LACTATION CONSULTANT SIDES WITH FED IS BEST?!?

Read time | 13 minutes

A major argument made by Fed Is Best (FIB) is that parents are not told the risks associated with breastfeeding, especially with regards to insufficient intake of human milk.

In an attempt to spread awareness about the importance of adequate feeding, they perpetuate a narrative that exclusive breastfeeding, rather than a lack of lactation help and support or close monitoring pre- and post-discharge, is inherently dangerous.

I want to create a message that spreads far and wide- one that parents, professionals, and clinicians may find helpful - and that takes an honest view of the associated risks regarding exclusive breastfeeding.

More importantly, I want to touch on risk-reducing measures that can be utilized to ensure healthy outcomes for breastfed babies and support parents in their human milk feeding goals.

Warning: This post is long.

The end of this post will contain all the supporting links. I understand not all of them are open access and that not everyone will be able to verify the methodology of the studies I refer to.

I have paid a lot of money to access these studies and will be providing summaries, as well as my opinions on the findings in the near future. Feel free to subscribe to my blog if you' want to follow that series on both the studies FIB uses to support their claims and other closed-source studies.

Risks of human milk feeding

Inadequate intake

Inadequate intake is a risk of all feeding methods but is increased with direct breastfeeding, as exact volumes of transfer are harder to monitor.

Colostrum is generally low in volume at birth [1] and continues to slowly increase in volume up to the point of Lactogenesis II, at which time, there’s a more rapid increase in milk volume [2].

Parents typically refer to this as their “milk coming in” and occurs, generally, between days 3-5.

In cases where colostrum volume is insufficient or when there is a delay in Lactogenesis II beyond day 2 or 3, inadequate intake is more likely to occur as it may not be apparent to parents or clinicians that there’s a problem.

This risk can be reduced or mitigated in hospital by initiating early hand expression for at-risk dyads (birthing/lactating parent and baby), encouraging parents to breastfeed AND provide expressed milk when indicated, and ensuring EVERY dyad receives high-quality lactation support by an IBCLC [3] [4][5].

Additionally, when sufficient quantities of parent’s own milk are unavailable, pasteurized donor milk should be offered to ALL parents prior to the suggestion of a breastmilk substitute such as infant formula [6]. Broaching the topic of donor milk prenatally, along with the associated benefits and risks, allows families to research and sort out if it’s something they would want to utilize should inadequate intake occur.

When parents are unable to provide sufficient volumes of human milk and decline to use donor milk, infant formula should be used following PHYSIOLOGICAL NORMS. Meaning, on day one and two, babies should NOT receive 1 or 2-ounce feedings [7][8][9].

Additionally, every parent who desires to human milk feed yet requires the usage of formula due to an insufficient quantity of their own milk, should receive high-quality lactation support in hospital, as well as a referral to an outpatient IBCLC, to help them build their supply and reduce the volume of formula.

Risk of Jaundice (Hyperbilirubinemia)

Jaundice is physiological in newborns, meaning that it’s both normal and common to have some elevation in blood bilirubin levels. Elevated bilirubin levels result in yellowing of the skin (jaundice) and somewhere between 60%-80& of full-term infants experience jaundice at some point in the days following delivery [10] [11].

Both exclusively formula-fed and exclusively human milk-fed babies can and do become jaundiced, however, exclusively human milk-fed babies tend to have more elevated blood serum levels and stay jaundiced for longer [12].

This may be due in part to the impact human milk has on the gastrointestinal clearance of bilirubin, which is the primary mechanism for clearing bilirubin out of the bloodstream as newborns have immature livers [13]. This elevation of bilirubin in breastfed babies may have long term health and protective benefits which may account for the decrease in illnesses such as NEC that is more common in babies who are not fed human milk [14].

Risk of Hyperbilirubinemia complications

Despite the emerging evidence that elevated bilirubin levels pose some short & long term health benefits in the newborn, there is a real concern if bilirubin levels rise too high. There is a lack of clear evidence at what blood serum level bilirubin starts to have an impact on the brain, but evidence supports that elevated bilirubin levels can lead to acute bilirubin encephalopathy (ABE) [14]which if serum levels elevate to or exceed >30 mg/dl may lead to Kernicterus.

Even lower levels, 20- 25 mg/dl may have some impact on brain development & function, even though the effects are not as severe as Kernicterus [15][16].

The prevalence of Kernicterus worldwide ranges from 1 in 50,000 to 1 in 200,000 depending on where you live [17].

Kernicterus can be fatal - nearly 30% of babies who develop it will die [18].

Roughly 75% of the cases of Kernicterus, however, occur in Sub-Saharan Africa and Southeast Asia where families may not have quick access to phototherapy or genetic factors predispose babies to hyperbilirubinemia [19].

Phototherapy is a low cost, non-invasive treatment for elevated bilirubin levels, and is typically the first-line defense of protecting against adverse outcomes when increasing human milk volume doesn’t resolve it.

Discharging at-risk dyads without proper feeding and lactation support and close follow is much more to blame for increasing the risks of complications of hyperbilirubinemia, thus leading to readmission, than exclusive breastfeeding.

I’ve seen first hand, babies with borderline-high bilirubin levels, scant stooling and moderate weight loss of 7% or more be discharged without a direct referral to lactation support and without next-day follow-up.

Frequent effective breastfeeding or feeding of expressed human milk will resolve jaundice issues in most cases.

Infant formula in small quantities, in addition to human milk (HM), can be used when levels rise quickly to dangerously high levels or in the rare event that phototherapy & HM alone don’t work [20].

With that said, the goal with phototherapy is NOT to prevent Kernicterus per se, rather, it’s to prevent more intensive treatments of Hyperbilirubinemia such as Albumin Fusion or Exchange Transfusion. And while it’s not ideal, the relatively low risks associated with short duration or conventional phototherapy on long term health may not exceed the short or long term health outcomes interrupting or ceasing the use of human milk [21-32].

Phototherapy can interrupt direct breastfeeding, skin to skin, and infant bonding, therefore, the risks of exposure to phototherapy and to long term breastfeeding should prompt providers to only utilize it for a short duration. Human milk feeding via expressed milk or donor milk should continue and be encouraged even when direct breastfeeding is not an option.

Risks of readmission

Because of the above-mentioned points, exclusively breastfed babies tend to be readmitted more frequently than exclusively formula-fed babies (4.3% vs 2.1%) [33]. Inadequate intake can lead to increased weight loss which can cause or exacerbate jaundice- the most common cause of readmission.

Additionally, inadequate intake can result in other complications such as excessive weight loss, hypernatremic dehydration, hypotensive dehydration, and hypoglycemia [39].

…speaking of weight loss..

Weight loss

Nearly all babies lose weight, however, breastfed babies tend to lose more weight than formula-fed babies in the early days post-birth, despite them gaining on par with formula-fed babies in the first 2-3 months [40].

The majority of breastfed babies will lose no more than 8 percent of their birth weight.

Babies born by Cesarean tend to lose more weight than babies born vaginally at both hospital discharge and between 48-72 hours[34].

Roughly 2 percent of babies, be they formula-fed or breastfed, will lose greater than 10 percent of their birth weight by discharge. That increases to nearly 6.7 percent of all babies by 72 hours, though exclusively breastfed babies make the majority [35].

Losing 10% or more in the first 24 hours has the potential to occur but is pretty implausible. Should a baby lose 10% in the first 24 hours, or more 15% at any given time, underlying medical causes should always be explored[36]. Weight loss in excess of 10% is associated with an increased risk in neurologic sequelae.

This highlights how important AND NECESSARY it is for all parents who desire to human milk feed to receive lactation support immediately post-discharge. The quicker at-risk dyads for continued weight loss are identified and the underlying issues addressed, the sooner babies return to birth weight.

Babies should not be discharged with >7% weight loss especially without a scheduled lactation visit for the same or following day.

If a visit wasn’t scheduled prenatally, providers should provide every dyad with the names and numbers to community resources and private practice IBCLCs before discharge.

The more weight an exclusively breastfed baby loses, the more likely they are to be supplemented with a breastmilk substitute [37], which makes sense, as despite what FIB may believe, no parent nor provider/lactation consultant would rather a baby continue to get inadequate volumes of human milk than consume formula.

Nutrient Deficiencies

All babies need adequate levels of Vit D, Vit B 12, Iron, etc. Because most US birthing and lactating parents are deficient in Vit D, because vegan human milk feeding parents may lack sufficient B 12 and because Iron stores are limited (or nearly non existent in preemies), supplementation of specific vitamins and minerals may be necessary [38].

The method of which to provide them, and when and who needs to do so will differ based on individual circumstances, but all parents and providers should be aware of the possibility of nutrient supplementation.

Ultimately it’s up to parents to decide how much human milk if any, they would like to provide for their babies. There’s a heap of evidence- even studies conducted by formula companies themselves- that reinforce the idea that human milk is optimal for most human babies.

The fact that it’s an optimal food source for growth and development may not have any bearing on if or how a parent chooses to use their lactating breast/chest to feed their baby. It also may not influence whether or not they will seek out human milk donated by other parents.

Similarly, the potential risks of human milk feeding - which unarguably are a primary result of lack of access to adequate lactation and breastfeeding support AND/OR a lack demand by FIB, health care providers,and society to provide it for every family- may be so high that a parent may choose to introduce a breastmilk substitute in addition to or in replacement of human milk.

What FIB fails to realize is that these risks are a concern to everyone in the healthcare field, especially the lactation professionals who have dedicated their lives specifically to help resolve these issues.

I agree with FIB that just as we discuss the “risks of formula usage” we too should be discussing the “risks of exclusive breastfeeding” so that parents can make an informed decision. However, we should also be arming parents with the knowledge of if they’re at risk, how to identify potential red flags, and from who and how to seek help.

FIB can no longer say Lactation professionals aren’t talking about the potential risks exclusive breastfeeding, if this post is shared nor can they say that Lactation providers are not attempting to rally together, both with FIB and amongst ourself and healthcare providers, to resolve these issues either.

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