Birth Experiences and Its Effect on Breastfeeding

Welcome to the Carnival of Breastfeeding for October. This month's topic is about birth and breastfeeding - on how your birth experience affected your breastfeeding relationship with your child. Please scroll down to read the entries of the other carnival participants.

==================

breastfeeding cousins

Picture this:

Mom A gave birth to a full-term baby girl through normal delivery with epidural. Baby Girl A is 6 pounds, 5 ounces and healthy. She was whisked off for about 10 minutes to be checked, weighed and wiped down. Baby Girl A was returned to Mom A's arms and she was able latch within 1 hour from birth, roomed-in and constantly experienced skin-to-skin contact.

Mom B gave birth to a premature baby girl through normal delivery with epidural. Baby Girl B is 4 pounds, 4 ounces and born at 32 weeks, 6 days old. She was whisked off by the neonatologist and placed in the NICU. She was never roomed in and separated from her parents for 2 weeks. Mom B visited her at the NICU for breastfeeding opportunities but only after 1 week. Prior to that she was fed with glucose water intravenously as neonatologist thought that she would choke on colostrum.

One month later…

Baby Girl A is now being mixed fed. At 2 weeks, she was diagnosed with jaundice and pediatrician recommended that she be given formula for at least 24 hours. Since then, Mom A started having supply problems. Mom A was able to recover and up her supply only when Baby Girl A was 7 weeks. Earlier on, Mom A also experienced sore and bleeding nipples due to improper latch.

Baby Girl B is still exclusively breastfed. After having latched at 2 weeks, she was nursing like a champ. Mom B never experienced sore nipples. Mom B also had supply problems but received breastmilk from relatives and friends. Baby Girl B is exclusively on breastmilk and has never tasted formula.

At 6 months…

Baby Girl A is back to being on exclusive breastmilk and has started solids. Mom A is back to work and has sustained milk supply to be able to meet Baby Girl A’s needs and donate extra milk.

Baby Girl B is still on exclusive breastmilk and has started solids. Mom B is back to work, still has milk supply issues but managed to meet Baby Girl B’s needs.

I think by now you may have guessed that I’m talking about me and my sister’s birth experience. I have previously shared about my experiences and my niece’s birthing story. However, for this carnival, I’d like to emphasize that whatever the birthing experience of the mom, there are other more important factors that will impact the breastfeeding relationship.

Top most of these important factors would be INFORMATION. When my daughter’s pediatrician suggested that I give her formula for jaundice, I didn’t know better. I never attempted to find a breastfeeding friendly pediatrician (I assumed that all were BF advocates) and thus get a second opinion.

Meanwhile, my sister immediately switched to breastfeeding friendly pediatrician when my niece turned 1 month. Their old pediatrician had mandated a 1 kilogram weight gain each month. My niece gained about 800 grams per month which was okay with the new pediatrician. The new pediatrician understood that babies grew in different ways and watched the developmental milestones instead of the weighing scale. Had they stayed with the old pediatrician, my niece would’ve been prescribed formula to up her weight.

Why did we make the choices we make? I didn’t know better and was ignorant of available resources. Meanwhile, my sister already learned from my experiences and was also able to read breastfeeding books and research on breastfeeding friendly pediatricians.

Another factor is SUPPORT.

When I gave birth, I only had my husband, Stan with me. Although there were lactation consultants that we visited, we didn’t really get relevant and helpful information. One LC even gave us free Enfamil 2oz. bottles! Meanwhile, when my sister gave birth, she already had a knowledgeable nanny, my mom turned advocate and of course, persistent sister with breastfeeding experience (although I have to admit that it was more difficult to counsel my sister compared to strangers and friends). Plus, my sister had a network of friends and relatives to turn to when her milk supply was low. She also had a very supportive doctor who worked with her and encouraged her to continue giving breastmilk to her daughter.

Let me conclude by saying that the birthing experience can have a ripple but not lasting effect on your breastfeeding relationship with your child. However, in the long run, other factors such as information and support are more effective in enabling mom and baby to bond at the breast and establishing a successful and enduring breastfeeding relationship.

Here are the other carnival participants. Links will be added through the end of the day:

Leslie @ Confessions and Observations: How to Start Breastfeeding and Why the Birth You Have Matters

Crib Keeper @ Tales from the Crib: On Not Being Discouraged

Suchada @ Mama Eve: Birth and Breastfeeding

Christina @ Massachusetts Friends of Midwives: Early Intervention Lactation Help

Jenny @ Chronicles of a Nursing mom: Birth Experiences and Its Effect on Breastfeeding

Jenny @ Baby Fingers: My Breastfeeding Relationships: Hospital vs Homebirth

Michelle @ Mama Bear: Long, wide shadow of bad births

Sarah @ Reproductive Rites: Fighting for Breastfeeding

Terry @ Mother Mirth: Breastfeeding: We CAN Change Our Culture

Tanya @ Motherwear Blog: The Birth/Breastfeeding Continuum

Elita @ Blacktating: Did my birth experience set me up to fail at breastfeeding?

Kate @ Tumbling Boobs: Nursing After Surrogacy or Adoption

Andi @ Mama Knows Breast:

Breast Crawl

What is a breast crawl? According to Breastcrawl.org, "every newborn, when placed on the mother's abdomen, soon after birth, has the ability to find its mother's breast all on its own and to decide when to take the first breastfeed." This technique is being promoted by UNICEF, WHO and WABA and is part of the Ten Steps to Successful Breastfeeding.

As part of the L.A.T.C.H. module what to expect in the first 2 weeks, we usually present a video of a breast crawl. Previously, we used a video depicting an Indian mother filmed in 2005. We have been fortunate enough to obtain a video filmed in the Philippines likewise depicting a breast crawl. I'm still trying to obtain a copy of the video for uploading but in the meantime, I'm sharing the video of a Maharashtra mom and baby doing the breastcrawl.

Recently, fellow L.A.T.C.H.er Mec shared about the institution of the Essential Newborn Care protocol in Asian Hospital - where she's giving birth. The breast crawl is included in this protocol, which is said to reduce infant mortality. I'm not sure which other hospitals have instituted this protocol but this definitely something to consider when choosing which hospital to give birth at in the Philippines.

Update - 28 July 2010. Thanks to Claire for sharing the Philippine breast crawl video!

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.

The cup of life

Photo by Rudy Liwanag, Manila Bulletin

I was quite excited to read the feature about the Philippine General Hospital's Milk Bank in Friday's Manila Bulletin. As I shared in my previous post, I was trying to get my milk pasteurized but they could't run the pasteurization machine because of lack of milk donations. Also, this article ran contrary to the practice at the other hospital used bottles for their premature babies. At the UP-PGH, premature babies were cupfed with their own mother's milk or pasteurized donor's milk.

UP-PGH Milk Bank is where I regularly donate milk in the past year. As emphasized by Dr. Jessa Sareno, a neonatologist fellow, their credo is as follows:

Human milk has no substitute. Breast milk also has immunoprotective properties that fight against life-threatening infections like sepsis, pneumonia, diarrhea, and enterocolitis. It likewise has components, which help the newborn’s intestinal tract to mature, allowing for easy digestion, better absorption, faster growth, and better health. Plus, it also has nutrients in a combination that no artificial product can duplicate.

This article is close to my heart because of my niece Anya Carissa. UP-PGH is a public hospital but I was amazed to read that their lactation unit took time out to teach mothers how to hand express milk and had the patience to cup-feed the babies. As opposed to my niece's hospital - where the doctor just told her breastfeed without details on how to breastfeed a premature baby or how to keep up her supply. My sister has been having problems with supply and Anya is still not up to her birth weight -- so now, Dr. Q is suggesting that my sister purchase Spirulina to mix to her breastmilk!

When my sister first breastfed her, Anya was removed from the NICU and taken to the breastfeeding room. Since only the mother and baby could stay in the breastfeeding room, I asked my sister if a nurse stayed with her to show her how to properly position and latch Anya. She said that the nurse only stayed for a short while and she was left to her own devices. I wish this hospital -- with all its expensive equipment, gear, marketing ploys - would set aside some of its budget to purchase a pasteurization machine and hire an honest-to-goodness lactation consultant. This hospital even has its own cord banking unit -- but no breastfeeding support.

Anyway, the article suggests some ways you can be a milk angel to the UP-PGH Milk Bank - by becoming a financial or milk donor, or by becoming a volunteer to cup-feed babies. Dr. Jessa even suggests celebrating your birthday in a unique way by volunteering to cup feed the babies. I'm guessing that the PGH neonatal unit is a much more loving setting and a far cry from Anya's cold, sterile own NICU.

To know more how you can help, contact the Lactation Unit and Human Milk Bank, 4th Floor, LCB, Philippine General Hospital, 5218450 local 3418/3409.

Preemies and Breastfeeding

anya carissa just after birth

Anya Carissa is getting bigger and improving! They've removed all her tubes today, except for her IV which will be removed after her last dose of antibiotics at about 11pm tonight. She has been in the NICU for 1 week and 3 days. For the first time today, her parents were able to hold her, albeit briefly. Having a preemie niece made me think about several questions or issues on breastfeeding, hospital policies some of which I was able to clear up with Dr. Z.

1. No colostrum

As I mentioned in my earlier post, Anya's doctor did not want to give her colostrum for fear that she might choke. Instead, she was given glucose water via IV and for her first 2 feedings. After that, she was given my sister's breastmilk.

2. Use of bottles at the NICU

Anya started using a feeding tube. The tube was eventually replaced by a bottle. I asked why a bottle was used instead of a cup. The hospital prided itself as being breastfeeding friendly and in their nursery, I was under the impression that they used cups to feed the babies. I clarified this with Dr. Z who shared that for premature babies, there are experts who prefer bottlefeeding because of the risk of choking/aspiration and more effort required and calorie usage from the baby. This is why although full-term babies are cup-fed, NICU babies at this hospital are bottle-fed. Little Anya is now up to 30ml per feeding, although she feeds slowly. I think that slow feeding is quite normal -- Naima used to take 1-1.5hours to finish 2oz of milk.

3. Direct Breastfeeding

There are certain guidelines for breastfeeding preterm babies which are quite different. As Dr. Z emphasized, feeding is a very big issue in the NICU, and is a skill that a baby needs to be competent at before he or she goes home. La Leche League has a comprehensive resource page on feeding premature babies. You can also check this page from About.com for a quick overview. I wish I had read the About.com article earlier. One of the tips she had was: "Even if your baby is being fed intravenously, you can swab the colostrum inside her cheeks." -- this would've certainly been helpful in our case since my sister could just produce drops of colostrum then.

4. Kangaroo care
It was only today or more than 1 week after she was born that Anya was held by her parents. Since she was born, she was placed inside the incubator, with her parents just being allowed to hold her briefly through the holes of the incubator with gloves. Just recently, ABC News ran a story about how premature babies get lift from kangaroo care that helps give moms (and dads) purpose. It was actually identified as one of the greatest gifts NICU staff can give the preemies' parents. Then again, the article goes on to discuss about how some doctors draw the line when the baby's on a breathing tube -- and don't allow kangaroo care.
Baby Anya had been either on canula (oxygen tube) or ventilator since she was born. It was just last night when her breathing tubes were removed. Maybe this was why kangaroo care was only practiced by Anya and her parents today.

5. Milk Donations
In the course of my breastfeeding career with Naima, I have donated gallons of milk to different babies - singletons, twins, triplets, preemies, full-terms. Except for the milk I donated to the PCMC and PGH milk banks, I'm pretty sure that my milk was not pasteurized before being fed to the babies. Dr. Z again reminded me that the safest alternative to mother's milk is pasteurized donor milk OR directed donor milk from a screened donor.
I tried checking with UP-PGH on how to get my milk pasteurized for Anya but was unsuccessful. The PGH milk bank has a huge pasteurizer which runs only when they have collected 71 8oz. Dr. Edwards bottles. This is equivalent to about 568 ounces and they were nowhere near that! (side note: if you have extra milk, now would be a good time to donate -- PGH continuously accepts donated breastmilk). Even if I donate all my old stocks of milk in my freezer, we still wouldn't be able to run the pasteurization machine.
I still collected milk once daily and whatever milk I collected was stored in the NICU freezer for Anya in case my sister couldn't express enough. I felt that my milk also served to boost up my sister's confidence and prevent her from stressing too much about her milk production. Since she was relaxed when pumping, she was able to make enough for Anya's demand and so far, it was only once that they had to give Anya my breastmilk.

Once her IV tubes are removed, she will be transferred to a transition room where my sister will be allowed to try direct breastfeeding. Hopefully, Anya's improvement will be continuous and we will be allowed to bring her home by the end of this week.