The message is out; breast is best. Canadian medical personnel involved in childbirth, infant health, and children’s medicine in general have learned that breastfeeding and breast milk are the normal, optimal feeding for our babies and support breastfeeding in general. If babies are healthy and women are healthy and all is well, there is agreement that breast is best. However, when babies are sick the Canadian medical system often reverts to bottle feeding and the breastfeeding relationship is lost~resulting in less than optimal feeding for our most fragile infants. Babies’ whose health challenges frequently interfere with breastfeeding include; babies with jaundice, blood sugar regulation problems, premature babies, babies with down syndrome, cleft lip, cleft palate, PKU, failure to thrive, laryngomalacia, and respiratory problems. All babies benefit from optimal feeding (breastfeeding), but in particular, infants who are ill or have a medical condition benefit even more from mother’s milk as they navigate their health challenges and strive to be as well as possible.
For example, premature babies sometimes have to stay in the NICU to give them the optimal chance at health and growth as they transition to life outside the womb. These fragile babies need varying levels of intervention to keep them alive, sometimes needing full ventilator assistance and constant monitoring of their vital signs and growth, and other times requiring simply a stable environment and observation as they grow. In theory everyone agrees that these tiny babies are best fed their mother’s milk, but in practice a high percentage of NICU preemies receive infant formula in part or in full during their stay. Why is this?
Partly, this is because of a failure to understand the basic physiology of breastmilk production. Breastfeeding must be frequent and effective in the first ten days to two weeks in order to establish adequate supply. ’Effective’ simply means that the breast is adequately drained and milk is transferred out of the breast to signal it to make more milk, and to establish a baseline ‘demand’ which will last for the duration of that breastfeeding relationship. If a breast is not drained often and effectively in the first two weeks, supply will not be adequate. Most women whose babies are born premature are taught the basics of establishing a milk supply, and provided with the equipment and space to pump~but some women are not. Giving birth in a hospital designated Baby Friendly ensures that women will be taught how to pump effectively in order to establish a milk supply for her premature baby, and that this milk will be valued and fed to her baby.
Beyond draining the breast effectively and often, the physiology of milk letdown is an important part of breastmilk production. The release of milk by the body is an automatic process which involves the nerves leading from the areola to the brain, hormones released in the brain, and muscle contraction in the breast in response to these hormones.
To optimize this part of breastmilk production, women’s bodies need optimal environments for producing oxytocin. Oxytocin is the love hormone, and the hormone involved in milk letdown. Factors which help optimize the production of oxytocin include frequent skin to skin contact with a woman’s baby, minimal disturbances during pumping and feeding, and a sense of emotional security. Pumping for a premature baby is incredibly physically demanding, and coping with an infant in the NICU is incredibly emotionally demanding~thus, if medical staff can create the most positive and supportive environment for parents, it will make all the difference in a woman’s ability to maintain a round the clock pumping regimen for her premature baby. Frequently, NICU moms will initially start off producing well, and then experience a dip in supply after a few weeks. No one really knows why this is, but it is very common. It is possible that our system’s lack of support for skin to skin contact between delicate premature babies and their mothers is a factor. Preemies tend to destablize during transfer between environments, so movement is discouraged. Many NICUs don’t have space for parents to recline for hours on end with a baby tucked on his or her chest, so frequent extended skin to skin contact is impractical. In fact, mother/baby separation should be avoided at all costs, since the mother’s body is the baby’s only known environment and interactions between the mother’s body and the baby’s physiology are complex and only beginning to be studied and understood. The mother’s body after the birth of any baby is fully focused on helping the baby’s body adjust to the outside world, and is the best possible environment for a baby to spend most of its time, whether it is premature or full term.
As a society, Canada needs to focus on changing the amount of mother/baby separation for premature infants. Dr. Nils Bergman has done research on premature babies in underdeveloped areas of the world which has remarkable implications for all premature babies. Preemies grow better, eat better, sleep better, maintain their temperature better, maintain blood sugar levels better, breathe more regularly, and have more regular heart rates when they are held skin to skin with their parents for extended periods of time, than when they are in incubators. Parents who advocate for kangaroo baby care to be implemented can go a long way towards improving premature babies’ health, and also prevent or minimize the dip in supply experienced so often by women who are exclusively pumping for premature babies. If enough parents request it, eventually the system will change.
Breastmilk banks are enormously important as well, for filling in the gaps in supply that women experience when pumping for a premature or otherwise medically fragile baby. Sometimes of course the mothers of preemies are sick as well, and are unable to provide their babies with their own milk. Breastmilk is a commodity which there is enough of in the world, but which is unevenly distributed for various reasons. Breastmilk banks are an incredible way to redistribute this liquid gold where it is most needed.
breastmilk bank donor milk ‘pooling’
Again, changing the fact that Canada is currently home to only two breastmilk banks is something consumers of health care can advocate for. Change in health care is largely driven by consumers.
Preemies are often fed via gavage, a tube that goes directly into the baby’s stomach. As they grow and mature to the point of being able to suck (and in particular manage the suck, swallow, breathe pattern required to adequately feed by mouth) without overtiring, they are gradually introduced to oral feeds. Some of these feeds will be at the breast, but a high percentage of them are done by bottle. Preemies cannot be discharged to go home while gavage feeding. They must be able to tolerate oral feeds and be gaining weight at a particular rate before being sent home. The prevailing belief is that babies learn to bottle feed quicker and are thus discharged faster than if exclusively breastfeeding, and thus parents and health professionals alike favor bottle feeding. In reality the difference in discharge time is generally only a day or two when premature babies are breastfed as opposed to bottle fed. In The Netherlands NICU babies must be a certain weight and be breastfeeding well before they are considered well enough to discharge. It would be of enormous benefit to premature babies’ long term outcomes if we implemented this standard in Canada as well.
Other medically fragile babies are frequently recommended by pediatricians and specialists to stop breastfeeding and be given infant formula instead. These babies can have a range of medical issues and nearly all of them would highly benefit from being exclusively breastfed, but pediatricians and specialists have little to no training on the physiology of breastfeeding, the in depth details of the benefits of breastmilk to infant health, nor the necessary lactation support information to implement breastmilk feeds into a sick baby’s medical care. Even babies with PKU, a condition which can cause severe brain damage if they are allowed to continue a breastmilk-only diet, can partially breastfeed. PKU specialized infant formula contains small amounts of phenylaline, which is the amino acid that causes brain damage for these babies, because without any phenylaline, these babies cannot survive. Rather than receive 100% specialized formula, these infants can benefit from mixed feeding, and careful monitoring of phenylaline levels to ensure an adequate but low amount. In this way these babies can benefit from some breastmilk but still be protected from high levels of phenylaline. Most pediatricians do not know this, and recommend immediate cessation of breastfeeding for PKU babies.
Babies who fall into the failure to thrive category often get formula in order to gain weight. Depending on the cause of the failure to thrive, formula feeding can be unnecessary. Again, breastmilk banks would go a long way in providing safe, pasteurized human milk for babies with failure to thrive whose mothers are not producing enough milk. But for babies with medical conditions which cause failure to thrive, such as the respiratory condition laryngomalacia, the medical recommendation is to stop breastfeeding. Laryngomalacia babies can receive breastmilk, but in a bottle rather than at the breast, and they often receive milk fortifiers made from cow’s milk as a supplement to the breastmilk to help them gain weight. With Laryngomalacia, breathing takes so much energy that it is difficult to get adequate calories into the baby to get him or her to gain weight adequately and be healthy. It is thought that breastfeeding burns more calories than bottle feeding (an assertion that is contested among lactation experts), hence the recommendation to bottle feed.
Firstly, breastfeeding at the breast is valuable. A woman’s body has a feedback system via the breast which signals her body to make antibodies specific to what her baby has been exposed to. Pathogens which the baby has picked up but the mother has not been exposed to will be detected via the breast, and antibodies specific to that pathogen are detectable in her milk within hours. Also, no studies have been done which show that breastmilk feeding by bottle has the exact same benefits as breastfeeding at the breast. It is possible that some of the health benefits of breastfeeding are from proximity to the mother, or skin to skin contact, as opposed to simply transmitted by the milk itself, and these benefits are lost when exclusively pumping. Breastfeeding is so much more than the transfer of milk from mother to child; it is a relationship that is mutually beneficial and positive. Pumping is hard work, takes twice as much time (because one must first pump and then feed), and is less mutually beneficial and relational. Women who exclusively pump more often fail to achieve their goals as far as breastmilk feeding duration than women who breastfeed at the breast. So, a pediatrician who recommends a woman exclusively pump is effectively reducing the duration that child will likely receive optimal feeding, and is subtracting the relational and mutual aspects of the feeding relationship.
Also, human milk fortifiers made from the mother’s own milk can help to boost infant weight without the need for cow’s milk fortifiers. To ‘make’ human milk fortifier, a mother pumps some milk and allows it to stand and the cream to rise to the top. This cream is then siphoned off and fed to the baby as a high fat, calorie rich boost in addition to breastfeeding. It can be fed to the baby via gavage, syringe, cup, or bottle, and if the baby is breastfeeding it can be fed to the baby via a small tube tucked into the corner of the baby’s mouth, similar to the supplemental nursing system.
Babies with cleft lip can often breastfeed at the breast with some expert help (find a lactation consultant either in hospital or through public health). Babies whose cleft extends to the palate cannot breastfeed at the breast because a proper, closed seal cannot be achieved. However, these babies can be taught to suckle on a recently pumped breast so as to associate ‘soother style’ sucking and comfort with its mother’s breast. They can then be fed pumped milk via special bottle until after their cleft is repaired via surgery (usually at around 9 months of age). It is then sometimes possible to switch partially or fully to breastfeeding at the breast, provided the baby knows how to suckle and receive comfort via the breast–which means that comfort only sucking has been established early and maintained on a daily basis until that point. With patience and perseverance, older babies can sometimes learn to breastfeed.
The most persistent problem with breastfeeding a baby with health challenges is lack of medical knowledge of and support for breastfeeding. With little to no training on human lactation, pediatricians and specialists are quick to introduce a bottle and formula as a solution when it is not entirely necessary. It would be of enormous benefit to extend Baby Friendly accreditation to children’s hospitals, NICUs, pediatrician’s offices, and beyond, and to include in depth breastfeeding physiology, anatomy, training, and education in medical training for any health professional who will be dealing with infants and small children. In the meantime, parents with medically fragile babies must advocate to include breastmilk feeding and breastfeeding in their baby’s health care treatment plan. The more we advocate, the faster change will come, to the benefit of all our babies.