There was some discussion on another thread (http://forum.mrmoneymustache.com/mini-money-mustaches/tips-on-saving-money-on-a-newborn/
) about the objective risks/benefits of breastfeeding. I wanted to start a new thread here because I didn't want to derail the OP's topic, and because there seems to be quite a bit of interest in this subject as well as alot of pushback. There is a shifting tide in public health right now surrounding breastfeeding. Old dogmas, such as those that preach no supplementation, or assume that almost every woman can breastfeed exclusively, are being debated and challenged in the medical and public health realm, but it will probably be a few years until these new understandings arrive in most breastfeeding classes, educational packets, and in-person discussions with front line OBs/midwives, lactation consultants, and pediatricians. It has come to my attention through my own breastfeeding struggles and my daughter’s subsequent hospitalization, that parents are not receiving the most up to date information regarding the benefits and risks of exclusive breastfeeding. I know this for a fact because I was one of these parents.
About me: I hold a masters degree in public health and worked for a prestigious hospital on infant feeding protocols. I am also the mother of an infant that suffered hyperbilirubinemia and dehydration due to ineffective breastfeeding in the first few days of life. I took breastfeeding classes and sought advice from well trained CNMs and lactation consultants, breastfed on demand, etc, so I was completely shocked when this happened to me of all people. I continued to breastfeed until about 3mo postpartum after battling back from the extreme challenges we experienced, so I know what it is like to be very committed to breastfeeding. I am not a medical professional (nurse/MD) but a public health researcher in women’s issues and pediatrics. All of my analysis is viewed through that public health lense.
Currently, breastfeeding is presented in classes and OB offices as a near perfect good. Benefits are touted left and right, and women can attend frequent classes and support groups to learn the mechanics of it. But very little information is provided on the risks of breastfeeding- and yes, there are documented risks, namely starvation related complications due to dehydration/not eating enough. If you doubt this, I encourage you to attend a class, or pick up a breastfeeding packet and see if any of the following information is presented at all, let alone in detail.
The bottom line is, every day there are newborns in the US who are re-hospitalized after initial discharge (or have their original stay extended) because they are essentially starving while breastfeeding. Starvation manifests through different physiologic conditions such as hyperbilirubinemia (high bilirubin), hypoglycemia (low blood sugar), hypernatremia (high sodium), and excessive weight loss breaching the 10% threshold set by the American Academy of Pediatrics. These conditions can be due to other factors, like cranial bruising in the case of hyperbilirubinemia, or gestational diabetes in the case of hypoglycemia, but they can also be caused, or greatly exacerbated, by dehydration. And they are deadly – when left untreated for too long, starvation results in widespread brain injury and eventual death. An infant can experience brain damage and seizures by day 3-4 of life if they have not had anything to eat. Hyperbilirubinemia, the condition my daughter had, is particularly prevalent and very confusing for parents to effectively navigate because jaundice (the red flag symptom of potential hyperbilirubinemia) is often downplayed as "common" or "normal" in infants.
The estimated prevalence of readmission for starvation related complications is 1-2% of all infants, but this does not include those infants who are not yet so severe and can be managed in the outpatient setting. Many infants require frequent weight and bilirubin checks, supplemental nutrition, and repeat lactation consultant evaluations at their pediatrician offices but who do not qualify for emergency readmission. My daughter was discharged with mild jaundice only to be readmitted the following morning because her seemingly normal jaundice had overnight turned into a full blown emergency - hyperbilirubinemia and was starting to demonstrate the symptoms of very early stage bilirubin encephalopathy (http://neuropathology-web.org/chapter3/chapter3eBilirubinencephalopathy.html
The old dogma is that these conditions in otherwise healthy babies are due to a mother’s lack of breastfeeding education, and that if she would just see a consultant, or take a class, or breastfeed the “right” way, the problem would never have happened. This is true in some cases, but new research demonstrates that we have underestimated the prevalence of lactation problems that are not within a woman’s control. In other words, there could be an awful lot of women out there who through no fault of their own are accidentally starving their infant in the first week of life. Research has estimated 20% of first time moms experience delayed lactation (https://www.ncbi.nlm.nih.gov/pubmed/12949292
) right after giving birth, where their milk doesn’t arrive within the normative 48-72 hours. The authors specifically conclude that effective lactation post birth is "strongly influenced" by parity. 72+ hours is a dangerously long time for an infant to go without milk as I just discussed, and if mom is discouraged from supplementing, or pumping to bottle/syringe feed, she can easily go three days just putting a baby on a virtually empty breast over and over again while the child deteriorates. And while many advocates claim that only 5% of women can’t breastfeed, this statistic is questionable. It generally references women who truly cannot breastfeed due to insufficient glandular tissue or other breast problems, but does not account for women who simply have suboptimal supplies or those women who have normal supplies but experience delayed lactation at first. We don’t have clear numbers on just how common general insufficient milk production for exclusive breastfeeding might be, but an interview with a breast milk researcher at Penn State suspects from her research that it is much higher than previously thought (https://themomivist.com/2016/08/02/moms-dont-feel-ashamed-about-your-breast-milk-supply-even-scientists-are-still-searching-answers-for-why-it-isnt-consistent/
UPDATE: New research released this year showed that anywhere from 1/3-2/3 of mothers did not produce the minimum amount of milk necessary for optimal nutrition within the first month of life, further strengthening the research showing that our previous assumptions about the "rarity" of insufficient lactation are incorrect. It is becoming more apparent that insufficient milk production, particularly in the first month postpartum, is not rare, but actually a surprisingly commonplace phenomenon. https://www.ncbi.nlm.nih.gov/pubmed/27897979
If you are particularly interested in starvation related complications, I highly recommend FedisBest.org. It is an evidence based organization founded by a physician and NICU lactation consultant, and they offer a bunch of great resources and information on how to breastfeed while also taking a proactive, preventative stance against starvation.
So what to make of all this? How do we support breastfeeding without putting babies at risk for starvation complications? A great read if you can access it, is a recent editorial in JAMA (http://jamanetwork.com/journals/jama/article-abstract/2571222
). It discusses the newest findings by the US Task Force on systemic breastfeeding initiatives like the renowned Baby Friendly Hospital Initiative, which prides itself on strict feeding rules like no bottles, pacifiers, or supplemental formula. The task force found that these sorts of policies DO NOT HELP improve long term breastfeeding duration, and that instead providers should focus on tailored individualized breastfeeding plans that fit a mother and baby’s unique needs. The editorial writers also worry that these rigid policies are harming infants by withholding pacifiers (associated protective factor against SIDS) and contributing to those starvation related complications in newborns. Instead, the new recommendations are for hospitals to tailor their breastfeeding education and recommendations to individual mothers. Hopefully as more research comes out, these recommendations will include more information like I provided here so mothers or babies at particular risk (first timers, early term babies, babies with other risk factors for hypoglycemia/hyperbilirubinemia) can take a preventative approach to dehydration/starvation through supplementing, combo feeding, or being particularly vigilant when exclusively nursing. Lastly, I want to point out that the fact that the US Task Force found that the BFHI was not effective is HUGE. And the fact that this editorial appeared in JAMA is also very notable, and just one of the little breadcrumbs we are finding sprinkled throughout the field regarding this shift in breastfeeding dogma and policy.
Update: More research questioning and challenging the rigidity of exclusive breastfeeding promotion. New research shows that breastfeeding mothers who fail to meet exclusivity guidelines are experiencing negative emotional impacts like guilt and disappointment, even if only supplementing a little bit for necessary reasons. The paper authors conclude that "it is important that future recommendations recognize the challenges that exclusive breastfeeding brings and provide a more balanced and realistic target for mothers." http://onlinelibrary.wiley.com/doi/10.1111/mcn.12364/full
Happy to provide more resources and sources if needed/interested!