8/14/2019

What is Fed Is Best? • Vocal online community • Specifically targets BFHI • Rhetoric is often inflammatory and divisive • But they highlight What We Can Learn from Fed Is Best some real issues Kathleen Kendall-Tackett, PhD, IBCLC, FAPA

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Fed Is Best site

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• • A day later, her son seemed Left the hospital after a to “mellow out,” which she few days thought meant that things Christie’s • LC told her to keep him were going better Story on the with hope • Instead, he had extreme of encouraging her milk dehydration and starvation to come in • Took him to the ER when • Next day, pediatrician he became non-responsive told her to keep • He developed brain despite damage after 4 days with significant weight loss no food

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“Safe breastfeeding management includes knowing and understanding conditions that require •Rule #1 supplementation” •Feed the baby!

MacEnroe 2018, Clin Lact, 9(4), 208-211

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Our challenge • How to empower Which system with are we information activating? without overwhelming them

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• Hospital-caused Problems I have delays in LG II identified • Organizational issues • Not listening to BFHI is often blamed for many of the problems mothers • Lack of postpartum follow-up • Implicit bias The problems seems to be in the implementation rather than the policies themselves

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“Unfortunately, “Serious complications there is now associated with strict emerging evidence adherence to the Baby that full Friendly Hospital Initiative and compliance with the 10 steps of the the WHO Ten Steps to initiative may Fed Is Best Successful Breastfeeding have inadvertently be site lead to preventable promoting hospitalizations for jaundice, potentially dehydrations, and hazardous practices hypoglycemia: known causes and/or having counterproductive of impaired brain outcomes” development”. Bass et al. 2016 JAMA Ped, 170(10), 923-924

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AHRQ review confirmed that BFHI is associated with increased rates of Alleged complications of the BFHI breastfeeding initiation and • Failure to recognize insufficient feeding duration • Delays in LG II • Insufficient milk • The risk of hospitalization, brain injury and disability from excessive jaundice, dehydration, and hypoglycemia

Feltner et al. 2018, AHRQ report, Rockville MD

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“Instead of Most difficult steps abandoning the BFHI, of BFHI to all of the stated implement: objections to the • Step 3, prenatal BFHI can be education addressed by proper • Step 10, postnatal staff training and breastfeeding support vigilance”

Walker 2017, JAMA Ped, 171(3), 304

Munn et al. 2016, Breastfeed Med, 11(5), 223-230

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Examining FIB concerns

Fed Is Best site

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• First 24 hours, 2-10 ml/feed • 5-15 ml/feed 24-48 hours • 15-30 ml/feed 48-72 hours • 30-60 ml/feed 72-96 hours

Walker 2018, Clin Lact, 9(4), 171-182

Fed Is Best site

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• Dublin Foundling Historical Review • Hospital (1775- Mortality rates for 1779). 10,272 bottle-fed babies: babies admitted, • 3 times higher, first month 45 survived. • 4 times higher, Mortality rate of second month 99.6% • 6 times higher, • 15th century, no third month breastfeeding in • 5 times higher, Woodbury (1925) Germany, fourth to seventh study in 8 Bohemia, Austrian month American cities Tirol, Finland, (N=22,422) Iceland or Russia. 50% mortality rate

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Does supplementation protect breastfeeding?

Fed Is Best site

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• EBF newborns 3,195 Canadian breastfed longer -infant than those dyads. Assessed at 3, supplemented with 6, 12, 18, 24 formula in the mos. 97% hospital initiated • 21% reduced risk breastfeeding, for bf cessation if 74% exclusive EBF in hospital • Particularly true among women with low SES Delay in Lactogenesis II

Vehling et al. 2018 Birth, doi: 10.1111.birt.12345

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• “Mothers are taught that What’s causing it is rare to have the delay in LG II? insufficient . Fed Is Best • But research shows site delayed milk production affects at least 1 in 5 Delay in LG II is women in the first days not the same as of an infant’s life.” insufficient milk

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Dewey et al. 2003 • Delayed onset of • 12% had excessive , 112(3), lactation (>72 hours) weight loss 607-619 occurred in 22% of • Risk factors include women primiparity, long • Risk Factors labor, labor • Primparity medications, and • C-section infant status at • Stage II labor >1 birth • Maternal BMI >30 288 mother in Davis, CA, • Flat or inverted Assessed at • Birthweight >3600g (for primips) days 0, 3, 5, 7, and 14. Data Babies were 7.1 times collected in more likely to lose 1999 excessive weight if their Dewey et al. (2003) Pediatrics, 112(3), 607-619 mothers had delayed LG II

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“All breastfeeding mother- • Risk factors identified by infant pairs should be Fed Is Best evaluated at 72 to 96 hours • First time mother postpartum” • C-section • Complicated labor and birth • Maternal BMI >30 • History of lactation failure • Psychological considerations • Ineffective and transfer • Nursing frequency: Less than 8 times in 24 hours

Dewey et al. 2003, Pediatrics, 112(3), 607-619

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Risk factors Marsha Walker identifies We need to flag • First time mother • Cesarean section these mothers • History of for follow-up • Diabetes • BMI >30 • Hypothyroidism • PCOS • Tubular or asymmetrical • Sore nipples • Mother perceives low supply

Walker 2018, Clin Lact, 9(4), 171-182

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• More frequent lactation “Almost all feeding assessment, support, and monitoring in the BFHI complications can be early Response prevented with close • Supplementation with monitoring for signs of mother’s own milk, Fed Is hunger and insufficient donor milk, or infant feeding and formula Best site supplementation when • Excellent postpartum breast milk is not enough breastfeeding education until breast milk supply is • Ongoing monitoring and support of the sufficient” breastfeeding couplet after discharge MacEnroe 2018, Clin Lact, 9(4), 208-211

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For mothers with Implicit biases that impact breastfeeding known risk factors for support delayed LG II • BF 10-12 times/24 hours • Use breast compressions • If baby does not latch or swallow well, hand express colostrum • If milk supply is low, ask for donor human milk • If donor milk is not available, use hypoallergenic formula Walker 2018, Clin Lact, 9(4), 171-182

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mPINC Survey Hospital Practices 65 50 35 20 5

>12.2% Black <12% Black Lind et al. 2014. MMWR, 63(33), 725-728 Fed Is Best site

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• “Because of the intense • “Long story short, I just pressure, I felt the need to didn’t have enough milk, exclusively breastfeed my and I didn’t find out until Mother’s daughter. Yet for the 3 weeks after my daughter was that I tried I had no idea that admitted to the hospital I was starving my daughter. story • This was the worst feeling Fed Is Best • My midwife was absolutely in the world. Formula is the useless and she is the biggest only reason my daughter is site reason why this happened as she told me to keep alive today breastfeeding and everything • Formula saved my was fine” daughter’s life”

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• “Listening and communicating skills are essential in breastfeeding management • Baby is inconsolable • If the mother • Baby is “on all the indicates that she time” believes breastfeeding is not • Mother is in pain going well, it is vital • Baby is not gaining to explore her weight reasons”

MacEnroe 2018, Clin Lact, 9(4), 208-211

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Call for help if: • Nurses feel • No wet for >6 hours constrained by what they • Urine is dark and smells strong perceive as • Baby: Baby-Friendly • Is lethargic, limp, or docile policies • Has dry mouth and no tears • Is irritable • Lack of staff • Cries inconsolably buy-in • Has a sunken fontanel • Don’t feel • Is feverish they can • Has yellow skin • Has skin remains tented up when speak up pinched Walker 2018, Clin Lact, 9(4), 171-182

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• “I see babies crying from being starved and “We probably have half of the breastfeeding babies in the dehydrated at work nursery at some point during the night because they are HEATHER, frequently and we aren’t crying and the moms are exhausted, medicated, have bloody NICU AND even Baby-Friendly … cracked nipples and need to sleep just an hour or two” NURSERY • Because we push breastfeeding so much even NURSE AT A our pre-term in the LEVEL 3 NICU end up suffering with NICU longer hospital stays because “We try hard not to supplement the babies who are we refuse to feed them with crying because we know our charts are being audited FED IS BEST SITE the appropriate bottles due to worries about and if we supplement too much, we are identified and confusion” called out”

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• “Nurses are frustrated over “We will sneak pacifiers to help soothe the strict feeding babies who are screaming and sometimes we will use sweet ease to help the ones who are guidelines and inconsolable” their inability to help the hungry “Some moms just do not have babies and their enough colostrum and these exhausted babies are paying the price” mothers”

Fed Is Best site

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• “Even when there is a true medical need for supplementation some “Health care babies even end up with providers an IV since some should not feel it is better than a little only know the bit of formula” policy but • “Early babies typically understand become tired after the reasoning attempting to breastfeed for such and end up with a feeding policy” tube to prevent using a Gomez-Pomar & Blubaugh 2018, J bottle” Perinatology, doi: 10.1038/s41372-018- 0068-0

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“Accidents are commonly caused by maternal exhaustion and falling asleep during skin-to- skin care or prolonged nursing, which is compounded by sleep deprivation Sudden Unexpected caused by 24/7 rooming in” Fed Is Best site Postnatal Collapse

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Unintended “As there are no consequences of studies that specifically current breastfeeding demonstrate that SSC confers initiatives benefits beyond • SUPC the early hours of life in term • Co-sleeping newborns, this • Leaving mother-baby unattended practice, when in first hours of life coupled with rigid compliance with • Overly rigid adherence to the 10 breastfeeding Steps exclusivity, has Bass et al. 2016, JAMA • Concerns regarding advice against raised safety Pediatrics, 170(10), 923- pacifiers, which has a protective concerns” 924 effect against SIDS Bass et al. 2019, JAMA Pediatrics, 173(1), 93-94

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• “BFHI expects mothers to be Safe skin to skin supported by • Infant’s face can be hospital staff seen while they are • Head is in sniffing rooming in with position their infants • Nose and mouth • Staff are aren’t covered expected to • educate mothers Head turned to one about safety side matters and • Neck is straight, how to request not bent support and • Shoulders and help when chest face mother necessary” • Legs are flexed Gomez-Pomar & Blubaugh 2018, J Perinatology, doi: 10.1038/s41372- MacEnroe 2018, Clin Lact, 9(4), 208-211 018-0068-0

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• Staff regularly monitors mother- infant dyad postpartum • When mother sleeps, The bigger infant is placed in bassinet or with an picture alert support person • Infant goes to nursery if mother is lethargic or asleep and there are no other family members to help

Gomez-Pomar & Blubaugh 2018, J Perinatology, doi: 10.1038/s41372-018- 0068-0 63 64

High oxytocin Both good means the and bad mother is experiences super attuned have long- to social cues range impact and is highly on her suggestible perception of and vulnerable her birth and to criticism breastfeeding experiences

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Does this action Look at the implementation of increase or decrease the 10 steps through this lens oxytocin? Which type of provider do you want to be?

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• Is it Postpartum welcoming? • Is the room warm and the lights low? • Are there people in the room the mother doesn’t know or like? • Does the mother have help? Birth environment • Are the • Are there people there she providers kind Kendall-Tackett & Uvnas doesn’t like? Kendall-Tackett & Uvnas Moberg or harsh? Moberg 2018, Clin Lact, 9(4), • Is she in pain? 2018, Clin Lact, 9(4), 193-199 193-199 • Is she exhausted?

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Baby-Friendly 10 Steps Lactivist • Rooming in • Skin to skin Effect • Breastfeeding education • LC-led vs mother-led • Empower vs scare • The Lactivist effect • Continuity of care Kendall-Tackett & Uvnas Moberg 2018, Clin Lact, 9(4), 193-199

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• “Not all negative “Proponents of fed- emotions around stopping is-best believe that breastfeeding are if we didn’t talk driven by the about the concept of “militant importance of lactivists” shaming women who do not breastfeeding breastfeed mothers would not • Rather, these feel badly when women feel badly breastfeeding didn’t because they wanted to. Not work for them” because they were Brown 2018, Clin Lact, 9(4), 200-207 told to” Brown 2018, Clin Lact, 9(4), 200-207

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What have we Special Issue of learned? Clinical Lactation • All personnel should is available for assess for effective purchase latch and transfer • $10 for USLCA • Empower mothers to members know what to look for • $25 for non- • Establish a relationship members where mothers feel free to ask any question Will ship internationally • Listen to what they say • Rethink our care [email protected] models of care. Do they promote oxytocin?

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Find Me on Social Media

Kathleen Kendall-Tackett Kathy Kendall-Tackett

@UptySciChick

Kathleen Kendall-Tackett

Email: [email protected] Marsha Walker’s handouts are FREE [email protected]

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• www.PraeclarusPress.com • www.UppityScienceChick.com • www.KathleenKendall-Tackett.com

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