I'm going to take a little break from the science-based focus of this blog and talk a little bit about something that is very personal to me: Postpartum Depression. I feel this is relevant to the blog because, being a breastfeeding blog, I'm sure it attracts readers who either are parents or work very closely with parents. I feel that anyone who works closely with parents and particularly postpartum mothers needs to know what postpartum depression is really like, from someone who suffered through it.
My husband and I tried for about 3 years to get pregnant. I had been so anxious to get pregnant that I really hadn't thought about much beyond the actual pregnancy itself. All of my fantasies were of finding out I was pregnant and how I would be so overjoyed.
The moment I took that first pregnancy test, things already started to deviate from the path. I thought the test was a mistake, so I took 8 more. All 9 tests said I was pregnant. Why was I not crying with happiness? Where was the overjoyed smile? The screaming? The jumping up and down? I WAS happy, I just didn't really know how to show it. Thinking back, that was probably the first sign that something was amiss.
I had a textbook pregnancy. There were no complications or anything. But I had this feeling, and I just couldn't place it. I felt a bit sad, but not for any particular reason. I didn't enjoy going out places, I didn't want to interact with my husband, I was overly sarcastic yet very easily offended. I loved being pregnant, but I just didn't feel right. Still, physically my pregnancy was great..up until 36 weeks. My water broke prematurely, and being unable to get to the proper hospital my daughter was born in triage at our local emergency clinic. She was transported by ambulance to the hospital and I was left behind to be stitched up.
Her birth happened so quickly and so unexpectedly that when I first heard a baby crying, I didn't believe it was my child. But at the same time, I KNEW that child was mine, and I had an overwhelming urge to maul everyone in the room, like a mama bear. I needed to protect my child from them, and the urge was so powerful that I almost ripped the IV out of my arm and walked the 15 miles to the hospital. When my own ambulance dropped me off at the hospital, a nurse wheeled me into my room and I saw my husband standing there waiting for me.
Where was my daughter? WHERE WAS SHE? I began to panic and could feel my heart speeding up. I asked the nurse where my daughter was and was told that she was in the nursery and would be in shortly. When she left I asked my husband where my daughter was and he told me the same thing. I was furious with him. I hated him. He abandoned her. The mama bear instinct was strong, and again I wanted to maul everyone in the hallway and run down the halls screaming until I found her. But I didn't. Instead I waited patiently until finally the nursery staff wheeled her in. I vowed at that moment to never let anything happen to her. I still didn't feel very emotionally attached to her, but biologically, my brain and my mothering hormones were in overdrive and I knew I would climb mountains to keep that child safe..at least until her real mother showed up.
The first few days were a blur. I cried a lot, and I was stressed out. I dreaded the sun going down because my husband would go in and go to bed and I would be left with this fleshy, crying blob. Breastfeeding wasn't going all that well and my daughter was jaundiced. They almost had to admit her to the NICU. She spent a lot of time wrapped in her bilirubin blanket sleeping, and I was pumping all the time. And at night I would curl up on the couch and cry by myself.
Over the next few weeks things significantly improved. I finally began to feel an attachment to her, but I could never quite shake the feeling that something was off. Since she was born early I didn't feel ready. I felt like I had been thrown into parenting and even tasks like changing diapers or bathing her were a struggle. My husband was very un-involved. He was getting ready to deploy and was very busy at work. In her first 3 months alone he spent almost 2 months gone. When my daughter was almost 4 months old he was in a training accident that left him permanently disabled and I was left to care for him as well as my daughter. That was when things went very far down hill.
I began having intrusive thoughts. I imagined the knives in the kitchen floating over into my hands, and my hands were stabbing my daughter, as if acting on their own. I imagined myself throwing her off balconies, drowning her, driving into walls with my car, and overdosing on medications. These thoughts were horrifying. I didn't want to kill her, or drive into a wall, or overdose on medication. I was not suicidal, nor was I homicidal, but these thoughts would come to me and my brain would force me to think them. If I tried to push them away my brain pushed back even harder. Eventually I just begrudgingly accepted them. Yet the thoughts I was thinking about myself paled in comparison to the things I thought about others. I was convinced that everyone around me was incompetent. I thought my husband was going to accidentally drown her, or that my dad would forget the ceiling fan was on and raise her in the air.
The drive to protect her was extreme at this point, and nothing anyone did was ever good enough. On the one hand, I believed that no one was capable of taking care of my child. But on the other hand I knew that I, too, was incapable of caring for her. I still don't even know how I got through that first year, and in retrospect I wish I would have asked someone for help. There were a few times where things got so bad I considered driving myself to the ER and asking for help, or even just calling the police. But the problem was that for every bad night I had, for every moment I wished I could go back in time and undo my daughter's conception, there would be a decent day. I would wake up and get a lot done, and I would think that I was over the hump and everything would be ok. That was the cycle I lived in for almost a year.
At the end of my daughter's first year, I left my husband. I told him months earlier I was leaving, and when he was finally medically discharged from the military I moved out and didn't look back. I hated him so much at that point. I hated him for not being in the room when my daughter was born, I hated him for not staying with her in the nursery, I hated him for not helping, I hated him for becoming disabled (by no fault of his own), and I hated him just because he was the only person around who I could even justify hating. I even had intrusive thoughts about him. I imagined him dying in horrific accidents or committing suicide. These were not things I wanted to happen, but my brain was forcing me to think them. I hated those thoughts so much, but I was powerless to them.
I'm writing this because I know now that what I was experiencing was not some freak occurrence. It's textbook Postpartum Depression (the intrusive thoughts fall a little in the realm of PPOCD). Postpartum Depression does not mean you just sit around and cry and feel sad all the time. Actually, I really didn't feel sad at all. Instead, I felt absolutely, completely, bat-shit insane. I recognized that my life was wonderful and that I was blessed, and objectively I realized that despite certain horrible event things were looking up. But I still felt completely powerless, like I was just being dragged through life by the seat of my pants. It was like someone scrambled my brain and I couldn't make normal connections anymore. I would be overcome by even simple childcare tasks, or I would open the fridge and stare blankly at the food inside, unable to comprehend what I was even looking at. I spent a lot of time hungry and ordering pizza because I couldn't seem to focus on complex tasks like food prep. Everything was just weird and surreal.
But I know I'm not the only one to experience that. And I know somewhere out there is another woman experiencing something similar, and she probably feels alone and anxious, and those around her have no idea how to help. Or else they may not even recognize her symptoms as being PPD. They may think she's just lost her mind and has gone crazy. My husband once asked me when I was going to get over "that postpartum crazy shit". That answer is still pending, since I'm still not completely healed and I still struggle with intrusive thoughts (albeit infrequently). I think I'm doing quite well now as a single mother. I moved back home and went back to school, got a certification in Lactation Education, joined La Leche League, and returned to college to complete my bachelor's in nursing. I do still struggle though. I'm a work in progress.
I suggest those who identify with this blog post to check out Postpartum Progress, and seek help from someone: a friend, family, your doctor, a counselor, or even an online community. There's no reason anyone needs to go through that alone. It's not worth martyring yourself because you're afraid of what others might say or think. There's NO shame in asking for help.
http://www.postpartumprogress.com/
Saturday, December 14, 2013
Wednesday, September 18, 2013
Debunked: Grains Before One?
One of the most common claims I see on the internet with regards to infant feeding is that the human body cannot digest grains until the age of one (or 2, or 4, or any other random age). This could not be further from the truth! Not only are grains easily digestible by the infant body, but they are a staple part of the diet, providing energy as well as many essential micro-nutrients.
What are grains?
When one thinks of grains they usually think of things such as wheat, barley, rice, corn, and oats. In reality, a grain is a type of fruit with a fused seed, and encompasses even things like legumes and beans, and other vegetables (USDA 2013). For the sake of this post, all discussion on grains will be restricted to "cereal grains", such as wheat.
A cereal grain is a type of grass that produces an edible seed with endosperm, bran, and germ (USDA 2013). The primary macro-molecular component of grains is polysaccharide chains of glucose known as "starch" (Raven et al. 2013). So when we talk about the ability to digest grains, what we're really looking at is the body's ability to break apart the glycosidic linkages of these starch chains.
How does starch digestion work?
1. Starch digestion begins in the mouth with salivary enzymes (Wardlaw et al. 2013). Enzymes are catalysts. That means they assist in chemical reactions but are not part of the reaction. An enzyme provides a binding site for larger molecules and, once joined with the molecules, will alter its shape, exposing the chemical bonds (Raven et al. 2013). Once exposed, these chemical bonds are broken in a process called hydrolysis. A water molecule is added to the bond site, splitting the 2 molecules apart. In starch digestion, the enzyme "alpha-amylase" binds to the starch, exposing the glycosidic linkages holding the glucose molecules together (Raven et al. 2013). The starch is then broken in to different disaccharides (maltose and isomaltose) and some oligosaccharides (alpha-dextrins, trisaccharides) (Lieberman, Marks 2012).
2. The second stage of starch digestion occurs in the stomach. There is very little enzyme activity in the stomach, however alpha-amylase retains its biological activity while in the fundus portion of the stomach, where it remains for about an hour before it mixes with gastric acid (Vance 1999; Matthews 1916) This means that the hydrolysis of starches by salivary amylase continues even after the food leaves the mouth.
3. After being broken down by the stomach, the shorter starch chains then enter the upper portion of the small intestine (duodenum). The pancreas secretes digestive enzymes, one of which is also alpha-amylase. This alpha-amylase is identical to the alpha-amylase in the saliva, acting as a catalyst in the further hydrolysis of alpha-dextrins in to maltose, isomaltose, and maltotriose. (Lieberman, Marks 2012).
The activity of alpha-amylase is limited to certain glucose polymers with glycosidic linkages at specific prime points. Therefore, alpha-amylase is not the only enzyme responsible for starch digestion. The maltose, isomaltose, maltotriose, and other oligosaccharides produced through amylase hydrolysis require additional enzymes to further break them down. This is where the brush-border region of the small intestine comes in to play. (Lieberman, Marks 2012).
4. The brush border region of the small intestine (lower portion of the duodenum as well as the jujunum) contains millions of microvilli attached to a single-layer of secretory and absorptive cells. The cells of the brush border region secrete more enzymes, such as glucoamylase, sucrase-isomaltase complex, lactase, and some others (Bowen 2006; Lieberman, Marks 2012). These enzymes are called "brush border enzymes". It is here that the products of amylase hydrolysis are further hydrolyzed to yield glucose monomers, which are then absorbed in to the bloodstream.
5. Any remaining starch that is not digested at this point will continue to the large intestine. Not all starches will be digested. Cellulose is a structural form of starch that comprises the cell walls of most plants (Raven et al. 2013). In cereal grains, cellulose makes up a portion of the germ and the bran. The glycosidic linkages that hold the glucose monomers together in cellulose cannot be broken down by simple hydrolysis, and thus cellulose makes up most of our dietary fiber (Raven et al. 2013; Wardlaw et al. 2013). In the large intestine, microflora aid in further starch digestion, breaking down the resistant starch polymers in to short chain fatty acids and gases (Lieberman, Marks 2012). Some recycling of nutrients occurs here, and the fatty acids are used in metabolic processes by the colon's own cells, but most of the biological activity in the large intestine serves to bulk and form the feces.
How do infants digest starches?
Much of the confusion surrounding starch digestion in infants stems from our understanding of infant pancreatic function. The pancreas is the organ responsible for secreting most of the digestive enzymes in to the small intestine. Because pancreatic function in infants is immature, their pancreas does not secrete large amounts of alpha-amylase (Karn, Merritt 1976). Salivary amylase begins being produced at about 18 weeks gestation, and has been found to be at full adult levels by around 5 months of age (Karn, Merritt 1976; Christian et al. 1999; Blackburn 2007). Pancreatic amylase production begins a few weeks to a few months after birth and slowly increases, approaching adult levels by about 16 months of age, though it may take years for full maturity to be reached in some children (Lebenthal 1987).
Erroneous application of that knowledge has resulted in claims that infants "cannot" digest starches. In fact, what is understood to be "adult levels" of alpha-amylase is actually an abundance of alpha-amylase (Lieberman, Marks 2012). Both the pancreas and the salivary glands secrete amylase in quantities that exceed biological need. So what is considered an "adult level" is far more than is actually used to digest starch. Adults can efficiently digest starches with as little as 10% of the alpha-amylase normally secreted (Lieberman, Marks 2012). Furthermore, the intestinal epithelial cells that secrete the brush border enzymes are fully mature and secretion of brush border enzymes is at 50-100% adult value at the time of birth, increasing even more rapidly in the next few days (Blackburn 2007).
To further determine the role of pancreatic amylase in starch digestion, we look at infants and children who have Cystic Fibrosis (CF). Individuals with CF have an inborn error that alters the way their cells diffuse water and salts across the cell membrane. This results in excess mucus being produced, which inhibits the secretion of many pancreatic enzymes. However, in infants and children with CF, starch digestion is one of the better digestive processes. Lipid and protein digestion is inhibited in much greater amounts than is starch digestion. Infants and children with CF are recommended to maintain a high carbohydrate diet, specifically because of the efficiency of starch digestion in the absence of full pancreatic function (Goodin, 2005).
There is no scientific evidence to suggest that lowered production of pancreatic alpha-amylase is in any way detrimental to infants. It is hypothesized that the lower production of pancreatic enzymes in infants is a protective method to avoid degradation of the intestinal epithelial lining. But other compensatory digestive mechanisms more than make up for the lack of pancreatic amylase (Blackburn 2007). In fact, infants also do not produce "adult" quantities of most other pancreatic enzymes either, which begs the question that if we cannot give our infants grains, what do we give them? Furthermore, do ALL components of a diet need to be fully digested? The answer is no. Human breast milk contains several types of indigestible oligosaccharides (pre-biotics) that survive digestion intact and feed the microflora of the colon. Insoluble fiber is also a necessary part of the human diet (Barile, Rastall 2013).
Complementary solid food feeding of infants should begin at 6 months (WHO 2009; AAP 2012), and the most suitable complimentary food is actually starch. While most arguments against grain introduction focus exclusively on cereal grains, the same polysaccharide starch chains that are found in grains are also found in many other vegetables. Carrots contain the same amylose and amylopectin starch chains that are found in grains, and yet I have not heard a single convincing argument with regards to why infants cannot digest carrots.
Starch digestion is a complex process that involves much more than the presence or absence of one singular enzyme. Meanwhile, whole grains continue to satisfy a majority of the human body's energy needs, as well as being a rich source of the essential nutrients folate, selenium, magnesium, and manganese, as well as many B vitamins.
References:
1. United Stated Department of Agriculture. MyPlate Recommendations. 2013
2. Biology (10th Edition). Raven, Mason, Johnson, Losos, Singer. C. 2014 Mcgraw Hill
3. Contemporary Nutrition: A Functional Approach. Wardlaw, Smith, Collene. C. 2013 Mcgraw Hill
4. Marks' Basic Medical Biochemistry (4th Edition). Lieberman, Marks. C. 2012 Lippincott Williams & Wilkins
5. Physiological Chemistry. Mathews. C. 1916
6. "Effects of Salivary Amylase". Vance. C. 1999 University of California, Clermont
http://biology.clc.uc.edu/students/114-Fall99/Amylase.htm
http://biology.clc.uc.edu/students/114-Fall99/Amylase.htm
7. "Small Intestine: Brush Border Enzymes". Bowen. C. 2006 Colorado State University
8. "Differential Expression of Salivary and Pancreatic Human Amylase Loci in Prenatal and Postnatal Development". Journal of Medical Genetics. Vol 13 p. 96-102 Tyre, Karn, Merritt. C. 1976
http://jmg.bmj.com/content/13/2/96.full.pdf
http://jmg.bmj.com/content/13/2/96.full.pdf
9. "Starch Digestion in Infancy". Journal of Pediatric Gastroenterology and Nutrition. Vol 29 Issue 2 p. 116-124. Christian, Edwards, Weaver. C. 1999
http://journals.lww.com/jpgn/Fulltext/1999/08000/Starch_Digestion_in_Infancy.4.aspx
http://journals.lww.com/jpgn/Fulltext/1999/08000/Starch_Digestion_in_Infancy.4.aspx
10. "Role of Salivary Amylase in Gastric and Intestinal Digestion of Starch". Journal of Digestive Diseases and Science. Vol 32 Issue 10 p. 1155-1157. Lebenthal. C. 1987
11. "Nutrition Issues in Cystic Fibrosis". Practical Gastroenterology. Goodin. C. 2005
12. "Human Milk and Related Oligosaccharides as Prebiotics". Current Opinion in Biotechnology. Vol 24 Issue 2 p. 214-219. Barile, Rastall. C. 2013
http://www.ncbi.nlm.nih.gov/pubmed/23434179
http://www.ncbi.nlm.nih.gov/pubmed/23434179
13. American Academy of Pediatrics. 2012. "AAP Reaffirms Breastfeeding Guidelines"
14. World Health Organization. 2009. "Infant and Young Child Feeding"
http://whqlibdoc.who.int/publications/2009/9789241597494_eng.pdf
15. Maternal, Fetal, and Neonatal Physiology: A Clinical Perspective. Blackburn. C. 2007 Elsevier Health Sciences
Saturday, August 10, 2013
Use of APNO in Treating Sore Nipples
I'm sure every breastfeeding mother has heard of the ubiquitous "APNO". Maybe it was recommended to you by an IBCLC, maybe you found it while trying to google solutions to your own sore nipples. All-purpose Nipple Ointment (or "APNO" as it is so endearingly abbreviated) is a mixture of various prescription creams, and was developed by Dr. Jack Newman. [1]
Mupirocin 2% ointment + Betamethasone 0.1% ointment + Miconazole powder to a final concentration of 2%
In laymen's terms, it's an Antibiotic + Steroid Cream + Anti-fungal.
Because those ingredients are prescription only, APNO has to be obtained via prescription from a compounding pharmacy. Despite this, I continue to see APNO recommended with near-reckless abandon to all breastfeeding women, regardless of the cause of their sore nipples. Some have even taken the liberty of developing over-the-counter substitutes for APNO, such as bacitracin, polysporin, lamasil, nystatin, hydrocortison, miconazole, and all sorts of combinations/variations.
Mupirocin/Antibiotic Ointment
Mothers with severe, persistent nipple pain are at a high risk of becoming infected with Staphylococcus aureus, a bacterial strain which can form biofilms, has methicillin-resistant strains, and has been isolated in cases of mastitis. [2],[3],[4] Staph. aureus has been found growing in the abrasions of severely damaged nipples, which has led to a strong correlation between cracked and bleeding nipples with Staph. aureus colonization. [5],[6]
However, colonization is not the same as infection. Colonization is just the presence of bacteria, but without any accompanying symptoms or illness. An infection, on the other hand, implies symptoms and illness. Colonization with Staph. aureus usually requires no treatment. In cases where severe nipple trauma is present, an antibiotic might be prescribed to prevent a Staph. aureus colonization from entering the bloodstream through the cuts and becoming an infection. The first ingredient in APNO, Mupirocin (trade name is bactroban), is known to be effective against strains of Staph. aureus, including MRSA.
That said, there are increasing reports of bacterial resistance to Mupirocin (used for nasal decolonization of MRSA), even being reported in up to 50% of community-acquired MRSA cases in some regions. [7],[8] Such resistance develops as a result of over-use of specific antibiotics, sometimes without cause. In accordance with Antibiotic Stewardship protocols, antibiotics should only be used when they are clinically indicated, in the lowest dose, for the shortest duration of time. [9] Recommending that women put Mupirocin on their nipples for cases of minor to moderate nipple pain with no accompanying abrasions is not good practice. Such practice may result in an increase in Mupirocin resistance, which may reduce the overall effectiveness of Mupirocin (or other antimicrobials) when treating true cases of Staph. aureus infection.
In some cases, oral antibiotics have even been found to be more effective than topical Mupirocin in treating Staph. aureus colonization [16],[17], suggesting that true cases of Staph. aureus nipple infections require treatment outside the scope of APNO.
Betamethasone/Other Cortisone Creams
The inclusion of Betamethasone in APNO is specifically to target nipple soreness that is caused by atopic dermatitis, eczema, or general inflammation. As a steroid cream, it may help reduce redness and swelling and irritation in the early days of breastfeeding.
That said, a double-blind study published in the Journal of Breastfeeding Medicine found no advantage to Betamethasone (in the form of APNO), versus pure lanolin. [10] When undergoing any treatment with medication, best practice indicates to always begin with the most basic treatment and work up. Therefore it stands to reason that mothers experiencing nipple soreness would be better off starting with pure lanolin rather than a prescription cortisone cream. Corticosteroid creams are not without risk, and their use needs to be monitored and kept within the shortest parameter's possible to prevent unwanted side effects. [11]
Another consideration with the use of Betamethasone ointment is the potential exposure of the infant to high levels of mineral paraffins. [12],[13] Most pharmaceutical ointment bases contain paraffin. Given that no significant benefit has been found for Betamethasone vs pure lanolin, most mothers would be better off using lanolin unless an actual case of atopic dermatitis has been identified.
Miconazole/Anti-Fungals
Some cases of nipple pain may be traced back to an overgrowth of Candida. Candida is a fungus that is present in all humans, but in some cases it may grow to high levels, causing a condition known colloquially as thrush. Thrush can be difficult to get rid of, and is very strongly associated with recent antibiotic use. Antibiotics kill many of the good bacteria that compete with Candida for food. Destruction of this good bacteria can allow Candida fungus to grow.
Miconazole is an anti-fungal and although it is not the first choice of many doctors for treating nipple thrush, it has nonetheless been found to be effective. When used in conjunction with a topical antibiotic it could potentially prevent thrush from developing. But, when it comes to APNO, Mupirocin already has anti-fungal properties and therefore is unlikely to result in thrush. [14],[15]
When it come to "all purpose" nipple ointments, I have to wonder if we really need to be treating ALL the potentials. A mother who has a known case of thrush is not going to need an antibiotic. A mother who needs a topical antibiotic probably doesn't need a steroid cream. Even. Dr. Newman acknowledges that when it comes to medicine, it is best to go with the single "right" treatment for the "right" problem. Any time a case of nipple pain can be isolated to its roots, treatment should be tailored to that specific problem.
The justification for prescribing APNO is that mothers who are suffering from sore nipples "without known cause" may not have time to play a juggling game with treatments, trying to figure out which one works. Therefore prescribing an ointment designed to knock out all of the potentials may be prudent, particularly if weaning is being considered. That is where APNO has carved out a very valuable place in breastfeeding management.
But it needs to be said that anytime a mother is experiencing such severe pain and trauma that she is considering weaning, she needs to be seen by an IBCLC. Such problems do not arise out of nothing, and it is critical to prolonged and sustained relief that the root cause be identified and corrected. I see many times where those in the breastfeeding community treat APNO as a substitute for proper lactation management, or they recommend it for mild to moderate transient pain, where pure lanolin would work just fine.
Also concerning is the upsurge in "over-the counter" APNO's, made by mixing various store-bought topical creams together. The proportions of these creams may vary, and over the counter antibacterial ointments have also been increasingly linked to antibiotic resistance in the community. Antibiotics in particular need to be used very judiciously, and there is no scientific basis for applying antibiotic cream or ointment to nipples for just transient pain. Antibiotic ointments themselves do not get rid of pain; they inhibit bacterial growth. Therefore they only need to be used in cases where the pain is either a direct result of an infection, or else the mother has nipple wounds and is at risk of developing an infection.
Whenever those in the breastfeeding community are dealing with sore nipples, start with the most effective treatment that also carries the fewest side effects. Unless a mother has sustained, severe pain and/or open nipple wounds, pure lanolin is most certainly the safest and best choice.
References:
1. International Breastfeeding Centre. 2009. "All Purpose Nipple Ointment (APNO)"http://www.nbci.ca/index.php?option=com_content&id=76:all-purpose-nipple-ointment-apno&Itemid=17
2. Journal of Emerging Infectious Diseases. 2007. "Postpartum Mastitis and Community-acquired Methicillin-resistant Staphylococcus aureus."
http://wwwnc.cdc.gov/eid/article/13/2/06-0989_article.htm
3. Journal of Obstetrics and Gynecology. 2008. "Community-acquired methicillin-resistant Staphylococcus aureus among patients with puerperal mastitis requiring hospitalization."
http://www.ncbi.nlm.nih.gov/pubmed/18757649
4. International Breastfeeding Journal. 2008. "The role of bacteria in lactational mastitis and some considerations of the use of antibiotic treatment"
http://www.internationalbreastfeedingjournal.com/content/3/1/6
5. Journal of Human Lactation. 1999. "The treatment of Staphylococcus Aureus Infected Sore Nipples: A Randomized Comparative Study." http://www.breastfeedingclinic.com/ckfinder/userfiles/files/TreatmentofStaphyloccocus.pdf
6. American Family Physician. 2008. "Management of Mastitis in Breastfeeding Women" http://www.aafp.org/afp/2008/0915/p727.html
7. Journal of Antimicrobial Agents and Chemotherapy. 2007. "Mupirocin-Resistant, Methicillin-Resistant Staphylococcus aureusStrains in Canadian Hospitals"
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2151460/
8. Journal of Clinical Infectious Diseases. 2009. "Mupirocin Resistance"
http://cid.oxfordjournals.org/content/49/6/935.long
9. The Nebraska Medical Center. "Antimicrobial Stewardship Program"
http://www.nebraskamed.com/careers/education-programs/asp
10. Journal of Breastfeeding Medicine. 2012. "An All-Purpose Nipple Ointment Versus Lanolin in Treating
Painful Damaged Nipples in Breastfeeding Women: A Randomized Controlled Trial"
http://online.liebertpub.com/doi/pdf/10.1089/bfm.2011.0121
11. Journal of Cutaneous Medicine and Surgery. 2004. "Nipple and Areolar Eczema in the
Breastfeeding Woman"
http://dermatologycentral.typepad.com/files/nipple-and-areolar-eczema-i.pdf
12. Journal of Regulatory Toxicology and Pharmacology. 2003. "Exposure of babies to C15-C45 mineral paraffins from human milk and breast salves."
http://www.ncbi.nlm.nih.gov/pubmed/14623482?dopt=Abstract
13. Drugs and Lactation Database
http://toxnet.nlm.nih.gov/cgi-bin/sis/search/f?./temp/~S8ICbU:2
14. The Journal of Antimicrobial Chemotherapy. 1999. "The antifungal activity of mupirocin."
http://www.ncbi.nlm.nih.gov/pubmed/10350391
15. International Journal of Dermatology. 1999. "Perianal candidosis--a comparative study with mupirocin and nystatin."
http://www.ncbi.nlm.nih.gov/pubmed/10487455
16. University of Michegan: Department of Pediatrics. 2003. "Oral Antibiotics and Positioning Are Effective in Decreasing Morbidity in Breastfeeding Mothers"
http://www.med.umich.edu/pediatrics/ebm/cats/bfeed.htm
17. Journal of Human Lactation. 1999. "The treatment of Staphyloccocus aureus infected sore nipples: a randomized comparative study."
http://www.ncbi.nlm.nih.gov/pubmed/10578803
Mupirocin 2% ointment + Betamethasone 0.1% ointment + Miconazole powder to a final concentration of 2%
In laymen's terms, it's an Antibiotic + Steroid Cream + Anti-fungal.
Because those ingredients are prescription only, APNO has to be obtained via prescription from a compounding pharmacy. Despite this, I continue to see APNO recommended with near-reckless abandon to all breastfeeding women, regardless of the cause of their sore nipples. Some have even taken the liberty of developing over-the-counter substitutes for APNO, such as bacitracin, polysporin, lamasil, nystatin, hydrocortison, miconazole, and all sorts of combinations/variations.
Mupirocin/Antibiotic Ointment
Mothers with severe, persistent nipple pain are at a high risk of becoming infected with Staphylococcus aureus, a bacterial strain which can form biofilms, has methicillin-resistant strains, and has been isolated in cases of mastitis. [2],[3],[4] Staph. aureus has been found growing in the abrasions of severely damaged nipples, which has led to a strong correlation between cracked and bleeding nipples with Staph. aureus colonization. [5],[6]
However, colonization is not the same as infection. Colonization is just the presence of bacteria, but without any accompanying symptoms or illness. An infection, on the other hand, implies symptoms and illness. Colonization with Staph. aureus usually requires no treatment. In cases where severe nipple trauma is present, an antibiotic might be prescribed to prevent a Staph. aureus colonization from entering the bloodstream through the cuts and becoming an infection. The first ingredient in APNO, Mupirocin (trade name is bactroban), is known to be effective against strains of Staph. aureus, including MRSA.
That said, there are increasing reports of bacterial resistance to Mupirocin (used for nasal decolonization of MRSA), even being reported in up to 50% of community-acquired MRSA cases in some regions. [7],[8] Such resistance develops as a result of over-use of specific antibiotics, sometimes without cause. In accordance with Antibiotic Stewardship protocols, antibiotics should only be used when they are clinically indicated, in the lowest dose, for the shortest duration of time. [9] Recommending that women put Mupirocin on their nipples for cases of minor to moderate nipple pain with no accompanying abrasions is not good practice. Such practice may result in an increase in Mupirocin resistance, which may reduce the overall effectiveness of Mupirocin (or other antimicrobials) when treating true cases of Staph. aureus infection.
In some cases, oral antibiotics have even been found to be more effective than topical Mupirocin in treating Staph. aureus colonization [16],[17], suggesting that true cases of Staph. aureus nipple infections require treatment outside the scope of APNO.
Betamethasone/Other Cortisone Creams
The inclusion of Betamethasone in APNO is specifically to target nipple soreness that is caused by atopic dermatitis, eczema, or general inflammation. As a steroid cream, it may help reduce redness and swelling and irritation in the early days of breastfeeding.
That said, a double-blind study published in the Journal of Breastfeeding Medicine found no advantage to Betamethasone (in the form of APNO), versus pure lanolin. [10] When undergoing any treatment with medication, best practice indicates to always begin with the most basic treatment and work up. Therefore it stands to reason that mothers experiencing nipple soreness would be better off starting with pure lanolin rather than a prescription cortisone cream. Corticosteroid creams are not without risk, and their use needs to be monitored and kept within the shortest parameter's possible to prevent unwanted side effects. [11]
Another consideration with the use of Betamethasone ointment is the potential exposure of the infant to high levels of mineral paraffins. [12],[13] Most pharmaceutical ointment bases contain paraffin. Given that no significant benefit has been found for Betamethasone vs pure lanolin, most mothers would be better off using lanolin unless an actual case of atopic dermatitis has been identified.
Miconazole/Anti-Fungals
Some cases of nipple pain may be traced back to an overgrowth of Candida. Candida is a fungus that is present in all humans, but in some cases it may grow to high levels, causing a condition known colloquially as thrush. Thrush can be difficult to get rid of, and is very strongly associated with recent antibiotic use. Antibiotics kill many of the good bacteria that compete with Candida for food. Destruction of this good bacteria can allow Candida fungus to grow.
Miconazole is an anti-fungal and although it is not the first choice of many doctors for treating nipple thrush, it has nonetheless been found to be effective. When used in conjunction with a topical antibiotic it could potentially prevent thrush from developing. But, when it comes to APNO, Mupirocin already has anti-fungal properties and therefore is unlikely to result in thrush. [14],[15]
When it come to "all purpose" nipple ointments, I have to wonder if we really need to be treating ALL the potentials. A mother who has a known case of thrush is not going to need an antibiotic. A mother who needs a topical antibiotic probably doesn't need a steroid cream. Even. Dr. Newman acknowledges that when it comes to medicine, it is best to go with the single "right" treatment for the "right" problem. Any time a case of nipple pain can be isolated to its roots, treatment should be tailored to that specific problem.
The justification for prescribing APNO is that mothers who are suffering from sore nipples "without known cause" may not have time to play a juggling game with treatments, trying to figure out which one works. Therefore prescribing an ointment designed to knock out all of the potentials may be prudent, particularly if weaning is being considered. That is where APNO has carved out a very valuable place in breastfeeding management.
But it needs to be said that anytime a mother is experiencing such severe pain and trauma that she is considering weaning, she needs to be seen by an IBCLC. Such problems do not arise out of nothing, and it is critical to prolonged and sustained relief that the root cause be identified and corrected. I see many times where those in the breastfeeding community treat APNO as a substitute for proper lactation management, or they recommend it for mild to moderate transient pain, where pure lanolin would work just fine.
Also concerning is the upsurge in "over-the counter" APNO's, made by mixing various store-bought topical creams together. The proportions of these creams may vary, and over the counter antibacterial ointments have also been increasingly linked to antibiotic resistance in the community. Antibiotics in particular need to be used very judiciously, and there is no scientific basis for applying antibiotic cream or ointment to nipples for just transient pain. Antibiotic ointments themselves do not get rid of pain; they inhibit bacterial growth. Therefore they only need to be used in cases where the pain is either a direct result of an infection, or else the mother has nipple wounds and is at risk of developing an infection.
Whenever those in the breastfeeding community are dealing with sore nipples, start with the most effective treatment that also carries the fewest side effects. Unless a mother has sustained, severe pain and/or open nipple wounds, pure lanolin is most certainly the safest and best choice.
References:
1. International Breastfeeding Centre. 2009. "All Purpose Nipple Ointment (APNO)"http://www.nbci.ca/index.php?option=com_content&id=76:all-purpose-nipple-ointment-apno&Itemid=17
2. Journal of Emerging Infectious Diseases. 2007. "Postpartum Mastitis and Community-acquired Methicillin-resistant Staphylococcus aureus."
http://wwwnc.cdc.gov/eid/article/13/2/06-0989_article.htm
3. Journal of Obstetrics and Gynecology. 2008. "Community-acquired methicillin-resistant Staphylococcus aureus among patients with puerperal mastitis requiring hospitalization."
http://www.ncbi.nlm.nih.gov/pubmed/18757649
4. International Breastfeeding Journal. 2008. "The role of bacteria in lactational mastitis and some considerations of the use of antibiotic treatment"
http://www.internationalbreastfeedingjournal.com/content/3/1/6
5. Journal of Human Lactation. 1999. "The treatment of Staphylococcus Aureus Infected Sore Nipples: A Randomized Comparative Study." http://www.breastfeedingclinic.com/ckfinder/userfiles/files/TreatmentofStaphyloccocus.pdf
6. American Family Physician. 2008. "Management of Mastitis in Breastfeeding Women" http://www.aafp.org/afp/2008/0915/p727.html
7. Journal of Antimicrobial Agents and Chemotherapy. 2007. "Mupirocin-Resistant, Methicillin-Resistant Staphylococcus aureusStrains in Canadian Hospitals"
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2151460/
8. Journal of Clinical Infectious Diseases. 2009. "Mupirocin Resistance"
http://cid.oxfordjournals.org/content/49/6/935.long
9. The Nebraska Medical Center. "Antimicrobial Stewardship Program"
http://www.nebraskamed.com/careers/education-programs/asp
10. Journal of Breastfeeding Medicine. 2012. "An All-Purpose Nipple Ointment Versus Lanolin in Treating
Painful Damaged Nipples in Breastfeeding Women: A Randomized Controlled Trial"
http://online.liebertpub.com/doi/pdf/10.1089/bfm.2011.0121
11. Journal of Cutaneous Medicine and Surgery. 2004. "Nipple and Areolar Eczema in the
Breastfeeding Woman"
http://dermatologycentral.typepad.com/files/nipple-and-areolar-eczema-i.pdf
12. Journal of Regulatory Toxicology and Pharmacology. 2003. "Exposure of babies to C15-C45 mineral paraffins from human milk and breast salves."
http://www.ncbi.nlm.nih.gov/pubmed/14623482?dopt=Abstract
13. Drugs and Lactation Database
http://toxnet.nlm.nih.gov/cgi-bin/sis/search/f?./temp/~S8ICbU:2
14. The Journal of Antimicrobial Chemotherapy. 1999. "The antifungal activity of mupirocin."
http://www.ncbi.nlm.nih.gov/pubmed/10350391
15. International Journal of Dermatology. 1999. "Perianal candidosis--a comparative study with mupirocin and nystatin."
http://www.ncbi.nlm.nih.gov/pubmed/10487455
16. University of Michegan: Department of Pediatrics. 2003. "Oral Antibiotics and Positioning Are Effective in Decreasing Morbidity in Breastfeeding Mothers"
http://www.med.umich.edu/pediatrics/ebm/cats/bfeed.htm
17. Journal of Human Lactation. 1999. "The treatment of Staphyloccocus aureus infected sore nipples: a randomized comparative study."
http://www.ncbi.nlm.nih.gov/pubmed/10578803
Tuesday, August 6, 2013
Neonatal Hypoglycemia
Neonatal Hypoglycemia has received an upsurge in attention recently. As breastfeeding is pulled more and more in to the spot light, hospital interventions are being painted in a much more negative light. One such hospital intervention is the routine testing of infant blood sugar, which is used to justify formula supplementation of newborns.
Neonatal Physiology and Hypoglycemia
Glucose is the main source of energy for humans, and up to 90% of our total glucose is consumed by the brain. While in the womb, the neonate is attached to the umbilical cord, which supplies a constant infusion of glucose to the developing brain. Once born, that supply is cut off, and the infant's body must then change over to an enteral supply of glucose. During the 3rd trimester, the infant begins laying down liver glycogen stores. These glycogen stores will act as fuel until the mother's breast milk volume increases and breastfeeding is established. [1]
Within the first few hours of a newborn's life, it's is physiologically normal for there to be a drop in blood sugar. When you move from a constant supply to intermittent supply of glucose, there is going to be some fluctuation. Ideally, the infant begins metabolizing stored glycogen and that, combined with regular breastfeeding of colostrum and skin to skin contact with the mother, allows the infant to maintain his blood glucose levels on his own. The blood sugar levels will then begin to rise, normalizing around the 24 hour mark. [1],[2],[3]
When Hypoglycemia Becomes An Issue
Some infants are unable to maintain their blood sugar. Preterm infants are at a particularly high risk, since they oftentimes lack the liver glycogen stores that full-term, healthy newborns have. In some instances, delaying the first breastfeeding can also result in blood sugar levels that are too low. While there is no single cut-off point for determining when an infant is hypoglycemic, there are different levels of intervention that are implemented at different points in the first days of life, all of which have the ultimate goal of preventing full-blown hypoglycemia. [3]
During full-blown hypoglycemia, the brain experiences a decrease in the amount of glucose it has available for fuel. Without that fuel, neurological damage can result. Treating Neonatal Hypoglycemia in a timely manner is of utmost importance and involves maintaining blood sugar levels while they are within treatment thresholds, BEFORE they reach the level of neurological impairment. Since no one really knows at what level an infant is going to experience neurological impairment as a result of low blood sugar, the therapeutic threshold of <40 mg/dL has been established as the point at which therapy becomes necessary. That level is variable though, and depending on who is responsible for care of an infant, therapy may begin at a higher blood sugar level for sick or preterm infants, or may be allowed to go lower in infants who are otherwise asymptomatic. [4]
The American Academy of Pediatrics established guidelines in 2011 for the monitoring and treatment of Neonatal Hypoglycemia, with 45 mg/dL designated as the target glucose level. The AAP also recommends against the routine testing of blood glucose in full term, healthy newborns. Rather, the implementation of a glucose screening program should target those infants who are at risk. [12] The rationale for such a recommendation is that routine blood sugar testing usually results in aggressive supplementation of infants who would have otherwise been breastfed. Breastfed infants have higher levels of ketone bodies, which may provide protection against hypoglycemia-induced neurological impairment, since the brain is also able to use ketones for fuel. [5],[7]
Stage 1 Intervention
The first stage of intervention applies to all infants, regardless of blood sugar levels. FEED THE BABY. Breastfeeding should be initiated within the first 60 minutes of an infant's life. If the infant is separated from the mother, or the mother is unable to bring the baby to breast, or the baby will not latch, then she should begin to hand express by the end of that first hour. The expressed milk can then be given to the infant through an alternative device (syringe, cup, dropper, SNS, etc). Colostrum is the preferred food source for preventing hypoglycemia because it is high in amino acid precursors and fatty acids which prompt the newborn's body to undergo gluconeogenesis, while minimizing insulin secretion. [5]
Stage 2 Intervention
The second stage of intervention is once again to feed the baby. If an infant is presenting with blood sugar levels below 40 mg/dL, but it asymptomatic, then protocol is to simply continue to offer breastfeeds. In addition to offering breastfeeding, it may be necessary to offer a small supplement of expressed colostrum with a syringe. If expressed colostrum is not available, human donor milk or formula can be used. Blood glucose can then be re-measured 30-60 minutes later. [4],[6],[7]
Stage 3 Intervention
Stage 3 intervention is for infants who are asymptomatic with a sugar level < 25 mg/dL, infants who are symptomatic with a sugar level < 40 mg/dL, or infants who have a persistent hypoglycemia who do not improve by increased breast milk feeding. It is also for infants who are unable to tolerate oral feeds.
The third stage of intervention involves the administration of an IV bolus of dextrose, followed by an intravenous infusion. Once an intravenous infusion of dextrose has been started, it cannot be stopped without first titrating down the dose. Sudden cessation of IV dextrose can result in reactive hypoglycemia. Infants who are unable to maintain their blood sugars are usually referred to the Neonatal Intensive Care Unit. [4],[6],[7]
Use of Infant Formula in the Treatment of Neonatal Hypoglycemia
With an increased awareness of the hazards of not breastfeeding, supplementing infants with formula is almost always regarded with disdain, regardless of the reason for the supplementation. When it comes to treating Neonatal Hypoglycemia, the first choice of supplement is always going to be breast milk, first from the mother, then from another mother.
But in some instances, breast milk is not available. The mother may be recovering from a difficult delivery, the infant may be in the NICU for other reasons, the mother may not have any success hand expressing or using a pump, or donor milk may not be available at that hospital. In those instances, formula is the next option.
There are some breastfeeding supporters who advocate for the use of IV dextrose as a "non-formula" alternative to supplementation, but I feel that kind of management goes against not only evidence but also better judgement.
Treating Neonatal Hypoglycemia should always involve the stage of intervention that is the least aggressive, but is going to allow for the best possible neonatal outcome, as well as the greatest preservation of breastfeeding. In infants who are not symptomatic and who can tolerate oral feedings, supplementation with a clinically indicated amount of formula is preferable to an IV infusion of dextrose. [6] IV dextrose is a much larger intervention, oftentimes involving moving the infant to the NICU. Such maternal/infant separation does more to undermine breastfeeding than a one-time limited formula supplementation. Infants who are allowed to be orally supplemented with expressed milk or formula can remain skin-to-skin with the mother. This type of kangaroo care helps the infant to regulate his body temperature, which results in less caloric expenditure and thus greater glycemic management. Oral supplements can be given in a way that does not affect breastfeeding, such as using an at-breast supplementation device or a syringe. And the duration of hospital stay is shorter than an infant receiving an IV infusion.
The other downside to IV infusions of dextrose is aluminum content. Many IV medications, including dextrose, contain aluminum. [8],[9] Intravenous infusions of aluminum are associated with larger accumulations of aluminum in the body, and neurological delays. This is of particular concern with preterm infants, and studies on preterm infants who receive Total Paraenteral Nutrition have shown slight neurological delays as a result of the aluminum given in the infusions. [10],[11] Formula also contains aluminum, but orally obtained aluminum is much easier eliminated from the body and very little is absorbed and accumulated.
For that reason, lower-level interventions should always be preferred and used to prevent Neonatal Hypoglycemia from getting to the point where an IV infusion of dextrose is indicated. IV dextrose should not be used as an "alternative" to giving an infant formula. Proper management of breastfeeding with neonatal hypoglycemia should, in almost all cases, remove the need for formula in the first place, and there is no evidence to back of the "routine" supplementation of infants with formula. [2]
References:
1. American Academy of Pediatrics. 1999. "Neonatal Hypoglycemia"
http://pedsinreview.aappublications.org/content/20/7/e6.full
2. International Breastfeeding Center (Dr. Jack Newman). 2009. "Hypoglycaemia of the Newborn (Low Blood Sugar)"
http://www.nbci.ca/index.php?option=com_content&id=71:hypoglycaemia-of-the-newborn-low-blood-sugar&Itemid=17
3. World Health Organization. 1997. "Hypoglycaemia of the Newborn: Review of the Literature"
https://apps.who.int/chd/publications/imci/bf/hypoglyc/hypoclyc.htm
4. National Neonatology Forum. 2000-2013 "Management of Neonatal Hypoglycemia"
http://nnfpublication.org/Uploads/Articles/4c86270b-ac2d-4c04-b55b-abc5add3e623.pdf
5. Walker, Marsha. 2009. Breastfeeding Management for the Clinician: Using the Evidence
6. Academy of Breastfeeding Medicine. 2006. "ABM Clinical Protocol #1: Guidelines for Glucose Monitoring and Treatment of Hypoglycemia in Breastfed Neonates"
http://www.bfmed.org/Media/Files/Protocols/hypoglycemia.pdf
7. International Lactation Consultant Association. Marinelli, Kathleen. 2012. "Hypoglycemia and the Breastfeeding Newborn"
http://www.ilca.org/files/USLCA/Education_Resources/Webinar_Materials/11-8-12/Hypoglycemia%20Marinelli%20USLCA%202012.pdf
8. B. Braun Medical, Inc. 2008. "Dextrose Injection USP"
http://dailymed.nlm.nih.gov/dailymed/archives/fdaDrugInfo.cfm?archiveid=8218
9. Journal of Parenteral and Enteral Nutrition. 2010. "Aluminum content in intravenous solutions for administration to neonates: role of product preparation and administration methods."http://www.ncbi.nlm.nih.gov/pubmed/20467015
10. American Academy of Pediatrics. 2009. "Aluminum Exposure From Parenteral Nutrition in Preterm Infants: Bone Health at 15-Year Follow-up"http://pediatrics.aappublications.org/content/124/5/1372
11. Proceedings of the Nutrition Society. 2011. "Aluminium exposure from parenteral nutrition in preterm infants and later health outcomes during childhood and adolescence."http://www.ncbi.nlm.nih.gov/pubmed/21781356
12. American Academy of Pediatrics. 2011. "Postnatal Glucose Homeostasis in Late-Preterm and Term Infants"http://pediatrics.aappublications.org/content/127/3/575.full
Neonatal Physiology and Hypoglycemia
Glucose is the main source of energy for humans, and up to 90% of our total glucose is consumed by the brain. While in the womb, the neonate is attached to the umbilical cord, which supplies a constant infusion of glucose to the developing brain. Once born, that supply is cut off, and the infant's body must then change over to an enteral supply of glucose. During the 3rd trimester, the infant begins laying down liver glycogen stores. These glycogen stores will act as fuel until the mother's breast milk volume increases and breastfeeding is established. [1]
Within the first few hours of a newborn's life, it's is physiologically normal for there to be a drop in blood sugar. When you move from a constant supply to intermittent supply of glucose, there is going to be some fluctuation. Ideally, the infant begins metabolizing stored glycogen and that, combined with regular breastfeeding of colostrum and skin to skin contact with the mother, allows the infant to maintain his blood glucose levels on his own. The blood sugar levels will then begin to rise, normalizing around the 24 hour mark. [1],[2],[3]
When Hypoglycemia Becomes An Issue
Some infants are unable to maintain their blood sugar. Preterm infants are at a particularly high risk, since they oftentimes lack the liver glycogen stores that full-term, healthy newborns have. In some instances, delaying the first breastfeeding can also result in blood sugar levels that are too low. While there is no single cut-off point for determining when an infant is hypoglycemic, there are different levels of intervention that are implemented at different points in the first days of life, all of which have the ultimate goal of preventing full-blown hypoglycemia. [3]
During full-blown hypoglycemia, the brain experiences a decrease in the amount of glucose it has available for fuel. Without that fuel, neurological damage can result. Treating Neonatal Hypoglycemia in a timely manner is of utmost importance and involves maintaining blood sugar levels while they are within treatment thresholds, BEFORE they reach the level of neurological impairment. Since no one really knows at what level an infant is going to experience neurological impairment as a result of low blood sugar, the therapeutic threshold of <40 mg/dL has been established as the point at which therapy becomes necessary. That level is variable though, and depending on who is responsible for care of an infant, therapy may begin at a higher blood sugar level for sick or preterm infants, or may be allowed to go lower in infants who are otherwise asymptomatic. [4]
The American Academy of Pediatrics established guidelines in 2011 for the monitoring and treatment of Neonatal Hypoglycemia, with 45 mg/dL designated as the target glucose level. The AAP also recommends against the routine testing of blood glucose in full term, healthy newborns. Rather, the implementation of a glucose screening program should target those infants who are at risk. [12] The rationale for such a recommendation is that routine blood sugar testing usually results in aggressive supplementation of infants who would have otherwise been breastfed. Breastfed infants have higher levels of ketone bodies, which may provide protection against hypoglycemia-induced neurological impairment, since the brain is also able to use ketones for fuel. [5],[7]
Stage 1 Intervention
The first stage of intervention applies to all infants, regardless of blood sugar levels. FEED THE BABY. Breastfeeding should be initiated within the first 60 minutes of an infant's life. If the infant is separated from the mother, or the mother is unable to bring the baby to breast, or the baby will not latch, then she should begin to hand express by the end of that first hour. The expressed milk can then be given to the infant through an alternative device (syringe, cup, dropper, SNS, etc). Colostrum is the preferred food source for preventing hypoglycemia because it is high in amino acid precursors and fatty acids which prompt the newborn's body to undergo gluconeogenesis, while minimizing insulin secretion. [5]
Stage 2 Intervention
The second stage of intervention is once again to feed the baby. If an infant is presenting with blood sugar levels below 40 mg/dL, but it asymptomatic, then protocol is to simply continue to offer breastfeeds. In addition to offering breastfeeding, it may be necessary to offer a small supplement of expressed colostrum with a syringe. If expressed colostrum is not available, human donor milk or formula can be used. Blood glucose can then be re-measured 30-60 minutes later. [4],[6],[7]
Stage 3 Intervention
Stage 3 intervention is for infants who are asymptomatic with a sugar level < 25 mg/dL, infants who are symptomatic with a sugar level < 40 mg/dL, or infants who have a persistent hypoglycemia who do not improve by increased breast milk feeding. It is also for infants who are unable to tolerate oral feeds.
The third stage of intervention involves the administration of an IV bolus of dextrose, followed by an intravenous infusion. Once an intravenous infusion of dextrose has been started, it cannot be stopped without first titrating down the dose. Sudden cessation of IV dextrose can result in reactive hypoglycemia. Infants who are unable to maintain their blood sugars are usually referred to the Neonatal Intensive Care Unit. [4],[6],[7]
Use of Infant Formula in the Treatment of Neonatal Hypoglycemia
With an increased awareness of the hazards of not breastfeeding, supplementing infants with formula is almost always regarded with disdain, regardless of the reason for the supplementation. When it comes to treating Neonatal Hypoglycemia, the first choice of supplement is always going to be breast milk, first from the mother, then from another mother.
But in some instances, breast milk is not available. The mother may be recovering from a difficult delivery, the infant may be in the NICU for other reasons, the mother may not have any success hand expressing or using a pump, or donor milk may not be available at that hospital. In those instances, formula is the next option.
There are some breastfeeding supporters who advocate for the use of IV dextrose as a "non-formula" alternative to supplementation, but I feel that kind of management goes against not only evidence but also better judgement.
Treating Neonatal Hypoglycemia should always involve the stage of intervention that is the least aggressive, but is going to allow for the best possible neonatal outcome, as well as the greatest preservation of breastfeeding. In infants who are not symptomatic and who can tolerate oral feedings, supplementation with a clinically indicated amount of formula is preferable to an IV infusion of dextrose. [6] IV dextrose is a much larger intervention, oftentimes involving moving the infant to the NICU. Such maternal/infant separation does more to undermine breastfeeding than a one-time limited formula supplementation. Infants who are allowed to be orally supplemented with expressed milk or formula can remain skin-to-skin with the mother. This type of kangaroo care helps the infant to regulate his body temperature, which results in less caloric expenditure and thus greater glycemic management. Oral supplements can be given in a way that does not affect breastfeeding, such as using an at-breast supplementation device or a syringe. And the duration of hospital stay is shorter than an infant receiving an IV infusion.
The other downside to IV infusions of dextrose is aluminum content. Many IV medications, including dextrose, contain aluminum. [8],[9] Intravenous infusions of aluminum are associated with larger accumulations of aluminum in the body, and neurological delays. This is of particular concern with preterm infants, and studies on preterm infants who receive Total Paraenteral Nutrition have shown slight neurological delays as a result of the aluminum given in the infusions. [10],[11] Formula also contains aluminum, but orally obtained aluminum is much easier eliminated from the body and very little is absorbed and accumulated.
For that reason, lower-level interventions should always be preferred and used to prevent Neonatal Hypoglycemia from getting to the point where an IV infusion of dextrose is indicated. IV dextrose should not be used as an "alternative" to giving an infant formula. Proper management of breastfeeding with neonatal hypoglycemia should, in almost all cases, remove the need for formula in the first place, and there is no evidence to back of the "routine" supplementation of infants with formula. [2]
References:
1. American Academy of Pediatrics. 1999. "Neonatal Hypoglycemia"
http://pedsinreview.aappublications.org/content/20/7/e6.full
2. International Breastfeeding Center (Dr. Jack Newman). 2009. "Hypoglycaemia of the Newborn (Low Blood Sugar)"
http://www.nbci.ca/index.php?option=com_content&id=71:hypoglycaemia-of-the-newborn-low-blood-sugar&Itemid=17
3. World Health Organization. 1997. "Hypoglycaemia of the Newborn: Review of the Literature"
https://apps.who.int/chd/publications/imci/bf/hypoglyc/hypoclyc.htm
4. National Neonatology Forum. 2000-2013 "Management of Neonatal Hypoglycemia"
http://nnfpublication.org/Uploads/Articles/4c86270b-ac2d-4c04-b55b-abc5add3e623.pdf
5. Walker, Marsha. 2009. Breastfeeding Management for the Clinician: Using the Evidence
6. Academy of Breastfeeding Medicine. 2006. "ABM Clinical Protocol #1: Guidelines for Glucose Monitoring and Treatment of Hypoglycemia in Breastfed Neonates"
http://www.bfmed.org/Media/Files/Protocols/hypoglycemia.pdf
7. International Lactation Consultant Association. Marinelli, Kathleen. 2012. "Hypoglycemia and the Breastfeeding Newborn"
http://www.ilca.org/files/USLCA/Education_Resources/Webinar_Materials/11-8-12/Hypoglycemia%20Marinelli%20USLCA%202012.pdf
8. B. Braun Medical, Inc. 2008. "Dextrose Injection USP"
http://dailymed.nlm.nih.gov/dailymed/archives/fdaDrugInfo.cfm?archiveid=8218
9. Journal of Parenteral and Enteral Nutrition. 2010. "Aluminum content in intravenous solutions for administration to neonates: role of product preparation and administration methods."http://www.ncbi.nlm.nih.gov/pubmed/20467015
10. American Academy of Pediatrics. 2009. "Aluminum Exposure From Parenteral Nutrition in Preterm Infants: Bone Health at 15-Year Follow-up"http://pediatrics.aappublications.org/content/124/5/1372
11. Proceedings of the Nutrition Society. 2011. "Aluminium exposure from parenteral nutrition in preterm infants and later health outcomes during childhood and adolescence."http://www.ncbi.nlm.nih.gov/pubmed/21781356
12. American Academy of Pediatrics. 2011. "Postnatal Glucose Homeostasis in Late-Preterm and Term Infants"http://pediatrics.aappublications.org/content/127/3/575.full
Sunday, August 4, 2013
Early Limited Formula: Exclusive Breastfeeding?
On May 13, 2013 the American Academy of Pediatrics published a study in their journal Pediatrics looking at the effects of Early Limited Formula on the duration of exclusive breastfeeding. As many outraged bloggers and health professionals pointed out in the days following its publication, the sample size was small and can hardly represent a larger population of women outside of the San Francisco area.
But there are some very overlooked facets of the study that I feel warrant additional criticism. Per definition, any infant who receives ANY breast milk substitutes in the first 6 months of life can no longer be considered "exclusively" breastfeeding for research purposes. It does not matter if an infant gets 1 bottle and is exclusively breastfed afterwards. For the sake of research, that infant cannot be considered exclusively breastfed.
Therefore, Early Limited Formula (ELF) does not increase exclusive breastfeeding rates. It is, by its very existence, a detriment to exclusive breastfeeding. That doesn't mean that ELF doesn't have its place, and as demonstrated by this study most of the mothers who gave ELF went on to wean entirely off the supplement and breastfeed their infants without supplementation. [1]
Which brings me to my second criticism: Early Limited Formula. ELF is not the haphazard feeding of formula to neonates "just because". It is a strictly controlled method of delivering formula supplements to infants who have a clinical indication, in a way that does not undermine breastfeeding. The women in the supplementation group gave only 10 mL's of formula via a syringe after each breastfeed. Infants who were assigned to the study were those who had lost > 5% of their birth weight in the first 24 hours of life. Such dramatic weight loss is correlated with overall weight loss of >10%. The formula supplements were discontinued at 3-5 days postpartum, when the mother's milk volume increased.
By their mere participation, the women in the supplementation group received additional education on the proper supplementation of a breastfed infant. By having strictly controlled formula amounts and a set timeline, these women were inadvertently educated on newborn stomach size as well as clinically indicated supplementation amounts. The ELF supplements were administered by a study nurse, who also educated them on how to supplement. That makes them much less likely to go home and try and give their baby a 2 ounce "top up" bottle of ready-to-feed (the most common form of formula given out to new moms as samples) .
This is education that the control group missed out on. In the study, the women in the control group were given education on an infant soothing technique.
This study shows that it's not the supplementation itself that benefits breastfeeding rates, but it's actually HOW you supplement. Many women stop exclusively breastfeeding because they perceive their supply to be low. They give overly large bottles, which results in the newborn's stomach stretching, flow preference developing, and breastfeeding becomes even more difficult.
Going off of 20 years of research, hospital supplementation of newborns is almost always correlated with reduced breastfeeding rates. This study has far too small of a sample size, with far too many clinical errors, to be considered groundbreaking. It does nothing to counter-act decades of research. [2],[3],[4]
Some other criticisms of the study:
1. Did the >5% weight loss in the first 24 hours control for women who received IV fluids? IV fluids given during labor pass through the placenta and over-inflate the newborn's birth weight. In the first 24 hours, the infant will urinate out much of that fluid, which results in a dramatic % weight loss. [6]
2. Not all of the women were on equal footing when it came to breastfeeding experience. The ELF group contained more multiparous women, and they even admitted that 78% of multiparous women were still breastfeeding at 3 months vs 33% of primaparous mothers.
3. Why formula and not donor milk? Pasteurized donor milk has been found to be a safe and effective supplement for newborns. [7],[8] This study has the side effect of promoting/justifying the use of infant formula, when really it was the supplementation method itself that had the effect and not the choice of supplement.
This study also brings up ethical concerns. Given that there are very real hazards associated with giving infants formula, the randomization of infants to receive either formula supplementation or exclusive breast milk is troubling. The criteria for including infants in the study only mentions that they had lost >5% of their birth weight. That alone should not be considered cause for supplementation. So by randomizing infants to receive possibly unnecessary formula supplements, this study has the potential to be considered unethical.
There are a number of "interventions" that have all been positively correlated with longer duration of breastfeeding:
1. Early initiation of breastfeeding. The sooner after birth a mother initiates breastfeeding, the more likely she is to continue breastfeeding after discharge. Higher rates of formula supplementation are associated with newborns born on the night shift, where access to IBCLC's and lactation support is more scant. [4]
2. Prenatal childbirth and breastfeeding education. Prenatal breastfeeding education is very positively correlated with greater breastfeeding initiation as well as longer breastfeeding duration. [4]
3. Staff support of breastfeeding, hospital policy, and home-based peer counseling. This includes things like formula samples, rooming-in, staff support of breastfeeding, and education of nursing staff on breastfeeding. Baby-Friendly Hospital Initiative is also positively associated with better breastfeeding outcomes, [5] as are peer-counseling programs.
References:
1. American Academy of Pediatrics. 2013. "Effect of Early Limited Formula on Exclusivity and Duration of Breastfeeding in At-Risk Infants"
http://pediatrics.aappublications.org/content/early/2013/05/08/peds.2012-2809.abstract
2. American Academy of Pediatrics. 1991. "Early Formula Supplementation of Breastfeeding"
http://pediatrics.aappublications.org/content/early/2013/05/08/peds.2012-2809.abstract
3. American Academy of Pediatrics. 1985. "Effect of Formula Supplementation in the Hospital on the Duration of Breastfeeding."
http://pediatrics.aappublications.org/content/75/3/514.short
4. Journal of Human Lactation. 2005. "In-Hospital Formula Supplementation of Healthy Breastfeeding Newborns"
http://jhl.sagepub.com/content/21/4/397.short
5. American Academy of Pediatrics. 2001. "Baby-Friendly Hospital Initiative Improves Breastfeeding Initiation Rates in a US Hospital Setting"
http://www.pediatricsdigest.mobi/content/108/3/677.short
6. International Breastfeeding Journal. 2011. "An observational study of associations among maternal fluids during parturition, neonatal output, and breastfed newborn weight loss"http://www.internationalbreastfeedingjournal.com/content/6/1/9/abstract
7. Journal of Human Lactation. 2001. "Donor Milk: What's in It and What's Not?"
http://jhl.sagepub.com/content/17/2/152.short
8. American Academy of Pediatrics. 2012. "Breastfeeding and the Use of Human Milk"
http://pediatrics.aappublications.org/content/129/3/e827.full
But there are some very overlooked facets of the study that I feel warrant additional criticism. Per definition, any infant who receives ANY breast milk substitutes in the first 6 months of life can no longer be considered "exclusively" breastfeeding for research purposes. It does not matter if an infant gets 1 bottle and is exclusively breastfed afterwards. For the sake of research, that infant cannot be considered exclusively breastfed.
Therefore, Early Limited Formula (ELF) does not increase exclusive breastfeeding rates. It is, by its very existence, a detriment to exclusive breastfeeding. That doesn't mean that ELF doesn't have its place, and as demonstrated by this study most of the mothers who gave ELF went on to wean entirely off the supplement and breastfeed their infants without supplementation. [1]
Which brings me to my second criticism: Early Limited Formula. ELF is not the haphazard feeding of formula to neonates "just because". It is a strictly controlled method of delivering formula supplements to infants who have a clinical indication, in a way that does not undermine breastfeeding. The women in the supplementation group gave only 10 mL's of formula via a syringe after each breastfeed. Infants who were assigned to the study were those who had lost > 5% of their birth weight in the first 24 hours of life. Such dramatic weight loss is correlated with overall weight loss of >10%. The formula supplements were discontinued at 3-5 days postpartum, when the mother's milk volume increased.
By their mere participation, the women in the supplementation group received additional education on the proper supplementation of a breastfed infant. By having strictly controlled formula amounts and a set timeline, these women were inadvertently educated on newborn stomach size as well as clinically indicated supplementation amounts. The ELF supplements were administered by a study nurse, who also educated them on how to supplement. That makes them much less likely to go home and try and give their baby a 2 ounce "top up" bottle of ready-to-feed (the most common form of formula given out to new moms as samples) .
This is education that the control group missed out on. In the study, the women in the control group were given education on an infant soothing technique.
This study shows that it's not the supplementation itself that benefits breastfeeding rates, but it's actually HOW you supplement. Many women stop exclusively breastfeeding because they perceive their supply to be low. They give overly large bottles, which results in the newborn's stomach stretching, flow preference developing, and breastfeeding becomes even more difficult.
Going off of 20 years of research, hospital supplementation of newborns is almost always correlated with reduced breastfeeding rates. This study has far too small of a sample size, with far too many clinical errors, to be considered groundbreaking. It does nothing to counter-act decades of research. [2],[3],[4]
Some other criticisms of the study:
1. Did the >5% weight loss in the first 24 hours control for women who received IV fluids? IV fluids given during labor pass through the placenta and over-inflate the newborn's birth weight. In the first 24 hours, the infant will urinate out much of that fluid, which results in a dramatic % weight loss. [6]
2. Not all of the women were on equal footing when it came to breastfeeding experience. The ELF group contained more multiparous women, and they even admitted that 78% of multiparous women were still breastfeeding at 3 months vs 33% of primaparous mothers.
3. Why formula and not donor milk? Pasteurized donor milk has been found to be a safe and effective supplement for newborns. [7],[8] This study has the side effect of promoting/justifying the use of infant formula, when really it was the supplementation method itself that had the effect and not the choice of supplement.
This study also brings up ethical concerns. Given that there are very real hazards associated with giving infants formula, the randomization of infants to receive either formula supplementation or exclusive breast milk is troubling. The criteria for including infants in the study only mentions that they had lost >5% of their birth weight. That alone should not be considered cause for supplementation. So by randomizing infants to receive possibly unnecessary formula supplements, this study has the potential to be considered unethical.
There are a number of "interventions" that have all been positively correlated with longer duration of breastfeeding:
1. Early initiation of breastfeeding. The sooner after birth a mother initiates breastfeeding, the more likely she is to continue breastfeeding after discharge. Higher rates of formula supplementation are associated with newborns born on the night shift, where access to IBCLC's and lactation support is more scant. [4]
2. Prenatal childbirth and breastfeeding education. Prenatal breastfeeding education is very positively correlated with greater breastfeeding initiation as well as longer breastfeeding duration. [4]
3. Staff support of breastfeeding, hospital policy, and home-based peer counseling. This includes things like formula samples, rooming-in, staff support of breastfeeding, and education of nursing staff on breastfeeding. Baby-Friendly Hospital Initiative is also positively associated with better breastfeeding outcomes, [5] as are peer-counseling programs.
References:
1. American Academy of Pediatrics. 2013. "Effect of Early Limited Formula on Exclusivity and Duration of Breastfeeding in At-Risk Infants"
http://pediatrics.aappublications.org/content/early/2013/05/08/peds.2012-2809.abstract
2. American Academy of Pediatrics. 1991. "Early Formula Supplementation of Breastfeeding"
http://pediatrics.aappublications.org/content/early/2013/05/08/peds.2012-2809.abstract
3. American Academy of Pediatrics. 1985. "Effect of Formula Supplementation in the Hospital on the Duration of Breastfeeding."
http://pediatrics.aappublications.org/content/75/3/514.short
4. Journal of Human Lactation. 2005. "In-Hospital Formula Supplementation of Healthy Breastfeeding Newborns"
http://jhl.sagepub.com/content/21/4/397.short
5. American Academy of Pediatrics. 2001. "Baby-Friendly Hospital Initiative Improves Breastfeeding Initiation Rates in a US Hospital Setting"
http://www.pediatricsdigest.mobi/content/108/3/677.short
6. International Breastfeeding Journal. 2011. "An observational study of associations among maternal fluids during parturition, neonatal output, and breastfed newborn weight loss"http://www.internationalbreastfeedingjournal.com/content/6/1/9/abstract
7. Journal of Human Lactation. 2001. "Donor Milk: What's in It and What's Not?"
http://jhl.sagepub.com/content/17/2/152.short
8. American Academy of Pediatrics. 2012. "Breastfeeding and the Use of Human Milk"
http://pediatrics.aappublications.org/content/129/3/e827.full
Thursday, August 1, 2013
The fallacy of being Pro-"feed the baby"
Whenever a discussion begins about breastfeeding, it's not uncommon to find a subset of individuals who fall prey to the "feed the baby" fallacy:
"Oh, I'm not pro-breastfeeding or pro-formula. I'm just Pro-'feed the baby' "
"Some women can't breastfeed. It's not about breast or bottle, just feed the baby."
"It doesn't matter how an infant is fed, as long as the infant is just fed, period."
Fair enough. I used to be one of those people (in a day before children). But now I can see some glaring errors in that kind of argument.
1. Who is advocating for starving an infant?
No one in their right mind would ever support infants not being fed. EVERYONE is Pro-"feeding the baby".
The deeper issue with this argument is that it plays in to the misinformation about breastfeeding, namely that breastfeeding is not enough, that mothers do not have milk, and that a desire to breastfeed results in infants "starving" until a mother's milk "comes in."
Some women cannot breastfeed. About 3% of the US population have Primary Insufficient Milk Supply (IMS). It's the inability of a woman to make enough breast milk right out of the gate. Causes may include breast reduction or surgery (mastectomies, cyst removal, biopsy, etc), untreated hypothyroidism, breast hypoplasia, or other hormonal or endocrine disorders.
Then there is secondary IMS, which could be a result of a tongue tie, premature birth, clefts in the lip or palate, Down Syndrome, infant scheduling, formula supplementation, etc. Secondary IMS is low milk supply caused by conditions that are secondary to a woman's actual biology. These women do produce enough milk and have the potential to exclusively breastfeed, but other causes result in their supply lowering from insufficient milk removal.
When someone says that they are Pro-"feeding the baby", they are giving credence to the argument that breastfed mothers are somehow not going to produce enough and will starve their infants. There are all kinds of personal stories out there about mothers who did not have adequate lactation support and almost starved their infants trying to breastfeed.
It is not the goal of a Lactation Consultant (or educator, peer counselor, LLL leader, etc) to force women in to breastfeeding in situations where it would not be reasonable. The number one goal of a Lactation Consultant IS to feed the baby. A baby who is fed has more energy to maintain their body processes and reflexes to latch. This is why in some situations it is actually beneficial to supplement newborns with formula or donor milk. A baby who is fed is a baby who can then be guided back to breast
Any Lactation person who believes otherwise, who believes that exclusive breastfeeding is the only goal, is seriously missing the boat. When a newborn needs to be supplemented is widely variable, which is why proper breastfeeding support and follow-up is so direly needed.
2. Feeding a baby does not have to imply that you cannot have a preference for a food source.
As we can see, everyone is Pro-"feed the baby". But when you're working to make sure an infant is being fed, it is ignorant to assume that you're not allowed to have a preference for a food source.
Breast milk is the baseline by which all other infant feeding methods are compared against. Breast is not best. Breast is merely normal. When it comes to advocating for the nutrition of infants, breast milk should simply be considered the default.
Usually around this time is when people like to point out to me that "some mothers just don't want to breastfeed." That's fine. Some people also don't want to floss their teeth or eat vegetables. A patient's personal lifestyle choices do not factor in to the promotion of optimal health practices. When your dentist tells you to floss your teeth, he does not take in to account whether or not your have time to floss, if flossing hurts your gums, or if you always forget to buy floss at the store. His job is simply to educate you on why you need to floss your teeth. If you choose not to heed his advice, that is entirely your doing.
It's the same with breastfeeding. The job of Lactation Professionals is to educate women about breastfeeding. Some of that education is going to involve some rather unpleasant statistics (like how preterm infants who are fed formula are at a higher risk of developing necrotizing entercolitis, or that formula is deficient in appetite-regulatory hormones). If you choose not to breastfeed because it does not fit in with your lifestyle choices, that is your prerogative. But your personal choices should not influence the education and support of others.
Many mothers make a choice not to breastfeed because they believe it does not fit in with their lifestyle, but with the proper support and education those same women may make a different choice. When working with women who are unsure if breastfeeding is going to work for them, most Lactation Professionals WILL take in to account personal lifestyle choices and help tailor a plan directly for the mother that both allows the child to breastfeed while not completely discounting situations that may make it harder for the mothers.
There are still going to be women who do not want to breastfeed, do not like it, think it is gross, or who simply are NOT interested and never will be. And that is fine. Every parent has the prerogative to make their own feeding decision for their children. But these types of situations represent a HUGE minority of cases, and should in no way influence health policy. The choice between breast milk and formula is not an equal choice. The 2 options are not on the same caliber as one another. Breast milk is the base line, and formula is beneath it. It is important to make that distinction to parents, not in an attempt to guilt mothers in to breastfeeding, but so that they can make a truly informed decision.
3. Is there even a breast vs bottle debate?
Outside of the mommy-sphere, No. As mothers, it's very important to have your parenting validated by others. Even if you know you're a good mother and are doing everything right, just having someone say "hey, you're a good mother" means the world.
When it comes to the breast vs bottle debate, many moms on BOTH sides are left feeling like they have been invalidated. Those who formula feed may take pro-breastfeeding sentiments very personally, and I'm not surprised. MOST women (about 90%) want to breastfeed. Breastfeeding initiation rates are high, in many areas they are even higher than the national goal. But according to a new report out by the CDC, only 16.4% of women are still exclusively breastfeeding at 6 months.
It would appear that almost 60% of women introduce formula or solids to their children before the recommended 6-month time frame. This could mean formula is given as a supplement or as a complete switch to formula feeding, or even that the mother breastfeeds but introduced solid foods like rice cereal prematurely.
Our healthcare system is failing these women. And I do not mean failing in the sense of "oh those poor babies aren't getting enough breast milk" way, but I mean failing in a "these mothers had breastfeeding goals and were not supported in their attempts to meet them" way. When you have an almost 80% breastfeeding initiation rate, and only 16% are actually meeting the AAP recommendation of exclusive breast milk for 6 months, that is a huge failure of the healthcare system.
And yes, breastfeeding absolutely IS part of the healthcare system. Infants who are formula fed have statistically more doctors visits, more ear infections, and an increased risk of obesity, all of which results in higher insurance and out of pocket healthcare costs, higher costs to public assistance programs (WIC), and higher costs to children's medicaid programs. The mothers are at a higher risk of developing breast and ovarian cancers. Breastfeeding is a matter of public health and deserves attention AS a matter of health and not just as a parenting choice.
Many of those women who initially wanted to breastfed but were not able to continue are going to feel let down. They're going to feel let down by their doctors, by their spouses/partners, their families, and even their own bodies. It's not a matter of making women feel guilty. No one is forcing guilt on women and deliberately trying to make them feel like crap for not being able to continue. Breastfeeding is not a carrot on a string that is being dangled in front of mothers while the "lactivists" taunt them in the background. This is a situation where a few bad apples have really spoiled the bunch. Guilt is a scapegoat that has allowed doctors and husbands and Mother-in-laws and friends and even women themselves to blow off breastfeeding as just some parenting option that doesn't really matter. When you're really struggling to breastfeed and you do not have the support, the validation that formula is "just as good" is comforting.
But when you stop looking at breastfeeding as nothing more than an acceptable feeding option and start viewing it through the lens of infant and maternal health, the debate of breast vs bottle virtually disappears.
Being Pro-"feed the infant" is nothing more than an attempt at pleasing everyone. It's not a logical place to be in the discussion on infant feeding.
"Oh, I'm not pro-breastfeeding or pro-formula. I'm just Pro-'feed the baby' "
"Some women can't breastfeed. It's not about breast or bottle, just feed the baby."
"It doesn't matter how an infant is fed, as long as the infant is just fed, period."
Fair enough. I used to be one of those people (in a day before children). But now I can see some glaring errors in that kind of argument.
1. Who is advocating for starving an infant?
No one in their right mind would ever support infants not being fed. EVERYONE is Pro-"feeding the baby".
The deeper issue with this argument is that it plays in to the misinformation about breastfeeding, namely that breastfeeding is not enough, that mothers do not have milk, and that a desire to breastfeed results in infants "starving" until a mother's milk "comes in."
Some women cannot breastfeed. About 3% of the US population have Primary Insufficient Milk Supply (IMS). It's the inability of a woman to make enough breast milk right out of the gate. Causes may include breast reduction or surgery (mastectomies, cyst removal, biopsy, etc), untreated hypothyroidism, breast hypoplasia, or other hormonal or endocrine disorders.
Then there is secondary IMS, which could be a result of a tongue tie, premature birth, clefts in the lip or palate, Down Syndrome, infant scheduling, formula supplementation, etc. Secondary IMS is low milk supply caused by conditions that are secondary to a woman's actual biology. These women do produce enough milk and have the potential to exclusively breastfeed, but other causes result in their supply lowering from insufficient milk removal.
When someone says that they are Pro-"feeding the baby", they are giving credence to the argument that breastfed mothers are somehow not going to produce enough and will starve their infants. There are all kinds of personal stories out there about mothers who did not have adequate lactation support and almost starved their infants trying to breastfeed.
It is not the goal of a Lactation Consultant (or educator, peer counselor, LLL leader, etc) to force women in to breastfeeding in situations where it would not be reasonable. The number one goal of a Lactation Consultant IS to feed the baby. A baby who is fed has more energy to maintain their body processes and reflexes to latch. This is why in some situations it is actually beneficial to supplement newborns with formula or donor milk. A baby who is fed is a baby who can then be guided back to breast
Any Lactation person who believes otherwise, who believes that exclusive breastfeeding is the only goal, is seriously missing the boat. When a newborn needs to be supplemented is widely variable, which is why proper breastfeeding support and follow-up is so direly needed.
2. Feeding a baby does not have to imply that you cannot have a preference for a food source.
As we can see, everyone is Pro-"feed the baby". But when you're working to make sure an infant is being fed, it is ignorant to assume that you're not allowed to have a preference for a food source.
Breast milk is the baseline by which all other infant feeding methods are compared against. Breast is not best. Breast is merely normal. When it comes to advocating for the nutrition of infants, breast milk should simply be considered the default.
Usually around this time is when people like to point out to me that "some mothers just don't want to breastfeed." That's fine. Some people also don't want to floss their teeth or eat vegetables. A patient's personal lifestyle choices do not factor in to the promotion of optimal health practices. When your dentist tells you to floss your teeth, he does not take in to account whether or not your have time to floss, if flossing hurts your gums, or if you always forget to buy floss at the store. His job is simply to educate you on why you need to floss your teeth. If you choose not to heed his advice, that is entirely your doing.
It's the same with breastfeeding. The job of Lactation Professionals is to educate women about breastfeeding. Some of that education is going to involve some rather unpleasant statistics (like how preterm infants who are fed formula are at a higher risk of developing necrotizing entercolitis, or that formula is deficient in appetite-regulatory hormones). If you choose not to breastfeed because it does not fit in with your lifestyle choices, that is your prerogative. But your personal choices should not influence the education and support of others.
Many mothers make a choice not to breastfeed because they believe it does not fit in with their lifestyle, but with the proper support and education those same women may make a different choice. When working with women who are unsure if breastfeeding is going to work for them, most Lactation Professionals WILL take in to account personal lifestyle choices and help tailor a plan directly for the mother that both allows the child to breastfeed while not completely discounting situations that may make it harder for the mothers.
There are still going to be women who do not want to breastfeed, do not like it, think it is gross, or who simply are NOT interested and never will be. And that is fine. Every parent has the prerogative to make their own feeding decision for their children. But these types of situations represent a HUGE minority of cases, and should in no way influence health policy. The choice between breast milk and formula is not an equal choice. The 2 options are not on the same caliber as one another. Breast milk is the base line, and formula is beneath it. It is important to make that distinction to parents, not in an attempt to guilt mothers in to breastfeeding, but so that they can make a truly informed decision.
3. Is there even a breast vs bottle debate?
Outside of the mommy-sphere, No. As mothers, it's very important to have your parenting validated by others. Even if you know you're a good mother and are doing everything right, just having someone say "hey, you're a good mother" means the world.
When it comes to the breast vs bottle debate, many moms on BOTH sides are left feeling like they have been invalidated. Those who formula feed may take pro-breastfeeding sentiments very personally, and I'm not surprised. MOST women (about 90%) want to breastfeed. Breastfeeding initiation rates are high, in many areas they are even higher than the national goal. But according to a new report out by the CDC, only 16.4% of women are still exclusively breastfeeding at 6 months.
It would appear that almost 60% of women introduce formula or solids to their children before the recommended 6-month time frame. This could mean formula is given as a supplement or as a complete switch to formula feeding, or even that the mother breastfeeds but introduced solid foods like rice cereal prematurely.
Our healthcare system is failing these women. And I do not mean failing in the sense of "oh those poor babies aren't getting enough breast milk" way, but I mean failing in a "these mothers had breastfeeding goals and were not supported in their attempts to meet them" way. When you have an almost 80% breastfeeding initiation rate, and only 16% are actually meeting the AAP recommendation of exclusive breast milk for 6 months, that is a huge failure of the healthcare system.
And yes, breastfeeding absolutely IS part of the healthcare system. Infants who are formula fed have statistically more doctors visits, more ear infections, and an increased risk of obesity, all of which results in higher insurance and out of pocket healthcare costs, higher costs to public assistance programs (WIC), and higher costs to children's medicaid programs. The mothers are at a higher risk of developing breast and ovarian cancers. Breastfeeding is a matter of public health and deserves attention AS a matter of health and not just as a parenting choice.
Many of those women who initially wanted to breastfed but were not able to continue are going to feel let down. They're going to feel let down by their doctors, by their spouses/partners, their families, and even their own bodies. It's not a matter of making women feel guilty. No one is forcing guilt on women and deliberately trying to make them feel like crap for not being able to continue. Breastfeeding is not a carrot on a string that is being dangled in front of mothers while the "lactivists" taunt them in the background. This is a situation where a few bad apples have really spoiled the bunch. Guilt is a scapegoat that has allowed doctors and husbands and Mother-in-laws and friends and even women themselves to blow off breastfeeding as just some parenting option that doesn't really matter. When you're really struggling to breastfeed and you do not have the support, the validation that formula is "just as good" is comforting.
But when you stop looking at breastfeeding as nothing more than an acceptable feeding option and start viewing it through the lens of infant and maternal health, the debate of breast vs bottle virtually disappears.
Being Pro-"feed the infant" is nothing more than an attempt at pleasing everyone. It's not a logical place to be in the discussion on infant feeding.
Monday, July 29, 2013
Introduction of Solid Food: Separating Myth from Reality
The topic of introducing solids is a controversial topic. Many pediatricians recommend rice cereals beginning at 4 months, with the gradual replacement of breast milk with solids foods. In recent years, this use of rice cereal and other infant grains has been heavily questioned, as has the duration of exclusive breastfeeding, and whether or not spoon-feeding is the proper way to introduce foods. But what does the evidence say?
Duration of Exclusive Breastfeeding
The American Academy of Pediatrics (AAP) recommends exclusive breastfeeding for "about" the first 6 months of an infant's life, followed by the introduction of complementary solid foods with continued breastfeeding. [1] The World Health Organization (WHO), as well as the United Nations Children's Fund (UNICEF) have set a global recommendation for "exclusive breastfeeding for 6 months (180 days)" followed by "nutritionally adequate and safe complementary feeding starting from the age of 6 months with continued breastfeeding up to 2 years of age or beyond." [2][3]
Neither organization supports prolonged exclusive breastfeeding beyond 6 months of age, with the WHO considering the too-late introduction of complementary solids to be of equal concern as the too-early introduction of solids.
In 2006, The Journal of Nutrition published a Mexican Cohort study on the implications of exclusive breastfeeding beyond 6 months. They found that infants in developing countries who were breastfed for longer than 6 months had an increased risk of developing Iron-Deficiency Anemia, particularly those whose mothers were also anemic. [4] These findings are supported by an AAP report published in 2010, where exclusive breastfeeding beyond 6 months was associated with an increased risk of Iron-Deficiency Anemia at 9 months of age. [5]
During the 3rd trimester, infants begin to store iron in their liver. These stores will satisfy the infant's iron needs for the first few months of life. Breast milk contains very low amounts of iron, but the iron that is in breast milk is bound to lactoferrin glycoprotein, making it incredibly bio-available to the infant. But by around 6 months, not only do infants begin requiring more iron, but their iron stores begin to deplete. Infants who are preterm, were born small for their gestational age, or who had immediate cord clamping are at an even higher risk of developing Iron-Deficiency Anemia in the second 6 months of life.
Food Before One: Is It Just For Fun?
With the growing increase in "Baby-led Weaning", a mantra has developed: "Food before 1 is just for fun." This is not entirely accurate. While BLW is considered to be a compatible method of infant feeding [6], care does need to be taken by parents to make sure that they are not unnecessarily delaying the introduction of solids, believing that food is of no nutritional value. Some infants, particularly those who are born premature or who have motor delays, may have nutritional requirements for solid foods before they possess the manual dexterity to self-feed. [7]
2. World Health Organization. 2009. "Infant and Young Child Feeding"
http://whqlibdoc.who.int/publications/2009/9789241597494_eng.pdf
3. World Health Organization. 2001. "Guiding Principles of Complementary Feeding for the Breastfed Child"
http://www.who.int/nutrition/publications/guiding_principles_compfeeding_breastfed.pdf
4. The Journal of Nutrition. 2006. "Risk of Infant Anemia is Associated with Exclusive Breastfeeding and Maternal Anemia in a Mexican Cohort."
http://jn.nutrition.org/content/136/2/452.long
5. American Academy of Pediatrics. 2010. "Diagnosis and Prevention of Iron-Deficiency and Iron-Deficiency Anemia in Infants and Young Children."
http://pediatrics.aappublications.org/content/early/2010/10/05/peds.2010-2576.full.pdf+html
6. Journal of Maternal and Child Nutrition. 2010. "Is Baby-led Weaning Feasible? When do Babies First Reach Out and Eat Finger Foods?"
http://onlinelibrary.wiley.com/doi/10.1111/j.1740-8709.2010.00274.x/full
7. Nutrients. 2012. "How Feasible is Baby-led Weaning as an Approach to Infant Feeding? A Review of the Evidence."
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3509508/
8. Journal of the American Medical Association. 1998. "Maternal Feeding Practices and Childhood Obesity."
http://archpedi.jamanetwork.com/article.aspx?articleid=189952
9. Journal of the American Medical Association. 1989. "Infant Sleep and Bedtime Cereal"
http://archpedi.jamanetwork.com/article.aspx?articleid=514762
10. Journal of the American Medical Association. 2003. "Timing of Initial Cereal Exposure in Infancy and Risk of Islet Autoimmunity."
http://jama.jamanetwork.com/article.aspx?articleid=197392
11. Journal of the American Medical Association. 2005. "Risk of Celiac Disease Autoimmunity and Timing of Gluten Introduction in the Diet of Infants at Increased Risk of Disease"
http://jama.jamanetwork.com/article.aspx?articleid=200903
12. http://www.allattamentoalseno.it/lavori/L99.pdf
13. Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Chicago. 2007. "The influence of gluten: weaning recommendations for healthy children and children at risk for celiac disease"
http://www.ncbi.nlm.nih.gov/pubmed/17664902
14. American Journal of Maternal and Child Nursing. 2007. "The importance of exclusive breastfeeding in infants at risk for celiac disease"
http://ajcn.nutrition.org/content/39/4/584.full.pdf
15. Journal of Digestive Diseases and Sciences. 1987. "Role of salivary amylase in gastric and intestinal digestion of starch"
http://link.springer.com/content/pdf/10.1007%2FBF01300204.pdf#page-1
16. Journal of Pediatric Research. 1983. "Mammary Amylase: a Possible Alternate Pathway of Carbohydrate Digestion in Infancy"
http://www.nature.com/pr/journal/v17/n1/abs/pr19833a.html
17.Journal of Pediatric Gastroenterology & Nutrition. 1999. "Starch Digestion in Infancy"
http://journals.lww.com/jpgn/Fulltext/1999/08000/Starch_Digestion_in_Infancy.4.aspx
Duration of Exclusive Breastfeeding
The American Academy of Pediatrics (AAP) recommends exclusive breastfeeding for "about" the first 6 months of an infant's life, followed by the introduction of complementary solid foods with continued breastfeeding. [1] The World Health Organization (WHO), as well as the United Nations Children's Fund (UNICEF) have set a global recommendation for "exclusive breastfeeding for 6 months (180 days)" followed by "nutritionally adequate and safe complementary feeding starting from the age of 6 months with continued breastfeeding up to 2 years of age or beyond." [2][3]
Neither organization supports prolonged exclusive breastfeeding beyond 6 months of age, with the WHO considering the too-late introduction of complementary solids to be of equal concern as the too-early introduction of solids.
In 2006, The Journal of Nutrition published a Mexican Cohort study on the implications of exclusive breastfeeding beyond 6 months. They found that infants in developing countries who were breastfed for longer than 6 months had an increased risk of developing Iron-Deficiency Anemia, particularly those whose mothers were also anemic. [4] These findings are supported by an AAP report published in 2010, where exclusive breastfeeding beyond 6 months was associated with an increased risk of Iron-Deficiency Anemia at 9 months of age. [5]
During the 3rd trimester, infants begin to store iron in their liver. These stores will satisfy the infant's iron needs for the first few months of life. Breast milk contains very low amounts of iron, but the iron that is in breast milk is bound to lactoferrin glycoprotein, making it incredibly bio-available to the infant. But by around 6 months, not only do infants begin requiring more iron, but their iron stores begin to deplete. Infants who are preterm, were born small for their gestational age, or who had immediate cord clamping are at an even higher risk of developing Iron-Deficiency Anemia in the second 6 months of life.
Food Before One: Is It Just For Fun?
With the growing increase in "Baby-led Weaning", a mantra has developed: "Food before 1 is just for fun." This is not entirely accurate. While BLW is considered to be a compatible method of infant feeding [6], care does need to be taken by parents to make sure that they are not unnecessarily delaying the introduction of solids, believing that food is of no nutritional value. Some infants, particularly those who are born premature or who have motor delays, may have nutritional requirements for solid foods before they possess the manual dexterity to self-feed. [7]
"This means it is also important that parents understand that a different approach may need to be taken for preterm infants or those with developmental delay, at least until they are able to effectively convey food to their mouth, and safely chew and swallow it, and also for those at increased risk of allergy; and perhaps during and following illness."*Nutrients. 2012. "How Feasible is Baby-led Weaning as an Approach to Infant Feeding? A Review of the Evidence."
Infant Rice Cereal
2. Use "responsive" weaning. Allow infants to self-feed soft foods, if they desire. Use a spoon or your own finger to feed mushed, pureed or soft foods to infants who have a desire to eat but do not have the motor skills to self-feed. Never force an infant to take food off a spoon or to finish a whole jar of baby food.
Many claims have been made about infant rice cereal, from it resulting in an increased risk of obesity, to diabetes, food allergies, as well as claims that it is nutritionally deplete, un-digestible, and unnecessary. Rice cereal is used by many pediatricians as a formula thickener for infants with reflux, and is believed by many parents to help a child last longer between feeds and even to sleep through the night. Clearly, what an infant is fed as a first food is of great debate.
The WHO recommends that all infant first foods should have a greater energy density than breast milk. They define the average caloric content of breast milk to be 0.8 kcal per gram (or 22 kcal per ounce). By this respect, infant rice cereal fits the bill. The Gerber Single Grain cereal contains 60 calories in 15 grams (4 kcal per gram). But concerns have been raised over whether feeding such a calorie-dense food is beneficial to an infant.
There has been some loose correlation between the early introduction of infant rice cereal and later obesity. One such study from the Journal of the American Medical Association (JAMA) found that mothers who introduce rice cereal prematurely are more likely to value their infants being "chunky", and are also more likely to use food as a rewards system for good behavior. This makes it incredibly difficult to differentiate between whether the increase in obesity is a result of complex feeding practices and behaviors or the actual nutritional content of the food being fed. [8]
The WHO recommends that all infant first foods should have a greater energy density than breast milk. They define the average caloric content of breast milk to be 0.8 kcal per gram (or 22 kcal per ounce). By this respect, infant rice cereal fits the bill. The Gerber Single Grain cereal contains 60 calories in 15 grams (4 kcal per gram). But concerns have been raised over whether feeding such a calorie-dense food is beneficial to an infant.
There has been some loose correlation between the early introduction of infant rice cereal and later obesity. One such study from the Journal of the American Medical Association (JAMA) found that mothers who introduce rice cereal prematurely are more likely to value their infants being "chunky", and are also more likely to use food as a rewards system for good behavior. This makes it incredibly difficult to differentiate between whether the increase in obesity is a result of complex feeding practices and behaviors or the actual nutritional content of the food being fed. [8]
Almost all the mothers in that study believed infant cereal to "fill their baby up" longer and to help them sleep longer. One of the first studies on rice cereal and infant sleep was also published in JAMA in 1989, finding that feeding infants rice cereal in a bottle "does not appear to make much difference in their sleeping through the night." [9]
On the other hand, the timing of cereal exposure may affect the risk of an infant developing islet autoimmunity (a marker for Type 1 Diabetes). Children who were exposed to rice cereal before 4 months and after 7 months had an increased risk of islet autoimmunity than those who consumed rice cereal within the window of 4-6 months. For those parents who want to use rice cereal, timing of initial introduction should be considered. [10]
What about gluten? Is gluten bad for babies?
Rice cereal is a gluten-free food, but as more and more parents shun the processed, boxed infant foods, it has become increasingly more common to see recipes for homemade porridge made from oats or other grains. One of the tenants of Baby-led Weaning is that an infant can consume pretty much any food (including bread) once they begin eating solids.
A study undertaken in 2005 looked at the incidence of Celiac Disease among children and whether or not it corresponded to the introduction of gluten-containing foods. Children exposed to gluten-containing foods in the first 3 months of life and also beyond 7 months of life were at an increased risk of developing Celiac Disease. But this increased effect was only noticed in children who were already at a higher risk of developing the disease in the first place (such as those were certain genetic factors or Type 1 Diabetes). The children who developed Celiac Disease were also less likely to be breastfeeding at the time of gluten exposure. [11]
A link between the introduction of gluten cereals and Celiac Disease was also noted by comparing countries with different rates of Celiac Disease with their cultural infant feeding behaviors. Infants in Estonia consume less gluten-containing cereal and have lower rates of Celiac Disease then infants in Sweden and Finland who consume more gluten-containing cereal. However, this study did not control for formula or breastfeeding, making the results difficult to apply to larger populations. [12]
Rice cereal is a gluten-free food, but as more and more parents shun the processed, boxed infant foods, it has become increasingly more common to see recipes for homemade porridge made from oats or other grains. One of the tenants of Baby-led Weaning is that an infant can consume pretty much any food (including bread) once they begin eating solids.
A study undertaken in 2005 looked at the incidence of Celiac Disease among children and whether or not it corresponded to the introduction of gluten-containing foods. Children exposed to gluten-containing foods in the first 3 months of life and also beyond 7 months of life were at an increased risk of developing Celiac Disease. But this increased effect was only noticed in children who were already at a higher risk of developing the disease in the first place (such as those were certain genetic factors or Type 1 Diabetes). The children who developed Celiac Disease were also less likely to be breastfeeding at the time of gluten exposure. [11]
A link between the introduction of gluten cereals and Celiac Disease was also noted by comparing countries with different rates of Celiac Disease with their cultural infant feeding behaviors. Infants in Estonia consume less gluten-containing cereal and have lower rates of Celiac Disease then infants in Sweden and Finland who consume more gluten-containing cereal. However, this study did not control for formula or breastfeeding, making the results difficult to apply to larger populations. [12]
What these studies suggest is that the ideal time to introduce gluten to an at-risk infant is between 4 and 6 months, and that mothers should also be breastfeeding at the time of exposure. [13]
Can Infants Digest Grains?
Another consideration that has been brought up is whether infants even possess the ability to digest grains. I've heard it repeated several times that infants cannot digest grains until 12-24 months old.
Another consideration that has been brought up is whether infants even possess the ability to digest grains. I've heard it repeated several times that infants cannot digest grains until 12-24 months old.
The enzyme primarily responsible for the digestion of grains is amylase. Amylase is produced both in the saliva and by the pancreas. Salivary amylase begins to digest starches while the food is chewed, and then pancreatic amylase is secreted after the food passes in to the duodenum (upper section of small intestine), further digesting starches. Salivary amylase is at 60% of adult levels by 3 months of life and 83% by 5 months. [14]
Despite its designation as "salivary" amylase, this enzyme also functions in the lower digestive tract. A majority of starch digestion occurs in the duodenum, but because the infant stomach has a higher ph than an adult stomach, the salivary amylase retains much of its digestive properties. It is thus proposed that the salivary amylase that mixes with the food will continue to digest the grains even after swallowed, compensating for lower levels of pancreatic amylase. Around 6 months the infant's pancreas begins producing more and more of its own amylase. [15]
Another feature in the digestion of grains in infants is the presence of mammary amylase. Mammary amylase is the amylase that is found in breast milk. It has been suggested that, like salivary amylase, much of the mammary amylase retains its digestive properties, aiding in the digestion of starches until the infant's own pancreatic juices can begin to mature around 6 months. [16]
The digestion of carbohydrates by infants is a complex process, involving more than just the presence of amylase. Colon micro flora, and other small intestine brush-border enzymes play a role, and there is no evidence suggesting that infants who are old enough to consume solid foods have any difficulty digesting starches. The full strength of pancreatic amylase is not reached until a child is between 5 and 12 years old. Given that most infants, and especially most children, are able to digest starches and complex carbohydrates without issue, we can deduce that the digestion of starches is much more complex than merely the presence or lack of pancreatic amylase. [17]
So then, what would be a reasonable plan of action for the introduction of solid foods?
1. Delay solids until at least 4 months, preferably 6 months.
1. Delay solids until at least 4 months, preferably 6 months.
2. Use "responsive" weaning. Allow infants to self-feed soft foods, if they desire. Use a spoon or your own finger to feed mushed, pureed or soft foods to infants who have a desire to eat but do not have the motor skills to self-feed. Never force an infant to take food off a spoon or to finish a whole jar of baby food.
3. Preterm infants or those who were born small for gestational age require special feeding care to make sure iron intake is adequate, especially after 6 months. An iron blood test is a simple procedure that can be done at your pediatrician's office, and can help you assess your child's unique iron needs.
4. If iron levels are low, the WHO recommends increased intake of iron-rich solid foods before relying on supplementation through drops or vitamins.
5. Breastfed infants should only be given iron supplements if they have iron-deficiency anemia (iron below 10.5) and are not consuming adequate food sources of iron (disclaimer: infants with Perinatal Crohn's Disease may have impaired iron absorption despite consumption of iron-rich foods)
6. There are no contraindications to consuming grains if a child is old enough to consume solid foods.
7. Families with an increased risk of Celiac Disease should introduce gluten between 4-6 months, while continuing to breastfeed.
References:
4. If iron levels are low, the WHO recommends increased intake of iron-rich solid foods before relying on supplementation through drops or vitamins.
5. Breastfed infants should only be given iron supplements if they have iron-deficiency anemia (iron below 10.5) and are not consuming adequate food sources of iron (disclaimer: infants with Perinatal Crohn's Disease may have impaired iron absorption despite consumption of iron-rich foods)
6. There are no contraindications to consuming grains if a child is old enough to consume solid foods.
7. Families with an increased risk of Celiac Disease should introduce gluten between 4-6 months, while continuing to breastfeed.
References:
1. American Academy of Pediatrics. 2012. "AAP Reaffirms Breastfeeding Guidelines"
http://www.aap.org/en-us/about-the-aap/aap-press-room/pages/AAP-Reaffirms-Breastfeeding-Guidelines.aspx?nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3a+No+local+token
http://www.aap.org/en-us/about-the-aap/aap-press-room/pages/AAP-Reaffirms-Breastfeeding-Guidelines.aspx?nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3a+No+local+token
2. World Health Organization. 2009. "Infant and Young Child Feeding"
http://whqlibdoc.who.int/publications/2009/9789241597494_eng.pdf
3. World Health Organization. 2001. "Guiding Principles of Complementary Feeding for the Breastfed Child"
http://www.who.int/nutrition/publications/guiding_principles_compfeeding_breastfed.pdf
4. The Journal of Nutrition. 2006. "Risk of Infant Anemia is Associated with Exclusive Breastfeeding and Maternal Anemia in a Mexican Cohort."
http://jn.nutrition.org/content/136/2/452.long
5. American Academy of Pediatrics. 2010. "Diagnosis and Prevention of Iron-Deficiency and Iron-Deficiency Anemia in Infants and Young Children."
http://pediatrics.aappublications.org/content/early/2010/10/05/peds.2010-2576.full.pdf+html
6. Journal of Maternal and Child Nutrition. 2010. "Is Baby-led Weaning Feasible? When do Babies First Reach Out and Eat Finger Foods?"
http://onlinelibrary.wiley.com/doi/10.1111/j.1740-8709.2010.00274.x/full
7. Nutrients. 2012. "How Feasible is Baby-led Weaning as an Approach to Infant Feeding? A Review of the Evidence."
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3509508/
8. Journal of the American Medical Association. 1998. "Maternal Feeding Practices and Childhood Obesity."
http://archpedi.jamanetwork.com/article.aspx?articleid=189952
9. Journal of the American Medical Association. 1989. "Infant Sleep and Bedtime Cereal"
http://archpedi.jamanetwork.com/article.aspx?articleid=514762
10. Journal of the American Medical Association. 2003. "Timing of Initial Cereal Exposure in Infancy and Risk of Islet Autoimmunity."
http://jama.jamanetwork.com/article.aspx?articleid=197392
11. Journal of the American Medical Association. 2005. "Risk of Celiac Disease Autoimmunity and Timing of Gluten Introduction in the Diet of Infants at Increased Risk of Disease"
http://jama.jamanetwork.com/article.aspx?articleid=200903
12. http://www.allattamentoalseno.it/lavori/L99.pdf
13. Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Chicago. 2007. "The influence of gluten: weaning recommendations for healthy children and children at risk for celiac disease"
http://www.ncbi.nlm.nih.gov/pubmed/17664902
14. American Journal of Maternal and Child Nursing. 2007. "The importance of exclusive breastfeeding in infants at risk for celiac disease"
http://ajcn.nutrition.org/content/39/4/584.full.pdf
15. Journal of Digestive Diseases and Sciences. 1987. "Role of salivary amylase in gastric and intestinal digestion of starch"
http://link.springer.com/content/pdf/10.1007%2FBF01300204.pdf#page-1
16. Journal of Pediatric Research. 1983. "Mammary Amylase: a Possible Alternate Pathway of Carbohydrate Digestion in Infancy"
http://www.nature.com/pr/journal/v17/n1/abs/pr19833a.html
17.Journal of Pediatric Gastroenterology & Nutrition. 1999. "Starch Digestion in Infancy"
http://journals.lww.com/jpgn/Fulltext/1999/08000/Starch_Digestion_in_Infancy.4.aspx
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