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Tuesday, February 23, 2010

Medical Reasons for Breast Milk Substitutes

During the breastfeeding classes I've attended and conducted, it is always emphasized that from birth to six months, exclusive breastfeeding is best for babies, unless there medical reasons prescribing otherwise.

These “medical reasons” vary though from doctor to doctor, with some doctors even saying that moms who underwent caesarian births cannot breastfeed for x number of days!

In 2009, the World Health Organization and UNICEF released a 12-page publication entitled “Acceptable medical reasons for use of breast-milk substitutes”. According to WHO and the UNICEF, they first developed a list of medical reasons for supplementation in 1992, as an annex to the Baby-friendly Hospital Initiative tool package.

With new and emerging scientific evidence, WHO and UNICEF agreed to update the list with the participation of the departments of Child and Adolescent Health and Development and Nutrition for Health and Development. Other additional evidence sources used were (1) The Drugs and Lactation Database, a peer-reviewed and fully referenced database of drugs to which breastfeeding mothers may be exposed, hosted by the United States National Library of Medicine; and (2) The National Clinical Guidelines for the management of drug use during pregnancy, birth and early development years of the newborn, review of which was done by the New South Wales Department of Health, Australia in 2006.

The WHO and UNICEF posit that only a small number of health conditions of the infant or the mother may justify temporary or permanent cessation of breastfeeding. Further, these conditions concern very few mothers and infants. In recommending the cessation of breastfeeding, the WHO and UNICEF mandates that the benefits of breastfeeding should be weighed against the risks posed by the presence of the listed conditions.

The following are the conditions for infants not to receive breast milk or any other milk except specialized formula:
1. infants with classic galactosemia (a special galactose-free formula is needed) – a rare genetic metabolic disorder that affects an individual’s ability to metabolize the sugar galactose (one of the components of lactose) properly
2. infants with maple syrup urine disease (an inherited disorder in which the body is unable to process certain amino acids or protein building blocks properly. If untreated, this leads to severe brain damage and death) – special formula free of leucine, isoleucine and valine is needed
3. infants with phenylketonuria (a genetic disorder that is characterized by an inability of the body to utilize the essential amino acid, phenylalanine) - a special phenylalanine-free formula is needed – some breastfeeding is possible, under careful monitoring

For all other infants, breastfeeding is best although the following infants may need other food aside from breast milk for a limited period:
  1. a. infants with very low birth weight – weighing less than 1500g
  2. b. infants born too early – at less than 32 weeks of gestational age
  3. c. newborn infants who are at risk of hypoglycaemia by virtue of impaired metabolic adaptation or increased glucose demand, if their blood sugar fails to respond to optimal breastfeeding or breast-milk feeding
  • preterm
  • small for gestational age
  • have experienced significant intrapartum hypoxic/ischaemic stress
  • those who are ill
  • infants with diabetic mothers
Just because a baby is premature, it does not mean that s/he should be given formula or any other fortifier (like Cell Life a.k.a. spirulina). WHO/UNICEF listed above specific instances when fortifiers are necessary.

As for maternal conditions that may justify permanent avoidance of breastfeeding, only one is listed – HIV infection, only if replacement feeding is acceptable, feasible, affordable, sustainable and safe (AFASS). WHO/UNICEF however recognizes that the most appropriate infant feeding option for an HIV-infected mother depends on individual circumstances – mother’s health status, health services available and most importantly whether there is replacement feeding AFASS.

Certain conditions justify the temporary avoidance of breastfeeding, such as severe illness that prevents a mother from caring of her infant (e.g. sepsis), herpes simplex virus-1, certain maternal medication (sedating psychotherapeutic drugs, anti-epileptic drugs, opioids, radioactive iodine-131, excessive use of topical iodine or iodophors (povodine-iodine), cytotoxic chemotherapy.

Meanwhile, the publication lists down certain conditions wherein breastfeeding can still continue, although health problems may be of a concern, namely: breast abscess, hepatitis B, hepatitis C, mastitis, tuberculosis, substance abuse. I highly recommend that you peruse the short publication to read the details on these conditions.

Clearly, there is a limited number of conditions for both infants and mothers to recommend the cessation of breastfeeding. I would definitely recommend that pregnant moms to read this WHO/UNICEF publication so they will be informed and know what questions to ask their pediatricians and ob-gynes. And if your doctor gets irritated when you ask questions, then I believe that it is time to look for a new medical provider.


Melodie said...

You have the most well researched and informative breastfeeding posts out there Jenny. Thanks for this.

Anonymous said...

I think it would be fabulous if moms did research this when they were pregnant. I think that so many of us (and I was guilty of this, too) don't want to consider what we will do if things don't go to plan. And when they DON'T go to plan, like when my daughter was born at 34 weeks, you aren't in a position to research. Better education up front could improve outcomes, I really think.

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