Sunday, 27 June 2010

Lest We Forget.... National Bash Breastfeeding Week

As we sit there, blood pressure pounding, ears numb from the screeching, eyes bleary from article after article after article, painting us as nuts, nazis, anti-woman, ant-feminsit and just plain obsessed and bossy... as we sit, whincing, about another person smugly leaving an article about how Breast Is Not Best anymore on our desks... and they've conveniently stopped reading before they get to... Formula Is Flawed... in the bottom in small print...

In short, as we sit there, grateful that another awful week of vitriol is past, and work on our resilience to cope with next's year's onslaught... read this.

The following is an advocacy statement prepared for a preemie baby, a couple of months ago.  The young teenage mother, had been told Social Services wanted her in a Mother & Baby Unit when the baby was born.  For no other reason that she, and the teenage father, had both been raised in care.  Therefore they were lacking essential parenting skills.

Think that through for a moment.

Rock and a Hard Place, non?

Having been deemed to lack essential parenting skills, and both having 'difficult' relationships with care home workers and their own social workers, a unit place was set up for the Mother & Baby.  But not the Father, of course, her main support.

But at least they had somewhere to go, after the birth.  


Baby had the temerity, the sheer gall... the proof that it too was not capable of working with Social Services.. . to birth itself 5 weeks premature.  This threw everyone into a panic.  Baby was here, in the preemie ward, but the place in the Unit, was timed to the due date.

What to do?

Well, obviously, the correct answer was to remove the baby from the mother, when it was discharged from the neo-natal ward.  And keep it in a foster home, until the placement came up, 4 weeks later.  Simples!  No problem there.

The sad thing is, the Social Workers didn't think there was any problem with the plan, at all.  When the midwives, and the lactation support people, all pointed out the disaster in this plan, not least from a viewpoint on the new mother actually bonding with her baby, the Social Workers scratched their head and went "eh?".

In this, we should be considerate of the dreadful position Social Workers are in.  In the UK, there are no guidelines for the care of the breastfeeding baby in care situations.  There are no tick boxes on the forms, no training, no protocols, no guidance.  So it's not surprising, that a Social Worker isn't going to think "breastfeeding" in these situations.  They only have their own personal experiences to go on.  And what's so important about keeping a mother and her baby together, for the first 4 weeks?  They can bond afterwards, surely?  Formula never hurt anyone...

So the following advocacy statement was put together, on behalf of the premature infant.  

The mother and baby were kept together.  The combined effort of the NHS staff on the ward, the lactation specialist for the area, and the advocacy statement.  All Hail The Midwives!

Ignore the screams this week, and next, and the week after.

They wouldn't be trying so hard to pummel us into the ground, if we weren't being heard.


RE: XXX XXX     DOB: XX/04/10

We are advocating on behalf of Xxx, a breastfeeding premature newborn. We would like to bring to your attention several pertinent points about Xxx, and his specific needs. These facts need to be taken into consideration when you discuss care arrangements for Xxx whilst care arrangements for the family are being discussed.

Xxx was born at 35 weeks gestation. Breastfeeding, is therefore even more vital for his normal development, than a term born newborn. In particular, his cognitive development and immune system has already been threatened by a premature birth. Breastmilk is the only substance that will provide Xxx with the nutritional benefits he is now missing from appropriate womb development.

Breast milk contains components to promote amyelinization which increases development of brain synapses. It has higher anti-oxidant activity than infant formula and pre-terms a have lower anti-oxidant capacity. In addition, human milk helps neutralize oxidative stress. Ezaki et al. J Clin Bio Nutr 42;133-137. 2008)

Breastmilk also contains sialic acid-containing oligosaccharides, vital to brain development, which is significantly lower (20%) in infant formulas. This cannot be synthesized by the infant and therefore interruption of breastfeeding to transfer to infant formula, directly reduces Xxx’s ability to recover the brain growth he has lost due to his premature birth. Higher brain ganglioside and glycoprotein sialic acid concentrations have been conclusively shown to lead to enhanced developmental outcomes (Wang et al. AJ of Clin Nutr.2003;78:1024-1029).  Preterm Infants (ELBW) who were exclusively formula fed had a 5 point deficit in their subsequent IQ development. Pre-terms infants that had the most human milk had an increase of 5 IQ points compared to their formula fed counterparts. (Vohr et al. Pediatrics. 2006: 118;e115-123)

Of significant concern, is that the risks of SIDS doubles in late preterm (Walker M, Breastfeeding the Late Preterm Infant in Clinics in Human Lactation 4. Hale 2 Publishing: Amarillo ,Tx; 2009) Breastfeeding can decrease the risk by 50% (Pediatrics.2009; 123 (3):e406-410). 

In terms of general health issues, for every 10ml/kg per day increase in breastmilk ingestion the likelihood of re-admission decreased by 6% (Vohr et al.Pediatrics, 118;e115-123) “Risk Ratio for Infant Mortality in Late Preterm vs. Term Infants (J Pediatr 2007;151:450-6)” shows that newborns such as Xxx are at increased risk for SIDS, Sepsis, Influenza, NEC and are more likely to die from these diseases. If you removed Xxx from his mother’s breast, you increase his risks of significant harm. These risks are very real, widely known and understood, and clearly underpin breastfeeding policy from the NHS, NICE, UNICEF and the World Health Organisation. Therefore these significant risks must be present in any risk assessment discussion, concerning Xxx and his access to his mother’s breast.

These risks are in addition to the normal risks associated with lack of breastfeeding for a full term infant. Lack of breastfeeding is associated with higher rates of illness for both baby, and mother. Again, this is supported and promoted by the NHS, NICE, UNICEF and World Health Organisation. Under Article 24 of the Convention on The Rights of the Child, Xxx has the

“right of the child to the enjoyment of the highest attainable standard of health and to facilities for the treatment of illness and rehabilitation of health. States Parties shall strive to ensure that no child is deprived of his or her right of access to such health care services.”

Access to his mother’s breast for actual breastfeeding, and not just receiving pumped human milk, would come under this convention, and The European Court of Human Rights has recognized this dynamic – the right of the child to the breast as long as the mother wishes it, as a basic Human Right, and this is recognized in the English courts:

"Local authorities also had to be sensitive to the wishes of a mother who wants to breast-feed, and should make suitable arrangements to enable her to do so, and not merely to bottle-feed expressed breast milk. Nothing less would meet the imperative demands of the European Convention on Human Rights."...In the matter of unborn baby M; R (on the application of X and another) v Gloucestershire County Council. Citation: BLD 160403280; [2003] EWHC 850 (Admin). Hearing Date: 15 April 2003 Court: Administrative Court. Judge: Munby J. Abstract. Published Date 16/04/2003

Perhaps of more crucial importance, given the significance of the need to assess care arrangements for Xxx, within his mother’s arms, the role that the lack of breastfeeding has in increasing risks of child abuse, should be highlighted. Breastfeeding supports a secure attachment between mother and child, and disrupting the bond that has already been established between Xxx and his mother, significantly reduces their chances of forming a successful, long term, relationship, as well as the harm abrupt cessation of breastfeeding could inflict on Xxx.
Within attachment theory, attachment behaviours are actions that a child uses to maintain proximity to their caregiver in order to obtain reassurance and experience feelings of safety (Sutton, 2001). Attachment theory is the dominant framework within which early relationships are understood (Thompson, 2000) and the development of a secure attachment between primary caregiver and child is deemed the most beneficial type of relationship (Schore, 2001). Securely attached children use their caregiver as a base from which to explore the world and are therefore able to more effectively deal with challenges (Drury-Hudson, 1994). Thus, breastfeeding may promote the development of a secure child-mother attachment. However, the importance of breastfeeding as an attachment behaviour also means that if breastfeeding is abruptly terminated it may have a serious adverse impact on the child-mother relationship. 

The observation that breastfeeding can be an attachment behaviour in young children and that abruptly refusing breastfeeds in harmful is not a new idea. It was first observed by the eminent attachment theorist Mary Ainsworth over 35 years ago who stated, in relation to her research in Uganda with breastfeeding toddlers, that “amongst those children who had had easy access to the breast on their own initiative, both day and night, the feeding behaviours become organised into the whole system of behaviours that constitute attachment, so that when the feeding relationship was destroyed by weaning the whole attachment relationship was severely threatened and made very anxious.” (Ainsworth & Tracey, 1972). Withdrawal of breastfeeding during a substantial portion on the day would be interpreted by the child as a rejection of the child and similarly pose a serious threat to the child-mother relationship. I would also like to point out that withdrawal of a child’s comfort strategies and attachment behaviours at a time of stress is extremely difficult for the child. It could be described as cruel.

In at-risk dyads breastfeeding should be supported not just because of its impact upon the child but because breastfeeding impacts the physiology and physical circumstances of mothers in such a way as to assist them to sensitively care for their children (Gribble, 2006). The hormone oxytocin is known to be essential for expression of maternal behaviour in some mammals (Insel, 1997; Keverne & Kendrick, 1992), and although the research is as yet scant, there is some evidence that oxytocin is also involved in the development of maternal love in humans (Bartels & Zeki, 2004). Oxytocin is released during breastfeeding (Matthiesen, Ransjo-Arvidson, Nissen, & Uvnas-Moberg, 2001). Prolactin is another hormone associated with promoting mothering behaviour that is released as a child suckles (Uvnas-Moberg, Widstrom, Werner, Matthiesen, & Winberg, 1990). 

Finally, the relaxant hormone cholecystokinin is released in the intestine of mothers during breastfeeding (Uvnas-Moberg et al., 1987). As a result of these hormonal effects breastfeeding women have decreased cortisol levels and blood pressure and respond less to stress than non-breastfeeding women (Groer, Davis, & Hemphill, 2002; Heinrichs, Neumann, & Ehlert, 2002; Uvnas-Moberg, 1998). This decreased responsiveness to stress is apparent in a “relaxation response” measured in the brain during breastfeeding (Cervantes, Ruelas, & Alcala, 1992). Mothers who are less stressed are able to be more responsive to their babies (Feldman, Eidelman, & Rotenberg, 2004; Rosenblum & Andrews, 1994) and there is a positive correlation between maternal sensitivity and the security of attachment in children (Pederson, Gleason, Moran, & Bento, 1998). 

Breastfeeding also requires mothers to remain in physical proximity to their babies and to interact with them on a regular basis in a positive and intimate manner (Blass & Ciaramitaro, 1994; Epstein, 1993; Smotherman & Robinson, 1994) which can only assist in promoting a healthy mother-child relationship.

The role of breastfeeding in allowing an at-risk mother to develop a healthy care-giving role with her infant, cannot be overstated:

“We clearly demonstrated that lack of breastfeeding increased substantially the odds of maternal (but not non-maternal) maltreatment, specifically child neglect. After adjustment for multiple confounders, there was a nearly fourfold increase in the odds of maternal neglect for non-breastfed children, compared with children
who were breastfed for _4 months. These findings suggest that breastfeeding may play a protective role in helping to prevent maternal neglect.”

Does Breastfeeding Protect Against Substantiated Child Abuse and Neglect? A15-Year Cohort Study DOI: 10.1542/peds.2007-3546 Pediatrics 2009;123;483-493 Lane Strathearn, Abdullah A. Mamun, Jake M. Najman and Michael J. O'Callaghan

To make that point again, if you remove Xxx from his mother’s breast, you significantly increase his risk of neglect by her, and significantly reduce her chances of proving she is a competent mother. In short, if you do not support Xxx’s access to his mother’s breast during the deliberations on his care package, you are greatly increasing the risk that his mother will be found incompetent. Given that plans are already in place to allow Xxx and his mother to maintain their contact in a mother-and-baby unit at a later date, any decision to separate them prior to this, would be difficult to justify.

This is particularly true when you examine the effect it could have on Xxx’s mother. Sudden cessation of breastfeeding so soon after the birth, will cause Xxx’s mother’s body to react as if the baby has died: her hormones will go into mourning:

“Opting not to breastfeed precludes and/or brings all of the processes involved in lactation to a halt. For most of human evolution the absence or early cessation of breastfeeding would have been occasioned by miscarriage, loss, or death of a child. We contend, therefore, that at the level of her basic biology a mother’s decision to bottle feed unknowingly simulates child loss.”

Bottle feeding simulates child loss: Postpartum depression and evolutionary medicine Medical Hypotheses, Volume 74, Issue 1, January 2010, Pages 174-176 Gordon G. Gallup Jr., R. Nathan Pipitone, Kelly J. Carrone and Kevin L. Leadholm

To summarise: continued, unrestricted access to his mother’s breast is a key component in Xxx’s subsequent health and normal development, particularly given his 35 week gestation. Any decision on Xxx’s health and well-being, within care guidelines, should include proper assessment of these risks. If decisions are made to separate Xxx from his mother, due care must be taken to ensure the breastfeeding relationship is not severed. WHO and NHS guidelines would require that Xxx’s ability to breastfeed should not be compromised by the introduction of bottle teats, or a dummy. The foster care-giver would be expected to cup-feed Xxx, his expressed mother’s milk.

In addition, in line with current medical understanding, we feel it important to point out that formula feeding itself is not benign, particularly for Xxx. Formula has a different ph balance to human milk, and it destroys the natural flora and fauna in the human gut. Xxx is at particular risk from developing ill-health, if formula is introduced to his gut, as he has several risk factors already:

*The gastrointestinal (GI) tract of a normal fetus is sterile
* the type of delivery has an effect on the development of the intestinal microbiota
- vaginally born infants are colonized with their mother’s bacteria
-cesarean born infants’ initial exposure is more likely to environmental microbes from the air,other infants, and the nursing staff which serves as vectors for transfer
- the primary gut flora in infants born by cesarean delivery may be disturbed for up to 6 months after birth (Gronlund et al, 1999)
* babies at highest risk of colonization by undesirable microbes or when transfer from maternal sources cannot occur are cesarean-delivered babies, preterm infants, full term infants requiring intensive care, or infants separated from their mother
Supplementation of the Breastfed Baby “Just One Bottle Won’t Hurt”---or Will It? Marsha Walker, RN, IBCLC NABA 2003

Therefore, if Xxx is separated from his mother, we would advise that as a medical intervention, medical permission would need to be obtained from Xxx’s mother or obtained via a court order, before formula could be given. Likewise, parental, or court permission would need to be sought before introduction of either a bottle teat, or a dummy, as both can immediately affect the attachment of the baby to the mother, and the baby’s subsequent ability to breastfeed.

If separation does occur, Xxx’s mother will require qualified lactation support, to sustain and maintain Xxx’s milk supply, and to guard her against developing mastitis or engorgement. Social Services would have to supply appropriate pumping equipment, storage and transport for the milk. This places a burden on Xxx’s mother, and that should be recognised when her care is being discussed, as I understand that Xxx’s mothers is, herself, under the care of Social Services.

All of the above factors should be present in any discussion of Xxx’s well being. We can, of course, supply more detailed information if required, as well as extend our support to Xxx at all times. Many lactation specialists within the international lactation community are aware of Xxx, and his specific needs, and we are confident that Social Services will support his health and well being in an appropriate fashion.

Please don’t hesitate to contact us for more information or expert witness.