Help Your Patients Breastfeed...Safely and Comfortably

Research of mothers’ opinions about their breastfeeding education and support from professionals is very clear: they are not satisfied. Parents want information that is more personalized, less authoritarian, and more realistic; in this survey of over 1,000 women who had initiated breastfeeding, 85% of mothers disagreed that “methods of breastfeeding promotion and education are currently excellent”; only 18% of mothers reported being happy with the information they received from health professionals during pregnancy.

This systematic review showed common complaints:

• Support was rigid and impersonal
• Insufficient practical support postpartum
• Being given unrealistic expectations prenatally
• Education was “strict and dogmatic,” and omitted information about alternative feeding methods such as bottles
• HCPs withheld information about formula
• Perpetuated guilt
• Experienced verbal and physical pressure.

Our breastfeeding education and protocols are out of date, inaccurate, even unsafe…

…nor do they work well for many modern families 

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Q: "Unsafe?" Isn't that a little alarmist?

A: Yes, it is. That's because there is reason to be alarmed. The evidence below speaks for itself:

Source: Global Health Media, an educational resource for health care providers that provides good videos on positioning and latch.

Number of studies showing that “virtually every mother” can make enough milk to support optimal infant growth from 0–6 months, as recommended: ZERO

Q: Should we still be encouraging breastfeeding?

A: Yes! Most mothers want to breastfeed, and human milk provides human-specific nutrition, antibodies, and other bioactive components.

Mean gastric residence times [food remaining in the stomach] was 45 min for aqueous solutions, 57 min for breast milk, 64 min for formula, 87 min for semi-solid food and 98  min for solid test meals.

Five milliliters of colostrum contains 3 calories. A 3000 g baby burns about three hundred calories per day.

So where are they getting those 300 calories? The theory is that healthy term AGA newborns have sufficient fat stores and glycogen to tolerate brief periods of very low feeding volumes without harm. However, no one has looked specifically at the long-term effects of low vs metabolically sufficient volumes in the first few days. Current medical opinion is that the “biological norm,” must be optimal—and safe—because it “emulates evolutionary feeding.” 

(Or does it?)

• Glycogen stores are exhausted after 12 hours of life, and many babies either do not store enough reserves (e.g., LPT/IUGR babies) or have already burned through them (e.g., in a long or difficult labor).
• Ketones as alternative fuel do not provide sufficient protection for newborns. 
• Babies have different calorie and fluid needs, based on their weight, gestational age, stresses during labor, and other factors such as cold stress or prolonged crying. The viscosity of colostrum, which makes it ideal for coating mucosal surfaces with sIgA antibodies, reflects its relatively low level of water content compared with mature human milk, and while it is high in protein, it is lower in calories and carbohydrates than mature milk. 
• If a baby does not get enough calories to support their metabolic needs, they will start digesting their own tissues to provide those nutrients (autophagy).
• Normal (i.e., natural) postnatal survival rates in humans (and other mammals) were abysmal for most of human history.
  

There is no evidence that it is sufficient—let alone optimal—for a newborn to have only drops of colostrum in the first 24 hours

If “evolutionary feeding” is our model, we must also listen to the powerful evolutionary strategy newborns have developed to get their needs met—crying. We must also listen to mothers, who have an equally powerful drive to respond to their babies’ cues and feed them until they’re satisfied.

In fact, withholding calories is probably one of the worst things you can do to babies’ future ability to breastfeed. Underfed babies sleep to conserve calories. Sleepy babies rarely breastfeed effectively. Effective breastfeeding (or pumping) is necessary for establishing a good milk supply. More here. 

Newborns are the only patients that must show clinical and laboratory evidence of dehydration and underfeeding before being given ad lib nutrition and fluids*

*Academy of Breastfeeding Medicine Supplementation protocol.

• Mother’s milk comes in late in about 35% of first-time mothers, and about 19% for multiparas.
• Ten to 15% of mothers experience chronic low milk supply. In 5–8% of mothers, the milk may not come in at all.
  
• Bilirubin levels ≥15 mg/dl can cause developmental delays.
• Donor human milk supplements for term and late preterm infants could cost as little as $13.73 per patient.
• In many cultures around the world where babies typically breastfeed for 1–3 years, breastfeeding is almost universally supplemented, especially in the first days before the milk comes in. Is this necessary? Possibly not, but it shows that supplementation does not invariably disrupt breastfeeding (when done in the context of a breastfeeding-supportive culture, which unfortunately we are currently lacking in the US).

Frequently Asked Questions:

Q: Should all babies be supplemented? 

A: No. Many mothers make enough colostrum.

Q: How will I know which ones need supplementing? 

A: Easy—listen to mothers, listen to babies, and trust your clinical judgment. If you are unsure, the safest and most breastfeeding-supportive intervention is to supplement and teach milk expression. Here is some supplementation guidance. This intervention must only be done with parental informed consent and education on when to return to exclusive breastfeeding (after the milk comes in and there's evidence the baby can transfer effectively).

Q: If babies are voiding and stooling, doesn’t that mean they are getting something?

A: Diaper counts do not reflect babies’ intake in the first few days because of normal diuresis and bowel functioning. Even babies who are NPO produce stools. The volume, frequency, and color of urine can be clues as to the baby's hydration, but the most accurate measures are test weights on a scale accurate to 2 g and their weight loss percentile on the Newborn Weight Loss Tool. 

Q: What about babies who won’t go back to breast after a bottle?

A: Most babies go back and forth fine, as long as they aren't too hungry and aren’t being forced. This 2020 study showed that the mechanics of breast- and bottle-feeding are similar. Evidence is conflicting on the concept of “nipple confusion” and “flow preference” with bottles (4 studies found evidence and 2 did not, and none of them established causality). However, if mothers are concerned about this possibility, here are some strategies. 

Q: Is cluster feeding normal for a neonate? When does frequent feeding become a sign of insufficient intake?

A: Cluster feeding is defined by the Academy of Breastfeeding Medicine as “several short feedings close together.” It is normal in a baby who is gaining weight well. However, in a newborn who is still losing weight, constant crying and continued hunger cues even after feeding are usually signs that they are not satisfied.

Q: Could suggesting supplementation affect mothers’ confidence?

A: There are no studies showing that temporary judicious supplementation decreases maternal confidence in long-term breastfeeding success, and in fact two studies (1,2*) showed it improved breastfeeding duration. Most mothers who have been pregnant and delivered a baby have experienced a little technology being used to reduce risks and/or augment their body’s natural birthing process. They are often relieved to have a strategy to address their baby's hunger and their own need for rest, the latter being important for the mother's health and desire to continue breastfeeding. 

In fact, mothers often feel more confident when their observations about their babies’ hunger are validated. It demonstrates clearly that they have good instincts and can trust themselves to know if their baby is satisfied or not. Knowing they can trust their own judgement also empowers them to know when it would be appropriate to discontinue supplementing. 

*The second study results about longer duration were not statistically significant.

Q: Is there long-term harm to the baby’s microbiome with the introduction of formula?

A: No. Really. 

Q: What about triggering allergies to cow’s milk, or other possible harms?

A: There is no harm of formula that equates to the risks associated with insufficient feeding, let alone small, temporary amounts. Long-term effects of breastfeeding and formula feeding are summarized here, and allergies in particular are discussed here.

For babies with a family history of cow’s milk allergies, a hydrolyzed formula may reduce risks, but the evidence is not strong.

These babies were injured or died due to HCP assumption that breast milk was enough, and because they refused to listen to mothers who knew it wasn't satisfying their babies:

"Twenty-five years ago my son almost died. I had chosen to breastfeed, as everyone around me kept reminding me that ‘breast is best.’ Even though I felt like something wasn’t quite right those first few days, everyone assured me everything was fine....that 'the great thing about breast milk is that you never have to worry about how much or how little he’s getting. Because he’ll always get what he needs.’"—Pamula Floyd, mother of Chaz, who had a stroke from hypernatremic dehydration at 6 days old and now lives with cerebral palsy. Full story here.

Pamula and Chaz Floyd

“[Landon] cried unless he was on the breast and I began to nurse him continuously…when I asked them why he was always on my breast, I was told it was because he was ‘cluster feeding.’ I trusted my health care providers.” —Jillian Johnson, mother of Landon, who suffered a cardiac arrest due to hypernatremic dehydration 12 hours post discharge. He did not survive.

Jillian and Landon Johnson

“After I gave birth to my son, my baby was very hungry and cried inconsolably. I was concerned there was no milk coming out of my breasts. I told my husband to go buy baby milk to give to our son until my breast milk flowed. But my doctor was opposed to this idea, saying that exclusive breastfeeding is the best. I listened to my doctor.” —Josephine ​(last name withheld), whose baby died at two weeks of age, after multiple health care providers told her he was getting enough milk. 

Josephine, pregnant with her late son

Mothers Matter Too

“Do not EVER feel bad or guilty about not being able to ‘exclusively breastfeed’ even though you may feel the pressure to do so based on posters in maternity wards, brochures in prenatal classes, and teachings at breastfeeding classes.”

—Kim Chen, husband of Florence Leung, who committed suicide after being unable to exclusively breastfeed

Kim Chen, Florence Leung, and their newborn

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