U.S. Study Shows Baby-Friendly Hospital Initiative Does Not Work

by Christie del Castillo-Hegyi, M.D.

On October 14, 2019, the Journal of Pediatrics published astonishing findings regarding the effects of the Baby-Friendly hospital certification on sustained breastfeeding rates as defined by the 2020 Healthy People Goals of: 

  1. any breastfeeding at 6 and 12 months
  2. exclusive breastfeeding at 3 and 6 months. 

They did so by measuring the relationship between statewide breastfeeding initiation rates data and the above breastfeeding rates. They then measured the contribution of Baby-Friendly hospital designation on these same breastfeeding outcomes.

According to the study authors, the increase in hospital designation in the Baby-Friendly Hospital Initiative (BFHI) began in 2011 when the U.S. Surgeon General issued a call to action for maternity care practices throughout the U.S. to support breastfeeding. The Centers for Disease Control (CDC) became involved in promoting the BFHI policies in hospitals and health facilities, as breastfeeding was thought to be associated with lower rates of childhood obesity. The assumption was that by increasing breastfeeding rates through the BFHI, there would be a concomitant decline in childhood obesity. Upon initiation of this program, the CDC initiated surveillance of state-specific data on breastfeeding outcomes after discharge including BFHI designation rates. This data is made available to the public through the CDC Breastfeeding Report Card, which provides annual reports from 2007 through 2014 and biennial reports from 2014.

As expected, they found that states with higher breastfeeding initiation rates had higher rates of these sustained breastfeeding outcomes. You cannot have high breastfeeding rates unless mothers are given education and successfully initiate breastfeeding. However, when they measured the effects of Baby-Friendly certification, this is what they found.

“Baby-Friendly designation did not demonstrate a significant association with any post-discharge breastfeeding outcome (Figures 1, B and 2, B). There was no association between Baby-Friendly designation and breastfeeding initiation rates.” Continue reading

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Is Breast Milk Stealing The Spotlight Of A Novel Anti-Tumor Compound?

BY ALEXANDRIA FISCHER, PHD CANDIDATE AT THE RENSSELAER POLYTECHNIC INSTITUTE, STUDYING SYNTHETIC MICROBIAL COMMUNITIES

The “magic” of breastmilk is never-ending, plastered everywhere on social media with little regard to true scientific analysis. The idea that breastfeeding prevents cancer is a huge promotion point for why mothers should breastfeed at all costs. But while the cancer-preventing benefits are overblown, there is an even bigger claim surrounding the anti-cancer properties of breastmilk; that breast milk kills cancer, in and of itself.  This is a claim that I have seen made many times, so I decided to dig into the research and see where this claim came from and how truthful the claim is.

So where did this idea that breastmilk can kill cancer cells come from? It’s actually a long, and interesting accident of science.  In 1995 researchers were studying the adherence of bacteria to lung cancer cells in the presence of human milk fractions [1]. Fractionation is simply the process where the different molecule types in any substance are separated from one another. One of the tested fractions showed not only inhibition of bacterial adherence but also induced apoptosis of the tumor cells. Apoptosis is just a fancy word for cell death. This fraction was α-lactalbumin, an abundant protein in milk. However, α-lactalbumin in its natural state has no effect on tumor cells.  So what happened in the 1995 study? It seems that the researchers fractionated the milk at a low pH (acidic) implying that there was some kind of change in the structure of the protein. Further work showed that a reaction between the α-lactalbumin and oleic acid (acids lower pH) form the HAMLET compound [2]. HAMLET stands for Human α-lactalbumin Made LEthal to Tumors. HAMLET is an incredibly interesting compound that induced cell death (apoptosis) in cancer cells but not human cells.

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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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FAQs Part 2: Does The Fed Is Best Foundation Believe All Exclusively Breastfed Babies Need Supplementation?

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

6. Does the FIBF believe all exclusively breastfed babies need supplementation before the onset of mature milk?

No, and we never have. 

As health care providers, we have an ethical and moral obligation to fully inform mothers of both the benefits and risks of exclusive breastfeeding when promoting exclusive breastfeeding. The high rates of delayed onset of lactogenesis II, as well as conditions that cause a poor transfer of breast milk, carry serious risks to exclusively breastfed newborns, as they depend on daily increases in calories and fluids until mature milk arrives on day three.

The current research tells us the actual rates of adequate breast milk production are unknown and the current estimates for lactation disruption range from 12-15% or one in eight mothers. We are learning that mothers are experiencing delayed lactogenesis II (onset of full milk supply greater than 72 hours post-birth) commonly, for complex biological and other unknown reasons. However, the fact that something is common does not mean it is normal or ideal. 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!

Click here to join us!

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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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Dr. Christie del Castillo-Hegyi and Jillian Johnson Speak at the 2020 USDA Dietary Guidelines Meeting

July 17, 2019

 

Washington, DC — On July 11, 2019, Dr. Christie del Castillo-Hegyi, Co-Founder of the Fed is Best Foundation and Jillian Johnson, Fed is Best Advocate and mother to Landon Johnson, who died from hypernatremic dehydration while exclusively breastfeeding, traveled to Washington, DC to provide testimonies to the 2020 USDA Dietary Guidelines Advisory Committee. This is the first year that the Dietary Guidelines for Americans (DGA) have included pregnancy and birth to 24 months.

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An Evaluation Of The Real Benefits And Risks Of Exclusive Breastfeeding.

by Alexandria Fischer, PhD candidate at the Rensselaer Polytechnic Institute, studying synthetic microbial communities

It’s a mantra we have all heard, on repeat. “Breast is best.” But what does that really mean? Moms are bombarded by messages about the benefits of breastfeeding, such as increased intelligence, less illnesses, and a decreased risk of cancer. But what mothers are not told, is the quantifiable proof of these benefits.

The paper “Is the “breast is best” mantra an oversimplification?“, published in the Journal of Family Practice in July 2018, sought to critically evaluate claims of breastfeeding benefits in an effort to truly understand them. These authors note that the same data has produced a wide range of conclusions about the reported benefits of breastfeeding. They sought to tease apart what variables were truly impacted, and which were not. In this review the authors determined the number needed to treat (NNT) for a myriad of health issues that are often claimed to be reduced by breastfeeding. The NNT simply means how many babies need to be breastfed in order for one baby to benefit. We need to use caution when examining NNTs because they cannot make a causal determination, meaning they cannot be used to say “breastfeeding prevented this infection” they are simply used to determine a correlative relationship.

“The NNT (numbers needed to treat) simply means how many babies need to be breastfed in order for one baby to benefit.”

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Fed is Best Foundations Statement to USDA Healthy People Goals 2030

Christie del Castillo-Hegyi, M.D.

From December 2018 to January 2019, the Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2030 published the proposed Healthy People 2030 Objectives for public comment. Of note, the proposed Healthy People 2030 objectives saw a marked change from the 2020 objectives, namely a reduction of the breastfeeding objectives from 8 goals to one, namely, “Increase the proportion of infants who are breastfed exclusively through 6 months” (MICH-2030-15 ). Among the objectives that were dropped from the list were:

  1. MICH-23 – Reduce the proportion of breastfed newborns who receive formula supplementation within the first 2 days of life.
  2. MICH-24 – Increase the proportion of live births that occur in facilities that provide recommended care (i.e. Baby-Friendly Hospital Initiative-certified hospitals) for lactating mothers and their babies.
Healthy People 2020 ObjectivesBaseline (%)Target (%)
Increase the proportion of infants who are breastfed (MICH 21)
Ever74.081.9
At 6 months43.560.6
At 1 year22.734.1
Exclusively through 3 months33.646.2
Exclusively through 6 months14.125.5
Increase the proportion of employers that have worksite lactation support programs (MICH 22)2538
Reduce the proportion of breastfed newborns who receive formula supplementation within the first 2 days of life (MICH 23)24.214.2
Increase the proportion of live births that occur in facilities that provide recommended care for lactating mothers and their babies (MICH 24)2.98.1
We applaud the removal of the last two objectives as patient safety issues have emerged from those two objectives, namely increased rates of neonatal jaundice, weight loss, hypoglycemia and dehydration readmissions. We have submitted the following statement regarding the Healthy People Goals for 2030 requesting for a revision of the current proposed objective and the addition of two new objectives.

Exclusive breastfeeding at discharge is a major risk factor for severe jaundice and dehydration. Both conditions can require in-hospital treatment and can result in permanently impaired brain development. Photo Credit: Cerebral Palsy Law

 

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Breast Milk Production in the First Month after Birth of Term Infants

by Christie del Castillo-Hegyi, M.D.

One of the most important duties of the medical profession is to make health recommendations to the public based on verifiable and solid evidence that their recommendations are safe and improve the health of nearly every patient, most especially if the recommendations apply to vulnerable newborns.  In order to do this, major health recommendations require extensive research regarding the safety of the real-life application of the recommendation at the minimum.

Multiple health organizations recommend exclusive breastfeeding from birth to 6 months as the ideal form of feeding for all babies under the belief that all but a rare mother can exclusively breastfeed during that time frame without underfeeding or causing fasting or starvation physiology in their baby. In order to suggest that exclusive breastfeeding is ideal for all, if not the majority of babies, one would expect the health organizations to have researched and confirmed that all but a rare mother in fact produce sufficient milk to meet the caloric and fluid requirements of the babies every single day of the 6 months without causing harmful fasting conditions or starvation. There have been few studies on the true daily production of breast milk in breastfeeding mothers.  Only two small studies quantified the daily production of exclusively breastfeeding mothers including a study published in 1984, which measured the milk production of 9 mothers, and one in 1988, which measured it in 12 mothers.  After extensive review of the scientific literature, it appears the evidence that it is rare for a mother to to not be able to produce enough breast milk to exclusively breastfeed for 6 months is no where to be found. In fact the scientific literature has found quite the opposite.

In November 2016, the largest quantitative study of breast milk production in the first 4 week after birth of term infants was published in the journal Nutrients by human milk scientists, Dr. Jacqueline Kent, Dr. Hazel Gardner and Dr. Donna Geddes from the University of Western Australia. They recruited a convenience sample of 116 breastfeeding mothers with and without breastfeeding problems who agreed to do 24 hour milk measurements through weighed and pumped feedings between days 6 and 28 after birth and were loaned accurate clinical-grade digital scales to measure their milk production at home. The participants test weighed their own infants before and after breastfeeding or supplementary feeds and recorded the amounts of breast milk expressed (1 mL = 1 gram). All breast milk transferred to the baby, all breast milk expressed and all supplementary volumes were recorded as well as the duration of each feed.

These were the results…

13 mothers perceived no breastfeeding problems while 103 mothers perceived breastfeeding problems.  The most common problem was insufficient milk supply (59 mothers) followed by pain (11 mothers),  and positioning/attachment (10 participants).  75 mothers with reported breastfeeding problems were supplementing with expressed breast milk and/or infant formula.

Of the mothers with reported breastfeeding problems, their average weighed feeding volumes were statistically lower than the mothers who did not report breastfeeding problems with an average feed volume of 30 mL vs. 63 mL in the mothers who reported no breastfeeding problems (p<0.001).  The daily total volume of breast milk they were able to transfer (or feed directly through breastfeeding) were also statistically lower than those who did not report breastfeeding problems. The moms without breastfeeding problems transferred an average of 693 mL/day while those that reported breastfeeding problems transferred an average of 399 mL/day (p<0.001).  The study defined 440 mL of breast milk a day as the minimum required to safely exclusively breastfeed. This is the amount of breast milk that, on average, would be just enough to meet the daily caloric requirement of a 3 kg newborn (at 70 Cal/dL and 100 Cal/kg/day). Babies of mothers with no reported breastfeeding problems were statistically fed more milk than those with breastfeeding problems, 699 mL vs. 567 mL per day (p = 0.007). All 13 mothers who perceived no breastfeeding problems produced and transferred more than the study’s 440 mL cut-off as the volume required to be able to exclusively breastfeed.  What this data shows is that a mother’s perception of breastfeeding problems is associated with actual insufficient volume of breast milk fed to her child.

Based on the 440 mL cut-off for “sufficient” breast milk production, some mothers who report their babies not getting enough in fact produced more than 440 mL.  However, since 440 mL is the amount of milk that is needed to meet the minimum caloric requirement of a 3 kg newborn, if the mother had a newborn weighing > 3 kg as they would expect to be past the first days of life if growing appropriately, many of the mothers reporting breastfeeding problems may be producing more than 440 mL but are still in fact producing less than the amount to keep their child satisfied and fed enough to grow.  A supply of 440 mL would actually be just enough milk to cause a 3 kg newborn to be diagnosed to fail to thrive at 1 month since they would not gain any weight if fed this volume of milk. Failure to thrive has known long-term consequences including lower IQ at 8 years of age.  So their conclusion that some mother’s perception of insufficient breast milk may in fact be inaccurate as a volume of 440 mL is in fact “not enough” for most newborns weighing > 3 kg.

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