Breastfeeding Medicine Blog

ABM Releases Revised Supplementation Protocol

During a time of abundant research surrounding the long term implications of feeding practices in the neonatal period on maternal and child health, it is of utmost importance that healthcare professionals are guided by the best available evidence regarding infant feeding while caring for breastfeeding dyads. We know that despite the recommendations against routine formula supplementation, this practice is commonplace in hospitals worldwide for a myriad of reasons. In developing ABM Clinical Protocol #3: Supplementary Feedings in the Healthy Term Breastfed Neonate (Read the protocol here) newborn physiology and management of breastfeeding mothers were highlighted to impress upon healthcare professionals the delicate balance involved in helping mothers establish exclusive breastfeeding in the early postpartum days. Many mothers set out with the goal of exclusive breastfeeding, but still in many countries, few reach their feeding goals. Studies clearly demonstrate that when healthcare teams have a clear understanding of these topics, provide antenatal education, and implement supportive hospital practices, the need for supplementary feedings in term neonates is rare.

Preventing the need for supplementation altogether should be a common goal for all members of the healthcare team. It has been well established in the literature that exclusive breastfeeding protects mothers and infants from various poor health outcomes, is cost effective, and is the physiologic norm. Thus, the authors of this protocol dedicated substantial time and focus on practices that have been shown to reduce this need, which include many of the ten steps required by the Baby Friendly Hospital Initiative. The revised protocol contains an algorithm for caring for the breastfeeding dyad before and during the birth hospital stay and responding to common concerns.

It is important to recognize true medical indications of supplementary feedings as well as the preferred choice and volumes of supplement, which are appropriately outlined in this protocol, re-emphasizing that, while there is a time and place for formula use, a mother’s own expressed milk or donated human milk in volumes that mimic normal breastfeeding physiology are preferable to breast milk substitutes. The preference for donor human milk over formula use has been suggested by the Academy of Breastfeeding Medicine for years, and is further supported by emerging research on the long term health consequences of the infant microbiome and the role that breast milk substitutes may have on individual health outcomes years down the road.

Educating ourselves as healthcare providers about how best to support mothers in their breastfeeding journey is crucial to their success in meeting their personal feeding goals. This revised clinical protocol highlights supporting evidence and contains information and strategies needed to provide state-of-the-art care and support.


The Burden of Proof

October is a busy month for me. I usually travel twice that month, once for the American Academy of Pediatrics Section on Breastfeeding Medicine meeting, and then again for the annual Academy of Breastfeeding Medicine meeting. One of my partners (who doesn’t have children) comes up to me and says: “Why are there so many meetings about breastfeeding? I mean we all know that’s the best thing for babies and we all should recommend it. How many meetings, research studies do you really need?” At first, I was stunned…not bad, not good, just surprised, I guess.

This reminds me of when I had invited Dr. Christina Smillie to Children’s Hospital of the King’s Daughters (CHKD)/Eastern Virginia Medical School (EVMS) to speak at our 1st Virginia AAP Breastfeeding conference in 2009. The first night I had her speak to the MPH school at EVMS. As Dr. Smillie always does, she gave a wonderful talk on the public health reasons, risks of death with sub-optimal breastfeeding, how breastfeeding is natural, etc. After 60 minutes of slides, statistics and videos, a male public health researcher raised his hand and asked: “So why isn’t everyone doing this…why aren’t BF rates at a 100%?” Dr. Smillie and I just smiled knowingly at each other.

After I thought about it, I explained to my partner that while there is so much new research/things discovered about breastmilk and its properties, I told her, that as a field, Breastfeeding Medicine is constantly battling critics and having to ‘prove’ our medicine. Whether it’s against the various industries, hospital systems, colleagues, or even other physicians, Breastfeeding medicine has to prove its worth. I was telling another ABM member about this conversation and I remarked at how I had attended an acne lecture at the AAP conference. As a general academic pediatrician, I wanted to get some new information, learn the research on various conditions that I commonly see in my practice. And it hit me like a ton of bricks. The dermatologist, while very knowledgeable and a good speaker, was quoting statistics from the 70’s and 80’s…that would be 1970/1980. Of course she spoke about the newer drugs being used, but the pathophysiology and meds/ointments used to treat this condition, well that data was over 25 years old!

This is not to say that other pediatric fields don’t have to do research and update their findings, but it was incredible to me! That would never be accepted within the BF medicine community. Other researchers/physicians, often via social media frequently attempt to debunk even the latest studies with strong findings.

Or if a physician has a bad experience, studies have shown that our personal breastfeeding experiences negatively affect our advice that we, as physicians, give to mothers/patients. That’s like me telling patients not to have a needed surgery since I had such terrible experiences with anesthesia.

So why does this happen? Why do folks not argue against the treatment of other medical conditions, such as acne, reflux, etc? It is because breastfeeding is personal, it is maternal and unfortunately, there is a lot of guilt attached to not being able to breastfeed and/or not meeting breastfeeding goals/expectations? Do we need to depersonalize the topic, make it less emotional? Is that even possible? Just like my partner or the public health researcher, it was like “duh…of course everyone should be breastfeeding.” Stepping out of your [breastfeeding] box, no matter what side of it you’re on, proves to be beneficial, to give perspective, to depersonalize it so one can see facts.

Ok, yes this may be oversimplifying the issue, as there are numerous facets (prenatal, hospital, postnatal, cultural, societal) to breastfeeding success, but the matter-of-factness of the health benefits of breastfeeding has been and continues to be proven. Period. And our goal as physicians is to give each and every mother the opportunity to give this to her baby. And there really should be no debating that.

“A newborn baby has only three demands. They are warmth in the arms of its mother, food from her breasts, and security in the knowledge of her presence. Breastfeeding satisfies all three.” ~Grantly Dick-Read

Natasha K. Sriraman is a general pediatrician and a professor of Pediatrics at Children’s Hospital of The King’s Daughters/Eastern Virginia Medical School in Norfolk, VA.

Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.


Trust and test weights

“Nobody seems to trust test weights in our unit.  What are we doing wrong?”

To “test weigh” a baby means to measure how much milk she has transferred by simply weighing her — clothing, diaper and all — before and after breastfeeding.  Test weights are often used in term infants using precise scales such as the Medela BabyWeigh.  A few studies have supported the utility of test weights in preterm infants: these include a Swedish study favorably comparing babies cared for in NICUs using test weights vs NICUs that did not (earlier attainment of exclusive breastfeeding and earlier discharge) as well as a small study from the illustrious LCs at my own institution describing the development of a technique for accurately performing test weights.

It still seems, though, that NICU providers and even parents have a tendency to distrust test weights in premies learning to breastfeed.  Some of this distrust, especially for the providers, is probably a residuum of earlier studies using less precise scales and/or less consistent, accurate weighing techniques.  (It is true that we NICU folks tend to love our numbers, and we prefer that they have as many significant digits as possible.) I suspect another large part of the distrust has to do with the fact that premies who are learning to feed don’t consistently transfer the same volume of milk even when their feeding quality seems to be subjectively “good.”  As with learning to walk or talk, learning to feed is an incremental and not a linear process… but when numbers-focused, pattern-seeking people see “inconsistency” in the amount transferred, we think “that can’t be right.” Finally — just perhaps — part of the distrust might be with breastfeeding itself.  If we can’t measure it or control it, we can’t trust it. And if parents hear us expressing distrust of breastfeeding, they are probably more likely to distrust it as well.

Fortunately, a new study in the Journal of Pediatrics provides new support for the distrusting among us. This group took the breastfeeding out of the picture altogether: in a larger number of premies, using the protocol developed above, they performed test weights before and after gavage feedings.  (This means that the volume given was known, and the test weight was compared to the volume given.)  They found that 85% of the test weights were within + 5mL, which is clinically acceptable for older premies (>34 weeks).   I admit to glossing over the finer details here and encourage anyone who is interested to read the paper more closely.  But knowing that test weights do correlate with a known volume given by gavage, there is no reason we shouldn’t be able to trust them in measuring “unknown” milk transfer at the breast.

Bottom line: be consistent in your weighing procedure, use a good scale, and… trust the babies as they learn to breastfeed. If we trust the babies, we can empower their moms,  which is one of the most important parts of our job.  NICU moms need to be able to trust themselves and their babies, not just their NICU providers!

Kimberly Lee is a neonatologist and member of the Academy of Breastfeeding Medicine. 

Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.