The Virgin Gut?

As many of you who have read my blog in the past know, I am a big proponent of breastfeeding.  It is the one topic that I have written about the most on my blog.  New parents are constantly being given the message these days that "breast is best."  We hear about the usual benefits which include among other things:  "a protective effect against respiratory illnesses, ear infections, gastrointestinal diseases, and allergies including asthma, eczema and atopic dermatitis. The rate of sudden infant death syndrome (SIDS) is reduced by over a third in breastfed babies, and there is a 15 percent to 30 percent reduction in adolescent and adult obesity in breastfed vs. non-breastfed infants."  Organizations such as the World Health Organization and the American Academy of Pediatrics recommend exclusive breastfeeding for the first six months of life.  Despite these recommendations, many mothers still choose not to breastfeed and give formula to their baby instead.  Mothers may have legitimate reasons such as not having adequate breast tissue or not producing enough milk.  However, I think with our society's portrayal of breastfeeding, many mothers simply choose not to attempt it.  It is tiring and a lot of work.  

In the event of a mother not entirely convinced that "breast is best," there is yet another reason to attempt breastfeeding and that is the case for the "virgin gut."  This is something that I had not heard about with my first baby but am hearing more about with my second baby.  I first heard about it on some of the message boards that I frequent so I began doing some research.  I came across the following blog and an excellent paper written with lots of scientific citations.  Both of these are worth reading and go into great detail (better than I could do with my limited time for blogging) about the "case for the virgin gut."

I will do my best to "summarize" the theory.  A baby is born with a  "sterile" gastrointestinal tract.  "The gastrointestinal tract of a normal fetus is sterile. During the birth process and rapidly thereafter, microbes from the mother and surrounding environment colonize the gastrointestinal tract of the infant until a dense, complex microbiota develops."  The type of colonization is influenced by delivery (vaginal vs. cesarean) and perhaps most importantly by the method of feeding the baby (formula vs. breastfeeding). The gut flora of a formula vs. a breastfed infant is different.  It is believed that the flora that is established with breastfeeding can have protective effects for the baby throughout their lifetime.  Some believe that even one bottle of formula can upset this balance and may take weeks of exclusive breastfeeding to undo.

A part of this theory also addresses the "open gut."  Essentially, when a baby is born, their gastrointestinal system is "immature."  As a result, there are openings in the gut which allow large, potentially allergy causing proteins and disease causing pathogens to pass directly into a baby's blood stream.  It is theorized that mother nature "intended" for these openings for large maternal antibodies to pass into the baby's blood stream to protect the baby from disease.  The antibodies will also coat the lining of the gastrointestinal tract to confer passive immunity to a baby.  Feeding formula (which many contain cow's milk protein) or introducing solids before the age of six months is believed to increase the likelihood of the development of food allergies or illness.  It is believed that the "closing" of the gut occurs around six months which is why food should not be introduced until after a baby has reached six months of age.  This is especially important in babies with a family history of food allergies.  It is also believed that a baby is less likely to get sick after six months when a baby begins to produce their own antibodies and do not have to rely as much on passive immunity from the mother.

I had always been a believer in exclusive breastfeeding for the first six months of life.  My older son received one tiny bottle of formula when he was four days old since my milk was slow to come in because of a bad latch.  My second baby who just turned six months old yesterday has not had a single drop of formula.  He has only had breastmilk and nothing else (not even water) to drink.  Breastfeeding with either baby has not been easy but after reading about the "virgin gut," I am more than happy that I did.  I had a lot of pressure from well meaning family and friends to give my babies formula or start them on solids before six months of age.

I had a lot of allergies as a kid.  There are pictures of me getting solid foods at two months old (which was apparently common in the 1970's).  So far, with my older child, he does not appear to have any allergies.  This includes foods that I was allergic to.  I am hoping the same will be the case for my younger son.  Since he is past the six month mark, we will start introducing solid foods to him in a few days.  It will be the beginning of an exciting new chapter for us.  We are keeping our fingers crossed that this may help us get some much needed rest.

So what if you cannot breastfeed?  This something that I know really torment a lot of women.  If you cannot breastfeed, there are different ways to go about getting breastmilk for your child.  Unfortunately, in today's society, many people would opt for formula before exploring some of these alternatives.  However, if you're really determined, I think the following are good choices.  There is wet nursing.  This was something done long ago before the advent of formula and it seems to be enjoying a resurgence in recent years.  There are even websites which show you how to become a wet nurse if you so desire.  Another option is through peer to peer sharing through organizations like human milk 4 human babies.  You can literally look this organization up on facebook in your area to post an ad or look for ads posted by mothers in your area who are looking or willing to donate their breastmilk.  If you want breastmilk that has been tested for diseases (much like blood donations are), then a milk bank is another option.  You can look up a milk bank in your area.  Since this milk is tested and pasteurized, there is usually a fee associated with getting the milk.  In my area, a prescription from a physician is required and it costs $3/ounce (shipping not included).  Since a prescription is required, some insurance companies will pay for the use of banked milk.

It is nice to know that there are alternatives to formula should you choose to preserve the "virgin gut."

Reverse Cycling?

Has anyone heard of "reverse cycling" or have a baby doing this?  Apparently, this is what my little guy is doing.  He will literally eat only 2-3 ounces all day when I am at work and then nurse almost continually once I return home from work.  Kellymom has a great article about this.  Basically, "if mom is away from baby during the day, baby may take just enough milk (by bottle or cup) to 'take the edge off' his hunger, then wait for mom to return to get the bulk of his calories. Baby will typically nurse more often and/or longer than usual once mom returns. Some mothers encourage reverse cycling so they won’t need to pump as much milk. Reverse cycling is common for breastfed babies who are away from mom part of the day, especially those just starting out with the bottle."

They say that I should "Be patient. Try not to stress about it. Consider it a compliment – baby prefers you!" This is OK if one does not have to go to work and be functional the next day.  It is also OK if one has the luxury to nap when baby naps during the day.  Unfortunately, the reality is I have a job that I must be alert for and a toddler who does not necessarily nap when baby naps.  If anyone has experienced this, I would LOVE to hear your stories and how you were able to break this cycle.  Being up all night to nurse a baby is wearing me down.  Co-sleeping is something I had never thought I would do but it is seriously the only way I can get any sleep these days.  I literally spend all night just rolling him from one boob to the other.

If there is an upside to all of this, I pump much more milk than my baby will ever eat.  As a result, I have been exploring my options with breastmilk donation.  In my area (Northern California), there are two options that I am exploring, the San Jose Milk Bank and Human Milk for Human Babies.  Does anyone have experience with either of these donation methods?  One is more formal than the other.  I would love your input on this as well.

Breastfeeding Doll?

I just came across an article about a breastfeeding doll.  As many of you who have taken the time to read my blog, I am very pro-breastfeeding.  I have breastfed my older son until he was 22 months old and am currently breastfeeding my 3-month old.  I have no problem breastfeeding in front of my older child because I believe that breastfeeding is a completely natural thing.  If he has any questions about it, I am happy to tell him that I am feeding the baby and that is how the baby eats.

However, I have to admit that I have mixed feelings about a doll that breastfeeds.  I don't have a daughter so this is probably not going to be something that I will be asked to buy.  If I did have a daughter, I would have no problem letting her "play" with her doll by pretending to breastfeed it by holding it up to her chest.  I find it a little uncomfortable that in this particular instance, a little girl can strap on a halter top with sensors that allows the baby to "breastfeed" complete with suckling sounds.  "The dolls, eight in all with a variety of skin tones and facial features, look like many others, until children don the little top with petal appliques at the nipples. That's where the sensors are located, setting off the suckling noise when the doll's mouth makes contact. It also burps and cries, but those sounds don't require contact at the breast."

I don't know, I think a big part of me finds this a little creepy.  I think this is taking pretending to breastfeed a little too far.  I don't think she needs to have fake "breasts" to pretend to breastfeed.  What do you think?  Would you let your daughter play with a toy that will allow her to "breastfeed?"

2 Month Update - Breastfeeding Woes

These last few weeks have been quite the circus around our home.  Adjusting to life with a toddler and a newborn along with my husband's hectic work schedule has been quite the challenge.  As the baby is getting bigger and my toddler is getting adjusted to life as a big brother, we are hoping to finally turn a corner and have more time to indulge in the little things like write a new blog entry.  Up until this point, my husband and I have had to juggle constantly holding the newborn.  Being able to type with two hands on a computer and not on my phone has been a luxury.

I would have to say that this baby has been an interesting experience when compared to my older child.  They say every baby is different and this is certainly the case for us.  With my older child, I had difficulty breastfeeding in the beginning due to a bad latch.  As a result, my milk took a while to "come in."  Since he was losing too much weight, we had to supplement him with some formula for a few days.  This baby, however, has been completely different.  Since I only stopped nursing my older child back in March (he was 22 months old and I was 20 weeks pregnant), I don't think I ever stopped producing milk.  As a result, my milk was pretty much ready for this baby from the very beginning.  At first it seemed great since I didn't suffer from the issues that typically surround the early days of nursing like sore nipples, engorgement, etc.  I had a brand new tube of Lansinoh and gel cooling pads ready to go and I didn't have to use any of it.  Since I already breastfed my older child, I didn't have any of the latch issues either.  I thought everything was going great until...

Reflux reared its ugly head.  My poor baby seemed to be getting too much milk!  After each nursing session, he would choke and appear to be drowning from my milk!  It was awful!  We couldn't lay him flat on his back as recommended because as soon as we did that, he would start to get horrible reflux.  It didn't matter if we kept him upright for an hour after nursing, he still would begin to spit up and appear to choke on his spit up.  The only way any one in our house was to get any sleep was to literally hold him upright for what appeared to be 24 hours a day.  To say that we are tired is a gross understatement.

Part of my problem after researching some of my favorite websites for information about breastfeeding was that I had a fast letdown (my milk would come out too fast) and I was over producing creating a foremilk/hindmilk imbalance.  With the fast let down, the milk literally came out of my body like a geyser.  Its the craziest thing which never happened with my older child.  I was so impressed by it, I actually took a video of it!  Since it came out so fast and hard, my baby would have to release his latch or risk choking on the milk!  I tried nursing at an incline so gravity would try to slow the flow and the baby would have to "work" at getting the milk out.  That, unfortunately, didn't work since even being flat on my back would cause the milk to shoot straight up.  Also, since I had too much milk, the baby would get full before emptying the breast.  As a result, he would get too much of the watery foremilk and not enough of the fatty hindmilk.  The poor guy had to deal with green, runny poop as a result of not getting enough of the fatty milk.  I had read that pumping before nursing would help but that left me with a catch-22 since pumping stimulates milk production which is what I didn't want to do.

I thought the best solution for everyone was to pump and then feed the baby a bottle at least once a day before bedtime so he could at least rest at night without having reflux issues.  It was a great idea until we realized the baby would not take a bottle!  It seems like if it wasn't one thing it was another.  On top of all of that, if he was going through a growth spurt, he would start cluster feeding which further stimulated my production.

Now that the baby is nine weeks old, it appears that things are beginning to get a whole lot better.  We can now put him flat on his back for at least a few hours at a time (we don't have to constantly hold him) and he is taking a bottle again at least once a night before bed.  I think the bedtime bottle has been key to helping him sleep for at least four hours at a time.   I also think that his reflux is getting better simply because he's a little older and his gastrointestinal tract is more mature and able to better handle eating.

Things are better for the most part but we are, unfortunately, still experiencing little "hiccups" along the way.  Tonight was a little strange since the baby refused the bottle from my husband.  Instead, I gave him the bottle which seemed to break the "mold" when it comes to bottle feeding a breastfed baby.  I have to admit that it was weird feeding him a bottle.  I think with my oldest, I only did that a handful of times like when we were in a car so feeding my babies from a bottle is in general a weird thing for me.

I am hoping this continues so everyone gets more sleep and I may even consider donating my breastmilk.  I had always wanted to do that but never seemed to produce enough.  Now that I seem to be producing too much, it is something that I'd like to explore.  Do you know of any good organizations that I could donate milk to?

I'd also like to share links to my favorite breastfeeding websites that provided me with invaluable information these last few weeks.  I hope that you may find these websites useful if you are experiencing difficulty with breastfeeding.  I would also like any feedback of other websites that are useful to the breastfeeding mother.

http://kellymom.com/
My favorite website.  I always look things up here first before exploring other websites.

http://www.workandpump.com/
Great resource for pumping questions.

http://www.breastfeedingonline.com/newman.shtml
A Canadian doctor's website.  He's very pro-breastfeeding and I appreciate his insight.

https://www.breastfeeding.asn.au/
An Australian website with great information.

Bottle & Pacifier "Strike?"

These last few weeks have been challenging with a newborn and toddler.  As a result, this blog and many other things in my life has been neglected.  My day to day life now consists of nursing every 2-3 hours, changing diapers, cleaning spit up (and occasional pooplosions) cooking, grocery shopping and entertaining a very active toddler.  My time spent on the Internet has been limited to whatever I can do on my cellphone while I nurse.  Typing one handed is frustrating and time consuming.  Despite all of this, I am finding a way to peck this post out of desperation.  I am presently functioning on no more than 3 consecutive hours of sleep since the baby was born 42 days ago.  To say that I am delirious is a gross understatement.  Please excuse any typos or grammatical errors since many things do not presently make sense.

My lovely baby has decided to go on a pacifier and bottle "strike."  He had taken a pacifier and bottle before.  Unfortunately, over the last week, he is refusing to take either one and only wants me to nurse him.  He is absolutely refusing to even latch onto a pacifier or bottle.  We have been trying nightly without any success.  A lot of milk has been wasted in our futile attempts.  To make matters worse, my husband has been working two weeks straight without a day off so I have been his primary caregiver.  I have turned to my favorite breastfeeding website, kellymom.com, for answers and despite trying many of their suggestions, the baby is still refusing to take a bottle.  We have a wedding to attend on Sunday but I am finding it less likely that I'd be able to go if this baby will not take a bottle.  I would also like to start getting more than 3 hours of sleep.  I can't do this if my husband cannot do a feeding with a bottle.  My supply is well established (which brought its own set of problems that I can write another post about) so supply being compromised is not a concern. I have plenty of expressed breastmilk ready to give to him and we do not have to use formula.  We have tried the following thus far:

1. Feeding the baby when their cues indicate hunger, rather than on a schedule.
2. Held in an upright position; it is especially important to avoid letting the baby drink from a bottle when lying down. Such a position is associated with bottle caries and an increased frequency of ear infections. Note also that babies should be held often at times when they are not being fed, to avoid the baby being trained to eat in order to be held.
3. Gently, allowing the infant to draw nipple into mouth rather than pushing the nipple into the infant’s mouth, so that baby controls when the feed begins. Stroke baby’s lips from top to bottom with the nipple to illicit a rooting response of a wide open mouth, and then allow the baby to “accept” the nipple rather than poking it in
4. Use a silicone rather than a rubber nipple to avoid an unpleasant odor or taste.
5. Warm the nipple under running water before offering the bottle to the baby.
6. Make sure the milk is not too warm and not too cold. If when holding the bottle in your palm, it feels warm to the touch, it is most likely too warm. If it feels cool to the touch, it is most likely not warm enough. If you can feel no difference in the temperature of the bottle and your palm, the milk is probably at the right temperature.
7. Most babies will accept expressed breastmilk more readily than formula.
8. Offer the bottle while holding the baby with his back to your chest so that he is facing outward, rather than trying to cradle him.
9. Move with the baby - rock, sway, bounce, walk, walk in circles, etc. as you offer the bottle.
10. Place the baby in a swing, bouncy seat, infant/car seat, etc. and offer the bottle. Try to distract the baby with something else as you offer the bottle.
11. Place an article of mother's clothing up near the baby while offering the bottle, or wrap the bottle with an article of mother's clothing.
12. Lightly tickle the baby's lower lip with the nipple and allow him to pull it in his mouth rather than trying to force the nipple in.
13. Offer the bottle when the baby is already sleepy or just waking up (but not fully awake) or once the baby is already asleep. Many babies will instinctively suckle at these times.
14. Try to use a bottle with a newborn or slow flow nipple no matter how old your baby is so that he always has to work hard with the bottle just as he does with the breast.
15. Having my husband feed the baby without me in the vicinity of the bottle.

We have tried Tommee Tippee bottles and Medela bottles.  Our older baby used the Tommee Tippee, Medela and Dr. Brown's bottles without any problems.  He also used a pacifier until he was four months old and we discontinued using the pacifier.  This baby is six weeks old and I do not know if the six week "growth spurt" is the cause of our troubles.  Does anyone else have any suggestions or ideas??  I love my baby but mommy needs to get some sleep!  

Vitamin D Supplementation for Breastfed Infants

Breastmilk is touted as "nature's perfect food."  It should contain everything that a growing infant should need for at least the first six months of life.  Major organizations from the American Academy of Pediatrics to the World Health Organization recommend exclusive breastfeeding for the first six months of life.  Exclusive breastfeeding means feeding the infant only breastmilk and no other solids or liquids.  If breastmilk is "perfect," why then do we need to give breastfed infants vitamin D supplementation?

According to the Centers of Disease Control and Prevention (CDC), "Breast milk alone does not provide infants with an adequate intake of vitamin D. Most breastfed infants are able to synthesize additional vitamin D through routine sunlight exposure. However, published reports of cases of vitamin D deficiency rickets among breastfed infants in the United States caused researchers to take another look at whether all breastfed infants were getting adequate vitamin D."  "Vitamin D deficiency rickets among breastfed infants is rare, but it can occur if an infant does not receive additional vitamin D from a vitamin supplement or from adequate exposure to sunlight. A number of factors decrease the amount of vitamin D a person will synthesize from sunlight. These factors include:
- Living at high latitudes (closer to the polar regions), particularly during winter months
- Air quality conditions: high levels of air pollution
- Weather conditions: dense cloud covering
- The degree to which clothing covers the skin
- Use of sunscreen
- Skin pigmentation: darker skin types
- Furthermore, there exists a major public health effort to decrease the risk of skin cancer by encouraging people to limit their sunlight exposure"

The American Academy of Pediatrics (AAP), recommends "that all infants and children, including adolescents, have a minimum daily intake of 400 IU of vitamin D beginning soon after birth."  The "guidelines for vitamin D intake for healthy infants, children, and adolescents are based on evidence from new clinical trials and the historical precedence of safely giving 400 IU of vitamin D per day in the pediatric and adolescent population. New evidence supports a potential role for vitamin D in maintaining innate immunity and preventing diseases such as diabetes and cancer. The new data may eventually refine what constitutes vitamin D sufficiency or deficiency."

"There are 2 forms of vitamin D: D2 (ergocalciferol, synthesized by plants) and D3 (cholecalciferol, synthesized by mammals). The main source of vitamin D for humans is vitamin D3 through its synthesis in the skin" when exposed to ultraviolet light.  "Historically, the main source of vitamin D has been via synthesis in the skin from cholesterol after exposure to UV-B light. Full-body exposure during summer months for 10 to 15 minutes in an adult with lighter pigmentation will generate between 10000 and 20000 IU of vitamin D3 within 24 hours; individuals with darker pigmentation require 5 to 10 times more exposure to generate similar amounts of vitamin D3."  Vitamin D3 which is derived from fish "has greater efficacy in raising" vitamin D levels.  It is the supplement of choice over vitamin D2.

"In a lactating mother supplemented with 400 IU/day of vitamin D, the vitamin D content of her milk ranges from <25 to 78 IU/L."  Even if a mother takes a vitamin D supplement and her infant drinks a liter of breastmilk a day, this is far less than the 400IU recommended daily for infants.   For a woman to produce the recommended amount of vitamin D in her breastmilk, she will have to consume 6400 IU/day of vitamin D supplements.  "Although vitamin D concentrations can be increased in milk of lactating women by using large vitamin D supplements, such high-dose supplementation studies in lactating women must be validated and demonstrated to be safe in larger, more representative populations of women across the United States. Recommendations to universally supplement breastfeeding mothers with high-dose vitamin D cannot be made at this time. Therefore, supplements given to the infant are necessary."

Vitamin D supplementation is recommended because "in adults, new evidence suggests that vitamin D plays a vital role in maintaining innate immunity and has been implicated in the prevention of certain disease states including infection, autoimmune diseases (multiple sclerosis, rheumatoid arthritis), some forms of cancer (breast, ovarian, colorectal, prostate), and type 2 diabetes mellitus.  Results from prospective observational studies also suggest that vitamin D supplements in infancy and early childhood may decrease the incidence of type 1 diabetes mellitus."

Despite the recommendations by the AAP, a study published in the journal Pediatrics, titled, "Adherence to Vitamin D Recommendations Among US Infants," found that "most US infants are not consuming adequate amounts of vitamin D according to the 2008 AAP recommendation. Pediatricians and health care providers should encourage parents of infants who are either breastfed or consuming <1 L/day of infant formula to give their infants an oral vitamin D supplement."  I don't find this particularly surprising since many message boards that I have been reading have threads full of mothers saying that their Pediatricians have told them that it "wasn't necessary."

I plan on supplementing my baby with vitamin D especially since I will not be exposing him to much sunlight during his first six months of life.  I remember that with my first baby, it was difficult in the beginning to get him to take his vitamin drop and I wasn't always that consistent with it.  After researching this topic, I am going to have to make sure that I am more diligent with the vitamins and also be more diligent with myself getting enough calcium and vitamin D.

Happy World Breastfeeding Week!

Did you know that August 1-7, 2012 is World Breastfeeding Week?  "20 years ago, the World Alliance for Breastfeeding Action (WABA) launched its first World BreastfeedingWeek (WBW) campaign with the theme: "Baby-Friendly Hospital Initiative."  It is celebrated every year from August 1-7 in more than 170 countries to "encourage breastfeeding and improve the health of babies around the world. It commemorates the Innocenti Declaration made by WHO and UNICEF policy-makers in August 1990 to protect, promote and support breastfeeding."

There are many celebrations around the world and country commemorating this week.  The La Leche League of the United States has information on their website regarding events in the United States. One of the big events scheduled this year is the "Big Latch On."  There are a number of sites around the country that will have women breastfeeding their babies at the same time (10:30AM) on either Friday, August 3 or Saturday, August 4, 2012.  You can check the following website to determine if there is a site near you participating in the "Big Latch On."

The Big Latch On is hoping to:

• "Support for communities to identify and grow opportunities to provide ongoing breastfeeding support and promotion.
• Raise awareness of breastfeeding support and knowledge available in communities.
• Help communities positively support breastfeeding in public places.
• Make breastfeeding a normal part of the day-to-day life at a local community level.
• Increase support for women who breastfeed - women are supported by their partners, family and the breastfeeding knowledge that is embedded in their communities.
• Communities have the resources to advocate for coordinated appropriate and accessible breastfeeding support services." 

As you all probably know, I am a big proponent of breastfeeding.  Unfortunately, this year, my baby is a little too young to go out in public.  I may not be able to be "officially" counted at an event but I am going to be latching my baby at 10:30 on Friday and Saturday in support of all of the mother's participating in the "Big Latch On."  Is anyone going to join me?

Is there anything that you should not eat while pregnant or nursing?

This is an interesting question that I have seen pop up quite frequently on some of the pregnancy message boards that I frequent.  According to the American Academy of Pediatrics (AAP) revised policies published in January 2008, "current evidence does not support a major role for maternal dietary restrictions during pregnancy or lactation" for mothers of children that are not at "high risk of developing allergy (ie, infants with at least 1 first-degree relative [parent or sibling] with allergic disease)."

When reading the policy, the AAP defines "atopic disease" as "clinical disease characterized by atopy; typically refers to atopic dermatitis, asthma, allergic rhinitis, and food allergy."

The AAP summarizes their findings based on available data below:

1. At the present time, there is lack of evidence that maternal dietary restrictions during pregnancy play a significant role in the prevention of atopic disease in infants. Similarly, antigen avoidance during lactation does not prevent atopic disease, with the possible exception of atopic eczema, although more data are needed to substantiate this conclusion.
2. For infants at high risk of developing atopic disease, there is evidence that exclusive breastfeeding for at least 4 months compared with feeding intact cow milk protein formula decreases the cumulative incidence of atopic dermatitis and cow milk allergy in the first 2 years of life.
3. There is evidence that exclusive breastfeeding for at least 3 months protects against wheezing in early life. However, in infants at risk of developing atopic disease, the current evidence that exclusive breastfeeding protects against allergic asthma occurring beyond 6 years of age is not convincing.  
4. In studies of infants at high risk of developing atopic disease who are not breastfed exclusively for 4 to 6 months or are formula fed, there is modest evidence that atopic dermatitis may be delayed or prevented by the use of extensively or partially hydrolyzed formulas, compared with cow milk formula, in early childhood. Comparative studies of the various hydrolyzed formulas have also indicated that not all formulas have the same protective benefit. Extensively hydrolyzed formulas may be more effective than partially hydrolyzed in the prevention of atopic disease. In addition, more research is needed to determine whether these benefits extend into late childhood and adolescence. The higher cost of the hydrolyzed formulas must be considered in any decision-making process for their use. To date, the use of amino acid–based formulas for atopy prevention has not been studied.
5. There is no convincing evidence for the use of soy-based infant formula for the purpose of allergy prevention.
6. Although solid foods should not be introduced before 4 to 6 months of age, there is no current convincing evidence that delaying their introduction beyond this period has a significant protective effect on the development of atopic disease regardless of whether infants are fed cow milk protein formula or human milk. This includes delaying the introduction of foods that are considered to be highly allergic, such as fish, eggs, and foods containing peanut protein.
7. For infants after 4 to 6 months of age, there are insufficient data to support a protective effect of any dietary intervention for the development of atopic disease.
8. Additional studies are needed to document the long-term effect of dietary interventions in infancy to prevent atopic disease, especially in children older than 4 years and in adults.
9. This document describes means to prevent or delay atopic diseases through dietary changes. For a child who has developed an atopic disease that may be precipitated or exacerbated by ingested proteins (via human milk, infant formula, or specific complementary foods), treatment may require specific identification and restriction of causal food proteins. This topic was not reviewed in this document.

With this revision, the AAP is stating that unless a child is at high risk for developing an allergy, there is no restriction as to what a mother can eat while pregnant or breastfeeding.  If a child is at high risk, exclusive breastfeeding (with no formula supplementation) for at least 4 months decreases the risk of developing atopic dermatitis (eczema) and an allergy to cow's milk.  For all children, breastfeeding for at least three months may protect against wheezing in early life.  If a child is at high risk for developing an allergy and is not exclusively breastfed, there is some evidence that eczema may be delayed or prevented by using extensively hydrolyzed formulas compared with cow milk formula in early childhood.  There is no evidence for the use of soy-based formula for the purpose of allergy prevention.  Solid foods should not be introduced before 4-6 months of age.  Furthermore, delaying introduction of solid foods after 6 months does not offer more protection against the development of allergies regardless if a baby has been fed formula or breastmilk.  Also, there is no evidence that delaying the introduction of foods such as fish, eggs or peanuts will protect against the development of allergies to those foods.

Pediatric Growth Charts

When I had my first child, I often wondered if he was gaining enough weight.  I breastfed him exclusively and found it difficult to assess if I was producing enough milk for his needs.  Looking at his growth in comparison to standardized growth charts was the only way for me to determine if he was getting enough breastmilk.  My baby was always on the smaller side and that concerned me.  However, as I began researching the topic, I began to realize that the growth charts in use today is very different from the growth charts used several years ago.

Prior to the year 2000, most providers referenced a growth chart from 1977.  The chart developed in 1977 was from a single study whose data was collected from primarily "formula fed, white middle-class infants in a limited geographic area of southwestern Ohio from 1929–75."  This chart was even adopted internationally by the World Health Organization.

The problem with this chart was it tried to compare children from around the world to a select group of people in the United States.  As you know, many people around the world differ in size according to their nutritional status and ethnicity among other factors.  It was this discrepancy that led to the  development of the new guidelines in use today.

In the US, the current growth charts now include a Body Mass Index (BMI) for age charts.  "BMI (wt/ht2) is calculated from weight and height measurements and is used to judge whether an individual's weight is appropriate for their height. BMI is the most commonly used approach to determine if adults are overweight or obese and is also the recommended measure to determine if children are overweight. The new BMI growth charts can be used clinically beginning at 2 years of age, when an accurate stature can be obtained."  The new charts also had a revised head circumference chart which "also show some noticeable differences when compared to the earlier charts. Compared to the original infant charts that were based on primarily formula-fed infants, the revised growth charts for infants contain a better mix of both breast- and formula-fed infants in the U. S. population."

The Centers for Disease Control (CDC) recommends the charts developed by the World Health Organization (WHO) for children 0-2 years old and the CDC growth charts to monitor children 2 and older in the United States.  There are separate charts because the WHO chart only covers children until they are 5 years old.

The WHO standards "establish growth of the breastfed infant as the norm for growth.  The WHO charts reflect growth patterns among children who were predominantly breastfed for at least 4 months and still breastfeeding at 12 months."  "The WHO standards provide a better description of physiological growth in infancy.  Clinicians often use the CDC growth charts as standards on how young children should grow. However the CDC growth charts are references; they identify how typical children in the US did grow during a specific time period. Typical growth patterns may not be ideal growth patterns. The WHO growth charts are standards; they identify how children should grow when provided optimal conditions."  For example, according to the CDC growth chart reference, if a "typical" growth pattern for a particular region is for children to be overweight, it is not an "ideal" growth pattern and children should not be compared to that reference.

"The CDC growth charts are based on primarily formula fed infants.  Only about 50% of infants measured to construct the growth reference charts were ever breastfed.  By 3 months of age, only 33% were breastfed.  In the US, 75% of infants born in 2008 were ever breastfed, 44% were breastfed for at least 6 months and 24% were breastfed at 12 months.  Consequently, the CDC growth charts may not adequately reflect the current growth patterns of infants in the US and they do not reflect a growth pattern typically seen in breastfed infants."

"Growth patterns differ between breastfed and formula-fed infants. Beginning around 3 months of age weight gain is generally lower for breastfed infants than for that of the formula-fed infant.  Linear growth generally follows a similar pattern for both breast- and formula-fed infants.  Formula-fed infants tend to gain weight more rapidly after age 3 months, they may be more likely to cross upward in percentiles on the WHO growth charts, perhaps becoming classified as overweight."

The WHO Standards were developed from data collected from "The WHO Multicentre Growth Reference Study (MGRS)."  "The WHO Multicentre Growth Reference Study (MGRS) was undertaken between 1997 and 2003 to generate new growth curves for assessing the growth and development of infants and young children around the world.  The MGRS collected primary growth data and related information from approximately 8500 children from widely different ethnic backgrounds and cultural settings (Brazil, Ghana, India, Norway, Oman and the USA)."  "The children included in the study were raised in environments that minimized constraints to growth such as poor diets and infection. In addition, their mothers followed health practices such as breastfeeding their children and not smoking during and after pregnancy."

"The MGRS was designed to provide data that describe “how children should grow,” by including in the study’s selection criteria specific health behaviors that are consistent with current health promotion recommendations (e.g., breastfeeding norms, standard pediatric care, non-smoking requirements). This new approach is fundamentally different from that taken by the traditional descriptive references. By adopting a prescriptive approach, the protocol’s design went beyond an update of how children in presumably healthy populations grow at a specific time and place and explicitly recognizes the need for standards (i.e., devices that enable value judgments by incorporating norms or targets in their construction). Arguably, the current obesity epidemic in many developed countries would have been detectable earlier if a prescriptive international standard had been available 20 years ago."  This study "reiterate the fact that child populations grow similarly across the world’s major regions when their needs for health and care are met."

A result of the new standards will be "that stunting (low height for age) will be greater throughout childhood when assessed using the new WHO standards compared to the previous international reference. There will be a substantial increase in underweight rates during the first half of infancy (i.e., 0-6 months) and a decrease thereafter. For wasting (low weight for length/height), the main difference between the new standards and the old reference is during infancy (i.e., up to about 70 cm length) when wasting rates will be substantially higher using the new WHO standards. With respect to overweight, use of the new WHO standards will result in a greater prevalence that will vary by age, sex and nutritional status of the index population."  This is not surprising considering the previous reference was based on "formula fed, white middle-class infants in a limited geographic area of southwestern Ohio."

The new standards establish the following cutoffs:
"Infants and children with a weight-for-length < 2nd percentile are classified as low weight-for-length.
Infants and children with a length-for-age < 2nd percentile are classified as having short stature.
Infants and children with a weight-for-length > 98th percentile are classified as high weight-for-length."

When a child transitions after the age of 2 "from the WHO weight-for-length chart to the CDC BMI-for-age chart may result in a change in a child's percentile classification" because of:

• Changes from one indicator to another indicator.
• Weight-for-length chart to BMI-for-age chart.
• Changes from a recumbent length measurement to a standing height measurement.
• "Standing height measures less than recumbent length. "  
• Changes to a different cutoff value and a different reference population.
• "Breastfed reference population to a primarily formula-fed reference population."

Apparently, many parents do not understand growth charts.  If a doctor is using the CDC growth chart instead of the WHO growth chart, who can blame them?  There was a study published in the journal Pediatrics in October 2009 titled, "Do Parents Understand Growth Charts?  A National Internet Based Survey."  "Understanding a growth chart requires the ability to understand several concepts, including trending over time, proportionality (height compared with weight), and graphical presentation. Health care providers may mistakenly assume that parents understand these concepts."  The study found "the majority of this survey's respondents were not able to comprehend growth chart data fully. The concept of percentile seemed particularly difficult for respondents to understand. Although most reported having heard of the term, many could not identify the percentile of a point shown on a growth chart, and an even larger number could not identify the definition of the term percentile."  "A significant number of respondents were mistakenly concerned about a proportionate child who is smaller (shorter and lighter) than average but growing normally, and they thought that it would be healthier for the child to be at higher percentiles. This confirms the findings of a recent study in which mothers misinterpreted percentile as indicating the percentage of children at that height or weight and thought that growth curves were more satisfactory at higher percentiles. Most respondents expressed concern if a child's growth was shown to measure in the 10th percentile for both height and weight, whereas significantly fewer showed concern about the health of a child who was in the 90th percentile for height and weight. Also, respondents showed much greater concern about a child's absolute weight, compared with a child's height or height/weight proportionality."  The study concluded, "few parents understand growth charts and the implications of the data they present."  The authors recommend, "non–growth chart-based approaches to teaching parents about their children's growth should be considered, because our results reveal that many parents clearly lack knowledge about the growth process and are uncertain about the best ways to assess a child's growth or, indeed, whether tracking a child's growth is even important. For example, our results indicate that parents typically rely on comparisons they make with other children of similar age, rather than growth charts, to judge their child's physical development, which can be deceiving when a large proportion of children in a community are overweight."

The big take home message for me, from all of this, is that if my child is proportionally growing normally (height and weight) and within the 2-98% cutoff, then it is OK.  My child may not necessarily need to be in the higher percentiles to be considered "healthy."  Also, I need to make sure my provider is using the WHO standards when evaluating my breastfed infant as opposed to the CDC references which show typical growth patterns that might not be ideal growth patterns.

Here are the links to the WHO Growth Charts:
Birth to 24 months: Boys Weight-for-length percentiles and Head circumference-for-age percentiles
Birth to 24 months: Boys Length-for-age percentiles and Weight-for-age percentiles
Birth to 24 months: Girls Weight-for-length percentiles and Head circumference-for-age percentiles
Birth to 24 months: Girls Length-for-age percentiles and Weight-for-age percentiles

Breastfeeding Beyond Infancy the Reality Show?!?!

There appears to be a reality series in development which will focus on mothers who breastfeed "older children."  This was inspired by the controversial Time Magazine article about attachment parenting featuring a mother breastfeeding her three year old child on the cover.  Would you watch such a show? If so, what do you consider to be an "older child?"

Many organizations like the World Health Organization recommend breastfeeding "up to 6 months of age, with continued breastfeeding along with appropriate complementary foods up to two years of age or beyond."  It appears that only in America do we have such a hangup about breastfeeding.  This topic can become very heated when placed in the context of breastfeeding in public or breastfeeding an "older child."  In my experience, most people would equate an "older child" as a child over the age of one.

As I have stated before, I think these kinds of shows do an injustice to breastfeeding.  I think it only serves to sensationalize what should be a natural thing between mother and child.  On one hand, out of sheer curiosity, I can see myself watching a show like this just to see what it's like.  On the other hand, I want to boycott a show such as this if the reviews indicate that it is sensationalistic.  If a show like this is done tastefully and is supportive of breastfeeding then I am all for it.  If it is only there to further stir up anger and resentment against breastfeeding mothers than I think there should not be a show like that on television.

Formula Feeding Does Not Equate with Improved Sleep

As you have probably already guessed from my previous posts about breastfeeding, I am a big supporter of breastfeeding.  I think I have heard everything when it comes to why I should stop breastfeeding and switch to formula.  My child is too old, formula is more convenient and feeding formula will let you have more sleep.  I stumbled across an interesting study published in the journal Pediatrics.  The purpose of the study, "Infant Feeding Methods and Maternal Sleep and Daytime Functioning,"was to explore maternal actigraphically measured sleep, subjective sleep reports, and daytime functioning on the basis of current feeding method status during postpartum weeks 2 through 12."

The study "did not find differences between women who were exclusively breastfeeding, exclusively formula feeding, or using a combination of the 2 methods, with respect to the assessed parameters."  "The contrast between our negative subjective maternal sleep findings and previous studies that showed that mothers reported that their breastfed infants awakened more often at night are intriguing. Without our and others’ evidence, it would stand to reason that, if the infants awakened more often, their mothers would too. It is possible that, despite their self-reports, breastfeeding mothers are awakening more often during the night to feed their infants but they return to sleep more quickly or sleep during feedings and consequently do not remember those awakenings."  The authors "suggest that, if breastfeeding mothers are awakening more often at night, then breastfeeding itself may have a compensatory effect. In other words, breastfeeding mothers awakening more often at night may return to sleep more quickly and not remember these awakenings. Possible reasons for this may include the fact that they are not exposed to as much ambient light or physical activity, compared with preparing formula. It also is possible that breastfeeding mothers sleep during feedings."  "4 nucleotides present in breast milk have strong maternal circadian rhythms and seem to facilitate a “hypnotic action” in infants. In addition, differences in circulating prolactin levels are suspected to have a primary role in sleep architecture differences among breastfeeding and formula-feeding mothers. Prolactin shows a nocturnal peak, which is vital for milk production, and usually is associated with facilitation of sleep onset and delta wave activity important for restorative sleep."

The authors concluded "to date, there is little evidence to support the notion that breastfeeding has a negative impact on maternal sleep.  Women should be told that a choice to formula feed does not necessarily equate with improved sleep. The risks of not breastfeeding should be weighed against the cumulative lack of evidence showing any benefit of formula feeding on maternal sleep."

I find the discussion of the study findings very intriguing.  Unfortunately, the study only had 24 participants in the first phase and 70 in second phase.  This is not a large sample size and undoubtedly the formula supporters will point to that as an argument to invalidate the study.  Despite the small sample size, I still find the notion that formula feeding will not necessarily allow a mother to get more sleep to be true.  I'm a horrible insomniac and if I had to wake up to prepare a bottle and then feed a bottle, I would find it difficult to return to sleep.  If I am breastfeeding, I can get the baby, nurse the baby and fall back asleep all without having to turn on the lights or going far from my bed.  It is just one more thing I can present to those who have tried to discourage me from breastfeeding.  

The US has the Least Favorable Environment for Mothers Who Want to Breastfeed

I first heard about this shocking statistic while reading a blog post oncloudmom.com.  The author of the post had been referring to a report by the organization Save the Children.  The report, "Nutrition in the First 1,000 days - State of the World's Mothers 2012" is the 13th such report.  "The focus (of the report) is on the 171 million children globally who do not have the opportunity to reach their full potential due to the physical and mental effects of poor nutrition in the earliest months of life. This report shows which countries are doing the best – and which are doing the worst – at providing nutrition during the critical window of development that starts during a mother’s pregnancy and goes through her child’s second birthday. It looks at six key nutrition solutions, including breastfeeding, that have the greatest potential to save lives, and shows that these solutions are affordable, even in the world’s poorest countries."  "Good nutrition during the critical 1,000-day window from pregnancy to a child’s second birthday is crucial to developing a child’s cognitive capacity and physical growth. Ensuring a child receives adequate nutrition during this window can yield dividends for a lifetime, as a well-nourished child will perform better in school, more effectively fight off disease and even earn more as an adult."

"The Breastfeeding Policy Scorecard examines maternity leave laws, the right to nursing breaks at work and other indicators to rank 36 developed countries on the degree to which their policies support women who want to breastfeed."  "In the industrialized world, the United States has the least favorable environment for mothers who want to breastfeed.  Norway tops the Breastfeeding Policy Scorecard ranking. The United States comes in last."

The report found the following barriers to breastfeeding:
"Experts recommend that children be breastfed within one hour of birth, exclusively breastfed for the first 6 months, and then breastfed until age 2 with age-appropriate, nutritionally adequate and safe complementary foods. Optimal feeding according to these standards can prevent an estimated 19 per- cent of all under-5 deaths, more than any other child survival intervention.  Yet worldwide, the vast majority of children are not breastfed optimally.

What are some of the reasons for this? Cultural beliefs, lack of knowledge and misinformation play major roles. Many women and family members are unaware of the benefits of exclusive breastfeeding. New mothers may be told they should wait several hours or days after their baby is born to begin breast- feeding. Aggressive marketing of infant formula often gives the impression that human milk is less modern and thus less healthy for infants than commercial formula. Or mothers may be told their breast milk is “bad” or does not contain sufficient nutrients, so they introduce other liquids and solid food too early.

Most breastfeeding problems occur in the first two weeks of a child’s life. If a mother experiences pain or the baby does not latch, an inexperienced mother may give up. Support from fathers, mothers-in-law, peer groups and health workers can help a mother to gain confidence, overcome obstacles and prolong exclusive breastfeeding.

Women often stop breastfeeding because they return to work. Many aren’t provided with paid maternity leave or time and a private place to breastfeed or express their breast milk. Legislation around maternity leave and policies that provide time, space, and support for breastfeeding in the workplace could reduce this barrier. For mothers who work in farming or the informal sector, family and community support can help them to continue breastfeeding, even after returning to work. Also many countries need better laws and enforcement to protect women from persecution or harassment for breastfeeding in public."

"In the United States alone, it is estimated that low rates of breastfeeding add $13 billion to medical costs and lead to 911 excess deaths every year.142"  "Children who are not breastfed are at higher risk of obesity. In addition, breastfeeding for at least the first six months of life appears to be a factor protecting against obesity.144  In the United States, 10 percent of children under age 5 are overweight and an additional 10 percent of 2- to 5-year-olds are at risk of overweight.145  In the United States, for example, 4 percent of young children are estimated to be stunted, which translates into 840,000 stunted children.147

Breastfeeding practices tend to vary widely across race, ethnicity, education and income levels. Often, disadvantaged mothers breastfeed less that their more privileged counterparts.  In the United States, more than 80 percent of Hispanics and Asians begin breastfeeding, but only 74 percent of whites and 54 percent of blacks do so.150  Women with higher levels of education are more likely to breastfeed, but racial differences are apparent across education levels. For example, even among wom- en with a college degree, blacks are less likely to breastfeed than whites.151 There are sharp geographical differences as well: in eight states, most in the Southeast, less than 10 percent of infants are exclusively breastfed at 6 months.152  A recent study in the United States found that less than 2 percent of low- income mothers who planned to breastfeed were able to meet their goals, while 50 percent of women from a more affluent population did. The low-income women reported the obstacles they encountered when breastfeeding led them to stop sooner than they had planned. The study suggested better support is needed from medical professionals to help low-income mothers succeed in their breastfeeding plans.156"

The implementation of the Baby-Friendly Hospital Initiative was started to ensure hospitals provide more breastfeeding support.  Sweden is currently the only country where all the hospitals are considered "baby friendly."

"Countries with generous maternity and parental leave policies – such as Denmark, Norway and Sweden – tend to have high breastfeeding rates. Public health researchers in the United States recently found that women whose maternity leave lasted longer than six weeks were more likely to initiate breastfeeding, continue for more than six months and rely mostly on exclusive breastfeeding beyond three months, compared with women who returned to work between one and six weeks after giving birth.161  Apart from the United States, all developed countries now have laws mandating some form of paid compensation for women after giving birth. Depending on the country, maternity leave can range from 12 to 46 weeks, with pay from 55 to 100 percent of regular salary."

Under the best policies – in countries such as Germany, Poland and Portugal – women may take an hour or more of paid nursing breaks each day, for as long as they need them. Laws in France, Japan, New Zealand, Norway, Sweden, Switzerland and the United States give women the right to nursing breaks, but without guaranteed pay. In Australia, Canada, Denmark, Finland, Iceland and the United Kingdom, women do not have the explicit right to nursing breaks, paid or unpaid.

The United States ranks last on the Breastfeeding Policy Scorecard. It is the only economically advanced country – and one of just a handful of countries worldwide – where employers are not required to provide any paid maternity leave after a woman gives birth. There is also no paid parental leave required by U.S. law. Mothers may take breaks from work to nurse, but employers are not required to pay them for this time. Only 2 percent of hospitals in the United States have been certified as “baby-friendly” and none of the provisions of the International Code of Marketing of Breast-milk Substitutes has been enacted into law. While 75 percent of American babies are initially breastfed, only 35 percent are being breastfed exclusively at 3 months."

There is much to be desired in the United States regarding breastfeeding and support.  I have touched upon the lack of paid maternity leave and the difficulties with maintaining breastfeeding once returning to work in previous blog posts. Unless there is a fundamental shift in the way American mothers are treated, the United States will continue to have dismal breastfeeding rates.

ENDNOTES from the 2012 State of the World's Mothers Report
142 Bartick Melissa and Arnold Reinhold. “The Burden of Suboptimal Breastfeeding in the United States: A Pediatric Cost Analysis” Pediatrics. April 5, 2010. pp.e1048–e1056
144 WHO Europe Region. Nutrition: Facts and Figures. euro.who.int/en/what-we-do/ health-topics/disease-prevention/nutrition/ facts-and-figures
145 Ogden, Cynthia, Margaret Carroll, Lester Curtin, Molly Lamb and Katherine Flegal. “Prevalence of High Body Mass Index in US Children and Adolescents, 2007-2008.” Journal of the American Medical Association. Vol.303, No. 3. January 13, 2010. pp.242- 249
145 Ogden, Cynthia, Margaret Carroll, Lester Curtin, Molly Lamb and Katherine Flegal. “Prevalence of High Body Mass Index in US Children and Adolescents, 2007-2008.” Journal of the American Medical Association. Vol.303, No. 3. January 13, 2010. pp.242- 249
150 Centers for Disease Control and Prevention. “Racial and Ethnic Differences in Breastfeeding Initiation and Duration, by State – National Immunization Survey, United States, 2004-2008,” Morbidity and Mortality Weekly Report, Vol. 59, No. 11, March 26, 2010. pp.327-334.
151 Ibid.
152 U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Breastfeeding Report Card – United States, 2011. (Atlanta: August 2011)
156 Hanna, Jennifer and Mari Douma.
Barriers to Breastfeeding in Women of Lower Socioeconomic Status, Michigan State University. 2012.
161 Ogbuanu, Chinelo, Saundra Glover, Janice Probst, Jihong Liu and James Hussey. “The Effect of Maternity Leave Length and Time of Return to Work on Breastfeeding.” Pediatrics. Vol.127, Issue: 6. May 30, 2011. pp.e1414-e1427

Television's Portrayal of Breastfeeding

I stumbled upon an interesting story today based upon a recent study that was published in the journal Health Communication titled, "That's Not a Beer Bong, It's a Breast Pump!" Representations of Breastfeeding in Prime-Time Fictional Television."  The author of the study recognizes that "although most people are aware of the benefits, many women do not breastfeed their babies past the first few months. These low rates can be partially explained by negative cultural attitudes toward breastfeeding, which have been reinforced by media messages."

The author found that "breastfeeding depictions are generally positive, but limited in scope to educated, older, Caucasian women breastfeeding newborns, with little discussion about how to overcome problems. Extended breastfeeding and nursing in public were conveyed as socially unacceptable, making other characters uncomfortable, often within the same storylines that sexualized breasts. While the frequency of representations in recent years was encouraging, the narrow definition of the "normal" nursing experience excluded many types of women and breastfeeding experiences. And, by failing to address breastfeeding challenges and conveying that extended breastfeeding or nursing in public is abnormal or obscene, these depictions reinforce myths about the ease of breastfeeding and may discourage women from breastfeeding past the newborn phase, and outside the privacy of their homes. These portrayals may help explain why breastfeeding has not been "normalized," despite an international consensus that it is the best health choice for babies."

I would have to agree with the author of this study.  Before I became I mother, I had no idea the challenges that face breastfeeding mothers.  I didn't know about the commitment and sacrifice that it takes to exclusively breastfeed a child for the first six months of their life and to continue to at least a year as recommended by guidelines.  Most of the general public's "experience" with breastfeeding is through television.  In television, you never see a baby past a few months old breastfeeding.  As a result, many people feel uncomfortable seeing older children breastfeed.  I have been told that I need to "stop" breastfeeding my child because he was too "old" (even though he was not even a year old).

If television shows do not begin to more accurately portray breastfeeding, people are going to continue believing the stereotypes that they see.  I have a co-worker who is originally from Africa and he cannot understand the "hang up" Americans have about breastfeeding.  It is a natural thing and it is what is best for babies.  Unfortunately, since many Americans are driven by what they see on television, producers of shows need to change the way in which breastfeeding is portrayed for it to become more "acceptable" to the "mainstream."

Are You Getting Enough Calcium and Vitamin D?

Calcium and Vitamin D are vitamins that we have been told will prevent osteoporosis when we are older.  However, an "interesting draft recommendation statement" recently made headlines when the U.S. Preventative Task Force (USPSTF) recommended that "evidence is lacking regarding the benefit of daily supplementation with >400 IU of vitamin D3 and 1,000 mg of calcium for the primary prevention of osteoporotic fractures, and the balance of benefits and harms cannot be determined.  The USPSTF concludes with moderate certainty that daily supplementation with ≤400 IU of vitamin D3 and 1,000 mg of calcium carbonate has no net benefit for the primary prevention of osteoporotic fractures."  They based this recommendation due to the lack of studies showing the benefits of calcium supplementation in healthy post-menopausal women in preventing osteoporotic fractures.  There were, however, "adequate evidence that supplementation with ≤400 IU of vitamin D3 and 1,000 mg of calcium carbonate increases the incidence of renal stones. The USPSTF assessed the magnitude of this harm as small."

With this "draft recommendation statement," the USPSTF could not recommend 1,000mg calcium and ≤400 IU of vitamin D supplementation in healthy post-menopausal women due to the lack of evidence showing a benefit in preventing fractures in comparison to the "adequate evidence" that supplementation can increase the incidence of renal (kidney) stones.  This is a "draft recommendation statement" and not a final recommendation and is available for public comment until July 10, 2012.

I think many people are applying this recommendation to groups other than post-menopausal women.  As a pregnant and soon-to-be lactating woman, it is still recommended that I take 1,000mg of calcium and 600 IU of vitamin D daily.  All 1,000mg of calcium should not be taken at one time.  "The percentage of calcium absorbed depends on the total amount of elemental calcium consumed at one time; as the amount increases, the percentage absorption decreases. Absorption is highest in doses ≤500 mg [1]. So, for example, one who takes 1,000 mg/day of calcium from supplements might split the dose and take 500 mg at two separate times during the day."  Vitamin D supplementation is needed along with calcium because "Vitamin D promotes calcium absorption in the gut and maintains adequate serum calcium and phosphate concentrations to enable normal mineralization of bone and to prevent hypocalcemic tetany. It is also needed for bone growth and bone remodeling by osteoblasts and osteoclasts.  Together with calcium, vitamin D also helps protect older adults from osteoporosis."

Unless new information becomes available regarding pregnant and lactating women, I will continue to take my calcium supplements and/or eat my calcium rich foods (like broccoli).  I think maintaining an adequate intake of calcium and vitamin D now will prevent the development of osteoporosis in the future.

Is Your Hospital "Baby Friendly?"

Pediatrics, the American Academy of Pediatric's Official Journal, published a study today entitled, "Baby-Friendly Hospital Practices and Meeting Exclusive Breastfeeding Intention."  The purpose of this study was "to describe mothers’ exclusive breastfeeding intentions and whether Baby-Friendly hospital practices are associated with achieving these intentions."  The Centers for Disease Control and Prevention (CDC) surveyed pregnant women about their intentions for exclusive breast-feeding (meaning only breast milk but no other liquids or solids) and then followed up with surveys conducted monthly over a year.

The study found that 85% of mothers had intended to exclusively breastfeed for the first three months.  However, only 32% (about 1/3) of mothers had actually breastfed as long as they had intended.  The study found that "increased Baby-Friendly hospital practices, particularly giving only breast milk in the hospital, may help more mothers achieve their exclusive breastfeeding intentions."

What exactly is a "baby-friendly hospital practice?"  In 1991, UNICEF and the World Health Organization (WHO) started the Baby-Friendly Hospital Initiative (BFHI).  The purpose of the BFHI was to, "ensure that all maternities,whether free standing or in a hospital, become centers of breastfeeding support."  There are currently 152 countries around the world implementing this initiative.  The United States even has an accrediting body for this initiative.  This organization, called Baby-Friendly USA, is a non-profit organization that implements the BFHI in the United States.

"A maternity facility can be designated 'baby-friendly' when it does not accept free or low-cost breastmilk substitutes, feeding bottles or teats, and has implemented 10 specific steps to support successful breastfeeding."

The 10 specific steps are:

1 - Have a written breastfeeding policy that is routinely communicated to all health care staff.
2 - Train all health care staff in skills necessary to implement this policy.
3 - Inform all pregnant women about the benefits and management of breastfeeding.
4 - Help mothers initiate breastfeeding within one hour of birth.
5 - Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants.
6 - Give newborn infants no food or drink other than breastmilk, unless medically indicated.
7 - Practice “rooming in”-- allow mothers and infants to remain together 24 hours a day.
8 - Encourage breastfeeding on demand.
9 - Give no pacifiers or artificial nipples to breastfeeding infants.
10 - Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic

According to the CDC, "Hospitals that wait to start the first breastfeed, or separate babies from mothers, or routinely give formula to breastfeeding babies make it harder for mothers and babies to be able to breastfeed.  When hospitals support mothers to feed their babies only breast milk, it helps mothers to continue feeding only breast milk at home."  Also, "babies who are fed formula and stop breastfeeding early have higher risks of obesity, diabetes, respiratory and ear infections, and sudden infant death syndrome (SIDS), and tend to require more doctor visits, hospitalizations, and prescriptions."

When I had my first child, I could not understand why we could not have our baby sleep in a "nursery."  As any new parent will tell you, those first few hours after birth can be exhausting and you just want to get some rest.  However, my hospital refused to let the baby leave my side.  At the time, I could not figure out why.  In retrospect, they were only practicing the steps outlined by the BFHI.  The hospital we had our baby initiated breastfeeding immediately after birth, had a lactation consultant who made daily visits, only allowed "rooming in," did not give pacifiers or artificial nipples and most importantly, did not give us any samples of formula.

I thought that my hospital was "unique" in this since many of my friends who had babies at other hospitals had been given formula samples, pacifiers, and other things prior to leaving the hospital.  However, on March 30, 2012, a "letter was sent to 2600 hospitals across the country. Over one hundred organizations signed on to the letter calling on hospitals to stop allowing formula companies to market infant formula in their facilities."

Mothers already face many obstacles when trying to initiate and maintain breastfeeding.  As mentioned in earlier posts regarding maternity leave in the US and breastfeeding and the working mother, we can now add, un-baby friendly hospitals to the list of obstacles facing mothers who are breastfeeding.

Maternity Leave in California

I started off doing research about maternity leave and what I can and cannot take as a new mother.  Unfortunately (or fortunately), I got a little off topic (as I oftentimes find myself) and wrote two other blog posts regarding maternity leave and breastfeeding and working mothers.  In the process of researching this topic, I learned a lot about what is available to me and found that little has changed since I last took maternity leave in 2010 after the birth of my first child.  Since I live in the state of California, I was able to take 19 weeks of maternity leave.  I took 1 week (it was supposed to be two but he came a week early) off before the baby was born and 18 weeks after he was born.

I'm lucky to live in California because it was recently voted the best state that supports working mothers by the National Partnership for Women and Families.  They were given this designation because of their job-protected leave provisions, flexible sick leave program, nursing-at-work rights and ability to allow pregnant workers to request a transfer to a less strenuous job if possible.

Despite that designation, I still find the options available to me very confusing.  I am not a lawyer and sometimes I feel like you have to be one to decipher what can be done.  I consulted the legal aid website and still find myself confused.  In one of my previous posts, I mentioned FMLA.  "FMLA entitles eligible employees of covered employers to take unpaid, job-protected leave for specified family and medical reasons with continuation of group health insurance coverage under the same terms and conditions as if the employee had not taken leave. Eligible employees are entitled to twelve workweeks of leave in a 12-month period."  This is a federal act.

California has other provisions that can be used by a mother on maternity leave.  The first is State Disability Insurance (SDI).  "The Disability Insurance program provides affordable, short-term benefits to eligible workers who suffer a loss of wages when they are unable to work due to a non work-related illness or injury, or due to pregnancy or childbirth."  Women who are pregnant may start receiving disability benefits in the state of California before delivery and for a specified length of time after delivery (depending if vaginal or cesarean delivery).  "The usual disability period for a NORMAL pregnancy is up to four weeks before the expected delivery date and up to six weeks after the actual delivery. However, your doctor may certify to a longer period if the delivery is by Cesarean section, if there are medical complications, or if you are unable to perform your regular or customary job duties."  "Disability Insurance (DI) benefits are not taxable except when considered to be a substitute for unemployment compensation when paid to an individual who is ineligible for unemployment insurance (UI) benefits solely because of the disability."  This program is funded through a mandatory payroll deduction.  "SDI deductions are not pre-taxed."  The contribution is taken out after federal, state and social security taxes are deducted.  An interesting thing to note is "the first seven days of your disability claim are a 'non payable' waiting period."  The state has a list of eligibility requirements listed on their website.  They also have instructions on how to file a claim.

California also offers the California Family Rights Act (CFRA) which is administered by the Department of Fair Employment and Housing.  This Act is similar to FMLA in that it has the same eligibility rules and allows 12-weeks of unpaid, job-protected leave.  This act was initiated so mothers could spend more time with their baby to "bond."  This is sometimes referred to as "baby bonding."  FMLA kicks in even if a mother suffers complications from her pregnancy and is required to take take time off BEFORE her pregnancy.  As a result of this, many mothers who suffered pregnancy complications did not have much time AFTER birth to spend with their baby.  CFRA kicks in AFTER State Disability (SDI) has been completed.  This runs concurrently with FMLA in the period AFTER delivery.  It does not give someone a total of 24 weeks of leave but it can extend FMLA once the FMLA leave has been exhausted.  The amount of extra leave depends on "how much time you take off before the baby is born, when the baby is born, and the type of delivery, you may get a few weeks less of job-protected leave."

Another leave that the state of California offers is Paid Family Leave (PFL).  It entitles eligible employees 6 paid weeks of benefits in a 12 month period.  Employees covered by the State Disability Insurance Program (SDI) are eligible for paid family leave.  This leave can be used by both the mother of the baby and the spouse or partner of the person who had the baby.  There is a 7-calendar day waiting period before benefits will be distributed.  However, there is no 7-day waiting period if you are "transitioning from a DI pregnancy claim into a PFL bonding claim."  "Claimants will automatically be sent a Claim for Paid Family Leave (PFL) Benefits when a pregnancy-related disability claim ends."  PFL does not offer job protection.  Job protection is given through FMLA or CFRA which must be taken concurrently with PFL.  "Paid Family Leave (PFL) benefits are taxable for federal purposes but not state tax purposes. The EDD will provide all claimants with a 1099G form and forward a copy of the 1099G to the federal IRS. The PFL benefits are not taxable or reportable to the California State Franchise Tax Board."  The following link contain instructions on how to file a claim.  There is also a great website with some Frequently Asked Questions (FAQ's) regarding PFL.

It is important to note that if you are receiving any wages from your employer such as "sick leave, bereavement pay, back pay, earnings (full or partial return to work)," then it must be reported when applying for SDI or PFL.

This table lists the expected benefit amounts while receiving Disability Insurance (DI ) or Paid Family Leave (PFL) benefits.  "The weekly benefit amount is calculated based on the calendar quarter with the highest earnings in the claimant’s base period. The base period covers 12 months and is divided into four consecutive quarters of three months each. The wages the claimant was paid approximately 5 to 18 months before the claim begins are included in the base period (they must be subject to the State Disability Insurance tax)."

This is all very confusing so I'll try my best to summarize the information presented above.
State Disability Insurance (SDI) - Eligible for benefits beginning 4 weeks before expected due date and continuing for 6-8 weeks (depending on delivery) after the baby is born.  There is a 1 week "waiting period."
Paid Family Leave (PFL) - Eligible for 6 weeks of benefits.  No "waiting period" if taken after SDI.
FMLA - 12 weeks of job-protected leave
California Family Rights Act (CFRA) - 12 weeks of job-protected leave (may run concurrently with FMLA) but starts after SDI ends.
Total leave if vaginal delivery:  4+6+6+6=4 before + 18 weeks after = 22 weeks (15 total weeks paid*)
Total leave if csection delivery: 4+8+6+6=4 before + 20 weeks after (17 total weeks paid*)
*Total weeks paid takes into consideration the 1 week waiting period.

The legal aid society has a great fact-sheet on your legal rights regarding paid leave.  The state also tried putting together a table comparing FMLA and CFRA.  However, I found the table confusing and found the following graphic to be better in summarizing the leave scenarios.  I tried linking the actual picture but it is copyrighted so you'll have to click on the graphic link above.

Who Cares About Breastfeeding and the Working Mother?

This is a follow-up post to the one I wrote yesterday titled "Maternity Leave in the US is Pitiful Compared to Other Countries."  In that post I stated that shorter maternity leaves are associated with decreased breastfeeding.  We as a country need to push for better legislation to encourage longer maternity leaves which will increase breastfeeding rates.  However, why should someone who is not breastfeeding care?  Breastfeeding is in the best interest of the country as a whole and not just for women with babies.

In February, the American Academy of Pediatrics reaffirmed their breastfeeding guidelines.  They recommend "exclusive breastfeeding for about 6 months, followed by continued breastfeeding as complementary foods are introduced, with continuation of breastfeeding for 1 year or longer as mutually desired by mother and infant."  This recommendation is "supported by the health outcomes of exclusively breastfed infants and infants who never or only partially breastfed. Breastfeeding provides a protective effect against respiratory illnesses, ear infections, gastrointestinal diseases, and allergies including asthma, eczema and atopic dermatitis. The rate of sudden infant death syndrome (SIDS) is reduced by over a third in breastfed babies, and there is a 15 percent to 30 percent reduction in adolescent and adult obesity in breastfed vs. non-breastfed infants. Approximately 75 percent of newborn infants initiate breastfeeding."

The Department of Health and Human Services published a booklet entitled "The Business Case for Breastfeeding:  For Business Managers."  In this booklet, they make the case for supporting breastfeeding mothers by showing a "return of investment."  They state that:
1. "Breastfeeding employees miss work less often."  75% of mothers of formula fed infants missed 1 day of work due to an illness in their infant compared to 25% of mothers of breastfed infants.
2.  "Breastfeeding lowers healthcare costs.  Babies who are not breastfed visit the physician more often, spend more days in the hospital, and require more prescriptions than breastfed infants."
3. "Investing in a worksite lactation support program can yield substantial dividends to the company."  Lower turnover rates are a result.  "Employees are more likely to return to work after childbirth when their workplace provides a supportive environment for continued breastfeeding.  Being able to keep experienced employees after childbirth means lowering or eliminating the costs a company otherwise would incur to hire temporary staff or to recruit, hire, and train replacement staff, both of which involve additional lost revenue while getting these new staff up to speed."

Even the Centers for Disease Control (CDC) has published information in support of breastfeeding in the workplace.  Yet despite all of this information, many in the public do not understand the importance of breastfeeding and being able to continue pumping after a mother returns to work.

Breastfeeding is all about supply and demand.  If a mother is not able to express breastmilk while at work, her body will simply stop producing milk.  Pumping while at work will "trick" the body into thinking the baby is nursing.  Thankfully in March 2010, a new federal law went into effect which requires an employer to provide "a reasonable break time for an employee to express breast milk for her nursing child for 1 year after the child’s birth each time such employee has need to express the milk; and a place, other than a bathroom, that is shielded from view and free from intrusion from co-workers and the public, which may be used by an employee to express breast milk."

The National Conference of State Legislatures also has published a list of states and their individual laws regarding breastfeeding and pumping when at work.  Some states actually have better provisions than the federal requirements.  There are also 12 states that exempt breastfeeding mothers from jury duty.

Are you apprehensive about approaching your boss or employer about breastfeeding/pumping after returning to work?  The La Leche League has some helpful hints published on their website.  The United States Breastfeeding Committee also has some great resources for employers and employees about breastfeeding at work.  The U.S. Department of Health and Human Services Office on Women's Health is also a great resource.  It is also best to educate your co-workers about the importance of breastfeeding and the continuation of it after returning to work.  I breastfed my baby for 22 months and pumped at work until he was 18 months old.  It was important to me and I made it a point to inform my co-workers and my management about my intentions.  I think education is key to making the transition back to work easier and to facilitate the continuation of breastfeeding.