Thursday, August 2, 2012

Our Babies, Our Guts, Or: What Napoleon Dynamite Can Teach Us About Breastfeeding

Mmm, Gut Flora
Is it normal for a breastfed baby to go for days without pooing? How about weeks? It comes up fairly regularly (puns always intended around here) in online breastfeeding-related support groups, and the conventional wisdom/majority opinion is inevitably that infrequent stooling in exclusively breastfed infants is fairly common and thus, it is normal. But what do we mean by "normal"? If by normal (in this context) we really mean common, then yes, that's true. But does that, therefore, equal healthy?

Usual pattern of discourse:
One parent: "My baby usually went for 4 or 5 days without pooing. Then she'd have a huge blowout/poo all day on the fifth day."

Another parent: "Breastmilk is such a perfect substance that the baby's body just absorbs it all! Breastfed babies don't need to poo regularly." 

Third parent: "Yes! Breastmilk is used so efficiently that there isn't any waste. Mine used to poo explosively once a week. It was just her 'natural rhythm', I guess."

Me: "But . . . if a baby not pooing is a sign that the body is 'absorbing it all', then what does it mean when a baby actually poos? That they are not using it so efficiently and aren't getting the nutrients? And if they are then having blowouts later - doesn't that mean they were not 'using it so efficiently that there is no waste' after all? (And on to information about infrequent stooling sometimes being a symptom of food sensitivities, suggesting a look into gut healing if it;s feasible for the mom, etc, blather, rinse, repeat.)"
You get the idea. I'm always conflicted about this topic and its usual pattern because the women arguing in favor of infrequent infant stooling ARE breastfeeding advocates and are trying to encourage and reassure other mothers. I can't NOT support that right? The intention is so good.

I posit that something being common does not, in itself, mean that it is therefore healthy. 

This frequent conversation was on my mind when I shared this link from The Healthy Home Economist on Facebook yesterday and enjoyed the brief discussion that followed. From her post on relieving baby constipation:
"As little as ten to fifteen years ago, it was almost unheard of for a breastfed baby to be constipated.  In fact, the baby books at that time almost universally stated that breastfed babies don’t get constipated. Nowadays, however, this situation is becoming more commonplace and the continuing decline in the quality of the diet of nursing mothers is a likely reason.
While it is an unpopular position within the breastfeeding community, the diet of the mother clearly impacts the quality of her breastmilk (fats, vitamins and minerals in breastmilk vary considerably based on the mother’s diet although protein and immunoglobulins do not) and studies such as the Chinese Breastmilk Study confirm this.

"Suggesting that a lactating mother can eat whatever she wants and still produce quality breastmilk is also irresponsible and defies all common sense and historical study of healthy traditional cultures which put great emphasis on the quality of the diet of nursing mothers."

I appreciate that she's willing to state an  unpopular opinion on two matters: That even a breastfed baby needs to stool regularly (the body "using it so efficiently" does not mean that there is zero waste and that it just dissolves magically; that's simply not how human digestion functions, whether said human is an infant or an adult), and that maternal diet DOES in fact have an impact on breastmilk composition. Yes, breastmilk absolutely IS still preferable to formula, even with a suboptimal diet, but that does not mean a nutritionally inadequate diet and a healthful diet (and what "healthful" means definitely and obviously varies from individual woman to individual woman) are therefore equivalent.

I think we as breastfeeding professionals and advocates are frequently afraid to address maternal diet because we don't want to create additional pressure on mothers, and I completely get that. I don't want moms to feel that they have to eat "perfectly", and opinions also do vary on what optimal nutrition even is, I know. (Believe me, I know.  Vegetarian? Vegan? Paleo? Raw? Low Carb? Macrobiotic? Kosher? Gluten-free? SAD? GAPS? FODMAPS? Aiiiieeeeee!)  

However, I do feel sometimes that we're assuming that women's commitment to breastfeeding is so fragile and tenuous that giving information that includes suggesting improvement to their nutrition, within whatever their means are (more on that in a sec) will cause them to throw up their hands and give up. I want to give moms more credit than that. Yet I have also heard (as in read-on-forums) moms deciding to formula feed because they can't afford a perfect organic diet for themselves, so what's the point? Clearly we need to do a much better job of getting accurate info out there re: this. 

To wit, while this very conversation was taking place, a comment was posted on an article about the Bloomberg initiative: "[Breastfeeding is] only healthier IF the mother eats properly and chooses to not take in UNHEALTHY substances. . ." 

To which my classmate Catherine replied: "Right. Because all those cows whose milk is being used to make Similac are on an organic diet (and eating "properly" - so no grains) and are never given unhealthy substances." Those cows are not farmed on a different, uncontaminated planet, either.

Christie Haskell then summed it up neatly: "We want people to know that eating healthy does make things better for baby, but we don't want to fuel the idea that if you don't eat healthy, you might as well formula feed either." This is the dilemma.

My wise friend Arwyn, famed for her excellent blog Raising My Boychick, offered some important perspective with some difficult but extremely relevant thoughts, thoughts that we should keep in mind whether approaching this from either an advocacy role or a professional one:

[T]he majority of toxins in milk come from our own stored backlog, which were laid down when WE were fetuses and infants and children. They come from car fumes and factory fumes and "fire retardants" and water pollution, from a thousand things we cannot control and which big money is invested in preventing us from regulating. Does diet make a difference? Yeah, of course it does. But I think any conversation about diet that takes place outside of a dominant cultural conversation about how our waters and lands and air and food are polluted is the wrong approach.
Arwyn makes very important points - I always appreciate her asking the tough questions. I think it's important to have address ALL of these things. Socioeconomic issues, environmental contaminants, AND also maternal nutrition. And as an IBCLC-to-be, the subject I know most about is the latter, so therefore, it's what I'm most qualified to speak about - that doesn't mean I don't recognize the other things as significant factors. I don't have expertise in social justice or environmental science, but I do in human lactation  It's the area in which I have the best chance of making any significant impact as a professional, therefore it is the main focus of my voice on this matter. She is absolutely right that I still need to remember to consider the big cultural picture - and check my privilege - on a regular basis in all of these conversations.

It is absolutely true that our own health has already been dramatically affected by our grandmothers, quite literally - I say all the more reason to do what we can for our grandchildren in addition to our nurslings. I think we can strive to increase access and be sensitive and empathetic about resource inequity - and also not perpetuate myths in our roles as professionals or advocates about breastfed babies only needing to poo once a month-ish.

No conversation about this would be complete without a link to Jennifer Tow, who is one of the most experienced  and brilliant IBCLCs on the planet, and her poetic musings on "The Gut, Microbes and Poop":

Someday, I am going to write “Confessions of an IBCLC Heretic”, because for almost 20 years, I have been saying that it is absolutely not normal for babies of any age to have fewer than several significant bowel movements per day. Not per week! Per day. The more I learn about the gut and the gut-brain axis, the more I have to learn. But, I am confident that human milk is not “all used up” and that babies are not “efficient enough that there is no waste”.

Such comments do not even bear up under the scrutiny of common sense. If all those babies who stop pooping at 4-6 weeks are using up all the milk, what are the babies who are pooping 6-8 times per day doing? Making it?

And finally, even Napoleon Dynamite knows that maternal diet impacts milk composition.


Napoleon Dynamite: [drinks glass of milk] The defect in that one is bleach.
FFA Judge No. 1 : That's right.
Napoleon Dynamite : Yessssssssss.
Napoleon Dynamite : [drinks second glass of milk] This tastes like the cow got into an onion patch.
FFA Judge No. 2 : Correct.
Napoleon Dynamite : Yessssssssss. 
[Side note: Lily has taken lately to saying "Yesssssss," whenever she's mildly excited about something, and sounds exactly like Napoleon here.]