Posted in Breastfeeding and Childcare

Resources for the safe use of medications in pregnancy and lactation

All too often, breastfeeding mothers are told to stop breastfeeding because they need to be on a medication that is thought to be harmful to the baby. Or mothers are advised to “pump and dump” – feed their baby an alternative (donor milk/formula), express their own milk and throw it away in order to maintain their milk supply while on the prescribed drug.  For many, this interruption which usually occurs during the early few weeks when breastfeeding is being established, is sufficient to sabotage the entire effort.

To be fair, the information on drugs in breastfeeding that has been available to most doctors in the past is quite limited. Many doctors will give the advise that they give because they feel it is the safest one for the baby. After all, most drug labels warn against their use during lactation. And since carrying out research on breastfeeding mothers and their infants is frowned upon by the scientific community, there has not been a lot of data available on the true safety of these drugs.  This puts mothers who need treatment and doctors who want to provide it, in a challenging situation.

The study of the transfer of drugs from mother to baby through her breast milk is a complex one. Not all medications are the same, and their transfer and effects depend on many factors. In general, most drugs that nursing mothers ingest will show up in their breast milk. However, the amount found in breastmilk is usually not more than 1% of the dose ingested by the mother.  (Lawrence R.  Breastfeeding: A Guide for the Medical Profession. 2011) That amount of drug is generally too small to be of any real consequence.

Thankfully, there are more resources available to us now than in the past. There is a more concerted effort to identify which medications are truly harmful to a nursing infant, and there are more resources and references available to mothers and medical professionals alike.

1. In August 2013, the American Academy of Pediatrics published an update to its guidelines in the article The Transfer of Drugs and Therapeutics into Human Breast Milk: An Update on Selected Topics.  In essence, the AAP states that most medications are likely safe for breastfeeding mothers. There is some debate regarding the AAP stand on galactagogues like domperidone (see Dr. Jack Newman’s comments on this here) but for the most part, it is a helpful reference.

2. The online resource LactMed is free to use and has a handy downloadable app.  Simply type in the name of the drug you are searching for and it will bring up the available information.

3. Dr. T.W. Hale, author of Medications and Mother’s Milk, has recently released a new app for the iphone and android called InfantRiskCenter.  The app costs $9.99 to download and is the most comprehensive database I’ve seen so far. The format is great – simple and easy to read, and there is information is specific to your trimester in pregnancy or the age of the baby you are nursing.

These resources were really made for the use of medical professionals, so please do not self-medicate or self-diagnose. But if you are a nursing mother and being told to stop breastfeeding because you need to take a medication that is deemed “safe” or “probably safe” by one of these references, please share it with your doctor.

Posted in Breastfeeding and Childcare, Health

The root of the MMR-Autism debate

I found this great graphic article through a friend. It is a wonderfully concise yet thorough explanation of the MMR-Autism controversy, beginning with Dr. Andrew Wakefield’s now-debunked “landmark study”. It explains how and why he faked his results, and what the consequences of his irresponsible actions have been. A good read for those who are still confused, or who still believe there is a link between Autism and the MMR vaccine.

Click on the link below to read the article.

The facts in the Case of Dr. Andrew Wakefield – Darryl Cunningham

Breast Anatomy and the Letdown Reflex

Click to see the video: Breast Anatomy and the Letdown Reflex

I haven’t posted anything in ages but today I was watching a video on Khan Academy and found this cool video that very clearly explains breast anatomy. There is a subsequent video that goes through the Letdown Reflex as well. It is a bit technical (they are made by the Stanford School of Medicine) but is the simplest and clearest one I have seen so far. Sharing them here for those who may find the information useful!

Posted in Breastfeeding and Childcare

Why mix feeding during a disaster is a very bad idea

This is my third post on this topic and my original post on protecting babies during emergencies contains greater detail but I felt the need to emphasize just a few points.

1. Formula is never safer than breastfeeding, and the dangers of formula feeding greatly increase in situations where families are displaced (natural disasters, war, etc).

2. A mother who begins mix feeding during a crisis situation will most likely continue mix feeding even when the crisis is over.  Mix feeding results in a decreased demand on the mother to produce breastmilk, which results in a decreased supply.  This makes returning to exclusive breastfeeding after the event more difficult and less likely.

3.  Mothers who receive free infant formula may not have to worry about purchasing formula during the time they are receiving donations but once they return to their homes they will have to continue to purchase formula until their infant turns 1.  Few Filipino families can afford to do this without sacrificing other basic needs.

4.  Mothers who are displaced are more likely to prepare formula improperly (dilute the powder) in order to make it last longer.  This puts the infant at risk of malnutrition.

5.  Infants who are formula-dependent require an uninterrupted supply of formula and clean water.  This is difficult to ensure during times of disaster particularly when the duration of displacement is uncertain.   Exclusive breastfeeding ensures that babies have a protected source of nutrition to which they have full access.

Protecting breastfeeding and supporting displaced mothers so that they continue to breastfeed is not cruel.  It is in the best interest of both mother and child. 

Posted in Breastfeeding and Childcare

The Fourth Trimester – AKA: Why Your Newborn is Only Happy in Your Arms.

Tips I often recommend to patients and friends and that I found extremely useful with my own children. I went from buying every device in the store for my firstborn (vibrating chair, white noise maker, etc) to simply keeping my youngest swaddled and wearing her in a sling. My youngest almost never fussed or cried, and at almost 6 is still the most calm of my 3 children.

 

Posted in Breastfeeding and Childcare

The Benefits of Breastfeeding and the Dangers of Formula: Two Sides of the Same Coin

In April 2012, the World Alliance for Breastfeeding Action (WABA) released a poster called “21 Dangers of Infant Formula”.  It has since been making the rounds of social media.  The intent is to create awareness and provide evidence-based information (the document includes references for each of its claims).   Surprisingly, it has been the object of some pretty violent reactions.  Some claim that campaigns such as this are ‘judgemental’ and ‘unfair’ to formula-feeding mothers who are being judged by society enough as it is.

Click here to view the PDF with references

Also in 2012, just a month before this poster was released, the American Academy of Pediatrics published an update of its policy statement on Breastfeeding and the Use of Human Milk.  Here is a simplified version of the table that appears on the 3rd page of the document and lists the Dose-Response Benefits of Breastfeeding.   The 17-page document discusses other benefits not included in this table.  I have yet to read a violent response to this one.

Dose-Response Benefits of Breastfeeding

Both documents contain similar information, the main difference being  what each considers to be the norm/standard.  The WABA document assumes that breastfeeding is the norm or the default choice.  And so it lists what the baby loses/risks when giving up breastfeeding and choosing formula in its place.  The AAP document enumerates how breastfeeding is superior, with formula as the base option.  According to the AAP,  a 6 month-old baby who is still breastfeeding exclusively has a 50% decreased risk of having an ear infection, and in WABA-speak,  a 6 month-old baby on formula has twice the risk of getting an ear infection when compared with a breastfed baby.  It really is just 2 sides of the same coin.

As far as feeding options for infants go, there really aren’t very many choices.  The choices are human milk or infant formula.  Things like juice, water, rice water, soup, condensed milk, evaporated milk, non-dairy creamer are absolutely inappropriate for infants (and yet many mothers who start with formula and cannot afford to sustain it end up feeding their children one or all of these – but let’s leave that for another post).

Surely, in order for a mother to make a good choice, she should be armed with the proper information.  Honestly, if I had learned all this in medical school, I would have done everything in my power even then to help my patients breastfeed.  It is information that is useful to all mothers – whether they choose to breastfeed or formula feed – and it is information that is useful to anyone who cares for babies, in the hospital or out.  We demand nutrition labels on our food and warning labels on our medications.  Why wouldn’t we want to know the effects of what we choose to feed our children for the first year of their life (or longer)?

This information isn’t meant to accuse certain women of ‘bad mothering’.  Obviously, every mother wants what is best for her child, and mothers make decisions based on the information available to them at the time.  Many doctors, nurses and hospitals all over the world will readily say “there’s nothing wrong with giving a bottle of formula”.  In the face of that ‘expertise’, how is a mother to know better?  Well, that is what information like this is for.

The vast majority of mothers should be able, with the right information and support, to provide 100% of the breast milk their child needs.  There will be a small number of mothers who, despite all effort, are unable to do so and may not be able to provide any breast milk at all.   Sadly, an overwhelming number of mothers feel they belong to this category when they actually do not.  They are the victims of poor information, an inadequate health care system, and lack of support.   Information campaigns such as these aren’t designed to pit mothers against each other, or to allow us to condemn others for their feeding choices.  This kind of information should instead act as motivation to seek more information and to make active decisions.

How does this kind of information make you feel? Will it change/would it have changed any of your feeding decisions? Do you feel this kind of information is important?  Leave a comment to share your thoughts!

Posted in Breastfeeding and Childcare

Yes, we want to protect formula-fed babies too!

At the height of the very recent Typhoon Maring, I posted about how the public can help protect babies during emergencies.  The article was a summary of recommendations by agencies such as WHO, UNICEF, and ENN (Emergency Nutrition Network) and our own Philippine Department of Health – agencies who have experience in disaster management and in addressing health and nutrition needs during disasters.  The article included links to official guides on Infant and Young Child Feeding in Emergencies  (IFE).  The guides are not new – the IFE Manual was first produced in 2001 and was updated in 2007.   And yet every time there is a call for relief goods and another call to ‘please, do not include infant formula in your relief packets’  the reminder is met with passionate objections.

Comments I have heard are : “So how about formula-fed babies? We just let them starve and die?”,  “sure we all know breastfeeding is best, but why force our personal views on other mothers? What about respecting a mother’s choice to formula feed?”, “isn’t being evacuated from your home stressful enough? We have to make a mother continue breastfeeding on top of that?”, “even if most mothers breastfed, not all of them do. We should support ALL mothers equally.”

I had hoped that my original post on this topic adequately addressed these concerns.  And anyone who actually read the attached guide to the public would have understood that these guidelines were designed not only for breastfeeding babies, but also specifically for formula-fed ones as well.  Adhering to these guidelines helps keep EVERY BABY safe.

If you still think I am making this up only to push my personal agenda of promoting breastfeeding at all costs (and that I take secret joy in the suffering of formula fed infants), let’s put ourselves in the shoes of the formula-feeding mother in an evacuation center.

The National Disaster Coordinating Council’s final report on Typhoon Ondoy in 2009 states that 15,798 families or 70,124 persons were evacuated into 244 centers.  The number of persons per center varied greatly, with some holding just a few families, and others like ULTRA, holding thousands.

One of the centers I visited during Ondoy was home to 350 families with an average family size of 4-6 persons each, putting the total number of evacuees at around 2000.   72 mothers had infants younger than 1 year, with the youngest infant being 2 weeks old.   Prior to their evacuation, 68 of the mothers were breastfeeding, 3 gave formula occasionally and 1 mother (the one with the 2 week old ) was giving her baby formula exclusively.  There was no source of running water in this center. There were about 10 portable toilets to be shared among all the evacuees.  Families gathered rain water in buckets to use for bathing, cooking and drinking.  They would take drinking water from the toilets as well.

In my previous post, I said that safely feeding an infant with formula requires 1) access to a constant supply of formula  2) access to clean water  3) access to heating implements (proper preparation of formula requires heating of water to a certain temperature in order to kill bacteria/decrease contamination)  4) ability to clean feeding implements.

Let’s look at the mother who is formula feeding and figure out how much clean water she needs to safely formula feed her baby in this setting.  Let’s say her baby takes 24 oz of formula a day – that means she needs 750 ml of clean water for mixing formula alone.  Formula that has been prepared but is not going to be consumed immediately needs to be refrigerated.  Since there is no refrigerator in the evacuation center,  she needs to prepare a fresh batch at every feeding – that is 6 to 8 times a day on average.  To prepare a fresh batch, she needs to wash her cup and spoon/mixing implement.  She will need clean water for that.  Let’s assume you can properly wash a cup and spoon with soap and water using only 8 oz of water.  Multiply 8 times and she needs 64 oz or almost 2 liters.  Now she needs to wash her hands before she prepares formula and feeds her baby.  Let’s again assume a minimum of 8 oz to properly soap and wash your hands (I don’t know anyone who can properly wash their hands in 8 oz of water) – again multiply by 8 and that is another 2 Liters.  We are not including the times she should wash her hands after changing her baby’s diaper or after she herself goes to the bathroom.   So a very conservative estimate is to say that she would need at least 5 liters of clean water per day in order to safely feed her baby with formula.  If we assume that she is to stay in an evacuation center for 5 days, then that is 25 liters of water for that period.  These are informal computations using very rough estimates, but we can say this is the very least amount of water such a mother would need.

How much water does an exclusively breastfed infant need?  None.  Zero.  That is at least 5 liters less per day than the formula-fed infant needs.  Now if we feel it is only fair that we provide formula to every mother – even the ones who are successfully breastfeeding – just so that they are allowed the option to formula feed, and we want to do the ‘responsible’ thing and provide enough clean water as well, how much water do we then need to provide?

72 mothers x 25 liters =  1800 liters of clean water in order to support “safe” formula feeding for 5 days.  But does providing sufficient water for making formula ensure that mothers are going to do it safely?  Why would a mother choose to use clean water to wash a cup or spoon or her own hands, when she, her husband and her other children do not have enough clean water to drink?  Why should a baby who needs 0 Liters of water suddenly deserve an allocation of 5 extra liters per day?  The approach does not make sense at all.  Imagine being a mother of a purely formula-fed child who now has to compete with breastfeeding mothers for a limited amount of clean water because suddenly the breastfeeding mom feels now is a good time to formula feed.

We know that breastfeeding mothers can continue to breastfeed in disaster situations.  We know that if they were capable of making enough milk yesterday or this morning, before the typhoon struck, then they are capable of continuing to make milk now, even in an evacuation center.  If you are an agency providing relief goods and have only an X amount of funds with which to purchase goods, would you spend the money on infant formula, clean water, feeding implements to be distributed to mothers who actually are able to feed their babies without any of these? Or would you rather spend that same money on food that can be made available to everyone in the center?

Keeping infant formula away from general distribution means breastfeeding mothers are not tempted to use it.  It protects formula-fed babies from having to compete with breastfed ones for limited resources.  Keeping formula away from general distribution DOES NOT mean that formula fed babies are not fed.  Formula-fed babies should be identified by the evacuation center staff and appropriate feeding is provided.  If you are concerned that these children are not being identified, then instead of putting a packet of formula in ever bag, why not speak to the person in charge of the evacuation center and find out how they are caring for the infants who are purely formula fed?

The threat of infectious diarrhea in a congested living space with no access to running water and no functioning sewage system is real.  Imagine how fast this can happen in a facility so overcrowded that people knowingly and unknowingly step in excrement, sleep on the floor, do not have the luxury of bathing or washing hands.  This general lack of hygiene easily contaminates the food and water supply.  It shouldn’t then surprise us to hear of outbreaks of diarrheal disease following natural disasters.  An article on “Epidemics After Natural Disasters’ by Watson, Gayer and Connolly that was published in 2007 cites  several instances – such as as 17,000-case outbreak of diarrhea in 2004 after flooding in Bangladesh and over 16,000 cases of cholera  in West Bengal in 1998.   Breastfeeding babies exclusively in these situations protects them from diarrheal disease, so helping mothers who were previously mix-feeding to return to exclusive breastfeeding isn’t about bullying or disrespecting them – it is about helping them choose the safest course of action. In the same way, helping a mother who formula feeds to relactate if she so desires, isn’t about making her life harder.

We heard it said many times that ‘it is easier to give than to receive.’  We can choose what we give and when.  But our ‘giving’ in disaster situations can permanently impact the lives of those we are trying to help.  Most of the time it is for better, and sometimes it is for worse.  Let’s all give responsibly.