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    Pearls from the trenches: Part 4

     

     


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    • Dr. Farber noted in the introduction, “I have heard it said that half of what we practice now will be out-of-date in 10 years, but the trick is to know which half.” Many of his clinical observations are quite valid and helpful for the practitioner. Unfortunately, one of the tips in this issue is out-of-date and could be counterproductive. Under “Words to Live By,” item #10 addresses breastfeeding routines and states that “After 10 minutes, if not sooner, a breast is mostly empty. Having a child feed for 20 to 30 minutes at the first breast will exhaust both the mother and the child (and can lead to very sore nipples). Particularly for newborns, I recommend 10 minutes at the first breast, switching breasts for another 10, and then “topping off” for another 5 to 10 minutes at each breast if the baby is still hungry.” This statement includes the Lancet reference. (Lancet. 1979 Jul 14;2(8133):57-8.) Indeed, as Dr. Farber has noted, in the more than 35 years since that publication, the understanding of breast milk production and transfer, as well as the composition of milk, has improved significantly. We also know that each baby is different, as he or she masters the skills of feeding from the breast with continued practice. While some babies may indeed consume a substantial volume of milk in 10 minutes, others, and especially newborns, may take significantly longer. (Breastfeed Med. 2013 Dec;8(6):469-73.) In addition, the greatest proportion of fat is consumed towards the end of a feeding. Frequent “switching” from side to side may result in relatively higher water and sugar intake, with proportionately less fat intake, tending to make babies more fussy and gassy, with frequent frothy, green stools. In some circumstances, these babies may suffer from growth faltering. (J Am Board Fam Med. 2016 Jan-Feb;29(1):139-42.) Therefore, it is no longer recommended that parents follow the clock when feeding, but instead observe the baby for signs of satiety, such as, relaxing of the posture or falling asleep. A full feeding (no specific time, but noted by less frequent swallowing or the baby drifting off to sleep) on the first breast offered, followed by as much feeding as desired on the second breast, if requested by a baby, works well for most babies, especially during the newborn period. (Breastfeed Med. 2010 Aug;5(4):173-7.) The breast never completely empties, because production continues throughout the feeding. Soreness of nipples does not correlate with the time spent nursing, but with the adequacy of latch. If the mother is experiencing sore nipples (J Obstet Gynecol Neonatal Nurs. 2005 Jul-Aug;34(4):428-37), the latch should be carefully evaluated by someone skilled in breastfeeding assessment, whether that be a doctor, nurse, lactation consultant, or other helping professional. Good breastfeeding routines are especially important in the early days and weeks in order to establish and maintain a good milk supply. Timed feedings may actually increase the risk of insufficient milk supply, which can be challenging to resolve. While the pearls gleaned from practical experience can be very useful in our clinical decision making tool kit, they must be combined with current knowledge of clinical practice. The majority of mothers initiate breastfeeding, however, 60% do not meet their own breastfeeding goals. (Pediatrics. 2012 Jul; 130(1): 54–60.) The inadequate education and clinical skill set of health care professionals about breastfeeding management is one of the barriers faced by mothers. Evidence-based medicine combines careful review of the medical literature with clinical experience and judgment. In order to support breastfeeding families optimally and achieve the improved health outcomes for both mothers and children, it is critical that physicians and other health care providers communicate current information and recommendations to colleagues, instead of relying only on our own observations and dated references. Joan Younger Meek, MD, MS, RD, FAAP, FABM, IBCLC Chair, Section on Breastfeeding, American Academy of Pediatrics

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