Tuesday, March 14, 2017
"The search for a scapegoat is the easiest of all hunting expeditions."
--Dwight D. Eisenhower
(Forward Note from Valerie: In 1992 I was 9 months pregnant, when my son, was stillborn. During a weekly routine check prior to labor, my midwife could not find a heartbeat. I went to the hospital for an ultrasound and was told that my son had died. The grief I felt was overwhelming. I do believe that one never gets over grief, one learns to live with it. I am deeply saddened for other mothers who have lost their children, their babies. Reading the recent articles regarding the mom whose baby died and believes that the cause was due to exclusive breastfeeding, was upsetting. I feel that this mom's situation needs more discussion to correct some misconceptions. I do not want to add to this mom's grief. Exclusive breastfeeding is the standard, global recommendation by various health agencies. Blaming a mother or mothers for following those recommendations is victimizing, not only to this particular mother but to all mothers who wish to exclusively breastfeed their babies. My sincere sympathy to Jillian and Jarrod Johnson at the loss of their son, Landon.)
The headlines in the Washington Post read like the National Enquirer, "She listened to her doctors--and her baby died. Now she's warning others about breast-feeding." (3/8/2017) On the day before this article, the USA Today had similar scary headlines, "Breastfeeding mom didn't know she was starving her baby to death." (3/7/2017) I am finding it harder and harder to read newspapers this year and these two articles were particularly gut-wrenching. Both the news articles were about the Johnson family whose full term newborn had died at 19 days old. The infant, Landon, was born by c-section weighing 7lb., 7oz in February of 2012 in a Baby-Friendly hospital.*
*Baby-Friendly Hospital Intiative began in 1992 as a result of the Innocenti Declaration to promote hospital practices that promote exclusive breastfeeding. While exclusive breastfeeding is promoted. The 6th Step states, "Give newborn infants no food or drink other than breastmilk unless medically indicated." see http://www.who.int/nutrition/topics/bfhi/en/
The American Academy of Breastfeeding Medicine, protocol #3 regardingthe use of supplementary feedings in a healthy term breastfed infant dated revised 2009 states, that an infant's physician should be notified if an infant weight loss is greater than 7%. It also states that an "8-10% weight loss may be within normal limits,...indication for careful assessment and possible breastfeeding assistance."
C-sections (medscape article) and IVs (Journal of Perinatal Education) can cause significant weight loss in some babies.
Jillian, mother of Landon, felt pressured to exclusively breastfeed her infant by the hospital personnel. The mom states in both newspaper articles that Landon lost 9.7 % of his birth weight by day 3, when they were discharged. Twelve hours later he became unresponsive at home and his father did CPR. He was taken to the ER and hospitalized on life support and died a few weeks later. According to the Washington Post coroner records state that Landon, "died of hypoxic-ischemic encephalopathy, or brain injury caused by oxygen deprivation; cardiac arrest; and hypernatremic dehydration." The article also states that Dr. Christie del Castillo-Hegyl, physician and founder of Fed Is Best related that Landon, "was born by emergency c-section because he was not getting enough oxygen during labor."
The question I have is: was exclusive breastfeeding the cause of this tragedy? The parents believe this to be true. And the organization, Fed Is Best, obviously believes that exclusive breastfeeding is the risk. Where is the evidence that exclusive breastfeeding is a risky practice? Will promoting the use of infant formula in the early days for all breastfeeding newborns, save more infants? Or are there far greater risk factors in demonizing exclusive breastfeeding?
Media articles will never tell us the full story of events that lead to this infant's death. Laws of privacy, prevent the medical community from commenting on this situation. So there is a lot we do not know and the information provided in these news articles may or may not be accurate. But the information that was provided by these articles (at least 3 articles that came out around the same time), have me questioning the premise that exclusive breastfeeding was the cause of death.
In one of the articles Jillian states that the best advice she received was from a NICU doctor, who said to her, "breast is best but follow with a bottle." (People Bodies interview, 3/3/2017) The mother again mentions a NICU doctor in the Washington Post who told her that, "...he suspected Landon was so severely dehydrated that his heart had stopped beating." She asked the NICU doc what he meant by severely dehydrated since she was exclusively breastfeeding. She had been told in the hospital that, "her latch was great" and, "she was doing fine." In another article she stated that she had sore and bleeding nipples.
The implication by the NICU doctor's statements appears to me to be a subtle passing of blame for the death of the infant onto the mom. The mom in another article states that had she "only" given her baby one bottle, then he would still be alive (usatoday). We cannot know whether just one bottle would have saved this baby.
No physician should ever state or imply to a parent that a parent's positive action (exclusive breastfeeding is a well established positive action, promoted world-wide) is the cause of death of a child. Unjustified blame becomes undeserved shame and guilt. Over the years, I have heard various comments by medical professionals who have made some oddball statements about breastfeeding. One doc stated to a mom that the cause of pyloric stenosis is breastfeeding. What?? A physical defect one is born with is caused by breastfeeding? Really? So hearing that a NICU doc in a Baby-Friendly Hospital implied that exclusive breastfeeding caused this infant's death is not so surprising.
From my perspective having worked with breastfeeding mothers for some 26 years, I think the articles suggest to me that this mom did not get the assistance and care needed. Preventing problems requires a knowledge of how certain interventions or lack of intervening increase risks of infant morbidity and mortality and maternal morbidity and mortality.
Like nutrition education, breastfeeding education in medical schools is not a requirement. Unless the person going to medical school has an interest in nutrition or breastfeeding, it means that there is a huge knowledge gap in those who are medically trained. Most hospitals hire licensed nurses who will support breastfeeding in the postpartum period. Most times those hired do not just work with breastfeeding moms, they also maybe required to fill in other duties on the hospital floor. I was told by various hospital-based lactation consultants (who had varying credentials regarding breastfeeding support from IBCLC, CLC, to no credentials) that they had about 10 minutes to spend per mom who had given birth. I was floored by their time limits. I did home visits as a WIC Breastfeeding Peer Counselor Coordinator and in private practice. The least amount of time spent per mom was 1 hour, and the most was 2 hours (for complicated situations) and there was follow-up phone calls and even follow-up home visits. With assembly line care instituted by health care institutions, how can a standard 10 minutes spot serious problems? All breastfeeding assistance in medical facilities is not equivalent and often dependent upon experience and knowledge. Most moms do not know what the credentials mean nor the fact that anyone can call themselves a lactation consultant (although this may change, as various states consider licensing of IBCLCs). Although I question whether licensing will remedy situations like this.
If the media articles are correct and the mom's recollections are accurate (this happened 5 years ago), then I see some very obvious red flags. A first time mom or a first time breastfeeding mom is at higher risk for breastfeeding problems. Moms who are in this category often need more support and one on one time from an experienced breastfeeding assistant. Moms who have had c-sections are at higher risk for various problems. For example, babies of c-sectioned moms lose more weight than babies who are born vaginally. Standard hospital practice in 2012 would have been that a 7% or greater weight loss would mean that infant's physician would be notified and steps would be taken to observe whether interventions were needed. Maybe this was done but not mentioned in any of the articles.
Mothers who have sore and bleeding nipples always require an evaluation. It can be a simple fix, changing the position of babies or moms. It can also be very complex situation. Unrelenting soreness can cause weight loss in babies because pain slows the let down reflex (and milk release may be minimal). Nipple pain can be excruciating (lots of pain nerve endings). Engorgement can be part of the problem. IV's used in labor and delivery can cause edema in the nipple and breast making a baby's latch on impossible or very painful. Engorgement is never normal. Yet many people (as well as medical professionals) believe it is normal. What engorgement shows is mother/infant separation and/or an IV overload. C-sectioned moms are more likely to have longer mom/baby separations as well as lots of IV solutions. Certain drugs for pain relief in labor and delivery may cause a newborn to be excessively sleepy or uninterested in nursing. How a mom gives birth impacts breastfeeding either positively or negatively.
The Washington Post article stated that Dr Christie del Castillo-Hegi. co-founder of Fed is Best, stated that Jillian, the mom, had an emergency c-section due to oxygen deprivation. The mom stated that she had sore and bleeding nipples and 14 hours of marathon (nonstop) breastfeeding. The baby had 9.7% loss of birth weight on day 3. Mom was released from the hospital on day 3 and went home only to return to the ER "fewer than 12 hours later." (usatoday). The mom had found her baby not breathing and her husband performed CPR and baby Landon was rushed to the ER and died several weeks later. According to the Washington Post, the LA County Coroner records state the cause of death was hypoxic-ischemic encephalopathy, or brain injury caused by oxygen deprivation, cardiac arrest and hypernatremic dehydration.
It appears to me that it is possible that this baby might have been physically in trouble before the mother started exclusively breastfeeding, that lack of oxygen during labor may have damaged the infant. But that is speculation not facts. The reality is that, if there is any blame to give, it has to be placed on a medical staff who did not see all the red flags. The mom did what was expected of her by the institution, exclusive breastfeeding. And the institution's staff failed the mother by not recognizing the need for interventions.
Yes, it is easy after-the-fact to recognize those red flags. And that recognition may not have prevented this tragedy. But we cannot presume in a society that all parents have enough information and support to exclusively breastfeed their newborns. We cannot even presume that all medical communities have enough information to create a supportive breastfeeding environment in hospitals. Exclusive breastfeeding is not the problem. Blaming mothers for exclusively breastfeeding masks the real issues that surround current birthing and breastfeeding practices in medical environments. After all, breastfeeding like birth is not a medical issue, except for a small subset of women who have medical problems that complicate birth and breastfeeding. Blaming exclusive breastfeeding for tragic medical outcomes is an alternative fact. It is a big lie that may destroy breastfeeding and create a nation of mothers who already fear birth and now will fear breastfeeding.
Copyright 2017 Valerie W. McClain
Tuesday, February 14, 2017
"Every man must decide whether he will walk in the light of creative altruism or in the darkness of destructive selfishness." Martin Luther King, Jr.
I heard the calls of the Red Shouldered Hawks that live down the road. They have lived here as long as I have or so I like to believe. Maybe they are descendants of the original pair. But they seem to be arguing politics lately in loud, raucous voices that carry in the wind entangling me in their drama. Today they are riding the wind, yelling at their newest baby who is flying like a bat out of hell. Watching momma and poppa chasing this baby reminded me of the days not so long ago, when my little ones ran ahead of me. The toddlers ran without fear, headlong and fast into the unknown. And, we the adults ran after them, trying to keep up. Fearful, ever fearful, scared that my treasured babies are too naive to run so fast. Into the future they run without fear, soaring and singing their songs. I stand back, breathless and tired and admire their strength and courage. The pair of hawks seem to be yelling at their baby to stop but their little one throttles forward moving faster and faster like a race horse out of the starting gate.
It was fun watching the Hawk family and wishfully making their behavior relevant to me. Pure escapism on my part because the world appears to be getting more and more troubling. I am feeling fearful for the future, my children and grandchildren. I have always kept that fear on the back burner of my mind. Yet that fear, that darkness that seems to be enveloping our world seems to be growing. I wonder whether insanity is contagious? Greed and hate and more greed and hate. The sad history of humanity with brief moments of peace and loving kindness.
Breastfeeding advocacy has been so much a part of my life energy that it is upsetting to see it being infected by profits. patenting and distorted science. When human milk science plays to the tune of corporate values, then it creates the victimization of women. Not that, we as women find anything new about being victims. Its that I believe women are tired of being victims.
For example, the other day I read in Breastfeeding Medicine an article dated in January of last year, "Relationships of Maternal Stress with Milk Immune Components in African American Mothers of Healthy Term Infants." (funded partly by Medela) After reading it, I was appalled. Why? The authors state that, "race/ethnicity and socioeconomic status were associated with increased stress and health disparities." And, "Historically African American have been at risk for health disparities; however recent evidence suggests that chronic stress may also play a role in health disparities such as hypertension, diabetes, and adverse birth outcomes." They mention that African American infants have the highest infant mortality rate and lowest breastfeeding initiation rates.
The authors decided to measure cortisol levels as an indication of stress. They would take breast milk and saliva collections (measuring cortisol levels) on Day3, 9, and 14 post delivery. The collection of breast milk was to monitor MIC (Milk Immune Components): IgA, milk cytokines, chemokines and growth factors. The instructions for mothers regarding these collections were amazing. For example with the saliva samples; it was to be done upon awakening, 30 minutes after awakening, and 60 minutes after awaking. No food or drink 30 minutes prior to collecting the saliva. With breast milk collection they were to collect 1 tsp of hind milk using either hand expression or breast pump. Samples were to be frozen and mothers had to transport those samples to the principle investigator. Mothers had to do a self report survey on physical and environmental stressors in their life. These mothers were recovering from childbirth (34% of the mothers had c-sections and were on antibiotics), taking care of their babies and then having to fill out questionnaires, pump-obtain hind milk, saliva collections, no food or drink prior to the saliva collections. Are the researchers kidding? How to stress out moms that were already stressed out? I find this ethically irresponsible. Not surprising that many moms weaned or did not do the samples. I remember after my first baby and how difficult it was to even eat or go to the bathroom and I didn't have a c-section. The whole concept of interfering with moms and their babies time together in the first weeks postpartum is just wrong. But to do this specifically with African American moms and babies who are at the most risk for stress and health disparities seems unethical. Mothers who returned all the surveys and milk and saliva collections received a $25 gift card. I suppose that represents 3 hours of work for minimum wage. It seems small compensation for such interference.
Of course, what makes this whole study more upsetting is that one of the authors, Maureen Groer is a listed inventor to patent #9345249 entitled, "Method of supplementing cytokine, chemokine and growth factors in donor human milk." filed 6 months before the above study. The study stated that there was no competing financial interests. So having a patent is not considered a financial interest? The patent is owned by the University of South Florida and it is probably available for licensing.
The patent states the problem of pasteurization of donor milk (Holder method) which is thought to "destroy the immune properties in milk and denature many other proteins." The patent proposes to supplement donor milk with chemokines, cytokines and growth factors. For this patent they boldly state that donor milk was provided from a single non-profit milk bank in Northern Texas. Since this particular research had government funding, the US government has certain rights to the invention.
Inventor and researcher, Maureen Groer, was quoted in the Tampa Bay Times in January of 2014 in regard to the media blitz about unsafe milk sharing over the internet. According to the article she stated, "Breast milk sold over the Internet is creating a very dangerous situation."
I wonder which is more dangerous? Breast milk sold over the Internet or patenting to create a "better" donor milk? Is this about controlling a natural resource or safety? Who wins and who loses in the drive to create a better donor milk? Who are we sacrificing on the altar of invention?
Copyright 2017 Valerie W. McClain
Sunday, January 15, 2017
"When I came back to the United States, I decided that if you could use propaganda for war, you could certainly use it for peace. And "propaganda" got to be a bad word because of the Germans using it, so what I did was to try and find some other words so we found the words "public relations." by Edward Bernays, the father of public relations
The falling star streaked across the sky; and my brain wondered whether I had really seen it or was I just looking for magic in the night sky? Did my neighbor see the falling star? Or was this just a moment in time that I, alone, observed it? I thought of the night sky in Arizona, where falling stars were part of the night-time landscape. But here in Florida, falling stars are a treat, not a common occurrence. Night-time lighting which blocks our view of the sky has certainly changed our world and our perceptions of life on this planet. Years ago, my brother told me about his summer job of camp counselor for inner city boys and girls of Philadelphia. The camp was out in the woods, far away from city lights and traffic. He said he was amazed that many of the very street-wise and tough-acting children of the inner city were full of fear of the darkness at nightfall. I was amazed as he was, because my brother and I had so much fun camping and our family even lived in the middle of the woods in Northern Ontario for a few years. So our experience and our fears as children were so different from the children living in a inner city environment.
It is hard to understand other people whose experience and fears are different from our own. Their fears are not our fears. Their experiences give them a different reality from ours. We can scorn and ridicule their fears but that doesn't give us a bridge to further understanding of other human beings on this planet. There are many examples in our lives of how divisive society can be, when our reality clashes with other people's reality.
Infant feeding decisions is one of those examples of a clash of realities. We are a society of conflicting opinions and realities regarding breastfeeding and bottlefeeding. But what is of concern to me is the use of propaganda, PR and social marketing techniques in this clash of realities. Is this just an ideological battle or is an industry using its power and monies to promote their reality?
This appears to me to be both an ideological battle of different viewpoints and the PR work of the infant formula industry. We have media campaigns pushing back against the "breastfeeding is best" slogan used in the social marketing of breastfeeding. "Fed is best" is the slogan used to counter "breastfeeding is best." We also have another campaign slogan called, "I support you." The intent of the "I Support You," campaign is about giving support to both breastfeeding and infant formula feeding mothers. Yet the criticism of the I Support You campaign appears to be only directed at breastfeeding advocacy.
The "I Support You" campaign was founded by Suzanne Barstow, the Fearless Formula Feeder blogger, who is also a CLC (Certified Lactation Counselor- a week long educational course on breastfeeding with a final exam at end). My impression is that Suzanne Barstow is a supporter and promoter of infant formula and I have written about her promoting the use of Similac coupons, etc.
Her campaign got support from some breastfeeding advocates. The Best for Babes Foundation seemed somewhat supportive of this campaign. One of their credos is, "All moms deserve to make a truly informed feeding decision and to be cheered on, coached ad celebrated without pressure, judgment or guilt." The presumption of this credo is that it is possible to have a "truly informed feeding decision" in our society. And the other presumption is that breastfeeding advocacy spreads guilt, judgment and pressure to breastfeed. The Best for Babes Foundation is also very supportive of breastfeeding but they do accept a belief that "informed feeding decisions" can be made in our society. I, on the other hand, have to question that premise because the infant formula industry through propaganda and advertising has created a bottlefeeding reality. Its influence in the medical professions and in infant feeding research is legendary. After all the bottle has been the symbolic representation of baby or babyhood. Escape from the societal mindset that infant formula is the default feeding program and that breastfeeding can be regimented like bottlefeeding is next to impossible. The infant formula industry through its patents shows us that the industry has been selling an inferior product over the years. They recognize the problems of their formulas and will solve the problems with various human milk components. The public usually hasn't a clue about what the industry is doing other than the smoke and mirrors of the industry's PR. So while many breastfeeding advocates may believe that informed choice exists in the US, the reality is that even breastfeeding advocates are clueless about what is in that can of formula. So informed choice exists in what world? Here is a few patents to look at that are owned by different formula companies. What do we really know as consumers and what does the industry know?
For example, Abbott Labs patent #9539269 filed in 2011 entitled, "Methods for decreasing the incidence of necrotizing entercolitis in infants, toddlers or children using human milk oligosaccharides." Abbott will use human milk oligosaccharides (a prebiotic) in their formulas to decrease the risk of necrotizing entercolitis (NEC) which can be a deadly infection in infants, particularly premature infants. NEC is a risk factor when infants/preterm infants are given infant formula.
A Nestle patent (#9498502) filed in 2010 called, "Prevention and treatment of allergic diarrhea." From the patent, "...the present inventors have discovered that a particular strain of Bifidobacterium breve originally isolated from human milk, B. breve CNCMI-3865 (NCC2950) is highly effective in the prevention and treatment of allergic diarrhoea." In the patent the inventors state that diarrhea is the second most common cause of infant mortality worldwide and that it causes 5 million deaths worldwide to children under 5 years of age.
How about a Mead Johnson patent (#9089157) filed in 2013 using human milk oligosaccharides (prebiotics) to inactivate Cronobacter sakazakii entitled, "Adherence inhibition of pathogens by prebiotic oligosaccharides." A quote from the patent,
"Cronobacter sakazakii(also called Enterobacter sakazakii) is a motile, petrichious, non-sporeforming, gram negative facultative anaerobe. It is an opportunistic pathogen that has been implicated in severe forms of meningitis, necrotizing entercolitis and sepsis in infants. Although the environmental source of the microorganism in unknown, powdered infant formula has been implicated in several outbreaks...Of particular concern are reports of the organism being isolated from powdered milk processing plants and hospital utensils such as spoons and other implements used to prepare infant formula."
The fatality rate for infants that contract a Cronobacter Sakazakii infection has been estimated to be between 40-80 per cent. And the CDC estimates that we have an average of 6 cases per year and this maybe an underestimation since there is only one state in the USA that has made this infection a reportable disease. Yet the public believes that infant formula is only a risk in developing nations?
Meanwhile I read in the blog, Momivist, that exclusive breastfeeding can cause life long disabilities. The blog is written by Jody Segrave-Daly RN, MS, IBCLC, one of the founders of Fed is Best Foundation. She states, "Every year in the US, approximately 60,000 newborns are readmitted back to the hospital for unforeseen complications from exclusive breastfeeding and insufficient intake." No footnote of where this statistic comes from other than 2 references at the end of the article. Both references lead back the Fed Is Best Foundation. With the last reference having a paper written in the Journal of Pediatrics entitled, "Recommendations from the Pediatric Endocrine Society for Evaluation and Management of Persistent Hypoglycemia in Neonates, Infants, and Children," published in 2015. I found no mention of exclusive breastfeeding in this paper and this paper had a chart entitled, "Recognizing and managing neonates at increased risk for a persistent hypoglycemia disorder." No mention of exclusive breastfeeding as a risk factor nor any statement about the 60,000 newborns readmitted due to exclusive breastfeeding and insufficient intake.
The mission of Fed is Best Foundation is laudable. Who would argue against saving babies from brain damage caused by insufficient intake (hypoglycemia)?
The question is where is the research behind the belief that exclusive breastfeeding is the cause of insufficient intake? No published research that I have seen. So this appears to me to be a hypothesis by the founders of this private Foundation.
Both founders of this Foundation are or were employed in hospitals. Jody Segrave-Daly is an RN and IBCLC working in a NICU (neonatal nurse specialist) and Dr. del Castillo-Hegyi is adjunct faculty member in the Department of Emergency Medicine in the University of Arkansas and a practicing American Board of Emergency Medicine-certified physician. She states she has a background in newborn brain injury research at Brown University. And she states that her child has autism due to newborn jaundice due to insufficient milk intake from delayed milk production.
They both have a medical perspective of this issue. What they see is through the eye of a medical system that has very little faith in breastfeeding which cannot be measured and seen. Jody Segrave-Daly states in her Momivist blog, "As a veteran NICU, nursery nurse and IBCLC, I have taken care of and fed thousands of babies over the years." Feeding babies is what a nursery nurse does because babies are separated from their mothers. This task maybe a requirement of the job in a NICU but it is not part of the task of an IBCLC. And expertise in feeding babies other than our own, helps in a NICU job but it is an endeavor that changes a person's vision of the reality of breastfeeding. Jody Segrave-Daly supports pre-lacteal feedings as "usual and customary all over the world." She asks, "how can supplementation destroy breastfeeding?" And then answers that it doesn't. She seems unaware of evidence to the contrary or that this behavior may not destroy breastfeeding but it certainly changes the newborn's gut and with that impacts an infant's immune system.
Only seeing bottlefeeding and only seeing the worse case scenarios in hospitals impacts what a person believes to be true. It's why labor and delivery nurses (in general) have the most difficult births and complications. And even midwives have more difficult births. I remember reading a medical book on symptoms of disease and by the time I finished the book I was sure I had every disease in that book. The sad state of affairs in the USA is that most OB/Gyns have never seen a normal birth. And I would say that the same could be said about breastfeeding and that doctors and IBCLCs who are medically trained rarely see normal breastfeeding in the early days in which babies do fine with exclusive breastfeeding.
The biggest fear that new breastfeeding mothers have is that they cannot produce enough milk. This FEAR has created the very low percentage of women exclusively breastfeeding their babies. How many women are actually exclusively breastfeeding their babies in the newborn period? Where is the data? How do we define exclusive breastfeeding? What is the impact of "mandatory"IVs for laboring moms on newborn weight loss? New studies now believe that IVs cause significant weight loss in newborns (dependent on amount and timing of IVs). How do these dextrose and salt solutions given to mom impact the baby in utero in the stages of being born? Readmittance to hospitals is more common in preterm infants for feeding problems and jaundice. Why? Do we send home preterm babies with mothers who want to breastfeed without ever having put the baby to breast? Separation of mothers and babies, even preterm infants, creates enormous physical stress on both babies and mothers. Sometimes this cannot be avoided, but often policies in hospitals and the lack of vision regarding breastfeeding creates the side effect of insufficient milk in mothers. Should we blame exclusive breastfeeding? Or is a viewpoint distorted?
I see the falling star, who else sees it? The darkness of the night sky does not scare me. I am embraced by it. It is my memory of my childhood. The city streets at night are far more scary. If we are isolated from the reality of exclusive breastfeeding, how can we support and protect it?
Copyright 2017 Valerie W. McClain