Friday, 9 December 2016

Should my Breastfed Baby Poo every day or is Breast Milk all used up?

Baby Girl Crawling Clip Art
Image licensed under creative commons
from www.clker.com/clipart-14527.html


I've been thinking of writing a blog on breastfed babies and poo for a while now.  Mainly because I seem to be posting in breastfeeding support forums and saying the same thing over and over.  A mum posts her concern that her breastfed baby hasn't pooed for several days.  Then lots of people reassure her that it's ok because breastmilk is all used up / there is very little waste / it's perfectly normal for a breastfed baby to have 10 days between bowel movements.  So today I want to talk a bit about frequency of bowel movements for a breastfed baby - and this idea that milk is all used up.






What's a normal frequency
"Let's start at the very beginning - a very good place to start," as they sing in the Sound of Music.  When a baby is born their bowel is full of meconium, a sticky tar like substance which is made of all the things that the baby has ingested in the uterus (amniotic fluid, lanugo and substances from the gut itself, like epithelial cells, bile etc).  A baby should start to move their bowels within the first 24 hrs to pass meconium.  One of the things which colostrum does at this stage is to act as a laxative to help clear out the colostrum, so a good sign of colostrum going into baby is that the meconium is moving out.  A newborn should be moving their bowels every day.
Within a few days (2-4 days usually) mums experience "milk coming in", technically known as secretory activation or sometimes referred to as the onset of copius milk production.  Once this happens and the baby is getting much larger amounts of milk there are much more frequent poos - several a day.  Often young babies will poo at every breastfeed.  This is normal and again is a good sign of milk intake and good breastfeeding.
In the early weeks a baby absolutely should be pooing EVERY day, and if a young baby is not pooing every day then feeding should be evaluated to see if baby is taking in enough milk, and to ensure there are no medical issues which might prevent stooling.

Slowing down
At around 6 weeks poo frequency does slow down.  The Wonder Weeks book discusses a change in metabolism around 5 weeks which I suspect may be related to the change in frequency - but I've been unable to track down the research yet which gives more detail on the metabolism change (if you know of it, please send it my way).  Some babies do continue to poo at every feed for some time yet, the majority of babies slow down but continue to poo each day (usually still more than once), but some start to have days between stooling at this stage.  Some babies may only have a day or 2 between poos, some babies might only poo weekly, some might be as long as 10-15 days. A French study (Courdent et al 2014) discusses a baby who had 28 days between stooling!  The weekly or 10 day pattern may be described as normal by your Health Visitor or GP and indeed it is considered statistically normal, however there are many things which may be considered statistically normal in our society which may not necessarily be physiologically normal.  If I take an example of allergy - a presentation to UK parliament in 2004 found that 45 % of adults had suffered from eczema, hayfever or asthma in the previous year.  Something affecting almost half of the adult population could well be considered statisically normal, but allergy is certainly not physiologically normal.  So could it be that infrequent stooling is not really normal?

Breastmilk leaves no waste?
I find that most mothers do wonder whether it could be normal when there is a change from frequent to infrequent stooling.  When they ask about this however, they are given this information about breastmilk having little or no waste.  So let's examine that shall we?  Could breastmilk be all used up?  What are the components of breastmilk which might be left over in poo?

Breastmilk contains far too many components for us to discuss them all, and we still don't know everything that is in breastmilk.  We can look what makes up the largest volumes in breastmilk though.  The most abundant constituent of breastmilk is water.  Breastmilk is almost 90% water.  So that one has some logic as excess water is excreted in urine.  Saying that though - mild dehydration is obviously a cause of infrequent stooling, and a baby who is not drinking enough will have infrequent stooling.  The next most abundant component are the sugars.  Within the milk sugars are lactose, and special milk sugars called Human Milk Oligosaccharides (HMOs).  HMOs make up the 3rd most abundant element in breastmilk, and guess what - babies cannot digest HMOs.  HMOs appear to be solely in milk in order to facilitate bacteria in the gut.  In their 2012 paper on HMOs Marcobal and Sonnenburg state:

"Human milk oligosaccharides (HMO) constitute the third most abundant class of molecules in breast milk. Since infants lack the enzymes required for milk glycan digestion, this group of carbohydrates passes undigested to the lower part of the intestinal tract, where they can be consumed by specific members of the infant gut microbiota. "

A paper from Jantscher-Krenn and Bode also in 2012 looking at HMOs states:
"HMO have long been regarded as metabolically "inert" to the host, as significant amounts are excreted with the fe-ces. HMO reach the colon intact where their prebiotic effects promote healthy gut colonization. HMO can also function as soluble decoy receptors and block adhesion of microbial pathogens to epithelial surfaces."

So we know that babies can't digest the HMOs.  They pass right to the colon where they affect the type of bacteria which colonise the area and significant amounts are excreted in faeces, i.e. not used up.  A second function is "decoy receptors".  This means that in the GI tract they physically attach themselves to pathogenic bacteria species and they take those pathogenic species out of the baby's body via the faeces.  This is a fantastic method of clearing out pathogens, another of breastmilk's amazing properties, and it is done via the faeces.  So HMOs pass in the poo, and they take bacteria out with them.  Poo contains billions of bacteria, good and bad species, and the bacteria is not "all used up" by the baby.  

What other components are in poo?  Well there are old cells which slough off from the intestinal lining.  There is bile, old blood cells etc.  Poo would be white if bile wasn't present - and this is one of the reasons that HCPs ask about the colour of your baby's poo. There will also be some mucus.  Mucus is made in the intestinal walls to lubricate the passing contents.  Usually the mucus is in small quantities so isn't really noticeable in your baby's nappy, but it is present in the poo (and isn't used up).  Large quantities of mucus (like globs of jelly or long strings) can be signs of intestinal irritation however.
Image titled Donate Partially‐Used Packages of Disposable Diapers Step 1


Setting aside this information about waste produced in a breastfed baby, there are 2 other points I think it's important to consider if you are told that there is no or little waste with breastmilk:



  • Babies who are pooing infrequently tend to have a massive "poosplosion" when they do finally poo, or they may fill several nappies in succession.  This completely flies in the face of the argument that the breastmilk was used up.  If it was used up then where did this large amount of poo come from?  What it does suggest is that the poo was actually sitting in the bowel for several days and simply wasn't moving out.
  • Most breastfed babies are still pooing daily after 6 weeks.  If breastmilk is all used up, then how could this be the case?  How could some babies drinking breastmilk be creating waste and others are not?  

As long as its soft it's not constipation?
Parents are usually told that its not constipation if the stool is soft.  Consistency may be a good indicator for adults, maybe even for formula fed babies - but does this apply to breastfed babies? 

A study looking at the effect of sugars on infant's stool characteristics (Scholtens et al 2014) states the following about HMOs:

"First, an increase in microbial mass due to the fermentation of the oligosaccharides can increase the faecal water content, which can results in softer stools. Second, the selective fermentation and growth of Lactobacillus species and bifidobacteria[,] and the subsequent production of SCFA can increase the water content of the faecal mass..... Third, as HMO are specific types of dietary fiber, they can be hypothesized to bind water and thereby increase the water content of the faecal mass"

So regardless of how long the poo sits in the bowel, breastmilk poo is likely to stay soft as water is increased due to the fermentation.  Anyone who has experimented with fermenting foods or creating a sourdough starter for bread will understand this principle.  As the poo (full of fermentable HMOs) continues to sit in the bowel (full of fermenting bacteria) it is reasonable to assume, I think, that fermentation continues and water continues to be increase in the faecal contents.


Is it a Big Deal if a Baby Skips Days?
We know it's common.  One French study (Courdent et al 2014) found that 37% of breastfed infants experienced at least one episode of infrequent stools (infrequent stools was defined as greater than 24hours between stools) over the first 34 weeks.  This is where I feel it's important to distinguish the difference between a baby who is having a few episodes here and there over the first few months where they miss a day or 2 between poos, and the baby who develops a consistent pattern of weekly stooling.  Babies who are teething may have a temporary change and miss a day or two and then return to daily stooling.  Illness, change of environment (maybe a holiday/ move of house), change of daily rhythm etc can all play a role, and temporary changes are to be expected.  That is a very different picture to consistent weekly stooling, or every 10 days.  In the book "Baby Poop: What Your Paediatrician May Not Tell You", Linda Palmer states the following:

"some exclusively breastfed babies will go 7 to 10 days, and dare I say even 17 days between poops, without having hard or painful stools.  This is common enough that most doctors call it normal.  In my experience, any such baby I've worked with has had some other issues going on and has benefitted from working through these issues.  You may like to think of it like constipation, in terms of searching for causes, especially when it regularly goes beyond 3 days"



Causes and How to Encourage Frequency
Causes of infrequent stooling (greater than 24 hours) in breastfed babies is wide and varied, and working with an IBCLC (International Board Certified Lactation Consultant) through the possible causes is the best idea to establish what might be happening with any individual baby.  Here I'm just going to mention a few common reasons and what you can do to encourage a daily rhythm again:

1.  Not enough milk
This is a really common cause of infrequent stooling, and is the reason that weighing is useful in the early days.  If there isn't enough "raw material" going in, then there really wont be very much waste, but nor will there be good growth.  See the previous blog on low weight gain for ways to increase milk intake and circumstances where feeding on demand is not enough.

2.  Teething / Illness / Temporary  Upsets
The word disease comes from the idea of dis-ease.  There are lots of things which disrupt the normal ease in our bodies, and it is very common for these to disrupt stooling pattern.  Teething babies can have a bit of inflammation going on for example.  They can swallow mucous, have a fever etc which will affect normal gut function.  Colds and bugs are similar.  Generally these are short lived and the baby returns to their daily pattern in a few days.  Tummy massage and frequent feeding can help baby with the discomfort of whatever is going on and help to move the bowels.

3.  Antibiotics / Temporary Lactose Intolerance / Tummy bug
Antibiotics don't just kill off pathogens.  They destroy populations of our good bacteria too including those lining the walls of the gut and in doing so the border cells can be temporarily damaged.  This damage to border cells also happens with a GI bug.  When this happens the baby produces lactase less effectively and doesn't digest lactose as efficiently (known as temporary lactose intolerance and discussed in more detail in this previous blog on Food Sensitivities.  This means that more lactose passes into the lower intestine undigested in the same way as the HMOs.  This can cause diarrhoea or conversely it can produce more infrequent stools and more gas.  An article by Lomer et al in 2007 in Alimentary Pharmacology and Therapeutics says the following:

"The typical symptoms of lactose intolerance include abdominal pain, bloating, flatus, diarrhoea, borborygmi, and on some occasions, nausea and vomiting.  In a few cases, gastrointestinal motility is decreased and subjects can present with constipation possibly as a consequence of methane production. Animal models have shown a marked reduction in the major migratory complexes of the gut when infused with methane, slowing gut transit"

Many mums and babies can be exposed to antibiotics during birth or in the early weeks due to something like mastitis.

This brings me on to the rotavirus vaccine. Some people find that their baby seems to change to a more infrequent pooing pattern after the rotavirus vaccination.  I have not been able to find any information on this in the patient information leaflets, but having a trawl through the research I found that lactase production is also reduced with infection by rotavirus, and indeed the patient.info site lists temporary lactose intolerance as a potential side effect of the vaccination.
Where temporary lactose intolerance is a cause of infrequent stooling, tummy massage again can be very helpful with relieving gas and moving the bowels.  Some dyads also find probiotics to be helpful (which would be another blog in itself).  I am also linking in the further reading section an article which give stats on how breastfeeding protects against rotavirus diarrhoea.

4.  Medications / Supplements
These can also play a role, in the same way that they can affect the gastric motility in adults.  A large number of babies are now being medicated for reflux.  Many parents find that alginates (e.g. gaviscon) can cause constipation.  Alginates may also reduce appetite and therefore milk intake.  Second line treatments for reflux can affect the microbiome and that may also affect gut function.  Again tummy massage is helpful, probiotics may also be helpful but ultimately getting to the root cause of the reflux and resolving so that medication is not needed is the ideal route in my view.  See part 1 and part 2 of my blogs on reflux for more details.
Supplemental iron in mum's diet can also cause constipation in her breastfed baby.

5.  Oversupply / Expressing
In number 3 I talked about the effect of too little lactase.  A mum who is in oversupply or who is expressing a lot of milk on top of feeding her baby may find that at times her baby is simply a little overwhelmed by lactose in her milk.  As I have mentioned in previous blogs many mums worry about oversupply when they actually have a completely normal supply, and I am certainly not suggesting that babies should stay on one side so they don't get too much foremilk! The result of that is frequently that babies don't get enough milk and we are back to cause number 1 (See previous blog on foremilk and hindmilk).
Some mums who are expressing regularly for a freezer stash can also find that their baby is unsettled, gassy and may have infrequent stooling. (See previous blog on potential problems with the freezer stash).

6.  Microbiome
We've mentioned bacteria a few times above.  Our gut is teeming with bacteria and many of them are essential to good gut function.  Functional constipation, which is constipation with seemingly no organic cause, is linked to an dysfunctional microbiome.  We inherit our microbiome from our mothers ideally through a vaginal birth, then through skin to skin with family members, through our home environment, through the bacteria in breastmilk etc.  For very many of us however, things don't go exactly to plan.  Babies born by C-section will have a slighlty different colonisation, those born in hospital have different colonisation to those at home.  Some babies spend time in hospital, and mothers will have different bacterial species in their milk depending on their diet and how that affects the species in her gut.  Add in antibiotics, and chlorinated water and our obsession as a culture with killing germs and our gut microbiome is often not what it should be.  Where the microbiome is affecting gut motility and stooling pattern probiotics may be helpful.
Interestingly the microbiome has also been associated with colic in many studies and the Baby Poop book quotes a study which found a higher percentage of colic in babies with infrequent stooling than in babies with daily stooling.

7.  Food Sensitivities
A common reason for infrequent stooling is food sensitivities - either food intolerances or allergy, and food sensitivities are increasing rapidly in the population in the last couple of decades. I discussed this in a previous blog on Breastfeeding and Food Sensitivities.
Food can also be a resolution to infrequent stooling.  The French study I mentioned above found a dietary influence, stating, " The most frequent action for infants was abdominal massage (79%), whereas in mothers it was consumption of fruit juice/mineral water rich in magnesium/vegetables"
Notice that it was the mother who consumed the fruit juice - not the baby!  I unfortunately still hear stories of fruit juice being recommended to babies under 8 weeks to aid with frequent stooling.  Babies of this age should be receiving breastmilk exclusively.


So is it anything to worry about?
Skipping days is statistically common, and although it's usually nothing to panic about, it is, however, a sign that gut motility is a little sluggish and the gut function isn't working quite as well as it could be.  In most cases that I have worked with, small changes do get babies back into a more frequent pattern of pooing, further contradicting the idea that breastmilk is all used up.  For most babies the resolution is optimising breastfeeding, daily tummy massage (The I Love You infant massage is particularly effective I find), removal of any allergens and often supporting the gut microbiome.  It might not be a big problem, but personally I prefer to see babies pooing regularly.





www.carolsmyth.co.uk



Further Reading and References:

1.  Allergy Burden in the UK: http://www.publications.parliament.uk/pa/ld200607/ldselect/ldsctech/166/16607.htm
2.  Courdent M1Beghin LAkré JTurck D  Infrequent stools in exclusively breastfed infants.   2014 Nov;9(9):442-5. doi: 10.1089/bfm.2014.0050. Epub 2014 Sep 22.
(https://www.ncbi.nlm.nih.gov/pubmed/25243969)
3.  A. MarcobalJ. L. Sonnenburg 2013 Human milk oligosaccharide consumption by intestinal microbiota Clin Microbiol Infect. 2012 Jul; 18(0 4): 12–15.
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3671919/)
4.  Jantscher-Krenn E1, Bode LHuman milk oligosaccharides and their potential benefits for the breast-fed neonate.   2012 Feb;64(1):83-99.
(https://www.ncbi.nlm.nih.gov/pubmed/22350049)
5.  Petra AMJ ScholtensDominique AM Goossens, and Annamaria Staiano Stool characteristics of infants receiving short-chain galacto-oligosaccharides and long-chain fructo-oligosaccharides: A review . 2014 Oct 7; 20(37): 13446–13452.(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4188896/)
6.  Lomer, Parkes, Sanderson Review article: lactose intolerance in clinical practice – myths and realities.  J. Alimentary Pharmacology and Therapeutics Volume 27, Issue 2 January 2008 Pages 93–103
(http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2036.2007.03557.x/full)
7.  Ramig.  Pathogenesis of Intestinal and Systemic Rotavirus Infection  . 2004 Oct; 78(19): 10213–10220.
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC516399/)
8.  Isabelle Beau,1,2 Jacqueline Cotte-Laffitte,1,2 Monique Géniteau-Legendre,1,2 Mary K. Estes3 and Alain L. Servin.  An NSP4-dependant mechanism by which rotavirus impairs lactase enzymatic activity in brush border of human enterocyte-like Caco-2 cells.  Cellular Microbiology (2007) 9(9), 2254–2266
(http://onlinelibrary.wiley.com/doi/10.1111/j.1462-5822.2007.00956.x/pdf)
9.  http://patient.info/doctor/rotavirus-and-rotavirus-vaccination
10.  Chang Hwan Choi* and Sae Kyung Chang  Alteration of Gut Microbiota and Efficacy of Probiotics in Functional Constipation  . 2015 Jan; 21(1): 4–7.(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4288092/)
11.  Dubois NEGregory KE Characterizing the Intestinal Microbiome in Infantile Colic: Findings Based on an Integrative Review of the Literature.   2016 May;18(3):307-15.
(https://www.ncbi.nlm.nih.gov/pubmed/26721871)
12.  Rotavirus vaccination vs breastfeeding reduction:  http://kellymom.com/blog-post/breastfeeding-protects-against-rotavirus/

 

Tuesday, 1 November 2016

What does On Demand (On Cue) Breastfeeding Mean? (and when on demand is not enough)

Women are told a variety of things about how often to feed their baby.  Feed on demand, feed on cue, Feed on demand every 3 hours (yep that one's particularly confusing), feed 8-12 times a day.  Unfortunately even now some mums are being sent home from hospital with the idea that their breastfed baby should be feeding every 3-4 hours.  In this blog I thought I'd delve into what feeding on demand (or on cue) looks like, what are cues for feeding, and what happens if you are feeding on cue but your baby's weight gain is low.

Feeding on Demand / Feeding on Cue
The language around baby led feeding is slowly changing from "On Demand".  The word "demand" sounds insistent.  To many "demand" gives the impression that a baby cries when hungry and ready to feed.  We know, however, that crying is a very late hunger sign.  A crying baby is a distressed baby and a distressed baby finds it very difficult to coordinate latching and feeding, so it is actually very hard to feed a crying baby.  More recent language focuses on feeding "on cue" or talks about responsive feeding - watching the baby for signs of readiness to feed.

This is a nice poster on the signs of readiness for feeding.  
Original image from kemh.health.wa.gov.au/services/breastfeeding/feeding-cues.htm
and published here under creative commons licence
 (https://creativecommons.org/licenses/by-nc-nd/3.0/au/deed.en)

Early cues for feeding are as basic as the baby beginning to rouse from sleep, or opening their mouth while in a light sleep.  If a baby is responded to when showing these cues it is usually easier to latch and breastfeed.  In this light sleep stage or just awakening, the baby tends to be relaxed and organised and coordinated.  

If those cues are missed the baby will become increasingly active to signal the need to breastfeed.  If these more active cues are missed the baby will then begin to cry.  The very act of crying means that the baby is now stressed, and in more of a sympathetic fight or flight type state.  In this state babies tend to be much less coordinated and it is much more difficult for the baby to latch.  Not only is the baby less coordinated, but his tongue is in the wrong position.  When a newborn cries he lifts his tongue up towards the roof of the mouth.  When he latches he needs to bring the tongue down and out to attach under the breast.  In practice what may happen with a crying baby is that he puts his mouth to the breast but can't attach to the breast and so continues crying.   He may shake his head at the breast or have flailing arms and hands as he can't get latched on well.   Perhaps he does manage to latch but the attachment is shallow and the mum has pain and he isn't able to drink easily.  All of this causes increased stress for the mum and can make her feel that breastfeeding just isn't working.   The baby now needs to be calmed into more of a relaxed state again so that he can latch and breastfeed well.  That may take a little time and if this is repeated throughout the day, not only can breastfeeding be stressful, it can also mean that some feeds are missed compared to the number of feeds that would have occurred if breastfeeding happened at the earliest cues.  It's not a good situation for either baby or mum.


Skin to Skin and Cues
There's more to consider than just watching for cues though, because whether a baby is being held or lying alone is part of what determines how frequently he cues for feeds.  Nils Bergman is a neonatologist whose research focuses on skin to skin contact and how that affects both the baby and the caregiver's physiology.  From his research Bergman shows that babies behave differently if held, compared to if they are lying without contact with a caregiver's body.  When held on a body a baby enters a specific program of feeding and brain building.  In this quote SSC stands for Skin to Skin Contact.


"After feeding the baby goes to sleep, and research has shown that only on mother’s body is this sleep  of the right quality for brain wiring. Sleep cycling is necessary for brain development, and SSC achieves REM sleep cycling with Quiet Sleep. When the baby wakes on mother, there is time for smell to initiate a cephalic phase preparing the stomach for food, so that when the baby starts to feed it is primed and prepared, and organized in its feeding. "
http://www.skintoskincontact.com/ssc-breastfeeding.aspx

Bergman explains that sleep cycles last approx 1hr-1.5 hrs.  When held on mother's body a baby completes a sleep cycle and then wakes to feed.  So when being held, a baby will cue to feed every 1-1.5 hrs.  Since it's normal for primate mammals to be in contact with their babies, this is a normal feeding frequency for our babies.  In contrast, if a baby is not in contact with mum's body, (e.g. in a moses basket, even if it is right next to mum) the normal state of feeding and sleeping doesn't happen.  The baby doesn't enter the same sleep cycling program.  So a baby who isn't being held may not cue for feeds with the same frequency as one who is being held.  I should just reiterate that the frequency for the babies who are held is the normal frequency.

Babies who are not cueing for feeds at normal frequencies (maybe only feeding 3hrly), or not being responded to at early feeding cues may have more difficulty with breastfeeding and may have more weight gain issues.


When Feeding On Cue might not be enough
Healthy babies who are feeding well and gaining weight appropriately cue for feeds when they need them and are able to manage their own intake.  We have known this for 25 years and this is why mums are encouraged to responsively feed when their child cues readiness.  A baby who is unwell, or a baby who isn't gaining weight appropriately however is another matter, and it is the latter that I want to talk about most.   Many babies in our medicalised system of birth don't get off to the best start to breastfeeding.  We have a large percentage of inductions, instrumental births (forceps / vacuum) or cesareans.  Many babies are sleepy after birth , perhaps due to drugs during labour.  Many babies have some separation from mum (even if it is short).  These deviations from normal physiology mean that lots of babies don't feed well in the early days.  This has a knock on effect to mum's milk supply as these babies just don't stimulate milk production as well as they should.  This can result in a baby who has low weight gain in the first week or 2.  See this previous blog on what weight gain should be and what to do to improve it.  In many of these cases the mum is following the baby's cues, but the weight gain continues to be low.   So what is going on?  Well, in essence I think that in the early days breastfeeding and milk supply drops into one of 2 cycles.



These are vicious cycles which feedback on themselves, centring around how much milk a baby drinks from the breast and how well mum's milk production builds up.  If a mum has a good milk supply and lots of milk in the breast, then milk flows easily.  Mum's body easily delivers the milk to the baby.  If supply is low, then it is harder work to remove the milk.  The milk supply of course is driven by how well a baby feeds so milk production and how well a baby feeds are closely linked.
If a baby is not feeding well in the early days, mum's milk supply doesn't build as it needs to.  A baby may then  fall in to a declining spiral where he sleeps more, doesn't cue for feeds and when he does feed, he doesn't get as much milk (due to the joint issue of sleepy feeding and low supply requiring more effort to feed).  In contrast, if feeding goes well in the early days then the dyad move into an upward spiral where baby gains weight well, cues for feeds frequently, milk flows easily and baby feeds well.


If this weight gain issue is identified in the early weeks then some simple interventions can move a baby from the declining cycle into the upward cycle.  Interventions should always involve optimising breastfeeding (looking at frequency of feeds, how a baby is positioned and attached, maximising the amount of milk that a baby drinks when at the breast, and resolving any physical issues that was preventing good milk transfer).  Interventions might also involve expressing and supplementing mum's milk alongside breastfeeds.  That expressing increases mum's supply (so milk will flow more easily).  Supplementing that milk gives the baby more calories with less work required so that baby starts to gain weight better.  Depending on age of the baby and what the weight gain is like, there may also be a requirement for some temporary supplementation of either donor milk or formula.  Often a very small amount of supplementation helps a baby to feed better at the breast.  Feeds actually become more effective as the baby has more energy, is more alert, feeds more actively without falling asleep, and therefore removes more milk.  Crucially these interventions may also involve not waiting for the baby to cue for feeds.  It means recognising that a baby not gaining appropriate weight may not be able to correctly cue for feeds and that feeds should be offered to the baby frequently.

Any supplementation to increase gain should be introduced with a plan so that both the family and the HCP know why supplementation is being given, what the goal is, when it will be appropriate to wean off the supplementation and how that weaning off will happen.  It should not be a case of an HCP casually mentioning the need to add in top-ups with no end in mind (see this blog on the top-up culture).  Don't be afraid to talk to your HCP about your goals.  If your goal is to exclusively breastfeed your baby, see this intervention as temporary, as a way to allow you to get to exclusively breastfeeding with healthy weight gain.  A tool which will allow you to breastfeed for as long as you wish.  Create a plan together which will allow you to meet that goal.  As ever, if you don't feel that you are getting the support you need to meet your goal, or in creating a plan to normalise your baby's weight gain then look elsewhere.  Contact a local breastfeeding counsellor or IBCLC (Lactation Consultant) for help.



Babies gaining appropriately  (approx 1oz / 30g a day in first 3 months) cue for feeds and manage their milk intake appropriately.  Babies who aren't gaining appropriately .... not so much.  They are simply a bit compromised.  Their bodies compensate for the lack of weight gain by conserving energy.  They sleep more, they feed less well, and to top things off, our Western culture contributes by encouraging separation from our babies.  Having our baby right beside us in a cot / Moses basket / pram etc may not seem like separation for us, but it is a huge thing for our babies.   Our babies need body contact and they need frequent feeding.  In contrast our mums are often not aware of just how often babies feed, and unfortunately our culture bombards us with these unrealistic 3-4 hrly timescales.

Earlier today I watched a documentary on TV about bears.  It followed one first time mother bear and her cub.  It struck me how carefully it explained that the cub was completely dependent on mum and needed to feed every few minutes.  I think that when we are able to embrace this normal mammal model for ourselves, rather than separating our mums and babies and giving unrealistic ideas of feeding frequency) breastfeeding will be easier for many mums and babies.




www.carolsmyth.co.uk




Further Reading
http://lactseminars.weebly.com/uploads/6/9/8/0/6980312/smillie_day_3-2_syllabus_swg_vicious_cycles_israel_2011.pdf

https://storify.com/GOLDLactation/christina-smillie-5722781b9b86708230c6d43a

http://www.kangaroomothercare.com/olanders.aspx

Saturday, 27 August 2016

Breastfeeding, Food Intolerance & Allergy

Suspicions, investigations and diagnoses of allergies is pretty high in our babies these days.  The NICE guidance on allergy states that cows milk protein allergy alone affects 7% of formula fed and combination fed infants.  Given that we know from the infant feeding survey that only 13% of babies are exclusively breastfed at 6 weeks in Northern Ireland (23% across UK) , many breastfeeding mothers are also dealing with allergy. The 7% are diagnosed allergies.  Many more babies and children suffer delayed food reactions of varying degrees (sometimes mild constipation or eczema which are not investigated) and when these are added in, it is estimated that 15-25% of infants and young children have some kind of food sensitivity /allergic reactions (Figure from "Baby Poop: What Your Paediatrician may not Tell you" -see further reading.)  Given that is the case, it's understandable that many mums wonder about intolerances and allergies when their baby is fussy.   Often when mums post on internet groups about their fussy baby they get many comments suggesting she remove dairy from her diet.  Many mums have removed dairy without any real investigation into whether a breastfeeding problem is linked to the fussy behaviour, or whether it may be developmental.  There seems to also be a lot of misunderstanding about what intolerance or allergy is, and also how it relates to breastfeeding so I thought that in this blog and the next, I'd try to cover about few basics about them.

Lactose Intolerance
Firstly lets start with the idea of lactose intolerance since there is a lot of population misunderstanding about dairy and lactose intolerance.  Intolerance is not allergy.  Intolerance means that the food cannot be metabolised / broken down and used by the body.

Lactose is a sugar.  Lact-ose - literally means milk sugar.  It is a made up of 2 other simple sugars (galactose and glucose), is contained in all mammal milks and is a very rich source of energy for infant mammals.  It makes up approximately 7% of Breastmilk by volume and provides about 60% of the energy in Breastmilk.  Since it is the main source of energy it is vital that a baby can digest lactose and it is designed to rapidly grow the human brain.

So we have a normal milk sugar called lactose in milk (both human milk and other mammal milk, including cows) which enters the baby's gut when the milk is drunk.  Babies (and all infant mammals) produce an enzyme in their gut called lactase.  The job for lactase is to break the lactose down into those 2 components of galactose and glucose, which can then be easily used as energy by the body.  Lactose intolerance is the inability to break down lactose.  It happens when the body does not produce lactase to break down the lactose.

Most mammals infants produce lots of lactase as they obviously need to break down the lactose milk sugar which is their major energy source.  As they get older they produce less and less lactase.  This is by design and is a natural part of the weaning process.  An animal moves to an adult diet, it no longer requires milk and therefore doesn't need the ability to digest milk.  So they gradually produce less lactase, they drink less lactose and they naturally wean to an adult diet.  This is also the case in most of the human world, BUT not in those of European descent.  Dairying has been a big part of culture in this part of the world for thousands of years.  We know that very large dairies were in place in Ireland 5000 yrs ago.  Around the same time as the rise of dairies we developed a mutation in our genes which allowed us to continue to produce lactase and therefore digest milk, into adulthood.  It was probably an important source of nutrition at that time if there was enough selective pressure to mutate the gene.  So for several thousand years people from this part of the world have produced lactase both as infants and adults, and are able to digest lactose throughout their life.

It is extremely rare for a baby to be born with a lactose intolerance as it would leave that baby unable to digest any milk.  That would be a biological disaster for a mammal, so if someone suggests to you that your baby may be lactose intolerant, it is extremely unlikely to be true.  

It is possible in some circumstances for a baby's gut can to be be overwhelmed by lactose however and for symptoms of lactose intolerance to appear.  There are 2 common conditions where this can happen:
  1. Baby or mum has had antibiotics or a stomach bug.  Lactase is produced by the border cells of the small intestine.  Both antibiotics or a GI infection can destroy the healthy gut bacteria lining the gut and in doing so the border cells can be damaged.  Until the cells are repaired there may not be enough lactase created to digest all of the lactose that a baby drinks.  It is known as temporary lactase deficiency and continues until the gut border is healed and the cells are creating lactase efficiently again.  Breastmilk has components which help to heal the gut!
  2. If mum perhaps has a oversupply of milk (maybe due to expressing or tandem feeding or swapping sides more often than her particular baby needs), or is scheduling feedings and feeding from very full breasts each time, it can mean that a baby gets more lactose than needed and that can overwhelm the amount of lactase in the gut leading to colicky symptoms.  Lactase is still produced, just not in the amount needed to deal with the overload of lactose.  So lactase breaks down the lactose that it can, but lots of lactose molecules are left over and not digested  This is common and easily resolved just by a little breastfeeding management around feeding frequency.  See my previous blogs on Foremilk/HindmilkOversupply and Fast Letdown.
Lactose attracts water so the result of lactose not getting broken down in the gut is comparable to eating a lot of dried fruit, prunes for example.  It pulls water into the intestine to join the lactose.  This creates a watery solution which passes through the gut very quickly.  It also means there is a lot of sugar to be fermented by bacteria in the gut.  The result is a baby who is colicky, gassy and has green slimy stools.

Occasional green stools are nothing to worry about.  It is likely that all breastfeeding mothers have times where their baby slept unusually long at night and fed from a very full breast in the morning and resulted in a green stool. 

If you are concerned that your baby is having frequent colicky, gassy, green stool symptoms, contact a breastfeeding counsellor or lactation consultant (IBCLC).  If it is caused by an overload of lactose, altering your breastfeeding daily rhythm is usually all that is needed.  This is not a true intolerance and you switching to lactose free dairy will not make any difference.  Your milk will still contain lactose, because it is produced in your breasts and that is what your baby needs for his rapid brain growth.


Food Allergy
In contrast to intolerance, where there is an allergy the immune system is involved and reacts to exposure.  Usually in dairy it is due to exposure to cows milk proteins, not lactose.  Commonly allergies are categorised into IgE-mediated reactions and non-IgE-mediated reactions. 

IgE stands for Immunoglobulin type E and is one of the 5 subtypes of antibodies which our bodies make (IgA, IgD, IgE, IgG, and IgM).  IgE antibodies are mostly found in the lungs, skin and mucous membranes. IgE antibodies are implicated in dietary allergy and have a fairly immediate reaction - often within minutes of eating the allergen and can range from skin issues like hives to hayfever like symptoms of streaming eyes and nose, or respiratory symptoms like wheeze and cough to life threatening anaphylaxsis symptoms.   Most people recognise this reaction as an "allergy"

Non IgE-mediated-reactions are delayed reactions which do not involve IgE antibodies.  Non IgE reactions can appear from a couple of hours to 2-3 days after foods, which makes identification and diagnosis much more tricky.  These reactions are often skin based or intestinal and in the general population are often described as the baby being a little intolerant to dairy.  This is not true intolerance however.  This is not a case where a food cannot be tolerated because the components needed to digest it are not present.  This is, in  fact, an allergy.  The most common non-IgE symptoms manifest in 3 systems of the body: the Gastrointestinal System (e.g.stomach pain, cramps, diarrhea); the Respiratory System (e.g. Wheezing, coughing); the Skin (e.g eczema, hives).  This has a different overall picture to lactose overload.


Allergy and Breastfeeding
Food components that we eat can pass into breastmilk, BUT it's not a simple picture.  A 1984 study by Kilshaw & Cant looked at the passage of dairy and egg proteins into breastmilk.  They looked at milk and blood from 29 women before and after they ate 1 raw egg and half a pint of cows milk.  They found a cows milk protein (β-Lactuloglobuin) in the breastmilk of 10 out of 19 women who drank cows milk.  They found an egg protein (ovalbumin) in the breastmilk of 13 out of 22 women who ate egg, and they found another egg protein (ovomucoid) in the breastmilk of 7 out of 9 women who ate egg.  It was not found in the breastmilk of the other 8, 9 and 2 women respectively.

Essentially then, they found that foreign food proteins CAN pass in to breastmilk - but they don't consistently pass in all women, and that has to make us think a little.  Breastmilk is made from our blood.  The milk making cells (lactocytes) manufacture some of the components of breastmilk, but they are also very extensively supplied with blood vessels, and it is from the blood that many nutritional and immune components pass into the milk (proteins such as immunoglobulins, fats etc).
Lets go back one step further and look at mum's digestion.  In my blog on reflux and stomach acid I discussed how proteins are supposed to be entirely broken down in to their constituent amino acids during digestion.  The amino acids then pass through the gut wall into the bloodstream to be used in the body.   Complete foreign proteins should not be in the bloodstream, yet studies like the one discussed above show that dairy and egg proteins can pass directly from our food into breastmilk completely unchanged in some women.  So, why does this happen?  Why in some and not in others?
The short answer is that we don't know.  It may be that the mum actually has a leaky gut.  It would take too long to go into leaky gut in this blog but I will link further articles in the further reading.  Studies have shown that many food additives that we eat nowadays for example damage the tight junctions between cells in the gut wall and allow food particles through the gut walls.  Perhaps the difference between the women in which the food passes and those in which it doesn't is their gut integrity.  It may be that the mum is sensitised to some food proteins herself without realising - perhaps through her own feeding as an infant with formula or the way that solids were introduced.    It may may that it is due to the type of food.  Dairy and eggs (both of which are common allergens) are growth materials designed for the young of that species.  They contain materials which are supposed to guide the growth of those young.  Egg white provides the growth medium for a fetal chick as milk does for a mammal infant.  In Baby Poop: What your paediatirican may not tell you, Linda Palmer says the following:

"Animal milks have proteins that are quite similar to human milk proteins; 
they are similar but not identical.  
All milks are designed to buffer the digestive system - preserving the structure 
of many of milk's proteins - and to allow certain milk proteins 
to pass right through a child's intestinal membrane....
milk has valuable antibodies and other agents that are meant 
to pass into baby's bloodstream...
If you think about it, egg-white is practically chicken milk"
Linda F. Palmer, DC - Baby Poop:  What Your Pediatrician May Not Tell You

We know about the value of maternal antibodies to our babies and how our antibodies pass in milk and protect our babies, so here is the point that we need to confront what we are drinking when we drink the milk of another mammal. That milk is designed for her baby.  Some proteins in that milk are designed to pass through the intestinal barrier.

Does that mean that we should all avoid dairy altogether?  Again not a clear picture because a study looking at women with allergic family history who avoided dairy found them to have lower sIgA  (secretory IgA) in their milk than the women who continued to eat dairy, and their babies had a higher incidence of cows milk allergy than the women who continued to eat dairy while breastfeeding (Jordan & Hogan, 2014).  Secretory IgA is important for gut health and for gut integrity and in the early days babies cannot make it themselves.  They only get it from breastmilk.

It's a complicated picture and the way that one mum and baby reacts to foods in their diet may be very different from the next.  I've discussed the prevalence of allergies above but it's also important to note that not every fussy baby is reacting to something in your breastmilk.  The first step for a fussy baby / fussy feeding / baby with suspected colic or reflux is a feeding assessment.  The root causes I describe in my reflux blog are also appropriate here.  Fussy, unhappy babies can be unhappy because of breastfeeding problems (poor milk transfer, oversupply, anxiety/stress in mum or baby, overstimulation, physical separation from caregiver, anatomical or functional restrictions), and breastfeeding problems have breastfeeding solutions.  A thorough assessment and interventions to resolve these can allow a content, thriving baby to emerge.  If other allergy symptoms sit along side the fussiness, (e.g. consistent projectile vomiting, consistently mucousy stools, excessive gas, constipation, blood in stools, eczema / skin rashes, persistent cradle cap, redness around the anus, chronic nasal stuffiness or mucus, frequent hiccups, repeated respiratory infections or colds etc) then it may be that the child is reacting to something in the diet.  An IBCLC working through a breastfeeding assessment should also ask about and take account of these symptoms.  It's important to note that of course allergies are not always food related.  Skin rashes can be caused by reactions to creams, lotions, washing powders etc, and food allergies are not always the growth mediums of milk and eggs.  Common food allergens are also nuts, wheat, soy, fish and shellfish.

Identifying what allergen your baby may be reacting to, and eliminating it can be another tricky area, and for another blog.  A final word on eczema....  The prevalence of eczema and the acceptance of it as "normal" in babies really disturbs me.  A study in England published in the Journal of the Royal Society of Medicine (Simpson 2009) found a increase of over 56% in prescriptions of eczema treatment over 2001-2005).  They found that 1 in 9 people experience eczema at some stage in their life making it the most common chronic condition.  Often when babies have eczema, creams are prescribed and parents reassured that they will simply grow out of the problem.  As with everything, looking at the root cause of eczema is important I think. The skin is an organ.   One of the primary functions of the skin is as a barrier between the inside of our bodies and the outside world.  Another function is as an excretory organ.  We excrete toxins and waste through the skin, primarily through sweat.  Toxins in foods are eliminated through the liver and kidneys but if the liver and kidneys are perhaps congested with the amount they are dealing with, you get sluggish function (you often see constipation) then the body moves to other ways of excreting - often the skin or through the breath.  In fact a 1995 study in the International Archives of Allergy & Immunology (Iukura et al, 1995) found that children with atopic eczema had reduced liver function.   Complementary therapists and naturopaths often work on supporting the liver as well as looking at the gut in patients with skin rashes.
Eczema isn't a normal condition, and it isn't just cosmetic.  It prevents normal function.  It isn't normal for our protective barrier to break open.  Children may indeed grow out of it later, but that doesn't mean it shouldn't be investigated now.  I can't imagine anyone saying that a child would grow out of recurrent lesions appearing on any other organ.

In short if you are concerned about fussy behaviour in your baby and are worried about allergy - speak to an IBCLC or breastfeeding counsellor.  Breastfeeding should be assessed first to look at root causes of the unhappiness in a baby, and as part of a thorough assessment allergy will be looked at.  Blindly eliminating foods without assessment or any guidance can be stressful and confusing, and stress doesn't help when you are dealing with a crying baby.  Reach out for breastfeeding help.


  


Further Reading
1. Development of Lactase Persistence in Humans - 
 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1182075/#!po=15.8537
2. UK Infant Feeding Survey - http://digital.nhs.uk/catalogue/PUB08694/Infant-Feeding-Survey-2010-Consolidated-Report.pdf
3. Prescribing Rates for Eczema - http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2746851/
4. Liver Function in Children with Eczema - http://www.karger.com/Article/Abstract/236973
5. Passage of Dietary Proteins in Breastmilk - http://www.karger.com/Article/Abstract/233582
6. Information on sIgA in Breastmilk - http://phenomena.nationalgeographic.com/2014/02/03/how-breast-milk-engineers-a-babys-gut-and-gut-microbes/
7. Reduction of sIgA in Breastmilk while on Elimination Diet - http://pediatrics.aappublications.org/content/134/Supplement_3/S139.1.full
8.  Food additives causing change in intestinal permeability - http://www.sciencedirect.com/science/article/pii/S1568997215000245
9.  Leaky Gut - https://chriskresser.com/9-steps-to-perfect-health-5-heal-your-gut/ 

Saturday, 23 July 2016

Open Letter To Sammy Wilson MP in response to his comments on Breastfeeding

Dear Sammy,

This morning I heard you interviewed on the Stephen Nolan show about the new independent report on sexism in Westminster.  The report (which was welcomed by the Speaker of the House) made many suggestions but one was to create a "role-model parent friendly institution" by allowing breastfeeding in the Westminster chamber.  The report stated that making this change would "enable all members to participate fully in House business".


Your response to this suggestion was to disagree and state that it was "voyeurism".  When pressed on the use of this word you then said that it was "exhibitionism".  Sammy, my job is as an IBCLC (International Board Certified Lactation Consultant).  Essentially I help women who want to breastfeed their babies.  You cannot imagine how unhelpful your comments have been this morning.


You stated that women could do it elsewhere in Westminster and don't need to do it in the Chamber.  Sammy, don't you see how this is no different to saying that a woman can breastfeed at home, she doesn't need to do it in a cafe, or in a church or in a leisure centre or anywhere else that she happens to be?  You questioned why a woman would want to breastfeed in the Chamber.  Perhaps it was exhbitionism you said.  Believe me Sammy, women are not trying to be exhibitionists when they  breastfeed in public.  Most women are fearful when they begin breastfeeding with others around. What if their baby won't latch?  What if he cries and everyone looks?  What if someone approaches them negatively?  What if they are asked to leave?

These fears cause women to feel isolated.  It causes them to stay at home more than they want at a time when they need social support.  It prevents them from participating fully in society.  For an MP it prevents her from doing her job.  The very act of stating that it should't be done in the chamber sends a message that there is something wrong with it.  That it is something not to be seen.  It influences mothers, pregnant women and young girls in the way that they think about babies and mothering.  All a breastfeeding mother is trying to do is feed her baby.  She has no other thoughts other than the thoughts of a mother for the welfare and comfort of her child.  


Image linked from http://tinyurl.com/jpr22dr
Breastfeeding in the European Parliament

Why would she want to feed in the Chamber?  I doubt any MP would think, "oh my baby is likely to be hungry soon, sure I'll just head into the Chamber to feed him."  The member would simply be doing her job, conducting her business in the house and responding to her baby's needs as they arise.  You said that perhaps babies shouldn't be in the Chamber at all.  That would on the face of it seem to get around this issue of breastfeeding I'm sure, but in reality what it does is isolate women again.  It tells women that they cannot be productive members of society if they are breastfeeding.  It prevents women who want to return to work when they have a small baby from doing so.   

It's not just as simple as feeding her baby before she enters the chamber either.  Babies are tiny, obviously.  That means they have tiny stomachs.  Small babies need to feed frequently and need to be at the breast most of the time.  Debates can be long, and it is not reasonable nor practical, nor biologically workable to expect a mother to schedule her baby.

You talked about the choice to breastfeed Sammy and here is where I think we get to the real nub of the problem.  When we talk about choice we imply parity of options, but for mothers and babies the choice of breastfeeding or giving an artificial baby milk are not equal options.  There are real implications, both for the health of the mother, the baby and for wider society.  Earlier this year the Lancet published a series of reports on breastfeeding (http://www.thelancet.com/series/breastfeeding).  In that series they stated that 



"The deaths of 823 000 children and 20 000 mothers each year could be averted through universal breastfeeding, along with economic savings of US$300 billion".  They stated "If breastfeeding did not already exist, someone who invented it today would deserve a dual Nobel Prize in medicine and economics. For while “breast is best” for lifelong health, it is also excellent economics. Breastfeeding is a child's first inoculation against death, disease, and poverty, but also their most enduring investment in physical, cognitive, and social capacity."  


They also made very clear that this was not just an issue in developing nations.   A UNICEF article provided a high level summary of some of the Lancet series.  It said,

"in high-income countries breastfeeding reduces the risk of sudden infant deaths by more than a third.... For mothers, longer-duration breastfeeding reduces the risks of breast cancer and ovarian cancer....Modelling conducted for the Series estimates that global economic losses of lower cognition from not breastfeeding reached a staggering US$302 billion in 2012, equivalent to 0.49% of world gross national income. In high-income countries alone these losses amounted to US$231.4 billion, equivalent to 0.53% of gross national income (Paper 2, table 2).  Furthermore, the authors calculate that boosting breastfeeding rates for infants below 6 months of age to 90% in the USA, China, and Brazil and to 45% in the UK would cut treatment costs of common childhood illnesses (eg, pneumonia, diarrhoea, and asthma) and save healthcare systems at least US$2.45 billion in the USA, US$29.5 million in the UK, US$223.6 million in China, and US$6.0 million in Brazil." 

(http://www.unicef.org.uk/BabyFriendly/News-and-Research/News/The-Lancet-Increasing-breastfeeding-worldwide-could-prevent-over-800000-child-deaths-every-year/).  

Those are significant figures, Sammy I'm sure you'll agree, particularly when our NHS is struggling.  The Lancet series was very clear that breastfeeding succeeds where it is protected, promoted and supported, and called on Governments to protect, promote and support breastfeeding.  The steps outlined in the report around breastfeeding in Westminster would be a wonderful step forward in regard to this.

One other point I want to make, Sammy.  You suggested that people of your generation don't want to see breastfeeding.  With all due respect, Sammy you appear to be making this about you and your discomfort. This isn't about you. A woman breastfeeding her child is simply feeding her child.  Your discomfort with her feeding her baby would seem to be about your own prejudices. Would you also feel uncomfortable with a women bottle feeding her child?  Do you have discomfort with a baby feeding, or with the fact that a women is designed to use her body to do it?  Our babies deserve better than this from our elected representatives.  Our babies are the future. They deserve to have less illness, and a better lifelong health trajectory.  They deserve to have a healthier mother with less chance of developing cancers.  They deserve to meet their genetic potential.  This issue is about the babies and the future of our nation, not about the cultural discomfort of a generation who weren't taught the importance of breastfeeding for the normal physiological growth of their children.


I encourage you to read the Lancet series and reconsider your position and words.  To leave you with the words of the series,


 "success in breastfeeding is not the sole responsibility of a woman — the promotion of breastfeeding is a collective societal responsibility.