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Surprises in the 2003 edition of The Breastfeeding Answer Book

Nancy Mohrbacher, IBCLC
Arlington Heights IL USA
From: LEAVEN, Vol. 39 No. 1, February-March 2003, pp. 3-7

How do you react when the breastfeeding information you’ve been giving mothers for many years suddenly changes? I face this every time we revise The Breastfeeding Answer Book, because a central part of our work is to question our assumptions. To do this, we examine the information in each chapter in light of current research and experience. Often we find that new information confirms what was previously written, but sometimes it does not. In my role as mentor to new lactation consultants, I like to quote Julian Huxley, a famous scientist who told his students around the turn of the 20th century, “During the next hundred years, half of what we know now will be proven wrong. Unfortunately, we don’t know which half.”

This idea applies well to a new field such as lactation. Although it can be exciting to be on the cutting edge of new understandings, it can also be disconcerting to realize how much we don’t know, and it can be difficult to accept changes as they occur. Here are a few examples of the many surprises you will find in the 2003 edition of The Breastfeeding Answer Book.

Nipple Shields

In my private practice, I often see mothers who quote outdated information that I wrote years ago. (I consider this a kind of poetic justice.) When this happens, I say, “Yes. We used to think that was true, but we have changed our thinking. And here’s why….” Probably the most common example of this is the use of nipple shields. In the past, LLL publications stated that “they usually cause more problems than they solve,” and in the previous edition of The Breastfeeding Answer Book, the use of nipple shields was mentioned for specific situations but always with reservations.

Throughout the 13 years I was an active LLL Leader, I cautioned mothers not to use nipple shields. If they were using them, I suggested weaning from them as quickly as possible. The thick, rubber nipple shields of that era were found to decrease milk supply (Woodridge 1980). A strong negative attitude was also a reaction to the overuse of nipple shields in many hospitals, where at one time they were given indiscriminately to every mother. However, newer silicone nipple shields that are now available have not been found to interfere with milk supply. Research has shown that they can be a useful tool to help babies breastfeed in certain situations. Some nipple shields, called “contact” nipple shields, have an open section for the baby’s nose to touch his mother’s breast so he can smell the breast and milk instead of rubber.

The pendulum began swinging toward the middle in 1996, when an issue of the Journal of Human Lactation featured a number of case reports in which the nipple shield was an essential element in a baby’s move to full breastfeeding (Bodley and Powers 1996; Brigham 1996; Clum and Primomo 1996; Elliott 1996; Sealy 1996; Wilson-Clay 1996; Woodworth 1996). A healthy debate began, and now the nipple shield is widely considered to be a legitimate breastfeeding aid product. But like any other product, it is important to use it wisely. The 2003 edition of The Breastfeeding Answer Book suggests the nipple shield as an option in the following situations after other strategies have been tried:

• latch-on problems;
• a baby with a tongue thrust, a retracted tongue, neurological problems, or a weak suck;
• a mother with inverted nipples;
• a premature baby who is not fully effective at the breast.

There is impressive evidence that suggests that premies are able to latch on more easily (Clum 1996) and take more milk from the breast when a nipple shield is used than when nursing from the bare breast. In one study of 34 premies (Meier 2000), the babies were able to take a significantly greater amount of milk with the shield than without and its use did not shorten the duration of breastfeeding. Although it is not yet known why the nipple shield works for premies, some think it helps to maintain the baby’s suck by staying more easily in the optimal part of the baby’s mouth, even when the baby is unable to generate strong suction (Meier 1999).

When a baby is having latch-on problems or is not yet breastfeeding effectively, one advantage to using a nipple shield is that the baby can get the mother’s milk through the holes at the tip of the shield, eliminating or reducing the need to express and feed the milk in another way. It also keeps the baby at the breast, which can be critical, because if a baby adjusts to another feeding method for an extended period of time, the transition to the breast may be more difficult. This is true no matter which feeding method is used.

The revised Breastfeeding Answer Book also includes vital information on how to:

• choose the right size nipple shield;
• apply the nipple shield to the breast;
• latch the baby effectively onto the breast with a nipple shield; and
• wean the baby off the nipple shield when the time is right.

Rather than encouraging a mother to wean from the nipple shield as quickly as possible, it is currently suggested that mothers use the nipple shield as long as the baby needs it, which may be days, weeks, or, rarely, months. When babies are allowed to use the nipple shield until they’re ready to wean from it, research indicates that they don’t become dependent on the nipple shield to breastfeed, as many experts previously believed (Meier 2000).

Premature Babies

It was a pleasure to include information on the work of Nils Bergman, MD, whose revolutionary approach to kangaroo care, which he calls “Kangaroo Mother Care,” has significantly lowered infant mortality in Zimbabwe (Bergman and Jurisoo 1994). Dr. Bergman’s work offers a new interpretation that has the potential to improve the care of premature babies everywhere.

Dr. Bergman suggests that human babies—like the babies of other mammals—are born with certain programmed behaviors that lead to the successful beginning of breastfeeding and elicit nurturing behavior in the mother to enhance their close relationship, both of which are essential to a baby’s survival and growth. Using biologists’ description of babies’ changing environments (womb, mother’s body, family, the world) as “habitats,” in which the baby is programmed to behave in a certain way to have his needs met, Dr. Bergman emphasizes the importance of keeping baby in his natural “habitat” after birth, i.e., on the mother’s body, so that these fragile natural behaviors and responses are appropriately triggered.

He also describes the baby’s (and all other mammals’) physical reaction when removed from his natural “habitat.” This is called the “protest-despair response,” which helps to ensure survival by decreasing energy consumption and growth via lowering heart rate and body temperature and massively increasing the production of stress hormones (Alberts 1994). Once mother and baby are reunited, baby’s heart rate and body temperature increase and stress hormones decrease.

Research has found that skin-to-skin contact of mother and baby reduces the production of stress hormones by 74 percent (Modi and Glover 1998; Mooncey 1997). High levels of stress hormones inhibit gut function, digestion, and growth. Dr. Bergman observes that what is currently considered to be the “normal ranges” of heart rate, temperature, and stress hormones of premies in incubators reflect this “protest-despair response,” and that what is truly normal needs to be redefined based on a premie’s physiological norms when in skin-to-skin contact with his mother.

In Zimbabwe, where no incubators were available, when Kangaroo Mother Care began to be used at birth for all premies, survival rates jumped from 10 percent to 50 percent for babies with birth weights between 1,000 grams and 1,500 grams (2.2 to 3.3 pounds) and from 70 percent to 90 percent for babies with birth weights between 1,500 grams and 2,000 grams (3.3 to 4.4 pounds). In areas of the world where neonatal support technology is not available, it is estimated that Kangaroo Mother Care could save a million lives every year. In areas where such technology is available, the recognition of these natural responses of the premie to his “habitat” may lead to a redefinition of normal physiological responses and an appreciation of the urgent need of the vulnerable premie for physical closeness with his mother to avoid or minimize the significant physical stresses associated with separation.

But the implications of this paradigm may be even broader. According to Dr. Bergman, “though Kangaroo Mother Care started for prematures, it is how all newborns should be treated.” For more information, see the Web site:
www.kangaroomothercare.com/

Latch-On and Breast Compression

Two other significant changes in information—the asymmetric latch-on and breast compression—have the potential to affect nearly every breastfeeding mother and baby.

In years past, the standard recommendation was to “center the nipple” in the baby’s mouth at latch-on, but time, observation, and trial and error have convinced many that for a latch-on to be as effective and comfortable as possible, the baby’s lower jaw needs to be positioned as far back on the breast as possible. Known as the “asymmetrical” latch-on, bringing the baby onto the breast chin first allows the tender nipple to extend more easily back to the “comfort zone” in the baby’s mouth, where the hard and soft palates meet (Royal College of Midwives 2002; Eastman 2000; Newman and Pitman 2000). With the nipple in this spot, breastfeeding is more comfortable for the mother and more effective for the baby.

Many experienced breastfeeding counselors have found that when an asymmetrical latch-on is used in combination with a technique called “breast compression,” a multitude of problems can be solved with a minimum of intervention. Potentially serious problems such as slow weight gain, exaggerated newborn jaundice, and many more can often be overcome simply by using these two techniques together. Breast compression, which was popularized by Jack Newman, MD (Newman and Pitman, pp. 81-83), replaces “super switch nursing” in the 2003 edition as a technique to keep baby active at the breast and improve milk intake at feedings. Breast compression is described in detail in both the “Positioning” and the “Weight Gain” chapters.

The “New Pessimism” and the “New Optimism”

Paradigm shifts have occurred in our thinking regarding two special situations: breastfeeding the baby with a cleft palate and induced lactation.

While the prevailing wisdom was once that the baby with a cleft palate could exclusively breastfeed if the cleft was not too extensive and mother was motivated and used good technique, research since the last edition (Turner 2001; Kogo 1997) and the experiences of mothers who have attempted this with their own babies (Miller 1998), indicate that exclusive feeding at the breast is rare due to the baby’s inability to generate and maintain suction. A “new pessimism” is reflected in the 2003 edition to give mothers more realistic expectations of what their babies can do at the breast. Establishing a full milk supply via an effective method of milk expression is the first step. With a full milk supply, a mother can feed her baby who has a cleft palate exclusively with human milk. However, a mother needs to realize that only a small percentage of babies with cleft palates will be able to feed exclusively at the breast. The majority of these babies will only be able to exclusively breastfeed after their cleft palate repair surgery. In many areas, this surgery is not scheduled until the baby is a year or older.

On the other hand, a “new optimism” is dawning with regard to induced lactation. In the “Relactation and Adoptive Nursing” chapter of the previous edition, it was suggested that mothers wanting to nurse their adopted baby be told that few mothers in this situation produce a full supply and to consider breastfeeding as a way to be close to their baby and any milk the baby receives as a “bonus.” Several things have changed. First, we can no longer use the terms “adoptive nursing” and “induced lactation” interchangeably. With advances in reproductive technology, some women wanting to induce lactation are having their own biological children via surrogate mothers. Second, protocols are being refined involving the use of the same hormones that stimulate breast tissue growth during pregnancy to “grow” a mother’s breast tissue while she waits for her baby (Goldfarb and Newman 2002). Reports indicate that depending on the number of months between the time a mother starts these protocols and the arrival of her baby, she may be able to exclusively breastfeed from the moment the baby is placed in her arms. Third, research from other countries indicates that by simply breastfeeding their baby eight to 10 times per day that some women are capable of bringing in a full milk supply within a month even without the use of hormones (Abejide 1997).

HIV/AIDS

Reviewing the most current information about HIV was extremely difficult, partly because it is a complicated subject with volumes of studies to read, but mostly I cannot read about HIV and AIDS without dwelling on the deaths so many mothers and babies worldwide. There is no topic today that is more important or that has a greater impact on our world.

One ray of hope emerged amidst the tragedy. A ground-breaking study indicates that mother-to-child transmission is no greater during the first six months when an HIV-positive mother exclusively breastfeeds than when her baby receives only formula (Coutsoudis 2001). Higher rates of HIV transmission appear to occur only when a baby receives mixed feedings, which is common practice even in Africa where breastfeeding is the norm. When I read this study, I realized that all the previous recommendations were based on the assumption that breastfeeding itself was the cause of the higher rate of transmission observed in breastfeeding babies. It now appears that if cultural norms can be changed to encourage exclusive breastfeeding for the first six months, mothers in developing nations may no longer be faced with the terrible choice of 1) breastfeeding and increasing the risk of HIV transmission to the baby or 2) artificially feeding and increasing their baby’s risk of death through infection and disease. We hold our collective breath as we await more research on this critical subject.

Breast Anatomy, Physiology, and Milk Supply

Who could have imagined that our understanding of breast anatomy and physiology would change so drastically within the past six years? Literally all the charts and diagrams depicting the inside of the breast are being redrawn, thanks to the work of Dr. Peter Hartmann and his research team from Perth, Australia.

In the older, now obsolete, diagrams of the interior of the breast, which were based on drawings made in the 1840s from experiments done when hot wax was injected into the breasts of lactating cadavers, the lobes, lobules, and alveoli looked something like stalks of broccoli. The bunches of alveoli drained in an orderly fashion into smaller ducts, which then branched into larger ducts, which ballooned into the milk sinuses near the nipple, which then narrowed again, ending in the nipple pores. When researchers today examine the live lactating breast with ultrasound, however, they describe the glandular tissue of the breast as looking disorderly, more like the roots of a tree, with many small milk ducts intertwined with one another. Most surprising of all, the “milk sinuses,” which previously explained many of our observations about how breastfeeding and hand expression work, do not appear to exist (Kent 2002). Clearly we have a lot of rethinking to do about how its form affects the function of the breast. In the meantime, we are excited that the 2003 edition of The Breastfeeding Answer Book will be the first book featuring these new pictures and descriptions of the interior of the breast.

In addition to their groundbreaking work on breast anatomy, Dr. Hartmann and his team have also changed our understanding about milk supply. We used to recommend that a mother wanting to increase her milk supply increase her number of feedings. Dr. Hartmann’s research indicates, however, that after the first month, a mother may more effectively increase her milk supply by draining the breast more fully at each feeding. Also new are the findings about the effects of “milk storage capacity” on milk supply and its effect on a baby’s number of feedings per day (Daly 1996; Daly 1993). This new information is helping us to develop a clearer understanding of why some mothers need to nurse their babies every two hours throughout the night for many months, while other mothers and babies enjoy longer sleep stretches. (Short answer: Babies whose mothers can comfortably hold more milk take more milk at each feeding and need fewer feedings per day.)

Also relating to milk supply, since the previous edition the use of both prescribed and herbal galactagogues (milk-increasing substances) has become commonplace. The 2003 edition covers most options and lists dosages, as well as giving an overview of the research and anecdotal information. One of our many reviewers was Diana West, IBCLC, author of LLLI’s excellent book, Defining Your Own Success: Breastfeeding After Breast Reduction Surgery (BFAR). In her work with BFAR mothers around the world through her Web site www.bfar.org, West brings a broad perspective on the use of these substances and their effects on the mothers who use them. Commentaries on fenugreek, blessed thistle, metoclopramide, domperidone, and others are included in the new Breastfeeding Answer Book.

Nipple Confusion

The language on this controversial topic has been softened in this edition to reflect the fact that “nipple confusion” has been used to describe a variety of situations. There is a lack of consensus as to what it really means. One Swedish study found that the early use of pacifiers was associated with incorrect sucking technique and that mothers tended to breastfeed for shorter periods when the baby had already become used to bottle-feeding (Righard 1998). On the other hand, some authors suggest that when specific techniques and specific nipples are used, a bottle can be “a tool to reinforce breastfeeding” for some babies having feeding difficulties (Kassing 2002; Noble and Bovey 1997). One recent review of the literature (Dowling and Thanattherakul 2001) examined the evidence for and against nipple confusion and concluded: “The relationship between exposure to artificial nipples and pacifiers and the development of the aversive feeding behaviors associated with nipple confusion is neither refuted nor supported in the research literature.”

Other Hot Topics

The list of hot topics covered in the 2003 edition is long. Which of the following would you like to know more about?

• The debate about vitamin D supplementation for the breastfeeding baby.
• New treatments for nipple pain and trauma, such as gel pads, hydrogel dressings, topical over-the-counter antibiotic ointments, and prescribed nipple ointments.
• New recommendations from the World Health Organization on the timing of starting solids.
• A new treatment option for allergic babies that does not involve restricting mother’s diet.

An entirely new section has been added to the “Breastfeeding Basics” chapter about breastfeeding in emergency situations, such as war, famine, earthquake, and other natural disasters. Because infant mortality related to formula-feeding has been found to increase by as much as twenty-five fold during relief efforts (UNICEF 1990), this new section also includes information on international guidelines that restrict the distribution of formula in these areas.

This One’s for You

With these changes and many more, this revision has been a huge undertaking. But it has also been very gratifying. When my co-author Julie Stock and I wrote the first edition of The Breastfeeding Answer Book in 1991, our goal was to create a comprehensive resource that would include all the hard-to-find breastfeeding information in one volume. Although some of what you find in this new edition may shock and surprise you, we’re hoping that it does an even better job of meeting this goal. Our hope is to provide you with cutting-edge information in an easy-to-use format to bring you up to date and make your job as an LLL Leader easier.

References

Abejide, O. et al. Non-puerperal induced lactation in a Nigerian community: case reports. Ann Trop Paediatr 1997; 17:109-14.
Alberts, J. Learning as adaptation of the infant. Acta Paediatr Suppl 1994; 397:77-85.
Bergman, N. and Jurisoo, L. The “Kangaroo-method” for treating low birth weight babies in a developing country. Trop Doctor 1994; 24:57-60.
Bodley, V. and Powers D. Long-term nipple shield use—A positive perspective. J Hum Lact 1996; 12:301-04.
Brigham, M. Mothers’ reports of the outcome of nipple shield use. J Hum Lact 1996; 12:291-97.
Clum, D. and Primomo, J. Use of a silicone nipple shield with premature infants. J Hum Lact 1996; 12(4):287-90.
Coutsoudis, A. et al. Method of feeding and transmission of HIV-1 from mothers to children by 15 months of age: prospective cohort study from Durban, South Africa. AIDS 2001; 15(3):379-87.
Daly, S, et al. Frequency and degree of milk removal and the short-term control of human milk synthesis. Exp Physiology 1996; 81(5): 861-75.
Daly, S., et al. The short-term synthesis and infant-regulated removal of milk in lactating women. Exp Physiology 1993; 78:209-20.
Dowling, D. and Thanattherakul, W. Nipple confusion, alternative feeding methods, and breast-feeding supplementation: state of the science. Newborn and Infant Nurse Review 2001; 1(4):217-23.
Eastman, Andrea. The mother-baby dance: positioning and latch-on. LEAVEN 2000; 16(4):63-68.
Elliot, C. Using a silicone nipple shield to assist a baby unable to latch. J Hum Lact 1996; 12:309-13.
Fisher, C. and Inch, S. Nipple confusion—who is confused? J Pediatr 1996; 129(1):174-75.
Goldfarb, L. and Newman, J. The protocols for induced lactation: a guide for maximizing breastmilk production, 2002. www.asklenore.info.
Kassing, D. Bottle-feeding as a tool to reinforce breastfeeding. J Hum Lact 2002; 18(1):56-60.
Kent, J. Physiology of the expression of breast milk, part 2.. Presented at the Medela Innovations in Breast Pump Research Conference, Boca Raton, Flordia, July 2002.
Kogo, M. et al. Breast feeding for cleft lip and palate patients, using the Hotz-type plate. Cleft Palate-Craniofac J 1997; 34(4):351-53.
Meier, P. Nipple shields for preterm infants: effect of milk transfer and duration of breastfeeding. J Hum Lact 2000; 16(2):106-14.
Meier, P. et al. “Breastfeeding the preterm infant.” In Breastfeeding and Human Lactation, 2nd ed., eds. J. Riordan and K. Auerbach. Boston and London: Jones and Bartlett, 1999, pp. 449-81.
Modi, N. and Glover, V. Non-pharacological reduction of hypercortisolaemia in preterm infants. Infant Behav & Dev 1998; 21:86.
Mooncey, S. et al. The effect of mother-infant skin-to-skin contact on plasma cortisol and beta-endorphin concentrations in preterm newborns. Infant Behav & Dev 1997; 20:553.
Newman, J. and Pitman, T. The Ultimate Breastfeeding Book of Answers. Roseville, California: Prima, 2000, pp. 55-66, 81-83.
Noble, R. and Bovey, A. Therapeutic teat use for babies who breastfeed poorly. Breastfeed Rev 1997; 5(2):37-42.
Righard, L. Are breastfeeding problems related to incorrect breastfeeding technique and the use of pacifiers and bottles? Birth 1998; 25(1):40-44.
Royal College of Midwives. Successful Breastfeeding, 3rd ed. London: Churchill Livingstone, 2002, pp. 49-50.
Sealy, C.N. Rethinking the use of nipple shields. J Hum Lact 1996; 12: 299-300.
Turner, L. et al. The effects of lactation education and a prosthetic obturator appliance on feeding efficiency in infants with cleft lip and palate. Cleft Palate-Craniofac J 2001; 38(5):519-24.
UNICEF. The State of the World’s Children 1990. Oxford, England: Oxford University Press, 1990.
Wilson-Clay, B. Clinical use of silicone nipple shields. J Hum Lact 1996; 12(4):279-85.
Woodworth, M. and Frank E. Transitioning to the breast at six weeks: use of a nipple shield. J Hum Lact 1996; 12: 305-07.
Woolridge, M. et al. Effect of a traditional and a new nipple shield on sucking patterns and milk flow. Early Human Dev 1980; 4:357-62.

Nancy Mohrbacher, co-author of The Breastfeeding Answer Book, has been an accredited La Leche League Leader since 1982 and is currently on Leader Reserve. An IBCLC since 1991, Nancy is a lactation consultant in private practice in the suburbs of Chicago, Illinois, USA and lives with her husband, Michael, her three sons, Carl, Peter, and Ben, and her granddaughter, Kayla Nancy Mohrbacher, who is two-and-a-half.

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