September 25, 2008 — vol. 44, no 7
Got milk? Breast-feeding is best - unless you can't
CHICAGO — Bente White was willing to try almost anything to breast-feed her infant son.She used fenugreek, blessed thistle, alfalfa, nettle, fennel, goat’s rue, bitter lettuce, brewer’s yeast, hops, oatmeal and two pharmaceutical drugs to increase her milk production. Nothing worked very well.
“You name it and I tried it,” said White, 32, a physical therapist from Suffolk, Va., who was forced to supplement baby Austin’s diet with formula. “I never thought breast-feeding would be this complicated and challenging.”
Almost 75 percent of U.S. babies now begin life breast-feeding, a practice that helps give them disease immunity and other benefits. Nobody knows how many women have trouble breast-feeding, but those who do run into a common frustration: Women who need help often are left on their own to sort fact from folklore.
Many doctors aren’t educated about breast-feeding problems, and there is little rigorous research to help. Health insurers, including Medicaid, generally don’t pay for lactation consultants — who are not licensed in any state. And some consultants recommend unproven, even risky herbal remedies and drugs.
A review of research on drugs used to enhance milk production, published last year in the journal Breastfeeding Medicine, concluded that such products “appear to have little or no added benefit” over good advice on breast-feeding techniques. The review found commonly cited research on two drugs — metoclopramide and domperidone — to be seriously flawed.
As for the drugs’ safety, many studies relied on casual observation of babies for side effects, or failed to mention infant safety at all.
There’s even less research on the usefulness or long-term safety of herbs, which have been used for generations and across many cultures to increase milk supply. What’s more, herbal supplements can be sold without government approval, dosing isn’t standard and some products have been known to contain toxic substances, according to the Academy of Breastfeeding Medicine.
“I’m not a big fan of herbals,” said Dr. Ruth Lawrence of the University of Rochester School of Medicine and the author of the primary medical text on breast-feeding. “They can put anything they want in that bottle. There’s no quality control.”
White didn’t notice any side effects in herself or her baby from the herbal remedies she tried. But she said she did get depressed while taking metoclopramide, or Reglan, an anti-nausea medicine that has been used “off label” to treat low milk supply. Depression is listed as a possible side effect on the package insert.
“I remember feeling like I was out of control,” said White. “I couldn’t control my emotions.”
What helped White most was a supplemental nursing system — a device that allows a baby to receive both formula and mother’s milk, by delivering formula through a tube attached at the mother’s nipple.
Most milk-supply problems can be solved by increasing the frequency of breast-feeding or by using a breast pump. These supply-and-demand methods should be tried first, according to the Academy of Breastfeeding Medicine.
Very few women have biological reasons for low milk supply, experts said. Breast surgery or endocrine problems can inhibit production, though more often the problem begins when something interferes with frequent and thorough feedings in the days after a baby’s birth.
Hospitals are partly to blame, said U.S. Centers for Disease Control and Prevention (CDC) nutrition chief Lawrence Grummer-Strawn. A recent CDC survey of more than 2,600 hospitals and birth centers found 24 percent reported giving formula to more than half of their healthy, full-term breast-feeding newborns.
In many hospitals, “there’s routine separation of mothers and babies, frequent use of pacifiers,” and not much help when new moms leave, Grummer-Strawn said.
“Physicians know less about breast-feeding than they could,” said Dr. Ann Borders, an assistant professor of obstetrics and gynecology at Northwestern University’s Feinberg School of Medicine and a breast-feeding mother. “I feel like I learned the majority of what I know about breast-feeding from personal experience.”
Much of the research on such problems is relatively new, based on small studies and funded by the breast-pump industry. It’s unclear how many women have inadequate milk supply and how many women perceive problems, but have enough milk.
Many mothers turn to lactation consultants, who may or may not be certified. No state licenses consultants and there are no standardized training programs. Experts recommend that mothers check credentials and ask about experience and training.
An international board conducts a certification exam for candidates who document at least 1,000 hours of experience. Those who pass, as 95 percent do, become International Board Certified Lactation Consultants.
More than 80 percent of those who take the exam are registered nurses and 2 percent are doctors. But they also can be dietitians, midwives or childbirth educators, and those with even less health care experience.
There are more than 9,000 certified lactation consultants in the United States, an 18 percent increase since 2003, according to the international examiners board.
That’s still too few, said Grummer-Strawn.
The CDC says there are two lactation consultants per 1,000 annual live births.
Amber Medel’s story shows what happens when doctors and lactation consultants work well together. She wanted to breast-feed her newborn son, Elijah, but he was losing weight fast within days of his birth.
A pediatrician referred Medel to a lactation consultant, who encouraged her to use a breast pump a half-dozen times a day. With milk flowing more easily, her baby soon caught on.
Medel, 30, of suburban Chicago, said the effort was worth it.
“It’s just so much more work than you think it would be. It’s harder than I thought it was,” she said. “Without support and without commitment, it would be so easy to give it up.”
(Associated Press)
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