Where We're At

There is much to celebrate in the breastfeeding world in regard to the world-wide increase in initiation rates (let's ignore Ireland's abysmal 47%). Alas, such numbers plummet as we speak about duration rates. Canada's disappointing record of 17% of babies exclusive breastfeeding at 6 months[12] is matched in many European countries, and USA and others are lower still. This is both strange and concerning in light of the World Health Organization's call for exclusivity to around 6 months. Do we not have enough marketing out there to demonstrate the importance of breastfeeding and the risks of not breastfeeding? Is it that mothers are not trying hard enough to make it work?

In fact, we have done a great job with our marketing - the initiation rates prove that. And many countries around the world have made great advances in ensuring babies have the right to breastfeed anywhere. Like childbirth, the reclaiming of breastfeeding as a woman's right has been a slow one but it has made concrete and substantial progress. There is still a significantly long road ahead, to be sure, and we will get there - of that I am confident.

The Issue of Support
This brings us to my second point, so let's get the record straight: mothers are trying hard enough - some (like patients in the clinic where I work) are visiting up to 9 practitioners just to get the breastfeeding help they need. The challenge is, though we encourage mothers to breastfeed, we don't always make it easy for them to do so: Birthing has become medicated all too frequently and studies are starting to reveal the adverse effects of this highly medicalized birthing model on the process of breastfeeding.[13],[14] Despite improving federal policies, on a micro level we still tend to make our public environments non-breastfeeding friendly by admonishing mothers when they breastfeed in places like airplanes, museums, swimming pools and restaurants, and we provide them with very little support on the how-to part of this natural-process-but-learned behaviour.

It is on this last point that I will focus these next few blog posts: the support, or lack of good support we give mothers who choose to breastfeed. This 'support' comes in many forms, too many to delve into in this article and many that will eventually work themselves out as the marketing of breastfeeding continues to snowball and win over the nay-sayers and the practitioners who claim: 'hey, I wasn't breastfed and look at me, I'm just fine' (see James Akre's The Problem with Breastfeeding[15] - it's an easy read which elegantly addresses this point). The kind of support I am most concerned about is that which is given in the guise of expert advice or care and yet is anything but. This support usually comes from nurses and lactation consultants and often from midwives and doctors. It comes from a lack of solid education in breastfeeding and lactation medicine. That so many practitioners put so little importance on breastfeeding is a significant part of the issue, to be sure (though obviously this cannot be said of all midwives, doctors, and lactation consultants). And even more, though they might believe in the importance of breastfeeding, many practitioners don't have faith in breastfeeding as a way to sustain life and help perpetuate the species. The fact that we are almost 7 billion strong demonstrates breastfeeding must be somewhat responsible in perpetuating our species - remember, commercially-prepared artificial baby milks have only been around for a relatively short while. In fact, up until very recently, few babies ever received any breastmilk substitutes, therefore it is safe to say that statistically speaking, almost every human being that has ever walked this earth was breastfed.

So back to the issue of support. Let me extend kudos to the practitioners who do make it their responsibility to stay updated with their skills and who are never afraid to say, 'I don't know how to fix this, let's refer you to someone who may.' The problem, however, lies in the numerous practitioners lacking proper training and education - or those underutilizing the training they dohave - and instead rely upon tools and gadgets to augment their breastfeeding support. Unfortunately, nothing can replace good hands-off/hands-on training and mothers far and wide are suffering from practitioners' ill-equipped attempts to mimic this type of support. Over the next few months I will share with you my thoughts around how and where we fail when it comes to getting mothers and babies off to the best start.

Support Pitfall #1 ~ Lack of Skin to Skin Contact: Early Separation/ Rooming in/Swaddling:
Rooming-in has become the norm in Canada for the most part, (thanks largely to The Baby Friendly Hospital Initiative - BFI[16], [17]) though all too often babies are removed from their mothers at night 'to give their mothers some rest.' In fact, an alarming but well-intentioned, non-evidenced based new programme is now in place in Toronto, Canada that separates mothers and babies for 5 nights where there is a concern or suspected risk of postpartum depression. All this in the face of tremendous research with overwhelming and compelling evidence that goes against such practices[18],[19],[20],[21],[22],[23].

In fact, immediately after birth, babies do best when placed skin-to-skin (SSC - skin-to-skin care/contact[24]) with their mothers for many hours throughout the day not just during feedings but in between feedings as well[25]. Yet in most hospitals in the US, babies are kept either separated from their mothers or are kept swaddled in blankets. In Canada, though most hospitals have made great strides toward SSC, many nurses still teach mothers how to wrap and swaddle babies in 2 or even 3 blankets to ensure baby stays warm instead of spending time teaching about the benefits of SSC (even though the evidence on SSC clearly shows that babies stay warmer when SSC with their mothers[26]). With breastfeeding, we want to ensure baby and mother achieve the best latch possible (more on that in the next blog). Imagine how challenging it is to latch a crying bundle with all those blankets in the way! When babies are kept SSC their SCRIP scores (stability of the cardiorespiratory system in premature infants36)are stabilized. Likewise, most mothers do better when their babies are with them; they witness less crying in their babies and breastfeeding gets off to the best start[27],[28],[29],[30],[31],[32],[33]. As importantly, when baby is SSC with mother, the baby will behave in a way which is neurologically appropriate for a newborn - waking when appropriate and cueing when hungry[34]. The baby who is wrapped or swaddled tends not to cue early, and, it is suggested, is more likely to sleep through his/her hunger, 'content to starve,' as the old paediatric adage goes. Or, they sleep so long and then when woken, are so desperately hungry they cry inconsolably and often refuse to eat. Conversely, SSC ensures timely waking and feeding. There are many recommendations for baby-led feeding and certainly SSC makes it increasingly possible.

Paediatrician and public health specialist, Dr. Nils Bergman speaks about placing baby in the correct habitat[35] so that s/he can behave in a way which is neurologically appropriate[36]. Dr. Bergman suggests that when babies are wrapped or swaddled their behaviour changes and becomes conservationist (of their energy - they shut down, and seem to sleep but really are doing nothing of the sort) or becomes desperate (they utter distress cries)[37]. Furthermore, when a baby is placed skin to skin with his mother he will find the way to the breast on his own and begin the 'breastfeeding process' (exchange of necessary sensory information[38]) well before actual sucking begins. This journey and subsequent sucking at the breast is critically important for baby's neurological organization and survival.

A baby will behave like a baby when in the habitat of her parent's body, especially her mother's. Wrapping or swaddling babies is an unfounded practice that needs to go and this applies to babies whose mothers do intend to breastfeed and even more so for those who don't. If we want babies and babies' brains[39] to have a healthy start it is crucial we help them get to the starting line. And as for establishing breastfeeding? Skin to skin! Provide the vehicle, and they will know the way.

[1]Breastfeeding Initiation in Canada: Key statistics and graphics 2007-2008 www.hc-sc.gc.ca

[2]Chalmers B et al. Breastfeeding rates and hospital breastfeeding practices in Canada: A national survey of women. Birth 2009, June;36(2)122-132

[3]Australian National Breastfeeding Strategy. 2009, Commonwealth of Australia on behalf of the Australian Health Ministers Conference (2009)

[4]Breastfeeding and Weaning Practices in New Zealand: Breastfeeding and Prenatal Nutrition Issues. Nutrition Research Newsletter. Aug 2002

[5]New Zealand Ministry of Health (2007) www.moh.govt.nx/moh.nst/index.mh/heha-nations-breastfeeding-campaign

[6]Centres for Disease Control and Prevention. www.cdc.gov/breastfeeding/data/NIS_data/index.htm

[7]Yngve & Sjostrom. Breastfeeding in countries of the EU and EFTA: Current and proposed recommendations, rationale, prevalence, duration and trends. Public Health Nutrition 4(2B)631-645

[8]Cattaneo et al. Protection, promotion and support of breastfeeding in Europe: Current situation. Public Health Nutrition 2005 8:39-46

[9] www.breastfeeding.ie/policy-strategy (2008)

[10]Tarrant & Kearney. Session 1:Public health nutrition. Breast-feeding practices in Ireland. Proc Nutr Soc 2008 Nov;67(4) 371-80

[11] www.breastfeeding.ie/policy-strategy (2008)

[12]It is important to note that many countries are still suggesting solid foods be introduced at 4 or 4-6 months and so this column might be somewhat skewed. Often the number will refer to any breastfeeding. Stats on true exclusivity are difficult to obtain. The stats do show, however, that even at 3 months, there is not much difference between 3 and 6 months when referring to exclusivity.

[13]Kroeger M & Smith LJ Impact of Birthing Practices on Breastfeeding: Restoring the Mother-Baby Continuum Boston, MA: Jones & Bartlett Publishers, 2004

[14]Ransjo-Arvidson, AB Matthiesen AS, Lilja G, Nissen E, Widstrom AM, Uvnas-Moberg K. Maternal analgesia during labour disturbs newborn behaviour: effects on breastfeeding, temperature, and crying. Birth. 2001; 28 (1): 5-12

[15]Akre, James, The Problem With Breastfeeding: a Personal Reflection, Hale Publishing, 2006

[16]The Baby Friendly Initiative's Ten Steps help to ensure rooming in is secure. However, so few North American hospitals have earned this accreditation.

[17]Pincombe J, Baghurst P, Antoniou G, Peat B, Henderson A, Reddin E. Baby Friendly Hospital Initiative practices and breast feeding duration in a cohort of first-time mothers in Adelaide, Australia Midwifery. 2006

[18]Buranasin B. The effects of rooming-in on the success of breastfeeding and the decline in abandonment of children. Asia Pac J Public Health. 1991;5(3): 217-20.

[19]Song JE. A comparative study on the level of postpartum women's fatigue between rooming-in and non rooming-in groups. Korean J Women Health Nurs. 2001;7:241-255.

[20]Kim ES, Park YS. The effect of rooming-in on maternal attitude and self confidence for infant care among primiparas. Korean J Women Health Nurs. 2001;7:256-270.

[21]Song JE, Lee MK, Chang SB. Differences of maternal fetal attachment between the rooming-in and non-rooming in groups of postpartum women. J Korean Acad Nurs. 2002;32:529-538.

[22]Kjellmer I, Windberg J. The neurobiology of infant-parent interaction in the newborn: an introduction. Acta Paediatr Suppl 1994; 397:1-2.

[23]Hofer MA. Early relationships as regulators of infant physiology and behaviour. Acta Paediatr 1994; Suppl 397: 9-18.

[24]This kind of care is based on KMC (Kangaroo Mother Care) started in Bogotá, Columbia by Dr. Rey and Dr. Martinez, 1979

[25]Bystrova K, Matthiesen AS, Widstrom AM, Ransjo-Arvidson AB, Welles-Nystrom B, Vorontsov I, Uvnas-Moberg K. The effect of Russian Maternity Home routines on breastfeeding and neonatal weight loss with special reference to swaddling. Early Human Develop. 2007; 83:29-39

[26]Anderson GC, Moore E, Hepworth J, Bergman N. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev. 2003;(2):CD003519

[27]Nissen E, Lilja G, Widstrom AM, Uvnas-Moberg K. Elevation of oxytocin levels early post partum in women. Acta Obstet Gynecol Scand. 1995; 74(7): 530-3.

[28]Boutet C, Vercueil L, Schelstraete C, Buffin A, Legros JJ. Oxytocin and maternal stress during the post-partum period. Ann Endocrinal (Paris). 2006; 67(3): 214-23

[29]Christensson K, Siles C, Moreno L, Belaustequi A, De La Fuente P, Lagercrantz H, Puyol P, Winberg J. Temperature, metabolic adaptation and crying in healthy full-term newborns cared for skin-to-skin or in a cot. Acta Paediatr. 1992; 81: 488-493.

[30]Michelsson K, Christensson K, Rothganger H, Winberg J. Crying in separated and non-separated newborns: sound spectrographic analysis. Acta Pediatr 1996; 85(4): 471-5

[31]Rapley G. Keeping mothers and babies together - breastfeeding and bonding. RCM Midwives.2002 Oct; 5(10): 332-4

[32]Vaidya K, Sharma A, Dhungel S. Effect of early mother-baby close contact over the duration of exclusive breastfeeding. Nepal Med Coll J. 2005;7(2):138-40

[33]Rapley G. Keeping mothers and babies together - breastfeeding and bonding. RCM Midwives.2002 Oct; 5(10): 332-4

[34]Hofer MA. Early relationships as regulators of infant physiology and behaviour. Acta Paediatr 1994; Suppl 397: 9-18.

[35]Bergman NJ, Linley LL, Fawcus SR. Randomized controlled trial of skin-to-skin contact from birth versus conventional incubator for physiological stabilization in 1200- to 2199-gram newborns. Acta Pediatr 2004; 93 (6): 779-85.

[36]Ferber SG, Makhoul IR. The effect of Skin-to-Skin Contact (Kangaroo Care) Shortly After Birth on the Neurobehavioural Responses of the Term Newborn: A Randomized, Controlled Trial. Pediatrics 2007; 113: 858-865

[37]Bergman NJ, Jurisoo LA. The 'kangaroo-method' for treating low birth weight babies in a developing country. Trop Doct 1994; 24(2): 57-60.

[38]McKenna JJ, Thoman EB, Anders TF, Sadeh A, Schechtman VL, Glotzbach SF. Infant-parent co-sleeping in an evolutionary perspective: implications for understanding infant sleep development and the sudden infant death syndrome. Sleep 1993; 16(3): 263-82.

[39]Schore AN. Effects of a secure attachment relationship on right brain development affect regulation, and infant mental health. Infant Mental Health Journal 2001; 22(1-2): 7-66

Posted by: Edith Kernerman, IBCLC, NBCI

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