Resources

  1. J Pediatr. 2018 May;196:84-90  

Transcript

Dr. Frank Domino:
You are seeing Mary, a 34-year-old woman, who is three days postpartum with baby Angela. Mary is upset, as Angela keeps dropping weight despite Mary's best attempts at breastfeeding. She says, "My milk is not enough. It's not come in and I'm hurting my baby. How can you help?" Hi, this is Dr Frank J Domino, Family Physician and Professor in the Department of Family Medicine and Community Health at the University of Massachusetts Medical School. Joining me today to discuss breastfeeding and its challenges is Dr Susan Feeney, Assistant Professor and Coordinator of the Family Nurse Practitioner Program at the University of Massachusetts Medical School and Graduate School of Nursing. Thanks for coming to discuss this, Sue.

Susan Feeney:
Thanks, Frank. 

Dr. Domino:
This is a pretty controversial topic, so I hope we can come to a good conclusion after I review this case and this paper.

Susan Feeney:
Yeah, so first of all, why don't we talk a little bit about what the recommendations are for breastfeeding? What does the American Academy of Pediatrics say? I think they believe in a six-month... The first six months of life should be exclusive breastfeeding, is what they recommend.

Dr. Domino:

That is what they recommend. And they recommend that you don't need any other vitamins, as long as the mom is healthy, with the exception of 400 international units of Vitamin D started within the first few days of life. Breast milk is amazing, okay? It's got the most absorbable form of iron that you can get. It's got the appropriate balance of calcium, fat, protein, and carbohydrate. It's highly portable and highly effective. So there's plenty of benefits to breastfeeding. Beyond that, there are the immunologic benefits, the passive immunity that's passed to the child, that lowers the risk of some infections, including, most importantly, GI infections, so breastfeeding and breastfeeding exclusively has so many positive attributes.

Susan Feeney:
And we know too that it also reduces, I think, obesity in childhood, and also that it may reduce the chance of SIDS.

Dr. Domino:
Absolutely, so there's many pros and very few cons to breastfeeding.

Susan Feeney:
So tell me about this study. What did that... They looked at supplementation at a particular time in breastfeeding. What impact did it have? And did it hurt breastfeeding rates?

Dr. Domino:
So this is the interesting thing. This was a study where they took a randomized controlled trial, where they took women who were breastfeeding and the child was rapidly losing weight, they dropped below the 75th percentile, and they randomize them to keep just breastfeeding, or after they would attempt breastfeeding, to supplement them with processed hydrolyzed formula using a syringe, using 10 mls of formula, only after breastfeeding. They did this until the mother's milk came in and then they stopped. And what they found at one month was that adding this formula after a breastfeeding attempt had zero impact, had no impact on breastfeeding rates at one month. So it also... And here's the best part. It lowered the risk of re-admission for both jaundice and dehydration, two common reasons for re-admission in the first month of life, often due to inadequate or altered nutritional state.

Susan Feeney:
That's really amazing, 'cause I know that the first three days postpartum are so stressful. I mean the baby's going through a lot of changes, so is mom, but that as the milk's coming in, it's very, very stressful, especially if mom feels like the baby's not getting hydrated and there's lack of growth.

Dr. Domino:
Oh, it's very stressful and breastfeeding has so many benefits. You don't wanna do anything to interrupt it. We know, as I mentioned, some of the physiologic benefits. There's the benefit to the child. There's the benefit to the mother's sense of well-being. On the flip side, when you can't adequately breastfeed, the mother often feels insufficient. She's worried that she's harming the child, and that adds to guilt and misconceptions, and it also increases the risk that the family, the mother, the providers, the nurses, everyone who's involved with the care of that child gets anxious, and the pressure to, "Alright, let's just start formula and overcome that," comes on. And we know that if you do that over a long period of time, you're gonna actually lower breastfeeding rates.

Susan Feeney:
But you're not... This study wasn't talking about universal supplementation. They were targeting supplementation to children who were losing weight beyond what is expected.

Dr. Domino:

Absolutely, so there were two key points. One is just that, that women were encouraged to breastfeed ad-lib, and then only supplement if the child lost a fairly dramatic amount of weight, and only supplement after they breastfed, and only supplement using a syringe. So I don't know. I think we have a lot of thoughts about nipple confusion. I don't know if it's a true thing or not, but this study controlled for that by just using syringe feedings rather than a bottle.

Susan Feeney: 
That's really fascinating. So, how generalizable do you think this... What population of people did they do this study on?

Dr. Domino:
One of the limits of this study was that the women involved were, for the most part, older than 25, and they had very few African-American moms in the study. So this study seems to apply to that population, but may not apply to African-American women, may not apply to younger women, two populations that we'd love to see have breastfeed longer and initiate breastfeed. I think when folks first hear about formula supplementation to breastfeeding, there's a great deal of apprehension. I view this study as something that actually improves breastfeeding outcomes. Doing this allows the child to grow, allows the parent to feel successful in caring for their child, and we have pretty good data, although this is just one randomized controlled trial, it has no adverse outcomes, including not interrupting the potential for going six months of breastfeeding.

Susan Feeney:
Well, I do seem to be following all the support going afterwards, that supplementing after breastfeeding using a syringe and stopping when milk comes in. So what other things can be done when a baby is struggling to breastfeed?

Dr. Domino:
Well, I think in the past, we had wonderful access at our institutions to lactation consultants, and I would use them regularly. If I thought a child was doing poorly, or if a mom had lots of issues or concerns, I'd refer them back the same day they presented to me, for maybe their two-week physical or their one-month visit, and try to get them involved. The other thing I found, and you know, it's almost universal that the mom and the child gets a visit within a few days of discharge, but possibly a second or a third visit, just having someone come out and tell them they're doing an okay job helps a great deal. What has been your experience when moms are struggling? What suggestions do you have?

Susan Feeney:

I do the same, and I also will bring them in just to see how they're latching on. Sometimes it's just poor positioning. It can also be, if she's engorged, giving her some ideas on how to get the nipple more ability for the baby to latch on better. So sometimes it's some early intervention. And we do that. We see the moms early after they come to see us, a couple of days after they've been discharged, because that can make a world of difference, but having access to a lactation consultant, even by phone, has been wonderful.

Dr. Domino:

I do think, as a man, I can't say for certain what I think helps, but I often feel like I need to query new moms about how they feel, and what they feel is successful, and how can I help them get there? And I always congratulate and support them wherever they go. Because I think, especially in the first few months postpartum, there's a variety of hormonal changes and emotional changes going on in their life, and they don't always feel successful at everything. They often feel unsuccessful at everything, and I wanna reassure them that that's both normal and appropriate, and that they're doing a great job.

Susan Feeney:

And that's really important, because that first couple of weeks is so stressful on mom and baby, and they're going through a growth spurt. It's really learning to dance with a new person, and just giving them support, telling them, "You're doing a great job. We can help you get through this," it works wonders.

Dr. Domino:
Well, thanks, Susan. I appreciate you coming to discuss this with me.

Susan Feeney:

My pleasure.

Dr. Domino:

Practice pointer: For most children, exclusive breastfeeding without formula supplementation should be encouraged for the first six months of life. When there are problems with waking, dehydration, or jaundice, using resources is always highly recommended. Join us next time, when we discuss how to introduce and discuss goals of care with patients who have serious illness. And for more timely, relevant, and practical medical education, check out Pri-med.com.