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.”
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:
- MICH-23 – Reduce the proportion of breastfed newborns who receive formula supplementation within the first 2 days of life.
- 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 Objectives||Baseline (%)||Target (%)|
|Increase the proportion of infants who are breastfed (MICH 21)|
|At 6 months||43.5*||60.6|
|At 1 year||22.7*||34.1|
|Exclusively through 3 months||33.6*||46.2|
|Exclusively through 6 months||14.1*||25.5|
|Increase the proportion of employers that have worksite lactation support programs (MICH 22)||25†||38|
|Reduce the proportion of breastfed newborns who receive formula supplementation within the first 2 days of life (MICH 23)||24.2*||14.2|
|Increase the proportion of live births that occur in facilities that provide recommended care for lactating mothers and their babies (MICH 24)||2.9‡||8.1|
Increase the proportion of infants who are primarily breastfed through 4-6 months who have received sufficient nutrition to ensure optimal growth and brain development and to prevent feeding complications (e.g. hyperbilirubinemia, hypernatremia, dehydration, excessive weight loss, hypoglycemia and failure-to-thrive).
We have requested the following additions to the 2030 Healthy People Goals:
New Proposed Objective #1: Reduce the proportion of infants who require treatment and/or extended or repeat hospital admission for insufficient feeding-related hyperbilirubinemia, hypernatremia, dehydration, excessive weight loss, hypoglycemia and failure-to-thrive.
New Proposed Objective #2: Increase the proportion of parents who have made the informed choice to partially- or exclusively-feed formula to provide safe and sufficient nutrition to their infants to prevent feeding complications (e.g. hyperbilirubinemia, hypernatremia, dehydration, excessive weight loss, hypoglycemia and failure-to-thrive) and optimize growth and brain development.
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.
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.
- Dr. Marianne Neifert, Clinical Professor of Pediatrics at the University of Colorado Denver School of Medicine, who co-authored a 1990 study of 319 breastfeeding women found 15 percent of the women were unable to produce sufficient milk by three weeks after delivery.
- Data from the Infant Feeding Practices Study (IFPS) II, a study of U.S. women, showed that one in eight women experienced early, undesired weaning from disrupted lactation due to physiologic reasons. According to the study, pain, difficulty with latch and insufficient breast milk supply were the most common reasons for early weaning.
- Dr. Shannon Kelleher talks about these staggering numbers in her publication, “Biological underpinnings of breastfeeding challenges: the role of genetics, diet, and environment on lactation physiology,” where she says the prevalence of lactation insufficiency may be much higher, as 40–50% of women in the US and 60–90% of women internationally cite “not producing enough milk” or that their baby was “not satisfied with breast milk” as the primary reasons for weaning prior to 6 months.
- We are learning that mothers in western societies are experiencing delayed lactogenesis II (onset of full milk production) for complex and unknown reasons. This study suggests that the prevalence of DOL has reached epidemic proportions.
Full video presentation available at Contemporary Forums Online.
Las Vegas, Nevada — On September 6, 2018, the national neonatology conference, “The Fetus and Newborn Conference” was held in Las Vegas, Nevada. Among the speakers was Jay Goldsmith, M.D., Neonatologist and Professor of Pediatrics at Tulane University, Member of the American Academy of Pediatrics Section on the Fetus and Newborn who gave a talk entitled, “Is Baby-Friendly Baby Safe?”
In the talk, he discussed the case of an Oregon woman who has filed an $8.6 million lawsuit against her hospital, Portland Adventist Medical Center, and a nurse who cared for her and her baby after accidentally suffocating her newborn after falling asleep with him in her hospital bed. According to the Washington Post, she had delivered her son by cesarean section a few days earlier and was given narcotic pain medication and sleep aids. A nurse gave her newborn to her while she was still drowsy and groggy to breastfeed in her hospital bed. About an hour after being left to breastfeed, the baby was found gray, not breathing with compromised vital signs in the mother’s arms after which he was rushed to the nursery. The baby received CPR and was put on life support but the child sustained severe and permanent brain injury. He ultimately died at 10 days of age. Continue reading
Christie del Castillo-Hegyi, M.D. and Jody Segrave-Daly, RN, IBCLC
We at the Fed Is Best Foundation give mothers across the globe a platform to tell their stories about how their babies suffered needlessly because they were denied information and supplementation for their hungry babies while under the care of the Baby-Friendly Hospital Initiative/WHO Ten Steps to Successful Breastfeeding protocol. Our Foundation has grown rapidly and demands significantly more time than we currently have because we are a 100% volunteer organization. We are inundated with messages from mothers, health professionals and media on a daily basis. We try very hard to prioritize what we can do collectively, every single day. Our first priority is to respond to mothers in crisis who contact us needing assistance on how to safely feed their distressed breastfed baby because they were not educated on appropriate supplementation. Baby Friendly USA (BFUSA) found time to critique our interpretation of studies and written materials, so we were forced to take time away from mothers to update written materials and clarify our interpretations. Our goal is to be completely transparent and we have provided our detailed response below with corrections and clarifications given publicly available published data. If there have been errors in interpretation of published information, then we go back to the original published data to provide better data for the public, which we have done below. We believe we have a responsibility to inform parents, the public, medical insurance companies and BFHI hospitals about the risks of exclusive breastfeeding when insufficient. We believe parents deserve to know that the BFHI has an exclusive breastfeeding (EBF) threshold mandate to meet if the hospital wants to remain credentialed. The mandate results in tens of thousands of newborn admissions every year in the U.S. alone, which we chronicle on our page. For the safety of infants across the globe, we will continue to provide education on how to recognize serious complications of exclusive breastfeeding and how every parent can prevent them.
Starvation jaundice (hyperbilirubinemia) of the newborn is defined as abnormally high bilirubin in a newborn who loses >8-10% weight. It is caused by insufficient elimination of bilirubin due to insufficient caloric intake from exclusive breastfeeding in the first week of life. This well-established phenomenon has been discussed by neonatologist Dr. Lawrence Gartner, who is listed as a Director on the Baby-Friendly USA website, in a lecture given to lactation consultants (not just physicians and nurses as stated by BFUSA) at a 2013 California Breastfeeding Conference, previously posted on their website. This public lecture was provided to educate lactation consultants regarding dangerous levels of jaundice that can occur in previously healthy breastfed babies that result from inadequate intake of calories from exclusive breastfeeding. Under Fair Use laws, dissemination of educational material for non-profit educational purposes is protected and we were subsequently asked to post the full lecture by Dr. Gartner via email. The Academy of Breastfeeding Medicine jaundice protocol acknowledges that exclusively breastfed newborns are at higher risk of hyperbilirubinemia from insufficient milk intake (“suboptimal intake”) and excessive weight loss. The vast majority of newborn hyperbilirubinemia is caused by starvation jaundice. Their protocol also states that 98% of kernicterus, or the most severe form of brain injury from jaundice, occurs in breastfed newborns. Nearly all of starvation jaundice can be prevented with timely and adequate supplementation. Nearly all newborns with starvation jaundice show signs of poor feeding including excessive crying and frequent, unsatisfied nursing or lethargy before they develop levels of hyperbilirubinemia that result in impaired brain development. While BFUSA has not previously denied the increased risk of hyperbilirubinemia in breastfed newborns, they have not routinely disclosed them to parents or subscribing hospitals, which has the unfortunate effect of causing hospitalizations that would have been prevented by supplementing a crying underfed newborn. Unfortunately, many parents and health professionals are taught that the signs of poor feeding including crying and hours of unsatisfied nursing are normal, widely known as the “Second Night Syndrome.” These unfortunately are also the earliest signs of other complications like acute bilirubin encephalopathy, kernicterus, hypernatremic dehydration and hypoglycemia, all known causes of brain injury and permanent disability, which can occur if those signs are overlooked as normal and supplementation is avoided in order to meet the goal of exclusive breastfeeding.
Christie del Castillo-Hegyi, M.D.
The WHO health policy that has been responsible for millions of preventable hospital admissions of newborns for insufficient feeding complications is Step 6 of the Ten Steps to Successful Breastfeeding: “Give no additional food or fluid other than breast milk unless medically indicated.” Complications of insufficient feeding from exclusive breastfeeding before copious milk production are now among the leading causes of newborn extended and repeat hospitalization, namely jaundice (hyperbilirubinemia), dehydration and hypoglycemia.
In 2017, the World Health Organization published its guidelines updating its recommendations for “Protecting, Promoting and Supporting Breastfeeding in Facilities Providing Maternity and Newborn Services,” which outlines the evidence for the WHO recommendations on breastfeeding support for newborns in health facilities based on the Ten Steps to Successful Breastfeeding. Here is the evidence presented to justify the recommendation to avoid supplementation in breastfed newborns.
The WHO guidelines authors went on to conclude the following:
How did very low quality of evidence turn into moderate quality evidence for exclusive breastfeeding particularly when the evidence showed improvement of breastfeeding rates in supplemented breastfed newborns? Continue reading
Christie del Castillo-Hegyi, M.d.
Newborn hypernatremia is a serious complication of early exclusive breastfeeding of newborns caused by insufficient feeding of milk. It is defined as an elevation of blood sodium levels (≥ 145 mEq/L) in response to insufficient fluid intake and most commonly occurs at day 3-4 of life, typically the point of greatest weight loss of a newborn. It is the most severe complication of dehydration and excessive weight loss and increases the risk of brain injury, developmental delay/disability, seizure disorder, vital organ injury and death. Oddie et al. showed that up to 98% of hypernatremia occurs in exclusively or near-exclusively breastfed newborns and the study group found the diagnosis of hypernatremia was rare. However, since blood sodium levels are not universally-screened, which could result in missed cases of hypernatremia, it has been unclear just how common the condition is among newborns.
A recently published prospective study of 165 healthy newborns ≥ 35 weeks gestational age looked at rates of hypernatremia (>145 mEq/L) in the first 3 days of life. They examined multiple variables that predict hypernatremia as well as the threshold weight loss values at which increased hypernatremia risk occurs. The results were astounding.
The study found that out of 165 newborns 51 or 30.9% developed hypernatremia.
The majority of cases occurred by 5% weight loss, the lowest percentage weight loss occurring at 4.77% weight loss, especially for male infants delivered by cesarean delivery to a mother with higher education level. Continue reading
Jody Segrave-Daly, RN, IBCLC and Christie del Castillo-Hegyi, M.D.
The Fed is Best Foundation is dedicated to ensuring safe infant feeding for every single child, a goal that can be achieved with exclusive breastfeeding, combination feeding, exclusive formula feeding and tube-feeding. We have no political affiliation. We support all mothers to help their infant thrive with safe, sufficient and sustainable feeding in order to protect their health and optimize brain development. Recent news has broken about the U.S. delegation at the 71st World Health Assembly opposing the first draft of the Infant and Young Child Feeding resolution. We have provided a line-by-line break down of the first draft of the resolution, which was set to be proposed by delegates from Ecuador, as well as the proposed draft submitted by the U.S. delegation along with our interpretation of the lines that the U.S. delegates opposed.
In an editorial published in the New York Post, two pediatricians, Dr. Alma Golden and Dr. Brett Giroir, who were key members of the U.S. delegation attending the 71st World Health Assembly, wrote about the rationale for the U.S. opposition of the first draft:
As pediatricians, US representatives at this year’s World Health Assembly in Geneva and supporters of breastfeeding throughout our professional careers, we were shocked to read recent headlines, in the New York Times and elsewhere, claiming that the administration has somehow called into question the importance of breastfeeding for infants.
The administration fully endorses breastfeeding, and the agencies where we work — Health and Human Services and USAID — communicate this unequivocally…We don’t just affirm these priorities in formal conference rooms in Geneva. For years, the US government…has invested millions of dollars to promote breastfeeding both at home and abroad.
All of which is to say: Breastfeeding wasn’t in dispute in Geneva. Rather, we raised objections to an early draft of the resolution we eventually supported, which made references to a controversial 2016 guidance document. The underlying policy goal of this guidance is unsupported by US nutrition guidelines and inconsistent with the practice of most families in our country…
In particular, the guidance recommends that countries impose stringent new regulations on the marketing of any commercially produced foods suggested for children between 6 months and 3 years old. Such restrictions, in our view, prevent parents from having access to all the factual information they might need. The guidance even advocates for the prohibition of free samples of formula — including in countries and conflict zones where supplies of formula could help save babies’ lives.
Most important, there are good and valid reasons, both medical and personal, why some mothers cannot breastfeed, or choose not to breastfeed exclusively. This is particularly true in situations where displacement, other trauma or malnutrition have made it impossible for mothers to breastfeed their children, and these babies’ lives are at risk without formula or other nutritional supplementation. Parents in these dire situations need all the information and choices available.
The issue of child malnutrition occurring in war torn countries has been reported on by CNN reporter Gayle Lemmon in her article, “Don’t make babies rely on breast milk in war zones,” where she interviewed members of Doctors Without Borders who reported taking care of many infants suffering from severe malnutrition as a result of the strict restrictions of the World Health Organization and UNICEF on formula donations.
‘Over the past couple of weeks we’ve seen an increase in the number of malnourished children needing treatment,” Doctors Without Borders’ Iraq country director Manuel Lannaud said in an interview released on the group’s Web site.
The surprising thing is that Lannaud and his colleagues at the humanitarian aid group didn’t place the blame for these underfed little ones just on war and the fact that the city was under siege. They also put the blame on other international organizations and policies that seek to do good.
“It isn’t a problem of access to food. The malnutrition we see here is primarily due to the scarcity of infant formula,” Lannaud wrote. “International organizations like UNICEF and the World Health Organization (WHO) promote breastfeeding … and provide infant formula, but only by prescription. We believe that distributing infant formula in a conflict situation like Iraq is the only way to avoid children having to be hospitalized for malnutrition.”
Doctors Without Borders says it agrees that breastfeeding promotion is a priority, but one that comes after dealing with the immediate crisis of a baby’s survival. Says Lannaud, if mothers “need formula, we give it to them.”
The mothers who need it are those facing down life-and-death situations each day, often while caring for multiple children in the shadow of war. That giving infant formula to them is so controversial speaks to a policy tripwire few outside the humanitarian realm even know exists: global “breastfeeding first” policies.
The WHO breastfeeding policies are not without flaws and aggressive promotion of exclusive breastfeeding has resulted in harm, namely an epidemic of newborn hospitalizations for jaundice, dehydration and hypoglycemia, known causes of brain injury and developmental disability, in the U.S. and across the globe. In addition, there has been a rise in accidental suffocation of newborns, called Sudden Unexpected Postnatal Collapse, from prone positioning during to skin-to-skin care and breastfeeding, made worse by maternal exhaustion from 24/7 rooming-in, practices encouraged but the WHO Ten Steps and by Baby-Friendly policies. The promotion of exclusive breastfeeding from birth has contributed to an epidemic of neonatal jaundice in the developed and developing world, which has contributed to an epidemic of perinatal brain injury and cerebral palsy particularly in the developing world, where few health care resources are available to monitor and treat exclusive breastfeeding complications. Promoting exclusive breastfeeding from birth over the local, traditional practices of supplemented breastfeeding (with wet nursing, animal milk or sugar water) until the onset of copious milk production has discouraged a practice that breastfeeding mothers used to prevent hunger and starvation-related complications like jaundice, dehydration and hypoglycemia, which now are the leading causes of newborn rehospitalization in the world.Continue reading