Infant feeding and safety

The safety of children is on top of the priority lists of parents, health care providers and governments. Parents are educated and governments try to legislate safety. WHO and UNICEF dedicate a prominent amount of their activities to this cause. In many resolutions and publications over and over again is emphasized that there is one single cheap and easy way to provide all children with a basic safety. A way that provides safe food, protection against infection and other diseases and applicable in all living conditions: to breastfeed children from birth on, much and often. A disadvantage to this apparent panacea is that not alone it does not cost any money, but no-one will financially profit from it. And thus, an intensive lobby from those who will gain from breastfeeding substitutes can cause governments to pay lip service, and even put into writing, to WHO’s visions, but still announce infant feeding a parent’s choice. Other safety interventions are being promoted with a lot more force and persuasiveness, where playing on feelings of guilt in parents is not dreaded. But parents who choose, or are made belief they can’t do anything else, to not breastfeed, choose to feed and care for their children in less safe way. By replacing breastfeeding, they refuse their child the protection human milk and suckling the breast offers, but on top of that expose them to a potential bacteriologic dangerous substance. Powdered infant formula (PIF) is not germ-free and children have died because of bacteriological contamination. Research shows that many parents do not read the labels on the PIF cans well or don’t fully comprehend what they read and many do not follow other hygiene precautions. Parents who care for the safety of their children will choose to breastfeed and they are entitled to all help needed to proceed doing so.
 Labiner-Wolfe J, Fein SB, Shealy KR: Infant Formula-Handling Education and Safety. Pediatrics 2008 122: S85-S90
Carletti C, Cattaneo A: Home preparation of powdered infant formula: is it safe? Acta Pædiatrica, 2008, 97(8):1131-1132

Galactogogues

The Academy of Breastfeeding Medicine (ABM), an organization by and for physicians about breastfeeding, develops and publishes protocols about handling many aspects of breastfeeding, in order to achieve a consequent and evidence based approach to breastfeeding care. These protocols are regularly updated. The latest newly edited protocol is about galactogoges, substances that enhance milk production. This new edition is remarkable and ABM blogger Marinelli explains is so different in comparison to the former version. As the revision group studied the research available it appeared that evidence for galactogoges was getting thinner and that health care workers who advise or prescribe them should be more careful and reconsider. Most striking is that the recommendations for daily practice start with the advice to first optimalise breastfeeding techniques and management (with a thorough list of how-to’s) and to examine for other, possibly medical reasons for failing milk production or inadequate growth. If medicinal support is necessary there fails to be one specific medicine to advise, nor any specific herbal remedy. Medications used for enhancing milk production appear to be a greater risk for negative by-effects than previously thought and as far as herbal remedies are concerned, those appear to be proven safe by centuries of use, but not proven to be effective.
Kathleen Marinelli MD, IBCLC, FABM: New Galactogogue Protocol–New Attitude?? http://bfmed.wordpress.com/2011/02/22/new-galactogogue-protocol-new-attitude/
The Academy of Breastfeeding Medicine Protocol Committee: ABM Clinical Protocol #9: Use of Galactogogues in Initiating
or Augmenting the Rate of Maternal Milk Secretion. BREASTFEEDING MEDICINE. 2011, 6(1) http://www.bfmed.org/Media/Files/Protocols/Protocol%209%20-%20English%201st%20Rev.%20Jan%202011.pdf

Professional and peer support

The promotion, protection and support for breastfeeding can be put into practice in many different ways. Breastfeeding support can be done both pre and post natally and be performed by professionals and peers. Researchers studied all varieties of breastfeeding support and even the studies were studied (reviews). The results differ widely. Ingham c.s. studied lay prenatal breastfeeding support. They found little effect from universal support programs (aimed at ‘’all’’ pregnant women of a certain socio-economic status), but measurable effects for target programs (aimed at pregnant women already decided to or considering to breastfeed).Chapman et al did not only consider breastfeeding initiation as an effect of peer counselling, but were interested to see any effects on infant health as well. In their review of the literature they found not only that peer counselling increased the incidence, exclusivity and duration of breastfeeding according to the vast majority of studies, but also a decrease in incidence of infant diarrhea and significantly increase the duration of lactational amenorrhea. A quite interesting study by Dennis, concluded that professional breastfeeding support may very well work out negatively when the professional’s advice is coloured by lack of breastfeeding knowledge and that even support by a knowledgeable professional only has a limited duration effect. Especially for those women who belong to the most vulnerable groups in regard to breastfeeding success (young, have a low income, belong to an ethnic minority, are unsupported, are employed full-time, decided to breastfeed during or late in pregnancy, have negative attitudes toward breastfeeding, and have low confidence in their ability to breastfeed) best chances to develop positive breastfeeding behaviour come from non-professional support.
Ingram L, MacArthur C, Khan K, Deeks JJ, Jolly K: Effect of antenatal peer support on breastfeeding initiation: a systematic review. CMAJ. 2010 Nov 9;182(16):1739-46.
Chapman DJ, Morel K, Anderson AK, Damio G, Pérez-Escamilla R: Breastfeeding peer counseling: from efficacy through scale-up. J Hum Lact. 2010 Aug;26(3):314-26.
Dennis CL: Breastfeeding initiation and duration: a 1990-2000 literature review. J Obstet Gynecol Neonatal Nurs. 2002 Jan-Feb;31(1):12-32.

Breastfeeding and development

In the large multi-year PROBIT study, Kramer et al researched they effects of increased breastfeeding upon intellectual development and academic results in 6,5 year olds. A total of 17.000 children born in 31 randomly chosen BFHI certified hospitals, that worked towards increasing incidence, exclusivity, and duration of breastfeeding, and traditional hospitals were enrolled. Children born in hospitals working according to BFHI standards had an increased chance to be exclusively breastfed at 3 months. IQ testing at 6,5 years showed an increased IQ score of 8 points for boys and 7 for girls compared to their counterparts born in non-BFHI hospitals. A very recent, smaller, but well-designed and prospective study by Oddy et al looked at the influence of exclusive breastfeeding for at least 4 months upon developmental milestones in the domains of gross and fine motor skills, adaptability, sociability and communication. Factors adjusted for in multivariable analyses included maternal sociodemographic characteristics, and stressful life events. Good results in these domains will enhance the chances of more complete development of intellectual potential. Oddy and collegues found small, but very significant differences in all studied domains after correction for confounding factors.
Kramer MS, Aboud F, Mironova E, Vanilovich I, Platt RW, Matush L, Igumnov S, Fombonne E, Bogdanovich N, Ducruet T, Collet JP, Chalmers B, Hodnett E, Davidovsky S, Skugarevsky O, Trofimovich O, Kozlova L, Shapiro S; Promotion of Breastfeeding Intervention Trial (PROBIT) Study Group: Breastfeeding and child cognitive development: new evidence from a large randomized trial. Arch Gen Psychiatry. 2008 May;65(5):578-84.
Oddy WH, Robinson M, Kendall GE, Li J, Zubrick SR, Stanley FJ: Breastfeeding and early child development: A prospective cohort study. Acta Paediatr. 2011 Feb 7. doi: 10.1111/j.1651-2227.2011.02199.x. [Epub ahead of print]

Introduction of solids

Fewtrell et al caused quite a bit of fuss with their review of dated literature on the introduction of solids and their claim that exclusive breastfeeding for 6 months is outdated. Despite the expert comments in the professional journals and on the WWW, media keep on publishing articles for the lay public. The persuasiveness of the Fewtrell-crew, of which ¾ are or once were paid by the baby-food industry, is so huge that some governmental agencies and health institutions already change their advice back from 6 to 4 months to start solids. And all that because some allergic reactions seem to be less after earlier introduction of other foods than mothers milk. This completely fails to take into account the much more substantial risk of much more serious illnesses and conditions that can be caused by too early introduction of solids. Especially in the light of the, in the Western World, pandemic proportions of overweight (along with the accompanying conditions as diabetes and cardiovascular diseases) it is important that as many children as possible are exclusively breastfeed for 6 months and then being sensitively introduced to family foods while breastfeeding continues to be the primary food source up till the first birthday. Campaigns against overweight aimed at schoolchildren and adolescents come too late, even preschool age is late. Anzman et al found that interventions to prevent overweight in school children and adolescents for most of them come too late and that we’d better start focusing on pregnant women and parents of infants. Seach et al found that early introduction led to an increase in overweight in 10 year olds, as did parental smoking around the time of birth. Besides nutrition sleep is an important factor for healthy growth and development of infants and toddlers as well. At Harvard Nevarez et al studied factors that influence sleep duration in children up to 2 years. They concluded that factors that led to decreased infant sleep (up to 1 hour a day) at 12 and 24 months included maternal depression, early introduction of solids (<4m), the child watching TV, and child day care use.
Fewtrell M, Wilson DC, Booth I, Lucas A: Six months of exclusive breast feeding: how good is the evidence? BMJ 342:doi:10.1136/bmj.c5955 (Published 13 January 2011)
WHO Multicentre Growth Reference Study Group. WHO child growth standards based on length/height, weight and age. Acta Paediatrica 2006;Suppl 450:76-85.
Ruth A. Lawrence. Childhood Obesity (Formerly Obesity and Weight Management). August 2010, 6(4): 193-197.
Nevarez MD, Rifas-Shiman SL, Kleinman KP, Gillman MW, Taveras EM: Associations of Early Life Risk Factors With Infant Sleep Duration, Academic Pediatrics, 10:3, May-June 2010, Pages 187-193
Seach KA, Dharmage SC, Lowe AJ,  Dixon JB: Delayed introduction of solid feeding reduces child overweight and obesity at 10 years. International Journal of Obesity , (25 May 2010)
Anzman SL, Rollins BY, Birch LL: Parental influence on children's early eating environments and obesity risk: implications for prevention. International Journal of Obesity 34, 1116-1124 (July 2010)

SIDS and sleep environment

Blair in his editorial defines SIDS as an exclusion diagnosis: a child died and after studying all factors involved we cannot demonstrate an adequate cause of death. In 1969 Beckwith put down this definition and after the following 40 years of intense research there is no prospective of finding a single plausible cause for cot death. There are, though, factors that increase the SIDS risk, including, but not limited to, breastfeeding or not and sleep arrangements. In different research groups Blair et al studied the correlations between sleep arrangements and SIDS and between bed sharing and breastfeeding. Thy found that sleeping place sharing children who died of SIDS always also had other risk factors involved, like prematurity, being ill of not well, parents who smoked or were under the influence of alcohol or drugs, the use of head-covering, pillows or sofa’s. Bed sharing in the first 15 months (or longer) proved positive in better breastfeeding outcomes. Health behaviour education for parents about sleep arrangements should always take into account these positive outcomes for breastfeeding. Good information about safe bed-sharing seem to have the best potential to secure breastfeeding and prevent SIDS as much as possible.
Blair PS, Fleming PJ: Recurrence risk of sudden infant death syndrome. Arch Dis Child 2008;93:269-270
Blair PS,  Sidebotham P, Evason-Coombe C, Edmonds M, Heckstall-Smith EMA, Fleming P: Hazardous cosleeping environments and risk factors amenable to change: case-control study of SIDS in south west England. BMJ 2009; 339:b3666
Blair PS, Heron J, Fleming PJ: Relationship Between Bed Sharing and Breastfeeding: Longitudinal, Population-Based Analysis. Pediatrics 2010 126: e1119-e1126

Breastfeeding and employment

Working per se is not necessarily a breastfeeding barrier, but the separation of mother and child certainly is, as is the attitude towards breastfeeding in mom’s close and wider society. Cooklin, Donath and Amir analyzed the data from 3697 Australian children and their mothers and found a positive link between more work and less breastfeeding at 6 months. Other studies in other countries did and continue to point to similar results. Other researchers don’t stick with counting, but try and find factors that may lead to these mechanisms and how to avoid the decrease in breastfeeding duration. Fein et al found that mothers who were able to directly breastfeed their children during the working day had the best chances to succeed, directly followed by those who could express breastmilk during the day. Not feeding nor pumping understandably led to the less chances of breastfeeding success. They advise that mother-child separation is as short as possible and that there should be in-company child care facilities where mothers can go to breastfeed and/or means for working mothers to feed the child at their own workplace if the child is brought to them. Johnston and Esposito found in their literature review that the personal characteristics of the mother and her paln of action are key factors for breastfeeding success, aided strongly by a supportive social environment and support groups. Other positive factors included part-time work, lack of long periods of mother-child separation, supportive work conditions and breastfeeding supportive child care facilities. The New Zealand Payne and James study pointed to three key factors for continuation of breastfeeding: the presence or absence of the factors of space, time and support. Their advice towards employers is to create breastfeeding supporting work conditions, but they do recognize the need for ‘’the society’’ as a whole to change its attitude towards working women who breastfeed.
Cooklin AR, Donath SM, Amir LH: Maternal employment and breastfeeding: results from the longitudinal study of Australian children. Acta Paediatrica (2008), 97:620–623.
Fein SB, Mandal B, Roe BE: Success of Strategies for Combining Employment and Breastfeeding. Pediatrics 2008 122: S56-S62
Payne D, James L: Make or break. Mothers' experiences of returning to paid employment and breastfeeding: a New Zealand study. Breastfeed Rev. 2008 Jul;16(2):21-7.