseline by which all other infant feeding methods are compared against. Breast is not best. Breast is merely normal. When it comes to advocating for the nutrition of infants, breast milk should simply be considered the default.

Usually around this time is when people like to point out to me that "some mothers just don't want to breastfeed." That's fine. Some people also don't want to floss their teeth or eat vegetables. A patient's personal lifestyle choices do not factor in to the promotion of optimal health practices. When your dentist tells you to floss your teeth, he does not take in to account whether or not your have time to floss, if flossing hurts your gums, or if you always forget to buy floss at the store. His job is simply to educate you on why you need to floss your teeth. If you choose not to heed his advice, that is entirely your doing.

It's the same with breastfeeding. The job of Lactation Professionals is to educate women about breastfeeding. Some of that education is going to involve some rather unpleasant statistics (like how preterm infants who are fed formula are at a higher risk of developing necrotizing entercolitis, or that formula is deficient in appetite-regulatory hormones). If you choose not to breastfeed because it does not fit in with your lifestyle choices, that is your prerogative. But your personal choices should not influence the education and support of others.

Many mothers make a choice not to breastfeed because they believe it does not fit in with their lifestyle, but with the proper support and education those same women may make a different choice. When working with women who are unsure if breastfeeding is going to work for them, most Lactation Professionals WILL take in to account personal lifestyle choices and help tailor a plan directly for the mother that both allows the child to breastfeed while not completely discounting situations that may make it harder for the mothers.

There are still going to be women who do not want to breastfeed, do not like it, think it is gross, or who simply are NOT interested and never will be. And that is fine. Every parent has the prerogative to make their own feeding decision for their children. But these types of situations represent a HUGE minority of cases, and should in no way influence health policy. The choice between breast milk and formula is not an equal choice. The 2 options are not on the same caliber as one another. Breast milk is the base line, and formula is beneath it. It is important to make that distinction to parents, not in an attempt to guilt mothers in to breastfeeding, but so that they can make a truly informed decision.

3. Is there even a breast vs bottle debate?

Outside of the mommy-sphere, No. As mothers, it's very important to have your parenting validated by others. Even if you know you're a good mother and are doing everything right, just having someone say "hey, you're a good mother" means the world.

When it comes to the breast vs bottle debate, many moms on BOTH sides are left feeling like they have been invalidated. Those who formula feed may take pro-breastfeeding sentiments very personally, and I'm not surprised. MOST women (about 90%) want to breastfeed. Breastfeeding initiation rates are high, in many areas they are even higher than the national goal. But according to a new report out by the CDC, only 16.4% of women are still exclusively breastfeeding at 6 months.

It would appear that almost 60% of women introduce formula or solids to their children before the recommended 6-month time frame. This could mean formula is given as a supplement or as a complete switch to formula feeding, or even that the mother breastfeeds but introduced solid foods like rice cereal prematurely.

Our healthcare system is failing these women. And I do not mean failing in the sense of "oh those poor babies aren't getting enough breast milk" way, but I mean failing in a "these mothers had breastfeeding goals and were not supported in their attempts to meet them" way. When you have an almost 80% breastfeeding initiation rate, and only 16% are actually meeting the AAP recommendation of exclusive breast milk for 6 months, that is a huge failure of the healthcare system.

And yes, breastfeeding absolutely IS part of the healthcare system. Infants who are formula fed have statistically more doctors visits, more ear infections, and an increased risk of obesity, all of which results in higher insurance and out of pocket healthcare costs, higher costs to public assistance programs (WIC), and higher costs to children's medicaid programs. The mothers are at a higher risk of developing breast and ovarian cancers. Breastfeeding is a matter of public health and deserves attention AS a matter of health and not just as a parenting choice.

Many of those women who initially wanted to breastfed but were not able to continue are going to feel let down. They're going to feel let down by their doctors, by their spouses/partners, their families, and even their own bodies. It's not a matter of making women feel guilty. No one is forcing guilt on women and deliberately trying to make them feel like crap for not being able to continue. Breastfeeding is not a carrot on a string that is being dangled in front of mothers while the "lactivists" taunt them in the background. This is a situation where a few bad apples have really spoiled the bunch. Guilt is a scapegoat that has allowed doctors and husbands and Mother-in-laws and friends and even women themselves to blow off breastfeeding as just some parenting option that doesn't really matter. When you're really struggling to breastfeed and you do not have the support, the validation that formula is "just as good" is comforting.

But when you stop looking at breastfeeding as nothing more than an acceptable feeding option and start viewing it through the lens of infant and maternal health, the debate of breast vs bottle virtually disappears.

Being Pro-"feed the infant" is nothing more than an attempt at pleasing everyone. It's not a logical place to be in the discussion on infant feeding.