Guidelines for Pregnant and Breastfeeding Mothers During the Coronavirus Pandemic

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By the Fed is Best Foundation Health Professional Team

We have summarized the current recommendations by the Centers for Disease Control  for Pregnant and Breastfeeding Mothers in the wake of the Coronavirus Pandemic (COVID-19). The American College of Obstetricians and Gynecologists have also endorsed the CDC recommendations. This information is intended to inform health care professionals and pregnant mothers who are confirmed positive for COVID-19 or persons under investigation (PUI) for COVID-19 in the hospital and postpartum settings.

The symptoms of coronavirus for pregnant and lactating mothers and infants are the same as those of the general population, which include:

  • Fever 
  • Cough
  • Shortness of Breath

The United States is currently has the highest number of coronavirus cases in the world, particularly in New York, California and Washington State. See the current world distribution of Coronavirus cases here.

Pre-Hospital Considerations (For Ambulance Transportation)

  • Pregnant mothers who are confirmed COVID-19 positive or have symptoms of COVID-19 or have been in close contact with a person with confirmed COVID-19 or PUI, should notify their obstetrician before coming to the hospital.
  • If coming by ambulance, you should also notify 911 of your symptoms.

During HOspitalization

  • Pregnant mothers who are confirmed COVID-19 patients or PUIs should be isolated from other patients similar to other patients who are confirmed or suspected to have COVID-19.
  • Visitors should be screened and should be kept to the minimum essential support members in accordance with hospital policy.
  • Infants born to mothers who are COVID-19 positive or consider suspected of COVID-19 should be isolated from the general patient population. Hospital personnel should use the same precautions using personal protective equipment when caring for those infants.

Mother/Baby Contact

  • There is no evidence at this time that COVID-19 is transmitted through breast milk. There is very limited evidence showing that there may be transmission of the virus through the placenta, with two infants documented to have immunological markers consistent with this. However those infants, at the time of the publication, had no symptoms of infection.
  • Infants born to COVID+ mothers are at risk of COVID-19 infection through infectious respiratory secretions from the mother. Separation of mothers who are COVID-19+ or a PUI from the baby for the current recommended isolation period should be strongly considered. A screened healthy support person, may provide care to the baby during that time.

According to the CDC:

“It is unknown whether newborns with COVID-19 are at increased risk for severe complications. Transmission after birth via contact with infectious respiratory secretions is a concern. To reduce the risk of  transmission of the virus that causes COVID-19 from the mother to the newborn, facilities should consider temporarily separating (e.g., separate rooms) the mother who has confirmed COVID-19 or is a PUI from her baby until the mother’s transmission-based precautions are discontinued, as described in the Interim Considerations for Disposition of Hospitalized Patients with COVID-19. The risks and benefits of temporary separation of the mother from her baby should be discussed with the mother by the healthcare team.”

  • Healthy visitors and hospital staff should also wear full PPE per CDC guidelines while providing care to the infant and mother.
  • A separate isolation room should be provided for the infant while they remain a PUI.
  • The decision to discontinue temporary separation should be made in consultation with physicians, infection prevention control specialists and public health officials based on the mother’s disease severity, signs and symptoms of illness and laboratory tests for COVID-19.
  • If the mother, after informed consent of the risk of COVID-19 transmission, wishes to room-in or rooming in is unavoidable due to facility limitations:
    • Facilities should consider providing physical barriers like a curtain with 6 feet distance between mom and baby in the room.
    • Mother’s should wear protective personal equipment (PPE) as well, including a face mask as well as a gown and gloves, if available, during contact with baby. Careful hand hygiene should be performed before and after putting on the face mask and gown. The last step should be putting on clean gloves.

Dr. Denise Jamieson, chair of the Department of Gynecology and Obstetrics at Emory University, said on a CDC teleconference for clinicians on March 12, that the safest option is to separate the baby and have the mother express milk and then discard it. She stated that there could be a small risk of virus in the milk, although so far there is no evidence that this happens with COVID-19. The next safest would be to separate mom and baby, pump milk and have a healthy caregiver give the pumped breast milk in a bottle. A less-safe option would be to have mom breastfeed the baby at the breast with a mask to prevent exposing them to respiratory droplets. The least safe option would be breastfeeding directly with extended close bonding with the baby. The risk of the last option is increased the more severe the symptoms are for the mom.

In an interview with undark.com, Dr. Jessica Madden, pediatrician/neonatologist in Cleveland, Ohio, states at this time, particularly in areas heavily hit with COVID-19, that it is unlikely that facilities will have another room to separate the baby, so separation behind a curtain with six feet between mother and child while a healthy care provider cares for the child would be the only option available. She stated that “until we have more cases to be able to base recommendations on, that the absolute worst thing would be to have a baby to get really sick because we haven’t taken the proper precautions.”

Dr. Madden is also concerned that expectant mothers are thinking about changing their plans for a hospital birth to a home birth because of the coronavirus guidelines for mother/baby separation. “I think that if you are pregnant and you know you have this virus or are suspected to have the virus, that that’s extraordinarily dangerous to deliver at home.”

Effects of COVID-19 Infection to Infants < 1 year old

In a study published in the journal Pediatrics looking at 2143 children in China less than 18 years old with confirmed or suspected COVID-19, 90% had mild to moderate disease (flu-like symptoms) and 4% had no symptoms. Of the remaining children, 5% had severe disease with low oxygen saturation < 92% and 0.6% had critical illness including respiratory failure and organ dysfunction, with only 1 death. The highest incidence of critical illness (11%) occurred in children less than 1 years of age. What this tells us is that although most children do well, the most vulnerable among them are infants. This makes protecting infants, particularly newborns, from exposure to infectious respiratory secretions produced by a COVID-19+ mother of particular importance. Ways to reduce exposure to an infant include:

  • Temporary separation of a COVID-19+ mom and baby and having a healthy care provider care for the infant 
  • Pumping breast milk and feeding expressed breast milk and/or formula through a bottle by a healthy care provider
  • If temporary separation is not feasible or desired, wearing personal protective equipment including a face mask and, if available, gloves and gown along with hand hygiene are important steps to protecting infants from COVID-19
  • Temporary separation should be discontinued in consultation with the mother’s and/or baby’s physicians, infection control experts and/or public health officials based on the signs, symptoms and severity of illness exhibited by the mother and/or results of COVID-19 tests per the CDC guidelines.

Discontinuation of Isolation/Temporary Separation

At this time, the CDC recommends that self-isolation and temporary separation between mother and baby may be discontinued based on the following criteria:

  1. COVID-19 Test-based strategy.
    • Resolution of fever without the use of fever-reducing medications and
    • Improvement in respiratory symptoms (e.g., cough, shortness of breath), and
    • Negative COVID-19 results from at least two consecutive nasopharyngeal swab specimens collected ≥24 hours apart (total of two negative specimens) 
  2. Non-test-based strategy.
    • At least 3 days (72 hours) have passed since recovery defined as resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms (e.g., cough, shortness of breath); and,
    • At least 7 days have passed since symptoms first appeared

Different guidelines apply to hospitalized and immunocompromised patients.

Regarding Breastfeeding

There is no current evidence that COVID-19 is transmitted through breast milk. 

  • COVID-19+ or PUI mothers who intend to breastfeed who are temporarily separated from their infants should be encouraged to express and pump their breast milk to maintain their milk supply.
  • All parts of the pump should to thoroughly disinfected according to the manufacturer instructions; use of hospital pumps with closed systems should be strongly encouraged over personal use breast pumps, which are open systems
  • Expressed breast milk should be provided to the infant by a healthy caregiver using PPE.
  • If mother rooms in with baby and mother chooses to feed at the breast, she should put on a face mask then practice hand hygiene before caring for and breastfeeding her infant.

Hospital Discharge

  • COVID+ and PUI mothers and infants should be given instructions to self-isolate from the general public and consider continued temporary separation at home if they are healthy enough to be discharged.
  • Discontinuation of temporary separation should be decided in conjunction with their health providers and/or infectious disease specialists and public health authorities.

Important Final Notes

  • If you or your infant have a fever and cough, you should contact your obstetrician, pediatrician and/or local public health authority in order to evaluate your risk for coronavirus and other important conditions. You should self-isolate and consider temporary separation while awaiting further instructions. 
  • Mothers who are breastfeeding and who are temporarily separated from their infants should maintain their milk supply by pumping every 2-3 hours, 8-12 times a day, during the separation. 
  • If you or your baby have severe shortness of breath, experience blueness of the lips, dizziness, fainting, lethargy, please call 911.

References

Interim Considerations for Infection Prevention and Control of Coronavirus Disease 2019 (COVID-19) in Inpatient Obstetric Healthcare Settings

Novel Coronavirus 2019 (COVID-19) Practice Advisory, American College of Obstetricians and Gynecologists, March 2020

CDC Discontinuation of Transmission-Based Precautions and Disposition of Patients with COVID-19 in Healthcare Settings (Interim Guidance)

Chinese expert consensus on the perinatal and neonatal management for the prevention and control of the 2019 novel coronavirus infection (First edition)

Epidemiological Characteristics of 2143 Pediatric Patients With 2019 Coronavirus Disease in China

For questions, please contact christie@fedisbest.org

 

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Relactation: A Science Based How To Guide

 

Our goal is to ensure you have the accurate information you need for the best chance of success, with adequate attention to your mental and physical health and well being.

Before you start, it is important to manage your expectations. The limited research we have shows that while most mothers can produce some milk, developing a full milk supply is often not the case, especially under these very stressful pandemic circumstances. Please be very gentle to yourself throughout the process, because all sorts of feelings can come up. This study talks about those feelings. 

In considering relactation, mothers need to consider the big picture.  There are cons…:
  • time spent pumping that takes time away from other important things, such as interaction with baby, sleep, and caring for other children
  • less free time for mom, which is important for mood and stress levels
  • potentially disappointing results
  • mental health considerations 
…as well as pros:
  • another source of milk for the baby
  • passive immunity from breast milk*
  • for mothers who enjoyed breastfeeding, an additional way to spend more one-on-one time with baby
  • feeling a sense of agency in a time when we have little control over our lives

*Since COVID-19 is caused by a novel coronavirus (SARS-CoV-2), no one has antibodies to prevent infection unless they have either been exposed to it or recovered from it. Once a mother is exposed and starts developing antibodies, it takes around two weeks to build up antibodies to have a clinical impact as passive immunity protection.  

Here are our answers to commonly asked questions about relactation:

How do I relactate?

Part 1: Breast Milk Production Basics

Breast milk production depends on these things: prolactin and oxytocin hormone levels, nipple stimulation, milk removal, and individual breast physiology. Prolactin is the hormone that stimulates your mammary glands and causes milk to be produced.  Prolactin has been called the “nurturing hormone,” because it is associated with caretaking behavior. Oxytocin is the other main hormone involved in lactation; it causes milk release during breastfeeding. Oxytocin can also be stimulated by environmental cues, such as hearing a baby cry, smelling or looking at your baby, and even the sound of your breast pump running.

Note: You should also review any medications you’re on with your doctor, as some can affect milk production. If you are taking hormonal birth control, you may want to switch to a non-hormonal method.  LactMed is a good resource for any questions or concerns you have about medications and breastfeeding.

Part 2: Creating a Relactation Plan

Generally speaking, you can expect to commit to at least two weeks of stimulation before seeing milk production results. It takes at least 30 days of relactation effort to get a good idea of what your milk supply will be. There are several ways to create a relactation plan, and they each have pluses and minuses. Before you start, it is important to develop a support system, as this will be very time-consuming. Your family should take on all daily chores for the duration of this process, including making sure you have sufficient food and water. 

Your pump should be a good quality double electric pump and if finances allow, consider renting a hospital grade pump. Having several pump kits to use will reduce the amount of washing and sanitizing parts in between pumping sessions. It is very important to change the valve membranes every 30 days, to have proper pump flange sizes(link), and to protect your nipples from getting sore by using a food grade lubricant before pumping to reduce friction (olive oil works well). Do not use lanolin as it is too sticky.  A hands-free pumping bra is essential. 

Plan 1  is the most time consuming, but most likely to result in more milk more quickly: 

  1. Pump eight times a day on both breasts for 15–20 minutes using hands-on pumping techniques.  Your first-morning session should be a power pump (see sample schedule below). 
  2. Hand express before pumping for three to five minutes.
  3. Spend some time every day cuddling your baby skin to skin (the amount of time should be what you find enjoyable rather than a certain number of minutes).
  4. Offer to latch your baby occasionally, as a playful or relaxing activity with no pressure. 
A typical schedule might look like this:

8:00 a.m.: pump 15–20 minutes

11:00 a.m.: pump 15–20 minutes

2:00 p.m: pump 15–20 minutes

5:00 p.m.: pump 15–20 minutes

8:00 p.m: pump 15–20 minutes

11 p.m.: pump 15–20 minutes, then go to bed. Another family member gives the baby a bottle while the mother sleeps for the next five hours.

4:00 a.m. to 5:00 a.m.: Power pump while someone else gives the baby a bottle.

Latch your baby as much as she’s willing, and use your pump when you can. If your baby will latch reliably, “parallel pumping” is more efficient than nursing followed by pumping.

Some relactation protocols suggest taking away the bottle and pacifier and only feeding the baby with a tube at the breast or with a cup. Mothers have frequently told us they found these alternative feeding methods stressful and time-consuming, so we will leave that decision up to individual parents.

Plan 2  is easier to work into your regular schedule, but you are likely to produce less milk and it may take longer. Many mothers find this to be a reasonable trade-off, as it allows more time for other important activities such as sleep. Doing some or all of the following should result in milk production of various amounts:

  1. Power pump for an hour, or two thirty-minute sessions, whenever you have time during the day, using hands-on pumping techniques. 
  2. Do not wake up at night specifically to pump, but if you’re up anyway, do some pumping before going back to bed (unless you are too tired). 
  3. Hand express whenever you can, such as in the shower; even if you’re not able to collect the milk, you’re sending the signal to the “factory” to ramp up production.
  4. Keep a hand pump within reach to use for when you have 5–10 minutes but not enough time for a full pumping session.
  5. Do a full pumping session (15–20 minutes) when you can, as opposed to doing it on a schedule.
  6. Continue to offer the breast to your baby (remember, no pressure). 

Plan 3  is to take what you want from Plans 1 and 2 and create a plan that works best for you.  

Other tips you can use in addition to the above:
  • Audio cues during pumping, such as the sound of your baby crying or cooing
  • Scent cues such as smelling your baby’s head or an item of clothing he’s worn
  • Looking at your baby and focusing on the cute things he does
  • Guided meditation for lactating mothers 
  • Imagining other sounds or images that remind you of letdown or milk release (such as picturing a waterfall and then changing that image in your mind to your breasts releasing a “waterfall” of milk); guided imagery is also freely available on the internet.
  • Try to make sure you are doing enough self-care and getting sufficient sleep
What are my chances of success?

The answer to this question depends on how you define success.  We define success as satisfaction with the amount of milk produced without adverse effects on the mother. Most mothers who attempt relactation do produce milk, sometimes a little, and more rarely, a lot.  It is unfortunately not possible to predict how much an individual mother will produce. There have been case reports and very small studies of mothers who have been able to produce a full milk supply, however larger and higher quality research, like meta-analysis, needs to be done in order for us to understand best practices and to predict outcomes. Publication bias is also likely (relactation cases with negative outcomes are less likely to be submitted or published). The concept of “relactation” is often poorly defined in the literature; in some studies babies were still partially breastfed when “relactation” was attempted, and in others, “successfully relactated” could mean full or partial lactation. Few studies followed infant weight gain or health, or maternal satisfaction, for a significant time after relactation was achieved.

Factors that are typically associated with relactation success are:
  • shorter time since cessation of lactation
  • full milk supply prior to weaning
  • support from family and health care providers
  • younger infant 
  • age and health of the mother
  • maternal motivation* 

*motivation is a slippery concept, because it can be a cause of success or it can be an effect of success; mothers who are having more success may find they are increasingly motivated, whereas mothers who are putting in a lot of effort and seeing little results naturally lose motivation. It is also a term that is emotionally loaded. After years of running the FIBF support groups, we are painfully aware of how the concept of “maternal motivation” can be used to victim-blame.  It is included here to reflect what the published literature states, but we would like readers to be aware of the connotations and limited definition of that term.

When trying to relactate, it is important to cultivate an attitude of acceptance of whatever amount of milk you end up producing. It would of course always be nice to have more, but remember—your worth as a mother is not based on milk production; it is based on your caring and love for your baby. 

How long before I see results?

If you have recently stopped lactating, you may still be able to express drops. You should plan to spend a few weeks building your supply to the maximal level your body is able to produce at this time.  If you have not lactated for several months, it may take 30 days or longer before you reach a ceiling (the point at which your supply stabilizes and further increases are not possible).

Will herbs or foods help increase milk production?

There are many herbs and foods that some cultures have traditionally used to increase milk production such as oats, fennel, and brewer’s yeast; however, there is no scientific evidence that these provide anything more than a placebo effect. That said, the placebo effect is real, and may help with milk production even if you are aware it is a placebo. Fenugreek should not be used, as it can have dangerous side effects such as low blood sugar, painful intestinal cramping for both mom and baby, and can reduce milk supply.  With regard to food for lactating parents, our only advice is to eat sufficient calories and drink enough fluids to stay well hydrated.    

I want to take Reglan or Domperidone to help increase my supply; is this a good idea?

You will need to talk to your physician to determine if prescribing medication is a good choice for you. Reglan is contraindicated for those who have a history of depression and in rare cases can cause side effects such as involuntary muscle movements. Domperidone can have serious cardiac side effects, and for this reason, it is banned in the US. In countries where it is prescribed, mothers should talk to their doctors about their cardiac history and request an EKG prior to considering this drug. Safety in infant feeding is our number one priority, for baby and mother.

What kinds of adverse physiological or emotional concerns should I watch out for and when will I know if I should stop trying to relactate?
  • insufficient sleep
  • obsessive feelings about number of milliliters produced
  • a sense of panic about not being able to increase milk production
  • increased stress or change in quality of life
  • insufficient time for self-care and relationship with spouse and other children

If you experience these side effects, we recommend reevaluating whether relactation is the best way to provide for your baby.  As stated above, although anxiety is understandable, there is no shortage of formula. Your mental health is important both because you are important, and because it can impact your relationship with your baby, partner, and family. 

What are some ways I can encourage my baby to latch? :

Before answering this question, we want to emphasize that your baby has a say in whether he wants to breastfeed directly or not. Latching should be approached as an experiment, not as something you need to “get” your baby to do, and experiments take time and patience. You and your baby will also have the best chance of success if you adopt a no-pressure attitude. Here are some strategies that tend to work well:

  • Supplementing at breast using a dropper, syringe, or supplemental nursing system (the presence of milk can be used to coax baby to breast and encourage him to maintain latch and continue swallowing)
  • Offering your breast while carrying your baby in a wrap
  • Giving most of the feeding using a bottle, then offering the breast at the end of the feeding as “dessert”
  • Offering your breast when your baby is half asleep (“dream feeding”)
  • Trying a nipple shield (some babies will latch more readily since nipple shields are similar to the bottle nipples they have been used to. Baby can be weaned off of the shield once he is reliably latching)
  • Nursing in a place that is free of distractions for mother and baby, or in a darkened room while listening to soothing music. 
  • Offering to breastfeed while rocking in a rocking chair or glider.

As you can see, relactation usually takes a lot of effort and time; it can also have emotional, physical, and relationship effects. We have heard many different reactions from mothers who were asked afterward “was it worth it?”  

We do want to know about your relactation experiences so we can give advice and tips to other mothers. We want to know the good, the bad, and everything in between. Above all, #wesupportyou!


Jody Segrave-Daly is a champion for debunking pseudoscience in the breastfeeding community because parents need to be truly informed when making parenting decisions. She is also a staunch advocate for protecting underfed exclusively breastfed babies and is the reason why she co-founded the Fed Is Best Foundation. She provides parents with the most up to date scientific resources and includes her extensive neonatal nursing knowledge and infant feeding clinical experiences, to help parents make the best infant feeding decision that works for them. Are you a lactation consultant who wants to join our infant feeding team? Contact Jody directly at jody@fedisbest.org

Jody Segrave-Daly, MS, RN, IBCLC

Resources:

https://abm.memberclicks.net/assets/DOCUMENTS/PROTOCOLS/9-galactogogues-protocol-english.pdf

https://www.liebertpub.com/doi/abs/10.1089/bfm.2010.0062

http://medind.nic.in/icb/t10/i2/icbt10i2p214.pdf

http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.837.87&rep=rep1&type=pdf

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6113782/

http://www.indianpediatrics.net/feb2002/feb-173-178.htm

https://sci-hub.se/https://www.liebertpub.com/doi/abs/10.1089/bfm.2011.0026 (10% succeeded in relactating but it’s implied that it was partial relactation, not exclusive bf)

 

 

 

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Will Breast Milk Protect My Baby From Getting Sick? Passive Immunity 101

Written by Jody Segrave-Daly MS, RN, IBCLC

As a veteran neonatal nurse and lactation consultant, I am often asked by parents to explain how the antibodies found in breastmilk work to protect their babies. Published research on immunology is extremely technical and difficult to understand, and unfortunately, the information that is readily available (especially on social media) contains a lot of false and conflicting information. So I’m here to share evidence-based information about this very important topic in a way that is easier for most parents to understand.

How does the immune system work?

Our immune system is very complex, but generally speaking, it is responsible for fighting off both germs that enter our bodies from our environment, and also for protecting us from diseases like cancer that occur within our bodies. I will be focusing on how the immune system fights off germs, which it does by producing antibodies.

What is an antibody and what does it do?

An antibody is a protein that is produced by the body’s immune system when it detects the surfaces of foreign and potentially harmful substances, also known as pathogens. Examples of pathogens are bacteria, fungi, and viruses, which are all microorganisms. The antibody response is specific; it will seek out and neutralize the microorganism and stop the invasion. There are five classes of antibodies: IgM, IgG, IgA, IgD, and IgE.

There are two ways babies acquire and develop immunity:
  • The first way is through passive immunity (temporary)
  • The second way is through active or acquired immunity (lifelong) 

Note: Antibody types and where they are acquired from are denoted by color throughout the blog.

Continue reading

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Mothers Describe Their Triple Feeding Experiences And The Impact It Had On Their Mental And Physical Health

Written by The Fed Is Best Foundation Lactation Consultant Team

Part 1: What is “triple feeding?” 

Triple feeding originated in the NICU and was used for premature infants. It is now being used for full-term babies, especially in home environments. Triple feeding is a breastfeeding plan in which, for every feeding, a mother feeds her baby at the breast, followed by immediate pumping, and then giving any expressed milk (and/or formula supplement) to the infant by a bottle, cup, syringe, or through a tube at the breast. Triple feeding requires a considerable amount of effort and time, and there is little time between feedings for the mother to take care of her own basic needs, such as sleep, eating, and hygiene.

Many mothers who have followed this regimen say that they were given little guidance on how long to triple feed and when to stop.  As a result, these mothers have endured the equivalent of caring for triplets (feeding a baby at the breast, “feeding” the pump, then feeding a bottle). In addition, there are pump parts to wash up to eight times a day, and sometimes other children to care for.

“I didn’t eat or drink for days because of the time constraints of triple feeding. By the time my baby was admitted to the hospital on day 5 of life, I lost consciousness and then broke down in the corner of his room from profound exhaustion. I’m a doctor and had done surgical and anesthesia residency. I’m used to sleep deprivation. Those five days were hell on earth. Not only did it not work, I unknowingly starved my baby under the care of lactation professionals.  They knew I had a breast reduction, but I was told to triple feed without a back up plan. That week of my life lives over and over in my head all the time.” —Dr. N. King 

Continue reading

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Dear Parents, Did You Know Just 2 Teaspoons Of Supplementation Can Protect Your Baby And Your Breastfeeding Journey?*

Written by: The Fed Is Best Foundation IBCLC Team

There have now been six studies showing that in some infants, a little bit of supplementation with two teaspoons (10 mL) of formula or donor breast milk after nursing had no effect on long-term breastfeeding. One study showed it prevented hospital readmissions in all of the supplemented newborns. Another showed it actually helped breastfeeding! 

Why aren’t medical and lactation professionals recommending this intervention?

Many medical and lactation professionals believe that a tiny amount of formula will contaminate the baby’s gut, causing lifelong health problems. They refuse to admit that formula supplementation can be helpful, and they have baseless concerns that temporary formula supplementation will become routine for all babies.  According to Baby-Friendly USA, “donor [breast] milk takes the fight out of this.” What they mean is that the few babies who are born in a hospital with donor milk can be fully fed, while the vast majority of babies who are born in hospitals without donor milk just have to tolerate hunger and thirst so as to avoid a few teaspoons of formula.  

Did you know two teaspoons of formula or donor milk has seven calories?  

Continue reading

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FAQs Part 3: Do You Believe Exclusive Breastfeeding is a Good Goal to Promote?

FREQUENTLY ASKED QUESTIONS

Our goal is to respond to the many statements that have been made about the Fed is Best Foundation and to answer questions we receive about what the Foundation stands for. Unfortunately, our #FedIsBest phrase has been used incorrectly by others, and it’s important that we clarify what it means and doesn’t mean. Our mission statement has evolved over time and reflects what our parents tell us they need to support them. Click here and here for FAQs part 1 and 2, respectively.

7. Do you believe exclusive breastfeeding is a good goal to promote?

 We do if a mother wants to exclusively breastfeed and they are fully informed about their individualized risk factors for delayed onset and or potential low milk supply. We promote and educate families about safe exclusive breastfeeding because no other health organization informs parents about the risks of insufficient feeding complications and how easy they are to prevent. To be fully informed, parents must be educated about both the benefits and risks of exclusive breastfeeding. Currently, they are only taught about the benefits and not the risks. Continue reading

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Neonatal Nurse Practitioner Talks About Excessive Newborn Weight Loss And Maternal IV Fluids While Exclusively Breastfeeding

By C. Faust

As a neonatal nurse practitioner in a community hospital, I see babies in the postpartum unit every day and make decisions about their discharge criteria.

The average length of stay after birth is 24-48 hours for a vaginal delivery and 48-72 hours for cesarean delivery.  A lot of information about breastfeeding, newborn care, and post-partum care must be conveyed in that short time, often to new parents who are exhausted and overwhelmed. In an ideal world, every mother-baby dyad would be well suited for breastfeeding. Many women are able to breastfeed without difficulty, but for some, it’s a struggle.  The majority of mothers are discharged before their milk comes in, which is why discharge criteria include pediatrician follow-up within 24-48 hours and why weight check appointments are critical so that all breastfeeding babies are protected from inadequate milk intake.

 “Days two to five are critical days for normal newborns to be seen by their pediatrician,” said Dr. Vicki Roe, M.D., a pediatrician at North Point Pediatrics in Indiana. “They are still losing weight and their jaundice levels could be increasing. A healthy baby can become a very sick baby quickly, and we must monitor them closely to prevent complications.”

Many of us work in “Baby Friendly” hospitals.  Requirements for the Baby-Friendly designation include displaying the WHO/Unicef Ten Steps for successful breastfeeding and adhering to these recommendations.  It is important to note that Baby-Friendly does not prohibit supplemental feeding in the case of medical necessity; nevertheless, both medical staff and nursing staff often report that they are afraid to violate  the Baby-Friendly “rules.”  I find it effective to specifically document the condition I am treating when I order supplemental feedings. This makes the plan of care transparent and easy to communicate, ensures accountability, and meets the requirements of certification. The exclusively breastfed baby with excessive weight loss (EWL) requires careful assessment.

Question: Would you consider laboratory testing if a baby has excessive weight loss and the mother’s milk is not in yet to meet discharge criteria?

A weight loss of 7-10 % certainly prompts further feeding evaluation.  A physical exam should be performed, looking for clinical signs of dehydration.  I would consider ordering a Basal Metabolic Panel (BMP) to evaluate for dehydration, hypernatremia, and hypoglycemia. In some situations, the decision to supplement based on excessive weight loss may be met with pushback; laboratory evidence of dehydration adds weight to the decision and may forestall disagreement.  In our facility, we usually do bilirubin (jaundice) screening using a transcutaneous meter at around 24 hours of life; if I were concerned about weight loss, particularly if there were visible jaundice or risk factors, I would repeat the screening.  And of course, if the infant’s clinical appearance were of concern, for instance, if the infant were hypotonic or lethargic, a CBC or complete blood count and blood culture would be of paramount importance to check for infection.

Question: Do you take into consideration the mothers’ risk factors for delayed onset of milk when considering supplementation? 

Absolutely. The considerations I have outlined below are drivers in assessing not only readiness for discharge but also whether there is an indication for supplementation.  A healthy infant born at term and appropriate size for gestational age with no complications can endure a couple of days of low volume colostrum feedings while mother’s milk is coming in. I use the analogy of a bear storing up for hibernation when I speak to parents about prenatal stores and normal expectations for breastfeeding. Maternal considerations and infant health status inform the decision of whether supplemental feeding is needed.  A lactation consultant may be of assistance if lactogenesis is delayed and can implement interventions such as pumping or adjusting the infant’s latch and positioning. It is important to work as a team; LCs can offer valuable input into the plan of care, but they can’t make decisions without consulting with the pediatrician. When a medical need for supplemental feeding is recognized, an appropriate plan of care must accurately be conveyed and followed by everyone involved in the care of the dyad.

Question: If a mother has IV fluids during labor, do you think babies who have excessive weight loss can lose more weight than the current guidelines from the AAP?

It has been posited that the administration of IV fluid in the intrapartum period can affect neonatal weight loss.  The assertion is that IV fluid “plumps up” (i.e., causes edema) of the fetus, leading to an artificially inflated birth weight.  Diuresis after birth then causes apparent significant weight loss.  But babies are not diuresing after birth, as evidenced by their low wet diaper output in general.

 A 2011 study published in Pediatrics (Chantry et al.) sought to examine potentially modifiable factors in excessive weight loss (EWL) in predominantly breastfed newborns.  This was a relatively small study of 316 infants with gestational ages between 32 and 40 weeks. The authors looked at a number of factors, including prenatal feeding plan, supplemental feeding, onset/delay of lactogenesis, nipple type, nipple pain, and interventions during labor, including IV fluid administration. They defined excessive weight loss as ≥10% of birth weight by three days of age.   Overall, 18% of infants who were exclusively breastfed or received minimal (defined as <60 ml total) supplemental formula had EWL. 19% of exclusively BF infants had EWL; 16% of minimally supplemented infants had EWL, and only 3% of infants who had supplemental feeds of >60 ml total had EWL. To greatly simplify the statistical analysis, the initial analysis showed a number of factors associated with EWL, including higher maternal age and education, hourly intrapartum fluid balance, postpartum edema, delayed lactogenesis, fewer infant stools, and birth weight. Further analysis found only two significant factors:  intrapartum fluid balance and delayed lactogenesis. EWL occurred in 30% of EBF/minimally supplemented infants whose mothers had high hourly intrapartum fluid balance, and 10% of those whose mothers had low hourly fluid balance. Around the issue of delayed lactogenesis (defined as not “feeling noticeably fuller” by 72 hours), 35% of EBF/minimally supplemented infants with mothers who reported delayed lactogenesis had EWL; for women who reported no delay in lactogenesis, 8% of EBF/minimally fed infants had EWL. 

I can’t help but wonder whether this study failed to see the forest for the trees. A higher fluid balance may be a marker for longer labor and labor complications, which in turn would certainly affect postpartum recovery, fatigue, and lactogenesis.  The authors relied on subjective perception by primigravidas as a definition of delayed lactogenesis and reported it as 42%, a much higher prevalence than the usual estimate of 15%. Indeed, the title of this article could have been “Excess weight loss in the first-born breastfed newborns relates to delayed lactogenesis”—not nearly as exciting. The authors themselves advise caution in interpreting weight loss and state that EWL should not be assumed to be fluid loss alone but may indeed represent insufficient feeding.

A later study by Elroy et al. (2017) also sought to examine whether there is a relationship between EWL, type of fluid (colloids + crystalloids or crystalloids alone), and IV fluid dose.  This was a larger study, involving 801 dyads. EWL was defined as >7% of birth weight. In this case, the authors did not find a difference in the rate of EWL associated with the type of fluid given, nor did they find a dose-response relationship between the amount of fluid and EWL.  As an aside, they mention the confounding variable of maternal hypotension, which of necessity would require fluid administration, but which could lead to impaired uteroplacental perfusion and fetal acidosis, affecting the vigor of the infant.

So do I think that a 7-10% or greater weight loss is grounds for concern?  Absolutely. Ascribing excessive weight loss to maternal IV fluid is disingenuous at best. 

While IV fluid may contribute to perceived weight loss, this relationship is by no means established, but the relationship between poor feeding and weight loss is.  With the exception of critical infants with certain prenatal conditions, I do not see infants born with perceptible edema.  

A comprehensive exam for every breastfeeding dyad will include:  
  • Maternal health.   In the aggregate, women giving birth today are older, have higher BMIs, and are more likely to have underlying chronic health conditions or pregnancy complications than women in previous generations. Delayed childbearing means that women may be having children after the age of 35. Older mothers are more likely to have pregnancy and childbirth complications.  The obesity epidemic has affected people of all ages and socioeconomic strata; obese women may have underlying chronic health problems such as diabetes and hypertension and may have more difficulty with mobility and healing.  Long or complicated labor may contribute to fatigue, which can delay(link) onset of milk production and can also increase the risk of (link)accidental suffocation of the infant. No mother plans to fall asleep with her baby in the bed, but if parents are awake for 36+ hours, their risks for falling asleep while breastfeeding or holding their baby increases.
  • Substance use.  About 10% of babies in our facility are affected by maternal substance use; about half of these are affected by opioids, whether illicit drugs, prescription drugs, or medication-assisted treatment (MAT) drugs such as methadone and buprenorphine.  We can and do support breastfeeding in women who are stable in recovery, even if on MAT, but we recognize that these women may have unique stressors that may make breastfeeding more difficult. Infants who are experiencing withdrawal often have disorganized feeding.  Hunger can exacerbate withdrawal, and weight loss is a symptom of withdrawal. These infants do stay in the hospital longer for observation; my threshold to start supplemental feedings is lower since they are at risk for significant weight loss.
  • Breast anatomy.  A history of augmentation or reduction surgery may impact milk production or transfer.  Wide-spaced, “tubular” breasts may be an indicator of insufficient glandular tissue. Flat or inverted nipples may present difficulty with latching; a breast shield may help, but the use of a shield should prompt careful follow up of feeding, milk transfer, and weight gain.
  • Feeding assessment.  Every breastfeeding dyad should have an evaluation of feeding by a lactation consultant or clinician with expertise.  Latch, nipple pain, and evidence of transfer, such as audible swallowing, are one part of the assessment. Can the mother get the baby on independently or does she require assistance?  If the nurse has had to get the baby latched for every feeding, the dyad is not ready for discharge.
  • Anatomy of the infant’s mouth.  Tongue ties and other anatomical considerations may present specific challenges to feeding.  (Link) Frenulotomy and lysis of lip ties have become common. Infants who may be at risk for feeding difficulty should be followed very closely, whether or not they have surgical intervention.
  • Timing of weight assessment.  A 7% loss has different implications depending on the day/hour or age. If the weight was done 16 hours earlier on the evening shift before the morning of discharge, I request a repeat weight.
  • Gestational age.  Late preterm (LPT) infants are often cared for in the well-baby setting and may masquerade as healthy term infants, but they are not. LPTs may have excessive weight loss; readmission rates for weight loss, jaundice, and other complications are up to three times higher than for term infants.  In our facility, late preterm infants are observed in the hospital setting for a minimum of 72 hours. Our protocol for the care of the LPT follows the recommendations of the Academy of Breastfeeding Medicine: we initiate supplemental feedings for a weight loss of ≥3% by 24 hours or ≥7% by day 3 or, of course, sooner if there is evidence of hypoglycemia, dehydration, jaundice or poor feeding.
  • Birth weight.  We assess weight loss by percentage since babies come in many sizes…however, a 7% weight loss in a baby who weighed five pounds at birth looks different than the same percentage in a large infant who has more reserves of fat and glycogen.
  • Output.  Passage of urine and stool are unreliable indicators of intake, but no or very low output suggests poor intake.  A breastfed infant may have only 1-2 wet diapers per 24 hours in the first day or two, but as mother’s milk comes in, the output should increase because of colostrum amounts increase.  I always discuss watching output at home and contacting the pediatrician promptly if the infant is not producing urine or dirty diapers. 
  • Experience.  Is this a first baby or has the mother successfully breastfed other children? Did she try breastfeeding before and stop?  If so, what were the issues?
  • Exam.  A physical exam includes assessment of hydration status:  fontanels, skin turgor, mucous membranes, as well as general well-being, suck, activity level.     

So would I discharge a baby with a greater than 7% weight loss and no supplemental feedings? It depends on the complex thought process that goes into discharge planning. Every mother-baby dyad is unique and requires individualized care.  An EWL baby can decline rapidly in 24 and It’s important to teach parents about what signs to look for insufficient breastfeeding so that they can safely supplement until they have their next day follow-up pediatrician appointment.  Weekends pose particular concerns. Discharging a baby on a Monday with an outpatient appointment the following day is a very different scenario than discharging on a Friday of a holiday weekend with no possibility of follow up until Tuesday.  In certain cases where risk factors are present, such as LBW or prematurity, I may order outpatient weight checks for a few weeks. As well, follow up with a lactation consultant can be invaluable for the mother who needs support.   

 


                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
 Resources:                                                                                                                                                                     Boies, E.G., Vaucher, Y.E. & the Academy of Breastfeeding Medicine (2016).  ABM Clinical Protocol #10: Breastfeeding the late preterm (34-36 6/7 weeks of gestation) and early term infants (37-38 6/7 weeks of gestation, second revision 2016.  Breastfeeding Medicine, 11 (10).Chantry, C.J., Nommsen-Rivers, L.A., Peerson, J.M., Cohen, R.J. & Dewey, K.G. (2011).  Excess weight loss in first-born breastfed newborns relates to maternal intrapartum fluid balance.  Pediatrics, 127, e171-9.Eltonsy, S., Blinn, A., Sonier, B., DeRoche, S., Mulaja, A., Hynes, W., Barrieau, A. & Belanger, M.  (2017). Intrapartum intravenous fluids for caesarian delivery and newborn weight loss: a retrospective cohort study.  BMJ Paediatrics Open 2017 (1).

WHO 2017 Revised Guidelines Provide No Evidence to Justify Exclusive Breastfeeding Rule While Evidence Supports Supplemented Breastfeeding

Weight Loss is Not Caused by IV Fluids: The Dangerous Obsession with Exclusivity in Breastfeeding:

FAQs: Does The Fed Is Best Foundation Believe All Exclusively Breastfed Babies Need Supplementation?

 

Informed Consent Regarding Risks of Insufficient Feeding

 

HOW YOU CAN SUPPORT FED IS BEST

There are many ways you can support the mission of the Fed is Best Foundation. Please consider contributing in the following ways:

  1. Join us in any of the Fed is Best volunteer and advocacy, groups. Click here to join our health care professionals group. We have:  FIBF Advocacy Group, Research Group, Volunteer Group, Editing Group, Social Media Group, Legal Group, Marketing Group, Perinatal Mental Health Advocacy Group, Private Infant Feeding Support Group, Global Advocacy Group, and Fundraising Group.    Please send an email to Jody@fedisbest.org  if you are interested in joining any of our volunteer groups. 
  2. If you need infant feeding support, we have a private support group– Join us here.
  3. If you or your baby were harmed from complications of insufficient breastfeeding please send a message to contact@fedisbest.org 
  4. Make a donation to the Fed is Best Foundation. We are using funds from donations to cover the cost of our website, our social media ads, our printing and mailing costs to reach health providers and hospitals. We do not accept donations from breast- or formula-feeding companies and 100% of your donations go toward these operational costs. All the work of the Foundation is achieved via the pro bono and volunteer work of its supporters.
  5. Sign our petition!  Help us reach our policymakers, and drive change at a global level. Help us stand up for the lives of millions of infants who deserve a fighting chance.   Sign the Fed is Best Petition at Change.org  today, and share it with others.
  6. Share the stories and the message of the Fed is Best Foundation through word-of-mouth, by posting on your social media page and by sending our FREE infant feeding educational resources to expectant moms that you know. Share the Fed is Best campaign letter with everyone you know.
  7. Write a letter to your health providers and hospitals about the Fed is Best Foundation. Write to them about feeding complications your child may have experienced.
  8. Print out our letter to obstetric providers and mail them to your local obstetricians, midwives, family practitioners who provide obstetric care and hospitals.
  9. Write your local elected officials about what is happening to newborn babies in hospitals and ask for the legal protection of newborn babies from underfeeding and of mother’s rights to honest informed consent on the risks of insufficient feeding of breastfed babies.
  10. Send us your stories. Share with us your successes, your struggles and everything in between. Every story saves another child from experiencing the same and teaches another mom how to safely feed her baby. Every voice contributes to change.
  11. Send us messages of support. We work every single day to make infant feeding safe and supportive of every mother and child.  Your messages of support keep us all going.
  12.  Shop at Amazon Smile and Amazon donates to Fed Is Best Foundation.

Or simply send us a message to find out how you can help make a difference with new ideas!

For any urgent messages or questions about infant feeding, please do not leave a message on this page as it will not get to us immediately. Instead, please email christie@fedisbest.org.

 Thank you and we look forward to hearing from you!

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Weight Loss is Not Caused by IV Fluids: The Dangerous Obsession with Exclusivity in Breastfeeding:

By Dr. Christie del Castillo-Hegyi, M.D.

The Fed is Best Foundation has written about countless cases of serious complications caused by poor standards of breastfeeding management established by multiple exclusive breastfeeding advocacy organizations. The primary causes of these poor outcomes are:

    • the persistent denial of the seriousness of newborn weight loss
    • the lack of transparency about the consequences of insufficient feeding complications in patient education and health professional training
    • and the dangerous obsession with exclusivity in breastfeeding.

Exclusive breastfeeding, according to the WHO, means “the infant receives only breast milk. No other liquids or solids are given – not even water – with the exception of oral rehydration solution, or drops/syrups of vitamins, minerals or medicine.” While breastfeeding is a positive thing to support, the obsession with exclusivity in breastfeeding promotion results in approximately 190,000 newborn admissions a year in the U.S. alone, mostly from complications of jaundice and dehydration caused by underfeeding. This article will discuss the actual reason why exclusively breastfed newborns lose weight and why newborn weight loss is not due to IV fluids given to mothers before delivery. This is to address a commonly circulated unsafe recommendation by exclusive breastfeeding advocates and lactation professionals suggesting we increase the AAP recommended maximum weight loss threshold of 7% and to weigh infants at 24 hours, which would likely increase newborn insufficient feeding complications, hospitalizations, and brain injury.

Part 1: Why a Newborn Loses Weight in the First Days

Let’s start the conversation off with why newborns lose weight in the first days of life. Exclusive breastfeeding advocates have hypothesized that infant weight loss is caused by fluid shifts and “diuresis” or elimination of fluid through urination. Diuresis is defined as overproduction of urine caused by excess body fluid, which should be at least 6-8 wet diapers a day, the normal urine production of a hydrated newborn. In fact, exclusively colostrum-fed newborns, only produce 1-2 wet and dirty diapers a day the first 2 days of life, which is lower than the normal number of wet diapers a day for a hydrated newborn. Therefore, weight loss is not in fact caused by fluid loss. 

Here are some basic facts about newborn nutrition:

  • The caloric requirement of a newborn from birth through the first weeks of life is 100-120 Calories/kg/day, a figure that is determined by the number of living cells a baby has to keep alive. 
  • The fluid requirement of a newborn is more variable, which can be affected by how much fluid reserve they are born with. But according to the pediatric literature it is approximately  60-80 mL/kg/day the first 2 days then 100 mL/kg/day thereafter. 
  • That means a 3 kg newborn needs 300 to 360 Calories per day and 180-240 mL of fluid for the first 2 days and 300 mL thereafter. 

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A Fully Fed Baby is the Biological Ideal

Abridged Comment Presented on July 11, 2019 at the USDA Dietary Guidelines Committee Meeting in Washington, DC

My name is Dr. Christie del Castillo-Hegyi, Co-Founders of the Fed is Best Foundation, a non-profit organization of health professionals and parents whose mission is to research and advocate for safe breastfeeding practices. We do this to prevent the complications of infant dehydration, excessive jaundice, and hypoglycemia from insufficient feeding, all known causes of brain injury, disability and rare deaths. I have come here representing over 700,000 supporters to raise awareness regarding these complications for the DGA committee as they prepare the infant nutrition guidelines.

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Feed Your Baby—When Supplementing Saves Breastfeeding and Lives

Jody Segrave-Daly, RN, MS, IBCLC

Mothers are taught that it’s rare to not produce enough milk to exclusively breastfeed in nearly every breastfeeding book, mommy group, and hospital breastfeeding class. The truth is, we have limited studies that provide an accurate percentage of the number of mothers who can produce enough milk for their baby for the recommended 6 months. Although actual rates of adequate milk production are unknown, there are estimates that range from 12-15 percent or more.  

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