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A case study

A mother and her 3 month old baby presented at the International Breastfeeding Centre in Toronto because of late onset sore nipples. I noted that the baby had a tongue tie, previously undiagnosed, which was one reason that caused the baby not to latch on well. Late onset sore nipples is usually due to late onset decreased milk supply.

There were several reasons why this mother would have had a decrease in her milk supply.

The mother, based solely on the appearance of her breasts (see photo 1), was diagnosed immediately after the birth as having “insufficient glandular tissue”. Based on this diagnosis, the baby was immediately, at his very first feeding, supplemented with formula with a lactation aid at the breast.

Photo 1: This mother was diagnosed as IGT simply on the basis of the appearance of the breasts. In spite of this false diagnosis, she went on to breastfeed exclusively by the time the baby was 6 weeks of age. The diagnosis of Insufficient glandular tissue should not be made only on the basis of the appearance of the breast.

Photo 2 : This mother, a different mother than in photo 1, was diagnosed as having insufficient glandular tissue, partly based on the shape and size of her breasts. In spite of the diagnosis, with support, she was able to breastfeed exclusively.

The baby was on a bottle for the first 6 weeks of his life. The baby was also using a nipple shield starting at 2 weeks of age and was on it for 20 days.

When we saw the baby at 3 months of age, the mother, on her own, had managed to get the baby off the bottles (except for 1 or 2 small bottles of expressed milk a week), and off the nipple shield. Thus, when she and the baby presented at the clinic, the baby was exclusively breastfed and had been so for 6 weeks. The baby was growing well and drinking well at the breast despite the initial “diagnosis” of insufficient glandular tissue.

We released the tongue tie, only one of the causes of her late onset sore nipples.

Insufficient glandular tissue is a diagnosis that should be avoided. For several reasons:

  1. It is a “diagnosis” which essentially tells the mother that there is no hope she will ever breastfeed exclusively.
  2. As this case shows, nobody can look at a woman’s breasts and nipples and predict her ability to breastfeed exclusively. In fact, we have had other such cases where the diagnosis of insufficient glandular tissue had been made and the mothers were able to breastfeed exclusively.
  3. As in the case discussed, the baby was supplemented immediately after birth, based simply on the appearance of the mother’s nipples and breasts (see photo below) even though, later on she was able to breastfeed exclusively. Given that why would she not be able to breastfeed exclusively from birth?
  4. Because of this false diagnosis, many interventions were imposed on this mother and baby pair, which resulted in unnecessary supplementation, use a nipple shield, but despite these unnecessary interventions, the mother eventually managed to breastfeed exclusively.
  5. Instead of looking at the at the size and shape of the breast, health providers should be watching the baby at the breast.
  6. New mothers are set up for failure when they receive such a “diagnosis”. They may decide that breastfeeding is not going to work and may not persist in getting good hands on help.

Need help with breastfeeding?  Make an appointment at our clinic.

Copyright: Dr Jack Newman, MD, FRCPC, Andrea Polokova, 2019

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Recently, an article has been published on line by Kavin Senapathy on SciMoms. It pretends that all the evidence about the importance of breastfeeding is pure propaganda and pretends that mothers truly have the possibility of making informed decisions about how they will feed their babies. The article concludes that exclusive breastfeeding or breastfeeding combined with formula feeding or exclusive formula feeding are equivalent choices and it makes no difference to either the mother or the baby what the mother “chooses”. Oh, the author does allow that breastmilk-fed or breastfed premature babies are protected against a destructive illness of the intestines called necrotizing enterocolitis, but mentions it only in passing, as if it’s of no real importance and, well, they are premature babies, and that’s a different situation, isn’t it? It seems very possible that such a devastating and life-threatening illness could be prevented in premature babies, and yet, breastfeeding cannot prevent any illness in full term babies. Does that make sense? And when does the transition from premature (breastfeeding is good) to full term occur (breastfeeding is not better)? At 32 weeks gestation? At 36 weeks?

The incidence of premature birth is about 9% of all births in most western countries. So, this is a considerable number of babies, about 400,000 every year in the US, who could receive protection by breastfeeding. However, because of the lack of knowledgeable support for breastfeeding (little or no Kangaroo Mother Care, an almost obsessive overuse of “breastmilk fortifiers”, little or no support for breastfeeding as opposed to breastmilk feeding), very few mothers of premature babies actually leave hospital breastfeeding at all, and those who do, well very few breastfeed exclusively.

The Studies are not Useful?

The article argues that women in affluent countries are more likely to breastfeed, more likely to breastfeed exclusively, are generally better educated, are less likely to use tobacco products, and therefore the studies are biased because the two groups are not the same. And there is something to this. There is no such thing as a double-blind, randomly selected study when it comes to looking at the short and long term effects of breastfeeding. We will stick our neck out to say that both groups of mothers know if they are breastfeeding or not. Furthermore, it would not be ethical to assign mothers to breastfeeding or formula feeding. The truth is, however, that mothers are indeed, very often “assigned” to formula feeding because of the shocking lack of support for breastfeeding in many, indeed very many, hospitals in affluent countries.

So how can we think about this rationally?

It is a big jump to conclude that because the studies are not ideal, and thus, because there is no rock-solid evidence for breastfeeding being better, that means breastfeeding is not better. So, mothers should just choose. But we have to look at this from another point of view.

At the risk of repeating ourselves, we would like to emphasize yet again that many mothers who chose to breastfeed did not get what they wanted. due to the appalling breastfeeding support in so many hospitals in the world. And here we speak of everywhere, even in so called resource poor countries. Only the poor in those countries get to choose because they have no choice. But western medicine, in connivance with the formula companies, works on the poor also. In fact, this has been known since the 1970s and it is still true.

But in resource poor areas of the world, it is actually the less educated, less well-off women who breastfeed. And not breastfeeding carries severe and well-documented risks in the condition of poverty and lack of resources. And, though it may be a surprise to the author of the SciMoms article, it must be emphasized that such conditions can be found even in affluent countries. Even in the United States which the SciMoms article seems to believe is the only place in the world and no other places exist.

Moreover, over the past few years many high quality well-designed studies have shown the importance of breastfeeding, the Lancet Breastfeeding Series being just one example. All this scientific evidence cannot be dismissed as attributable to women´s social status.

It needs to be said, over and over, that it is breastfeeding that is the physiological and biological norm and thus it is in fact absurd that breastfeeding is required to prove its worth. And it needs to be said, over and over, that formula feeding is an intervention and as such, it should not be recommended routinely.

Breastmilk and formula

Breastmilk and even the most modern formulas are very different from each other. We would say that breastmilk is a living fluid, full of live cells and hundreds, in fact, thousands of unique components whereas formula is an artificially manufactured combination of animal-derived and plant derived ingredients numbering fewer than 50 items; thus, formula is missing hundreds, if not thousands of ingredients that are normally present in breastmilk. We are not talking about a couple of ingredients. These ingredients, hormones, immune factors, anti-inflammatory factors and many more, all of them missing from formulas, have important functions that improve the baby’s resistance to infection, that develop brain cells and neurons, that give him/her a specific microbiome all of which has life-long health consequences.

The article slides away from discussing the microbiome (the billions of bacteria that live in the gut and influence not only the immune system but also the development of the brain), as if it’s not that important. In fact, it is very important, and we are just beginning to understand how important the microbiome is. Here are just a few studies:

1. Cabrera-Rubio R, Collado MC, Laitinen K, Salminen S, Isolauri E, Mira A. The human milk microbiome changes over lactation and is shaped by maternal weight and mode of delivery. Am J Clin Nutr 2012;96:544-51
“Our results indicate that milk bacteria are not contaminants and suggest that the milk microbiome is influenced by several factors that significantly skew its composition. Because bacteria present in breast milk are among the very first microbes entering the human body, our data emphasize the necessity to understand the biological role that the milk microbiome could potentially play for human health.”
Our comment: What does this mean when so many babies receive formula as a first feeding?

2. Johnson CL, Versalovic J. The Human Microbiome and Its Potential Importance to Pediatrics. Pediatrics 2012;129:950-960

“The human body is home to more than 1 trillion microbes, with the gastrointestinal tract alone harboring a diverse array of commensal microbes that are believed to contribute to host nutrition, developmental regulation of intestinal angiogenesis, protection from pathogens, and development of the immune response. Recent advances in genome sequencing technologies and metagenomic analysis are providing a broader understanding of these resident microbes and highlighting differences between healthy and disease states.”

3. Sim K, Powell E, Shaw AG, McClure Z, Bangham M, Kroll JS. The neonatal gastrointestinal microbiota: the foundation of future health? Arch Dis Child Fetal Neonatal Ed 2013;98:F362-F364

“Lifelong good health may be dependent on the GI microbiota established at a very early age. Neonatologists have been at the forefront in recognizing the importance of establishing enteral feeds, preferably with mother’s own breast milk, and the judicious use (and withholding) of antibiotics in establishing and maintaining the GI microbiota.”

4. Clarke G, O’Mahony SM, Dinan TG, Cryan JF. Priming for health: gut microbiota acquired in early life regulates physiology, brain and behaviour. Acta Paediatr 2014:103;812-819

“We are only beginning to appreciate the potential health benefits that could be accrued from this venture across diagnostic, preventative and treatment realms. We look forward with great anticipation to this transformed appreciation of how our microbial wealth during early life primes for health in adulthood.”

And Immune Factors?

The immune system of breastmilk is made up of many ingredients, not just antibodies, each of which has its role, some of their roles not yet determined with certainty. The elements of the immune system interact with each other in a living fluid that helps protect the baby against infection, inflammation and autoimmunity. This tables below, taken from this article Future Research in the Immune System of Human Milk in the Journal of Pediatrics, written by Armond Goldman, a well-known and well respected immunologist. Some of the agents mentioned have been known for a long time, but others have only recently been described and are probably unknown to most pediatricians. For example (note the word “example”);

What does it all mean?

If we only mentioned all the ingredients present in breastmilk that are not in formulas, this article would be very very long. The point is, that saying that formula, with the addition of ingredients that are good for marketing (DHA, for example) has made formula almost the same as breastmilk, is laughably untrue.

So, here is how science works. We have one natural, normal product of the human body, called breastmilk. We have an artificial product, manufactured by fallible humans, called formula. Breastmilk, and breastfeeding, are the normal ways of feeding babies and toddlers. Formula, and bottle feeding, are interventions. Formula was initially used when the mother died and a wet nurse could not be found. And then through the lack of knowledge of health professionals and marketing, as well as other reasons, formula became big business and began to be used even when it was not necessary, as a “choice”.

It is the rule in medicine, in order that a medical intervention, whether a new surgical procedure, or a new drug, be approved and used, the intervention has to be proved safe and actually does something good, and, we would add, shows distinct advantages other interventions. In the situation where breastfeeding is possible, using formula has never been proved safe and that it actually does good – in fact, cow milk in its normal form can be harmful to the digestive tract of the baby. It is the intervention that must be shown to be safe and provides an advantage. A situation that might explain that those of us that promote breastfeeding are not crazed radicals, we sadly accepted that mothers who were HIV positive should not breastfeed where formula feeding was safe, acceptable culturally, feasible (clean water available) etc. But then it was shown that if the mother was treated for HIV during pregnancy, and the baby was started on treatment as soon as the baby was born, there was little risk the baby would be infected, not greater than feeding the baby formula. As so, formula is no longer an acceptable intervention when the mother is HIV positive.

Some more points

The article goes on to state that “We SciMoms strongly believe that infant feeding comes down to an informed choice that takes into account family lifestyle, mother’s schedule and employment status, employer pumping policy, personal comfort, and more.” Oh, we are back in the USA!  But how can mothers make “informed choices” when the entire health system undermines their ability to succeed at breastfeeding. What is mind blowing is how this “choice” changes – when pregnant women are asked how they want to feed their babies, in some areas, 90% or more, state that they want to breastfeed. Then over 50 % of babies receive formula in the first few days after birth. And often, those few bottles of formula in the first days so undermine the ability of the mother to breastfeed that many end up feeding the baby combined breastmilk and formula or not uncommonly, only formula.

So, the real question is how that it happens that the women’s “choice” changes so dramatically? The answer is the mothers did wish to breastfeed and even started breastfeeding and then experienced difficulties. And this is where the health system failed their “choice” – instead of mothers receiving good help to prevent and overcome difficulties; instead of mothers being shown how get their babies drinking sufficient amounts of breastmilk, even in the first few days after birth like this 24 hour old baby drinking lots of milk; instead of mothers being shown how to prevent sore nipples; instead of hospital staff ignoring their sore nipples with the statement “it is normal for breastfeeding to hurt; instead of mothers being shown how to deal with a crying baby, how to get a baby to take the breast, the health system forced them into a “choice” that was not originally theirs – formula feeding.

The author then goes on to state: “If science is the only factor on which we base infant feeding policy, and if the science showed that breastmilk leads to significantly better health and socioeconomic outcomes, then it makes sense to prescribe exclusive breastfeeding across the board. Even in that hypothetical situation, depending on the circumstances, I personally believe that a mother would still have the right not to breastfeed, because women have a right to bodily autonomy.” But mothers have the right to breastfeed, and that right is taken away from them from even before the baby is born, when they get free samples of formula from their health provider or in the mail, by the mother not able to make an informed consent about interventions during labour and birth and being told these interventions do not affect breastfeeding, by using unscientific protocols to encourage supplementation (10% weight loss, for example). And how can you make an informed choice to breastfeed if everything is working to make breastfeeding fail?

Response to SciMoms, copyright: Jack Newman, MD, FRCPC and Andrea Polokova

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Breastfeeding: Empowering Parents, is a brand new eBook as well as a paperback available from Amazon.com or Amazon.ca or other Amazon websites. The book contains real, practical information for women, their partners and health professionals. In its interactive version, it provides links for further reading and for videos which demonstrate the topics explained in the book. Much of the material includes new approaches and solutions for breastfeeding problems. Many long-held breastfeeding beliefs are exposed as myths. It is worth reading prior to giving birth and also answers numerous questions new mothers encounter. For health professionals, this book will be a treasured reference in their efforts to help breastfeeding women continue breastfeeding when faced with medical issues.

Here is how you can get the book from Amazon around the world:

Canada (amazon.ca):

Interactive eBook

Paperback

United Kingdom (amazon.co.uk):

Interactive eBook

Paperback

United States (amazon.com):

Interactive eBook

Paperback

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