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Efforts to Encourage Breastfeeding Like the Baby-Friendly Hospital Initiative (BFHI) May Have Unintended Consequences

A brand-new newborn. According to BFHI rules, he must maintain continuous skin contact with Mom and start breastfeeding with in the first half hour.

A brand-new newborn. According to BFHI rules, he must maintain continuous skin contact with Mom and start breastfeeding within the first half hour.

“Breast is best,” but current efforts to increase the rate of breastfeeding may be misguided. A recent article in JAMA Pediatrics by pediatricians Joel Bass, Tina Gartley, and Ronald Kleinman is titled “Unintended Consequences of Current Breastfeeding Initiatives.” They criticize the Baby-Friendly Hospital Initiative (BFHI), saying “there is now emerging evidence that full compliance…may inadvertently be promoting potentially hazardous practices and/or having counterproductive outcomes.”

The BFHI

The Baby-Friendly Hospital Initiative was launched by WHO and UNICEF in 1991 and has been adopted in 152 countries. In the US it has been promoted as the standard of care by government agencies like the CDC and the Joint Commission, and has been implemented by a growing number of hospitals. The criteria for a hospital’s Baby Friendly accreditation include:

  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 half-hour of birth.
  5. Show mothers how to breastfeed and maintain lactation, even if they should be separated from their infants.
  6. Give newborn infants no food or drink other than breastmilk, not even sips of water, unless medically indicated.
  7. Practice rooming in – that is, allow mothers and infants to remain together 24 hours a day.
  8. Encourage breastfeeding on demand.
  9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants
  10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

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Posted in: Obstetrics & gynecology

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Questioning the Evidence for Breastfeeding

Breastfeeding_baby
Six years ago I wrote about the evidence for breastfeeding. I questioned an article that claimed 900 babies’ lives could be saved every year in the US if 90% of mothers breastfed for at least 6 months. I didn’t think that was true, but I did think the evidence supported the claim that breastfeeding was clearly better for babies. Now I’m not so sure we can trust that evidence.

A new study reevaluated the evidence from previous studies and found that the studies hadn’t adequately ruled out significant confounders. There are social, cultural and economic factors that contribute to the choice to breastfeed, factors that may have skewed the results of those studies to favor breastfeeding. The new study tried to correct for these issues.

Results from standard multiple regression models suggest that children aged 4 to 14 who were breast- as opposed to bottle-fed did significantly better on 10 of the 11 outcomes studied. Once we restrict analyses to siblings and incorporate within-family fixed effects, estimates of the association between breastfeeding and all but one indicator of child health and wellbeing dramatically decrease and fail to maintain statistical significance. Our results suggest that much of the beneficial long-term effects typically attributed to breastfeeding, per se, may primarily be due to selection pressures into infant feeding practices along key demographic characteristics such as race and socioeconomic status.

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Posted in: Nutrition

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Kangaroo Mother Care, Skin-To-Skin Contact, and the Risk of Sudden Unexpected Postnatal Collapse

Skin to skin sleeping baby
In January, a study published in Pediatrics, the American Academy of Pediatrics’ flagship peer-reviewed journal, presented evidence in support of Kangaroo Mother Care (KMC) and its primary intervention: prolonged skin-to-skin contact (SSC) between a mother and her newborn child. I was originally asked to discuss this report at the time by the editors of The Scientific Parent, which is a great resource by the way, but I wanted to expand on my initial thoughts after letting them simmer for a bit over the past few weeks. Please check out the great work done by Leslie and Julia over at TSP after you finish this post.
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Posted in: Science and the Media

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Separating Fact From Fiction in the Not-So-Normal Newborn Nursery: Pacifiers and Nipple Confusion

Pictured: Confusion

Pictured: Confusion

My first “real world” employment after completing residency was as a full-time newborn hospitalist in Houston. After spending three years in Space City, often rounding on as many as 30 newborn infants in the Level 1 and Level 2 units each day at the county hospital, I feel as if I’ve probably about seen it all when it comes to the nursery. I then left the babies behind while working as a pediatric hospitalist in Baton Rouge for four years, but now I’m back in the newborn business up here in Boston. While there have certainly been a few changes since 2009, many things remain exactly the same.

I help take care of a very vulnerable population in my current position: parents. Parents, in particular the young and first time variety, often approach parenting with a blank slate. Sure there is frequently a grandparent or four there for assistance, but the healthcare professionals working in the nursery are looked to for vital knowledge about how to care for the new arrival. Even some of the more experienced parents will still have questions, and most respect and follow the advice given during those first few days while at the hospital. These questions most commonly focus on topics such as feeding, vaccinations and vitamin supplementation, but I am regularly asked about a variety of routine parenting skills such as swaddling, and even baby “gear” like Angel monitors.

Parents love their children and want what is best for them, and they frequently express fear and anxiety over some of these topics. Love and fear are two powerful factors in the acceptance of pseudoscience and bad advice, which is why parents are set up to be fooled. Over the next few posts, I plan to cover some examples of newborn issues known to cause excessive parental anxiety and that sometimes lead to poor decisions, in large part because of bad information received from people who should know better.

First up is a concept that is well-known in the nursery, and strikes fear in the hearts of lactation consultants all over the world. I’m talking about nipple confusion. This is a concept that may seem silly to those unfamiliar with the world of parenting, but it is something that newborn doctors deal with daily and there is a great deal of controversy. Not “vaccines and autism” controversy unfortunately, but if after reading this post you find yourself feeling let down because I didn’t start with something sexier, take solace in the fact that winter is coming. (more…)

Posted in: Science and Medicine

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I Am Not Your Enemy: An Open Letter to My Feminist Critics

Note: The previous post is my usual weekly contribution to SBM. I am taking the liberty of posting this additional entry today on an issue that is peripheral to Science Based Medicine. If you are not interested in the recent squabbles within the skeptical movement, you will probably want to skip it. But it does respond to a detailed critique of an article I posted here two weeks ago, and some might find that of interest. We have seen the same kind of behavior on this blog, where commenters have responded not to what we said, but to what they wanted to believe we said.


I have been falsely identified as an enemy of feminism (not in so many words, but the intent is clear). My words have been misrepresented as sexist and misinterpreted beyond recognition. I find this particularly disturbing and hard to understand, because I’m convinced that my harshest critics and I are basically arguing for exactly the same things. I wish my critics could set aside their resentments and realize that I am not the enemy.

Two weeks ago I published an article on gender differences and the recent divisions in the skeptical community.  Ophelia Benson showed up in the comments. Not unsurprisingly, she disagreed with me about the Shermer incident, but then she said “I like the rest of this article a lot. I particularly like the point about averages and individuals, which is one I make all the time.”

I took that as a hopeful sign that friendly communication might be achieved, but my bubble was quickly burst by a hostile takedown of my article on Skepchick by “Will.”  His critique is demonstrably unfair. He attacks me for things I never said and tries to make it look like I believe the exact opposite of what I believe. (more…)

Posted in: Science and Medicine

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Breastfeeding Is Good but Maybe Not THAT Good

An article entitled “The Burden of Suboptimal Breastfeeding in the United States: A Pediatric Cost Analysis,” by Bartick and Reinhold, was published in Pediatrics 2010 April 5. According to this news report, it showed that 900 babies’ lives and billions of dollars could be saved every year in the U.S. if we could get 90% of mothers to breastfeed for at least 6 months. It says breastfeeding has been shown to reduce the risk of stomach viruses, ear infections, asthma, juvenile diabetes, Sudden Infant Death Syndrome and even childhood leukemia.

This new study did not provide any new evidence. It simply took risk ratios from a three year old government report, extrapolated, and estimated the costs.
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Posted in: Nutrition

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