After several reports providing reassurance to breastfeeding mothers, two very recent reports are giving me reason to pause. The Canadian Pediatric Society has been recommending breastfeeding if a mother has COVID19 with precautions in place; Breastfeeding when mothers have suspected or proven COVID-19. It would be heresy to suggest that a mother not be permitted to breastfeed her infant but what follows are two reports that at the very least may need to enter the discussion when a COVID19 positive mother gives birth and is deciding about route of feeding.
Toronto Case Report
The first report was notable not so much for breastmilk but rather that a mother with a chronic immunodeficiency and pneumonia from COVID19 had placental surfaces that tested positive on PCR for COVID19. This was the main focus of the paper Probable congenital SARS-CoV-2 infection in a neonate born to a woman with active SARS-CoV-2 infection. In the same paper though, testing of breastmilk in this mother demonstrated a positive PCR with a semi-quantitative cycle time result (there are 40 cycles of amplification of RNA in PCR testing- the further away from 40 cycles the more likely it is a true positive).
The results above were positive at 2 days and negative at 7 days. One could possibly excuse this case as an anomaly since the mother in this case not only was sick but also has chronic neutropenia but then along comes another report.
Second Research Report
This week a second report emerged that adds to the uncertainty around breastmilk. Detection of SARS-CoV-2 in human breastmilk looks at two mothers one of whom was negative on testing of breastmilk but the other unfortunately tested positive. The authors included the following timeline which is very informative.
From the timeline above you will note that in the second case the mother becomes positive at 11 days of age and the infant tests positive around the same time the milk comes back positive. The infant in this case also develops RSV which likely explains the symptoms they developed later in the course. What is concerning to me though is that in this case while the mother was COVID19 positive, she was not acutely ill. When thinking of vertical transmission this has been something that has been postulated in suspecting that those with more severe illness have higher viral loads and therefore may be capable of vertical transmission. Not the case here if the results are to be believed. Adding to the strength of the result are Ct values for SARSCoV2 N peaked at 29∙8 and 30∙4 in whole milk and skimmed milk respectively so this seems real.
How does this differ than past testing?
What intrigues me about this study in particular is that past research on transmission into breastmilk has failed to detect the virus. It could be that previous testing close to delivery was negative and that with time might the virus enter breastmilk? At eleven days I think this may be the latest testing done. In virtually all cases reported about COVID19 positives in newborns the authors have always explained the painstaking steps they took to prevent postnatal infection. I do wonder now if some of these cases may be related to a small percentage of women carrying the virus in their breastmilk. This leaves us in a tough spot. What do we tell women who are thinking of breastfeeding and have COVID19? There will need to be discussion on this but one option is to proceed with feeding accepting there may be a small risk of transmission. A second option would be to test milk but if the transmission occurs late you may miss it in hospital on initial sampling Finally it may be worth pumping and discarding milk until mothers test negative and using donor breastmilk in the meantime (or formula for those who don’t have DBM).
Regardless I think this information coming out will need to be digested and centres think about how they will approach this issue. My guess is these will not be the last reports on this.
As a Neonatologist, there is no question that I am supportive of breast milk for preterm infants. When I first meet a family I ask the question “are you planning on breastfeeding” and know that other members of our team do the same. Before I get into the rest of this post, I realize that while breast milk may be optimal for these infants there are mother’s who can’t or won’t for a variety of reasons produce enough breast milk for their infants. Fortunately in Manitoba and many other places in the world breast milk banks have been developed to provide donor milk for supporting these families. Avoidance of formula in the early days to weeks of a ELBWs life carries benefits such as a reduction in NEC which is something we all want to see.
Mother’s own milk though is known to have additional benefits compared to donor milk which requires processing and in so doing removes some important qualities. Mother’s own milk contains more immunologic properties than donor including increased amounts of lactoferrin and contains bioactive cells. Growth on donor human milk is also reduced compared to mothers’ own milk and lastly since donor milk is obtained from mothers producing term milk there will be properties that differ from that of mothers producing fresh breast milk in the preterm period. I have no doubt there are many more detailed differences but for basic differences are these and form the basis for what is to come.
The Dose Response Effect of Mother’s Own Milk
Breast milk is a powerful thing. Previous studies on the impact of mother’s own milk (MOM) have shown that with every increment of 10 mL/kg/d of average intake, the risk of such outcomes as BPD and adverse developmental outcomes are decreased. In the case of BPD the effect is considerable with a 9.5% reduction in the odds of BPD for every 10% increase in MOM dose. With respect to developmental outcome ach 10 mL/kg/day increase in MOM was associated with a 0.35 increase in cognitive index score.
The same group just published another paper on this cohort looking at a different angle. NICU human milk dose and health care use after NICU discharge in very low birth weight infants. This study is as described and again looked at the impact of every 10 mL/kg increase in MOM at two time points; the first 14 and the first 28 days of life. Although the data for the LOVE MOM trial was collected prospectively it is important to recognize how the data for this study was procured. At the first visit after NICU discharge the caregiver was asked about hospitalizations, ED visits and specialized therapies and specialist appointments. These were all tracked at 4 and 8 months of corrected age were added to yield health care utilization in the first year, and the number of visits or provider types at 4, 8, and 20 months of corrected age provided health care utilization through 2 years.
What were the results?
“Each 10 mL/kg/day increase in HM in the first 14 days of life was associated with 0.26 fewer hospitalizations (p =
0.04) at 1 year and 0.21 fewer pediatric subspecialist types (p = 0.04) and 0.20 fewer specialized therapy types (p = 0.04) at 2 years.” The results at 28 days were not statistically significant. The authors reported both unadjusted and adjusted results controlling for many factors such as gestational age, completion of appointments and maternal education to name a few which may have influenced the results. The message therefore is that the more of MOM a VLBW is provided in the first 14 days of life, the better off they are in the first two years of life with respect to health care utilization.
That even makes some sense to me. The highest acuity typically for such infants is the first couple of weeks when they are dealing with RDS, PDA, higher oxygen requirements etc. Could the protective effects of MOM have the greatest bang for your buck during this time. By the time you reach 28 days is the effect less pronounced as you have selected out a different group of infants at that time point?
What is the weakness here though? The biggest risk I see in a study like this is recall bias. Many VLBW infants who leave the NICU have multiple issues requiring many different care providers and services. Some families might keep rigorous records of all appointments in a book while others might document some and not others. The big risk here in this study is that it is possible that some parents overstated the utilization rates and others under-reported. Not intentionally but if you have had 20 appointments in the first eight months could the number really by 18 or 22?
Another possibility is that infants receiving higher doses of MOM were healthier at the outset. Maternal stress may decrease milk production so might mothers who had healthier infants have been able to produce more milk? Are healthier infants in the first 14 days of life less likely to require more health care needs in the long term?
How do we use this information?
In spite of the caveats that I mentioned above there are multiple papers now showing the same thing. With each increment of 10 mL/kg of MOM benefits will be seen. It is not a binary effect meaning breastfed vs not. Rather much like the medications we use to treat a myriad of conditions there appears to be a dose response. It is not enough to ask the question “Are you intending to breastfeed?”. Rather it is incumbent on all of us to ask the follow-up question when a mother says yes; “How can we help you increase your production?” if that is what the family wants>
I have to admit I know very little about this field despite having friends are practitioners. Anecdotally there are reports of premature infants who are not progressing as fast as parents want and requests are made for an an alternative healers. Such families may be delighted with the care they were receiving and as they see no adverse effects following treatments they wish the practice to continue.
As I reflected on these reports I turned to the literature to look at the third most common health practitioner in North America after doctors and dentists; the Chiropractor. The truth is I have known for some time that Chiropractors provide treatments for newborns and children but have been somewhat oblivious as to what services they can offer. My curiosity was piqued by finding that Chiropractors have been treating newborns for difficulties with breast-feeding. Before I turn to the evidence for such practice it is worthwhile reviewing what Chiropractic is based on.
Chiropractic is actually a relatively new field having been developed by D.D. Palmer in 1895, who was a magnetic healer. He believed that many diseases were caused by joint subluxations of the vertebrae, which would lead to interruptions of neurological impulses thus creating disease. Having said that the indications for Chiropractic have expanded over time as the profession has developed. While initially practiced in adults the use of such manipulations has expanded over time to include children some as young as newborns. One such goal is to improve success with breastfeeding and a sample manipulation is shown in this video:
When it comes to breast-feeding the number of studies examining efficacy are few and far between but the largest study is worth studying as at the very least it outlines what it is that the Chiropractors believe they are treating. In 2009 JE Miller et al published the following article: Contribution of Chiropractic Therapy To Resolving Suboptimal Breastfeeding: A Case Series of 114 Infants. In this case series, maternal infant dyads who were on average 3 weeks of age at presentation (but the most common age of presentation was 1 week) were referred to a Chiropractor for help in establishing exclusive breastfeeding. The infants in this study most commonly presented with issues latching on rather than drawing milk once latched. In fact the issue more often than not was simply not having the infant show interest in latching. The findings of the Chiropractors assessing these infants as to the etiology of the problem were as follows:
Altered tongue action resulting in ineffective latch
Aberrent cervical range of motion and/or posterior joint restrictions affecting infant posture and position
Hypo or hypertonic orbicularis oris, masseter, digastric muscles causing imbalance in muscle torque
Temporormandibular joint laxity or imbalance
Mechanical changes in neural function relative to cranial or cervical distortion
The number of treatments were from 1 to 9 with a mean of 4. These manipulations typically involve the hyoid bone, TMJ or cervical spine. Exclusive breastfeeding was reached in 78% based on a 10 point numerical scale and discussion with families.
Interestingly the frequency of birth trauma was notably higher in these patients than in the general population, which is used as an argument to suggest that these infants were at risk of injury in need of manipulation.
I have to give credit to the authors of this paper as they presented this information but acknowledged that the improvement in breast-feeding rates could be a function of allowing time for the skill to develop as opposed to the effect of their treatment. The only other study I located was a similar case series from 2012 looking at 19 patients showing similar improvements. The problem though in all of this is the lack of blinding of the interventions. Families that seek out a Chiropractor as they have already seen a lactation consultant, midwife and physician are clearly dedicated to the plan of breastfeeding and are motivated to take that extra step to achieve it. Whether the manipulations provided were effective or it was simply the result of dedication and time one will never know but I suspect that may be the case.
An additional factor that is worth mentioning is that with a higher rate than in the general population of birth trauma it is plausible that the delay in initiation of breastfeeding is related to after effects of birth as opposed to any true subluxation whether true or not.
Lastly one significant concern with respect to manipulations of the head and neck despite being well intended is the risk although small of vertebral artery dissection and stroke. This has been reported in adults and only once in Pediatrics but all families need to ask whether the proposed benefit is worth the small risk of a significant neurologic injury. My bias as you can probably guess is that implementing unproven therapy that carries a small but devastating risk is not worth it.
There is no doubt that the literature will become scattered with such case reports showing the benefits of Chiropractic care in achieving breast-feeding but my suggestion is to give it time. If it is meant to happen it will and exposing your infant to manipulation of the hyoid bone or neck is too fraught with danger to be worth pursuing.
Will that be q2h, q3h or q4h feeding? When I started my residency in Pediatrics that was the question I needed to ask before writing an order to start oral feeding in a preterm infant. At the time it seemed perfectly reasonable but I have to admit the question for me was “What if they aren’t ready?”. Does a baby who won’t take the breast or bottle at the 3 hour mark clearly show they aren’t able to feed or that they really are just not ready to feed? We commonly say that children are not small adults. Hospitalized adults commonly will utter the words “I’m not hungry” when their food tray is brought to them. This may be a reflection of what has been put before them rather than whether hunger exists or not but they seem to be able to be ready to eat so why not children and by extension preterm infants in the NICU.
My approach to feeding premature infants was fairly consistent until about 10 years ago when nurses in Edmonton, Alberta (in a level II unit) introduced me to “semi-demand” feeding. What I find interesting about this, is the paucity of evidence that existed on the subject. At the time, the evidence really centred around one paper but the impact of the approach was undeniable. In 2001 McCain et al published the randomized controlled trial involving 81 infants A feeding protocol for healthy preterm infants shortens time to oral feeding. The concept of semi-demand feeding was to assess each infant (once preterms reached 32-34 weeks CGA) before a feed for signs “of feeding readiness”. This was accomplished through offering non-nutritive sucking every three hours before a scheduled feed. If the infant was found to be in a wakeful state, the oral feeding was commenced but otherwise the infant was left for 30 minutes with NNS attempted again. If the infant was still not ready then a gavage would be given. The key here is that the infants were monitored for signs of feeding readiness rather than insisting upon an arbitrary time for their next feed. The study findings were a halving of the time it took to reach full feeds (10 days in control vs. 5 days in semi-demand) with no difference in weight gain observed between groups. The latter point is worth emphasizing, as the concern with semi-demand has been from some that in a worst case scenario where feeds took place every 3.5 hours a baby would miss one feed compared to another infant on a q3h schedule. This fear though does not bear out in the study.
The experience in the centre I currently work at has been so positive that it is hard to find a patient that is not fed in such a way whether a physician orders the approach or not! What is truly fascinating to me is how effective the approach seemingly is and has been adopted again with very little evidence compared to that traditionally needed to change a practice in the neonatal world. Interestingly, although we can’t say for sure we have noticed year over year declines in length of stay for infants born with a birthweight of 1500 – 2000g since the introduction of semi-demand feeding. This could be a coincidence as this has not been the only practice change in our units but it certainly is interesting.
I was delighted to see a paper published this week on the topic by Wellington and Perlman. This was a Quality Improvement project entitled Infant Driven Feeding in Premature Infants: A Quality Improvement Project. This study compared three periods. The first was one in which physicians set the feeding schedule (PDF), the second a training period for a new system and the last the infant driven period (IDP). In the PDF phase, the physicians would order one oral feed a day, then two, three and so on when the full feed was attained at each prescribed level. In the IDF period an assessment sheet for feeding readiness would be completed before each attempt and the decision to offer an oral feed based on the perceived ability to feed at that time.
While this study was not an RCT it is a much larger group of patients than the study by McCain. This comparison was between 153 PDF vs 101 IDF patients. Feeding readiness assessments would start at 32 weeks CGA but feedings would not be offered by either approach until 33 weeks CGA similar to our own approach to feeding for the most part. The use of IDF made no difference to timing of first attempt at nipple feeding. The time to attain full nipple feeding was where significant differences in approach became apparent.
Time to reach full nipple feeding by gestational age at birth:
<28 weeks: IDF versus PDF group reached full NF 17 days sooner (374/7 vs 40 weeks; p=0.03)
28–316/7: IDF versus PDF group reached full NF 11 days sooner (35 4/7 vs 37 1/7 weeks; p<0.001)
≥32 weeks: IDF versus PDF group reached full NF 3 days sooner (354/7 vs 351/7 weeks; p=0.04).
Affect on discharge
<28 weeks GA, no difference between the IDF versus PDF group (41 3/7 vs 39 4/7 weeks; p=0.10).
28–316/7 weeks GA, IDF group were discharged 9 days earlier (366/7 vs 381/7 weeks; p<0.001).
≥32 weeks GA, the IDF group were discharged 3 days earlier (36 weeks vs 363/7 weeks;
Although the findings are clear there does need to be the usual acknowledgement that this is not the gold standard RCT but the practice change in the unit was done pretty carefully. The concept is one that makes a great deal of sense regardless. The lack of difference in discharge for the smallest infants makes some sense as it may well be apnea of prematurity that is the last to resolve. There is no disputing however the benefit in earlier discharge for the 28 – 31 6/7 week group. They achieve feeding earlier and go home faster. From a family centred approach this is the best of both worlds. One should not write off the use of this technique in the smallest infants either as they will have their care normalized much earlier with the NG tube being removed and the parents getting to participate and practice feeding much earlier in their course. Although not measured in this study, it would be intriguing to look at the number of patients who were admitted to hospital post discharge with failure to thrive.
Imagine the impact as well on hospital length of stay data if you multiple the reductions in length of stay by the total number of patients seen in these gestational age categories each year. This almost certainly can represent over a year of patient days for many hospitals.
As I see it the direction is clear. We should not force our premature infants to follow a schedule that works for us. Rather use the cues that only they can provide to tell us when and how much milk they desire. Both the parents, infants and our hospitals will benefit.
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.