Wednesday, August 4, 2010

Avoiding Early Introduction of Supplementation: One Reason That Often Gets Overlooked

World Breastfeeding Week is generating a panoply of incredible writing. Touching, inspirational, galvanizing, fascinating. I plan to do a round-up of my favorites, both from this week and of all time, on Friday, after I post part 2 of my story about postpartum OCD, but for today, I thought I'd post something more rudimentary, to contrast with all the eloquent boobsmithery out there right now. It's a bit dry, but something that's been on my mind.

Even the most rudimentary breastfeeding information usually contains at least a mention of "nipple confusion", the most commonly cited reason to avoid introducing bottles too early. No matter what the supplement happens to be, this is indeed to be approached with extreme caution in the early weeks. Some lactation consultants feel the issue is more accurately dubbed "flow confusion", and it's a fair distinction. Either way, the site Breastfeeding Basics explains it quite well:
The mechanics of breast and bottle-feeding are quite different. When a baby nurses, his tongue and jaws must work together rhythmically, cupping his tongue under the areola, and pressing it up against his palate. This flattens and elongates the tissue around the nipple. He then drops the back of his tongue to form a groove for the milk to flow from the nipple to his throat. He swallows, then takes a breath. His lips are flanged out tightly around the breast to form a tight seal.

When a baby drinks from a bottle, the milk gushes out (you’ll notice that the milk drips out if you hold a bottle upside down). In order to keep from choking, he lifts his tongue uses it to block the flow of milk. He purses his lips around the hard rubber nipple, and he doesn’t have to use his jaws at all. There is a constant flow of milk that he doesn’t have to work for, unlike during breastfeeding, where the milk ‘lets down’ initially, then slows to a trickle, and the process repeats as the baby sucks harder and longer. This occurs several times during a feeding, and is one of the reasons breastfed babies are less likely to become obese than bottle-fed babies: they regulate their own intake by how long and vigorously they suck. Bottle-fed infants will often finish a bottle not because they are hungry, but because they love to suck, and the milk flows so easily.

The risk of nipple confusion , whether by introducing a bottle or pacifier, is greatest during the early days of nursing. The longer you wait to introduce artificial nipples, the less risk there is of confusing your baby. Breastfeeding is a learned behavior, in most cases, although there are some babies who seem to be born knowing exactly what to do. Although sucking is a newborn reflex, the mechanics of effective latching on aren’t. It usually takes a couple of weeks, and sometimes longer, for mothers and babies to get really good at nursing.

The whole article is quite thorough and worth a read. Should supplementing become necessary early on, while the issues (whatever they are) get worked out, it's far better to use an alternative method such as cup or syringe-feeding, or using an at-breast system like the Lact-Aid (preferable) or the SNS.

Many sources will also go a step further and talk in greater detail about the impact that each instance of supplementation will have on mother's supply, the second common reason often given to avoid supplementing unless absolutely necessary. In the simplest terms, every feeding that does not come from the mother's breast is a message to that breast to not make as much milk. Continued supplementation without working to make up for it WILL impact mom's supply (and in fact, pumping is not as effective at removing milk from the breast as an efficiently nursing baby is, so this decision is not to be made lightly). This is particularly critical in the first 2-3 weeks, when supply is being established in the first place. If supplementation is truly indicated, even if it's done in the best possible way to avoid nipple/flow confusion, pumping will have to be done to make up for it.

Poor early lactation management is so often to blame for this in the hospital - it's one of the all-time biggest Booby Traps. You can see how quickly the vicious cycle takes hold. On the second day, a new mom's milk hasn't yet transitioned from colostrum to breastmilk, despite baby not needing anything else. Supplementation is then recommended by a staff member without adequate training in breastfeeding. Mom accepts the recommendation from this staff member, believing them to be the voice of authority, and supplements with a bottle, wanting to do what is best for her baby. Her supply adjusts itself accordingly and produces less milk, creating a need for more supplementation. And on it goes. A very real problem is created when there was no problem in the first place.

But there's a third reason to take care when supplementing that DOES have to do with what is actually being used, and that has to do with the impact that artificial milk has on a baby's gut. Many people are unaware of the significance of this, even in small amounts, the intestinal flora is dramatically altered. If the supplementation is temporary, it is possible to return the gut to health with weeks of exclusive breastmilk. But if it continues, the impact is permanent. Ann Calandro, RN and IBCLC, wrote the must-read article "The Case of the Virgin Gut: Why Even The Occasional Bottle of Formula Has Its Risks", and I implore you to read it now. A taste or two:
Many babies who are breastfed begin their lives in hospitals that routinely supplement with artificial formulas. Sometimes babies are given artificial milk for medical reasons such as low blood sugars or because their mother is very ill. More often, they are given artificial milk for non-medical reasons, because nurses offer it to keep them quiet, or because mothers are concerned that their babies are hungry because they are nursing so often. Some mothers want to sleep and leave their baby in the nursery all night, so they ask the nurses to feed the baby formula.

Innocent enough reasons – and common. So common, in fact, that very few babies leave the hospital with their virginal guts. But what happens when breast milk is not the only food in that little gut? The truth is very interesting and also very scary.

When babies are born, they have sterile gastrointestinal tracts. If babies are exclusively breastfed, they develop a natural healthy gut flora. This means that the major flora in breastfed babies has reduced numbers of bad types of bacteria and increased numbers of good bacteria. Formula-fed babies have increased numbers of bad bacteria, leaving them at more risk for illness.

It takes many weeks for the baby's gut to close up the leaks in order to seal off germs and to develop the ability to shut out allergenic proteins. If given formula in the early weeks, this closing up is delayed and the risk of allergies and illness increases. The type of bacteria in the gut becomes less protective. In other words, Baby is more at risk for illness.

Just one bottle of formula - given for any reason - can sensitize babies who may be allergic to cow's milk protein or soy protein.
Of course, special circumstances arise, and Calandro addresses them here:
Sometimes the addition of artificial formulas to infant diets is unavoidable for a variety of reasons. If this is the case, there is very little that can be done to remedy the situation and save the virginal gut. Some hospitals provide banked human milk for babies that must be given supplemental food until mother's milk is available. The majority of hospitals do not. Recent studies have shown that giving hydrolyzed formula to a baby born in a family with a history of allergies may be the best alternative if formula must be given.
Marsha Walker, RN and IBCLC, addresses this, along with the aforementioned risks, in her similar and much more technically detailed "Just One Bottle". Walker spoke at a 2005 La Leche League conference in her session "Resisting the Tide of Early Supplementation and Other Selected Barriers to Breastfeeding". The WHO guidelines have long established that the hierarchy of infant feeding is 1) direct breastfeeding, 2) the mother's breastmilk via supplementer or bottle, 3) donor milk, and finally, 4) formula. Walker breaks it down even further:

Marsha notes too that when supplementation is necessary, a hierarchy of foods should be used. The first supplement used should be the mother's own fresh milk, if at all possible. If not, the following choices could be used, listed in order of what is best for the baby:

  • Baby's own mother's refrigerated milk
  • Baby's own mother's frozen milk
  • Baby's own mother's fortified milk (for preterm babies)
  • Banked pasteurized human donor milk
  • Hypoallergenic or hydrolyzed formula (the proteins in these formulas have been subjected to a splitting process that reduces their allergy potential. Examples are Nutramigen, Pregestimil, and Alimentum)
  • Elemental formula (specialty formulas consisting of basic amino acids that are used in more extreme situations)
  • Cow's milk formula
  • Soy formula
  • Water or glucose water
Interesting to note that as of the above conference, though breastfeeding rates had risen, so had supplementation. "For example, in 1982, the overall breastfeeding rate was 61.9 percent, with 55 percent of babies exclusively breastfed and 6.9 percent breastfed along with supplements. By 2003, the overall breastfeeding rate was 66 percent, with 44 percent of babies exclusively breastfed and 22 percent breastfed along with supplements." I'd be curious to see this breakdown today. YES, some breastmilk is absolutely better than none. But we can do better than this for our moms and babies. Much, much better.

[A fourth reason that can hardly even begin to be covered here is the complex influence that supplementation, for any reason and in any form, has on maternal confidence in her body and her ability, but I have to resist the temptation to wax philosophical on that for the moment.]

This is not about being 100% anti-bottle. In our current collective lives, many, many mothers who are devoted to breastfeeding their babies must return to work, and bottles will have to become part of their baby's life in some way. Their commitment to pumping and continuing provide breastmilk during the times they're separated is awe-inspiring, especially if it helps them to get to the minimum guidelines for exclusive breastfeeding recommended by the AAP and WHO. Extenuating circumstances of all kinds do exist - the point is simply to introduce them as carefully as possible, and only use anything other than human milk as a last resort.

It's also worth discussing some of the ways to optimize bottle-feeding, maximizing the bonding opportunities and minimizing some of the potential pitfalls; just because a bottle will sometimes be necessary for some babies part or even full-time doesn't mean the caregivers should give up, figure all is lost, and start propping bottles. Another topic for another day. I leave you with these resources:

Links on how to tell if your baby is getting enough milk and info on true supply issues:
Dr. Jack Newman
Anne Smith, IBCLC
Dr. Jay Gordon
La Leche League
Why Delay Solids?


P.S. Related but taking a tangent: This post comes on the heels of a new article, pointed out to me by Blacktating, about the article mentioning that the Duggar's latest child, Josie, a preemie, is now being fed formula after receiving breast milk in the early days. The lactation pros (some real luminaries, too) responded with great information.

PD: Now about Josie.
We are so thankful. It could've been much more serious. We're grateful that it was a diet change that made the difference for her. We changed from breast milk to a predigested formula that has no lactose, and within 12 hours she was better. And, within a week, she was pooing on her own, without us having to give her an enema. She was a totally different baby a week later.

PD: Wow, breast milk was the culprit?
Typically, they never want to take a preemie off breast milk, but in her case the lactose in my milk was causing a problem. Her body was not producing lactase, which breaks down the lactose.

PD: Whose idea was it to suggest a possible lactose intolerance?
Dr. [Robert] Arrington, he is such an ace doctor. And he encourages moms to breast-feed, so for him to resort to this was a big deal. He wanted to try this, and he asked me if it was okay and I said, 'Yes, anything to help Josie.' He said that breast milk intolerance is a rare occurrence for babies, maybe one percent or less, but he said we're going to try it for a week and see.

The pros in the thread, including author Diana West, pointed out that yes, preemies are often not YET able to produce lactase, as Michelle herself states - but the better course of action is to add lactase to the preemie's breastmilk feedings until he or she can produce it on their own, rather than jumping immediately to formula.

West elaborated: "While it's possible that the parents were given incorrect information, it's also possible the parent misunderstood what they were told. This could be galactosemia where the baby can't metabolize the sugar galactose. It's life threatening in some situations and may (but not always) require weaning to a special formula. It is impossible for a baby to be 'lactose intolerant.' Lactose is a milk sugar that babies need for brain growth and an intolerance to it is only developed in adulthood when the enzyme lactase stops being secreted in the stomach."

At least Michelle Duggar added this much, from the interview above: "He said that breast milk intolerance is a rare occurrence for babies, maybe one percent or less, but he said we're going to try it for a week and see." Even if is is a misrepresentation, and the issue of why they didn't look into the alternative of adding lactase to the breastmilk was not addressed, AT LEAST the doctor wasn't all, "Oh yeah, we see this all the time, formula's just as good, etc."

A mixed bag at best. As West said, "I think it's hard for us to know what is going on in this situation, but the tough thing is that it's now in the media that human milk is dangerous for some babies."


  1. All very interesting things to think about. I'm always amazed by how many women expect to leave the hospital with milk. I'm even more surprised by how some are even using breastpumps while in the hospital when there is nothing wrong with their babies! Doesn't it make more sense to let baby nurse on demand and as long as he/she wants rather than to pump? My milk never came in until at least 4-5 days after the babies were born (with my 4th. child it was a week), so the whole worrying at only the 2nd. day just doesn't make sense to me.

  2. "I'm even more surprised by how some are even using breastpumps while in the hospital when there is nothing wrong with their babies!"

    Right - UNLESS there is something going on with the baby. I know that's exactly what you're saying - I just thought it was worth emphasizing. :O) If baby isn't latching on regularly and effectively for some reason (like Lily's early neurological compromises and tongue tie), *then* a breast pump can be vital. I definitely don't support pumping for no good reason in the early days, and it should not, not, not be the norm, but there are also times it's a vital miracle of modern life.

    I guess that's what often irks me most. Can we not understand that there are norms, particularly biological ones, and that there are also exceptional variations on norms? If you follow? I wish it didn't seem like "Everyone should pump right away or you'll never get a full supply!' vs. "No one should ever pump right away, it's unnatural and unnecessary!'

    Does that make sense? It's getting late for me to be thinky.

  3. I never know what to say when women tell me they had to switch to formula because their milk never came in before they left the hospital. My milk came in the morning I left the hospital because my daughter nursed round the clock for the two days prior. Otherwise, mine wouldn't have come in so soon. It really bugs me that the mechanics of how breastfeeding works isn't covered by doctors. I had to make sure to read the "right" books, and I had a wonderful childbirth instructor who gave me good information. If I had not had that education, I would have given up or been talked out of breastfeeding by clueless relatives and nurses.

  4. I watched this episode last night and was wondering why Michelle did not eliminate dairy from her own diet in order to continue breatfeeding. I don't know if that would have solved the issue, but it is worth a shot over formula. But perhaps I misinterpreted.

  5. Deanna, I truly hope the education of medical professionals starts to change. It's such a big factor. You might find this interesting - not from a physician but a biologist, addressing her alma mater and asking why, in all her time studying mammals, the process of lactation was NEVER studied on any level (I'm posting this in the round-up on Friday fer sher), and she points out that medical students got the same, as has been corroborated by others. It's pretty appalling. Doctors and nurses who want to be well-educated on breastfeeding have to seek their training elsewhere. I think the Academy of Breastfeeding Medicine has a major impact on that.

    DDL, I do wish there was more attention paid to the impact of mom's diet on breastfeeding, but it sounds like this MAY have not been the case. The more I think about this story, the more aggravating it becomes because of how little we know, particularly on the timeline of events.

    But I do want to point out that breastmilk, by definition, has lactose (a form of sugar) in it. Lots of it. When babies are sensitive to dairy in mom's diet, it is the cow's milk PROTEINS (i.e. casein and whey) that are the problem, not the sugars. Almost all babies are designed to digest breastmilk, with the exception of some preemies (as is the case here) and those with galactosemia; babies produce lactase in order to digest lactose. (Even galactosemia is different, as it's yet another milk sugar, galactose, that they have trouble with.) Many adults lose the ability to produce lactase as they get older, hence lactose intolerance. But virtually all babies are designed for it - again, EXCEPT for some preemies.

    Again, we don't know all the details. Would Josie have eventually started producing lactase on her own? When was this decided? Could they have saved up some stored milk for later and continued? Why was adding lactase not on the table? When did the infrequent stooling begin? There are just so many questions.

    I bring these questions up NOT to critique the Duggars for a decision that I'm sure they took very seriously and made according to what they really felt was best (though I'm still annoyed at the article). I bring them up as a point of interest to those who are interested in the technicalities of breastfeeding and challenges thereto. In a different Facebook thread than the one I reference in the post, I saw a lot of women going "Ugh! She should have given up dairy herself, DUH!" Well . . . as much as I think that's appropriate in many cases, it's sometimes more complex than that, as it seems to be here.

  6. Anne, do you know why are hypoallergenic formulas "better" than elemental formulas? Hypoallergenic formulas still contain traces of milk or soy whereas elemental formulas do not and are so complete that there is very little waste product produced from the baby (or toddler in our case).~Tracey