There is the potential for a very significant issue to arise in the NICU environment in the coming years. As I was preparing the last blog piece following the decision by SCOTUS to allow same-sex marriage in all 50 states I began to think about the so-called ripple effect. In other words, now that the law has been changed, what impacts could this have that might have been unforeseen. The first thought that crept into my mind was that as male same-sex parents they would read the same literature that promotes breast milk feeding in the NICU and no doubt want the best for their infant in the NICU or for that matter any baby. In many NICUs however there are weight or gestational age restrictions indicating who will receive donor breast milk if the mother is not able or not willing to produce her own. In our unit for example we given DBM to all babies currently under 1250g and those recovering from NEC or other bowel surgery. Might men in a same-sex marriage who have adopted a child or used a surrogate who is not willing to breastfeed demand the same?
In looking into this I came across a very strange story from 2013 in which a nurse in the UK offered to “rent her breasts” to gay parents. The story at the time caused a fairly big stir as it raised a number of questions as to safety and the morality of it all. In some ways it was ahead of its time as there have been a number of articles recently addressing the very issue of safety of milk (will be addressed further in the article obtained outside of HMBANA approved breast milk banks.
As same-sex couples increase and many then choose to have children of their own to raise what demands will be made of access to breast milk? There is no question “breast is best” and I have either written or posted to Facebook many articles suggesting decreased incidence of allergy, necrotizing enterocolitis, improvements in the microbiome and many other benefits as well. What do we do in the situation of the same-sex family who declares that they want to provide breast milk to their infant in hospital as it is the best source of nutrition for their infant. If we say for example that their 2 kg, 34 week infant is too big to qualify for DBM is this fair given that they have no option for producing their own milk in the setting of male same-sex partners? Could we as health care providers be labelled as discriminating?
One option is to allow such parents to bring in their own milk but then where do they source it from? Milk purchased online or from the community may be contaminated with bacteria, viruses or contain some cow’s milk as some recent publications have demonstrated. Can we knowingly allow families to bring such milk into the hospital to feed their infant? Perhaps, but only if we have medical legal safeguards in place that protect the hospital from knowingly allowing patients to bring in milk which could be contaminated. Waivers of liability would need to be in place in each hospital permitting such sourcing of milk. If however we strongly discourage such practice will we direct them to the milk bank supplying our local hospital. Herein lies the challenge though. If availability of volume was not an issue, we could provide to all infants in the unit but the reality is there is simply not enough to go around. Furthermore, the larger the infant, the more donor milk they utilize and the more depleted the supply becomes for those of our smallest infants who are most in need of avoiding formula. Finally, who should pay for this milk if the family cannot produce any as in this situation. This is not a case of a mother who could produce but chooses not to but rather a family who is desperate to use what they have read is best but physically is incapable of producing. The same of course could be said for those women who try and cannot or due to prior surgery are unable to produce milk. I believe this is an issue that will come up across the US and Canada and I will be interested to see how it plays out and what role Bioethics may play in helping to resolve some of these questions.
This will be a slippery slope. If male same-sex parents are provided with free access to donor milk I don’t see how donor milk will not be made available to all families who cannot provide their own. Why would the male parents who biologically be unable to provide milk be given this “liquid gold” while other mothers who are pumping round the clock, taking domperidone and seeing a lactation consultant and getting only drops be denied as their newborn is 1600g and above the weight cutoff. I hope you can see the issue of equity popping up in this discussion.
Finally why not allow those parents who are male same-sex partners to simply pay for the milk they need if they don’t qualify for “free” milk under a unit’s program? Sadly the issue then becomes one of equity again. Do we want to care for infants in an environment where the wealthy who can afford to pay for the donor milk from an HMBANA milk bank get it and the poor are only offered formula? I have to admit I realize there are health care systems where this is the case but in Canada where we have a socialized medical system this kind of two tiered system would cause many to become nauseated.
I fear that this issue will come up as the number of people marrying and choosing to have children in same-sex relationships increases. If it leads to a 100% human milk diet for infants in the NICU I would say that is a good thing but I think the road like Winnipeg will be paved with many potholes that we will have to do our best to navigate around.
Nineteen seventy two was notable for many things aside from the year of my birth. Canada defeated the Soviets in the summer series, the Watergate scandal took down a Presidency, The GodFather was released and for the purposes of this post breastfeeding rates in the US reached an all time low of 22%. For an excellent review of the history of breastfeeding the article by AL Wright is excellent.
Rates of breastfeeding began a steady decline in the 1960s as more and more women entered the workforce and seemingly had to choose between employment and breastfeeding. This was a time when it was not seen as being acceptable to breastfeed in public (although that is not the case in many places still to this day) and the workplace was not as conducive to supporting women as in current times (think onsite daycares). Add to this that the 1970s also saw a backlash of sorts in the appeal of breastfeeding due to science “perfecting” a better source of nutrition in formula and we had the low rates that we did. In fact through discussions with parents from that generation, mother’s who chose to breastfeed may have been viewed by some as being silly for not using something like formula that could let the whole family in on the experience. Mom, Dad, kids and grandparents could all take part in the wonderful act of feeding. Why be so selfish?
Following this period as research began to demonstrate improved outcomes with breastfeeding including reductions in atopic disease, less hospital admissions and more recently positive impacts on intelligence and your microbiome the trend reversed. In fact, as the above graph demonstrates, rates approximating 70% were reached by the late 1990s. Since that time the CDC has shown that initiation rates have continued to rise and currently are at the highest documented levels in history.
Looking at the CDC data though reveals some very important information. While the rates of any breastfeeding reach 80%, the rates at 6 months hover around 50%. This means that a significant portion of US women are using some formula when they come home and from the graph on the right about 35% by three months are exclusively breastfeeding. This number is far short of the goal the WHO has set to encourage exclusive breastfeeding for the first 6 months however it is a remarkable achievement for infant health.
A recent trend on social media and print media has been the Brelfie. As you may know, this involves taking a picture of yourself breastfeeding your baby and posting it in one forum or another. This has been popularized by many celebrities and made it’s way onto the cover of Elle magazine this month.
So called Lactavists have been overjoyed to see such public acceptance and promotion of breastfeeding. As a Neonatologist I am delighted to see such high rates of breastfeeding and with it the beneficial effects that it brings.
Curiously, though all of this attention and promotion of breastfeeding has created a culture that is now being called bressure. This is defined as pressure to breastfeed and was the subject of a recent survey by Channel Mum in the UK. The highlights of the survey that went out to 2,075 mums showed:
– 16 per cent of bottle-feeding mums have been on the receiving end of cruel comments from other mothers they know
– one in 20 being attacked on social media
– 69 per cent of bottle-feeding mums said they had been judged negatively
– 41 per cent made to feel they have ‘failed as a mum and failed their child’ by not breastfeeding
– 15 per cent of mums have even lied to cover up their bottle-feeding and appear to be ‘better’ mums.
This so called bressure has led to a public campaign to increase awareness of the harassment that some mothers feel which involves taking selfies with cards having one word describing what breastfeeding meant for them. A video from Channel Mum can be seen here
While I am all for breastfeeding, I find it peculiar that the experience that breastfeeding mothers (all 22% of them) had in 1972 is now being felt by a larger percentage in 2015 who are bottle feeding. It is unfortunate that assumptions are being made of many of these women who put a bottle in the mouths of their infants. How many times does one conclude that the mother simply chose not to breastfeed because they were worried about the way their breasts would be affected cosmetically or that they simply chose to go back to work and breastfeeding would just get in the way. I suspect in most cases the truth is much different. Many of these mothers have tried to breastfeed but couldn’t produce enough. Others may have suffered from cracked nipples, mastitis, abscesses or due to prior surgery were unable to produce milk. Many such mothers have agonized over their “failure” to do something that they hear “everyone can do”. While they are told it takes some work for many that is a huge understatement. Is it not bad enough that these women have suffered the feeling of failure? To be looked at or spoken to in a disapproving way does nothing to support them. Add to this that by 3 months of age at least in the US 65% of mothers are providing some formula and it seems silly to take the “high and mighty” approach in the first couple of months and assume the worst of these women. Many of the “breastfeeders” will soon enough join the ranks of those using some formula.
Maybe the better option is to try and help. Many of the above problems whether it be producing enough quantity or pain related to breastfeeding can be addressed through tips on technique. While I am not an expert in this, hospitals would do well to increase staffing of on site lactation consultants to help mothers who wish to breastfeed get off on the right foot so to speak. A larger working force of midwives in North America in particular could certainly provide help in this regard. What I can say is that if a woman suffers a bad experience with breastfeeding in their first pregnancy the likelihood they will try again the next time is lower especially if we as a society make them feel like a failure.
Yes we need to promote breastfeeding and we should do what we can to follow the WHO recommendations and minimize the use of formula when possible. While bressure may have been intended to yield something good we need to be sensitive. Perhaps a better strategy next time a friend says they are going to use formula is to ask if they are having trouble with breastfeeding and if they need some help. Not having the discussion will ensure that nothing changes and a chance to do something will be lost due to misdirected bressure.
Its hard not to hear about probiotics these days. They are in our grocery stores as supplements to yoghurt and other foods and can be purchased in health food stores or at your local pharmacy. They appear to be everywhere as word spreads about the importance of your microbiome in maintaining good overall health.
It didn’t take long for clinician scientists to turn their attention to the neonate who is at risk of necrotizing enterocolits (NEC). It has been known for some time that formula feeding versus breast milk plays a role in the development of NEC as premature infants fed formula repeatedly were found across studies to have a higher incidence of NEC. The evidence is so strong in fact that the Cochrane review on the subject states “Enteral supplementation of probiotics prevents severe NEC and all cause mortality in preterm infants. Our updated review of available evidence strongly supports a change in practice.“ If you have read such reviews you know that they rarely come out this strong in their support of something! Furthermore, infants fed formula may have a different preponderance of more pathogenic bacteria in the colon and less lactobacillus and bifidobacterium species. The idea behind providing probiotics to neonates would therefore be to repopulate the intestine of these vulnerable infants with good bacteria and potentially reduce the incidence of a devastating condition like NEC.
If only it were that easy though
The issue of using Probiotics in preterm infants is a contentious one to say the least. While the evidence appears to indicate an overall benefit in terms of reducing rates of NEC there remain concerns regarding the safety of providing bacteria to this population even though the bacteria are thought to be beneficial. The people who urge caution in the use of probiotics say so due to a few reports of sepsis after the introduction of probiotics with the organism that the patient was provided or with a different species that was could be traced to a contaminated product. As noted in an article on CBC recently these products fall under the category of a nutritional product rather than a medication with Health Canada and therefore are not subject to the same rigorous quality control standards as other comparable medications would be.
Others while recognizing the potential for contamination and sepsis would argue that the risk is low compared to the benefit provided to the infants overall and therefore claim benefits outweigh risks.
Manipulating Breastmilk in a Double Bling RCT
Given the above concerns regarding administration of these products to neonates I was excited to see the randomized double blinded study by Benor S et al; Probiotic supplementation in mothers of very low birth weight infants. This study enrolled mother and infant pairs within 72 hours after birth to commence on maternal treatment with Lactobacillus acidodphilus and Bifidobatera lactis versus placebo until discharge. The rationale for giving probiotics to lactating mothers was based on a previous study showing less atopic dermatitis in the offspring of mothers who took such treatment while breastfeeding and in a study of breast milk demonstrating lower levels of the inflammatory cytokine transforming growth factor beta (TNF-B). Less inflammation might equate to less NEC.
The primary outcome was Bell Stage II NEC and the investigators required 90 mothers in each arm to show a difference in the incidence of NEC based on previous work in their centre. All included pairs needed to be providing >50% EBM in order to minimize any effect from formula. The overall incidence of NEC at the completion of the study was 27% in the placebo group vs 12% probiotic group and for NEC II 18% vs 4% in those treated with probiotics. The rates of NEC were quite high compared to what we typically see and the authors noted that even for their site (for uncertain reasons) there was a higher rate than they expected. Neither of the rates of NEC were statistically different (both reached p=0.15 levels) but there was a significant issue with this study.
The total recruitment was 25 in the probiotic and 33 in the control arm. This was a far cry from the estimated 90 needed per side. The reason for this goes back to the start of this blog entry. The study needed to be stopped due to poor enrolment. Why so low? The majority of mothers approached for this study did not want to risk not getting probiotics so they opted to simply take them due to the perceived health benefits that as adults they already believe exist. Sadly I think this problem would resurface in many places if the study was replicated. This loss of equipoise by the families will make obtaining consent for such studies very difficult and we may not get a satisfactory answer.
Interestingly the authors of this study also measured TNF-B and found a strong trend towards lower levels in the breast milk of the probiotic supplemented group matching the trend towards less NEC.
I sincerely hope that another study such as this can be done without such issues in recruitment as the strategy would address the issue of not providing the bacteria directly to the neonate while still potentially reaping the benefits of less NEC. For now we will have to wait and see.
I wrote this post almost a year ago and could not believe such practice was going on. Here we are this week and the following was published in Men’s Health magazine indicating breast milk consumption by body builders has not gone away quietly.
For my own thought on this including updates to the original post please read below.
It may seem like I am making a joke but sadly it is the real deal as you can see from the USA Today video released in the past couple weeks. The benefits of drinking breast milk to add muscle mass has spread quickly among that community. That is not to say that the majority are using it but there definitely is a following. Taking a look at the website “Only The Breast“ reveals the sad truth. There are currently 6368 classifieds for women selling breast milk with 804 of these women specifically targeting men who wish to buy (Update: As of February 23, 2016 the number of offerings has risen to 10135 with 1294 offering to men so the problem is getting worse not better!). Contrast this with only 113 women willing to donate their milk. This is only one site as women are also resorting to Craigslist and Kijiji to just name a couple of alternatives. There is money in selling breast milk and sadly those who most need it may not be getting it.
The amount of evidence supporting the benefits of an exclusive breast milk diet for preterm infants in particular has exploded in the past few years. There is no question in my mind that breast milk should be distributed to babies whose mothers are unable to provide enough milk for them while in the hospital. The proven reductions In necrotizing enterocolitis; a major cause of morbidity and death in the NICU are reason enough to exclude formula from a low birth weight preterm infant. See Formula versus donor breast milk for feeding preterm or low birth weight infants.
If each case of necrotizing enterocolitis costs the US Health care system approximately $150000 imagine how much money could be saved when estimates from other studies such as the one by Sullivan et al target the reduction in NEC at about 70%. In our own centre with approximately seven cases per year we would expect to see 5 less babies affected by this per year.
Aside from the above concerns about using breast milk in a population that has no likely benefit there is substantial risk to purchasing milk online. As mentioned in the USA today video the FDA has spoken out against such practice due to high likelihood of contamination by bacteria secondary to non standardized methods of storage. The article cited in the video can be found here.
Where is the harm?
The rate of contamination at 74% is frightening and in turn puzzling that people so focused on treating their bodies like a temple would consider ingesting it. A search on Pubmed using a combination of different search criteria combined with a broader search using google failed to come up with one article showing any evidence supporting the consumption of breast milk by those wishing to build muscle mass. Given the lack of evidence and the potential for harm this is a practice that needs to be eliminated as soon as possible. The selling of excess supply from mothers to males who have no potential to benefit is tragic. Each ounce that is sold in such a way is a waste of liquid gold and in essence is “stolen” away from the pool of milk that could be sent to a Human Milk Banking Association of North America approved Milk Bank. All Milk Banks that follow their standards provide breast milk which has is safe to consume as opposed to those sourced from online sites. Furthermore newer organizations such as the Mother’s Milk Coop pay for such milk as an alternative for mothers seeking income through the selling of their excess supply. There are of course possible issues that arise from paying mothers for their milk but if they are looking to profit then perhaps the coop is the preferred option. Selling milk and giving formula to their infants is not something I condone but if they are going to do it anyway the online route is the worse of the two options.
It is my hope that this post serves to educate even one mother that while their efforts to earn some income are understood there are better and safer ways to do so than an unregulated site such as “Only The Breast” or others. If you come across anyone who even hints at selling their milk through the means mentioned above, direct them to the closest breast milk bank or to the Coop mentioned above (recognizing that this too is not ideal)!