Tuesday, March 14, 2017

The Blame Game: Victimizing Women & Breastfeeding

"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