The Dangers of Inadequate Breastfeeding
Breastfeeding is supposed to be the most natural thing a mother can do for her baby. It is as easy as just placing a baby in the bosom and the baby latches on, right? That is not always the case. Several factors can affect breastfeeding, including breastmilk supply, breast morphology, latch, newborn alertness and mother’s nutrition. As a postpartum nurse, I have witnessed the dangers of inadequate breastfeeding when any of these factors are ignored. Hypernatremic dehydration and jaundice are real dangers of inadequate breastfeeding. When a newborn does not obtain any or enough food (whether breastmilk or formula), s/he depletes whatever resources left since the separation from the placenta. The newborn starts to lose more calories than it is gaining, and thus, starts dehydrating.
These dangers have harsh consequences. Dehydration may lead to serious complications: cerebral edema (swelling of brain tissue), seizures, intracranial haemorrhage (bleeding within the skull), disseminated intravascular coagulation (a life-threatening condition where there is excessive clotting or bleeding throughout the body), kidney failure, permanent brain injury and even death . Also, if the newborn is not well hydrated, s/he will not pass meconium or stool. Meconium is a sterile product of debris build-up in the intestines. The newborn excretes bilirubin through both meconium and stool so if this does not occur, the bilirubin level starts to rise and can lead to jaundice (yellowing of the skin). Severe jaundice can cause bilirubin to pass into the brain (acute bilirubin encephalopathy) and permanent brain damage (kernicterus). None of these complications are solely theoretical but have already occurred. Current studies have confirmed this: exclusively breastfed babies are more likely to become severely jaundiced than formula-fed babies. Both the Centers for Disease Control and Prevention and the American Academy of Pediatrics (AAP) discovered increased cases of kernicterus and warned that breastfeeding is a significant risk factor for the development of severe jaundice . Several current studies indicated that the incidence of breast-feeding associated hypernatremic dehydration in healthy term newborns is increasing [3, 4]. In one study, one out of 66 healthy exclusively breastfed term newborns developed hypernatremic dehydration .
So what are the causes of these dangers? The major causes are an inadequate latch and low breastmilk supply. Regarding the former, if the newborn does not have a good latch, each feeding will be suboptimal. As for low breastmilk supply, if there isn’t a sufficient amount of breastmilk to adequately hydrate and nourish the newborn, s/he is at risk for dehydration and jaundice.
In assessing the exclusively breastfed newborn for proper nutrition, the daily wet and soiled diapers are counted. As a general rule, the newborn should have at least one wet diaper and one soiled diaper within the first 24 hours of life, and at least two wet and two soiled diapers the following day. I am concerned about the validity of the first wet diaper in reflecting the newborn’s current hydration status. Some newborns have a wet diaper within 4-6 hours of delivery. My concern is whether the void resulted from hydration from breastfeeding or hydration via placenta in utero prior to delivery. This has to be carefully considered because if a newborn voids as a result of hydration prior to delivery and is not obtaining adequate hydration from breastfeeding, a whole day has gone by without notice. Imagine how an adult would feel if s/he does not eat for a whole day. Then consider what it would be like for a newborn, which is still so fragile.
Another matter that concerns me is the idea that 5-7ml of colostrum is a sufficient feeding for every newborn because that is the capacity of their stomachs. I find it hard to believe that newborns with weights ranging from 2500 – 4000 grams would have the same stomach capacity. A study by Naveed et al discovered that the larger the newborn, the greater the stomach capacity . They found that newborns that weighed 2500g had at least 18ml stomach capacity. Moreover, differed metabolic rates, caloric needs, and the frequency of feedings can affect the feeding volumes of newborns . I have seen a newborn only a few hours old take down 20ml of formula without difficulty and would have taken more if I let her. When I spoke to a neonatal nurse practitioner about this newborn, she told me of another newborn who took 30ml of formula without difficulty, which is why she and her colleagues advise to let the newborn eat as desired. Newborns have different stomach capacities so some will eat more than others and some will eat less. A rule of thumb will not work for all newborns.
There is a myth circulating that malnourished mothers can provide nourishing breastmilk (both colostrum and mature milk). I would like every mother to contemplate how this is possible. The so-called malnourished mothers in developing countries may not appear healthy or nourished but these mothers have been preparing to breastfeed since pregnancy and they eat certain foods to assure their colostrum and mature milk is nutritious. I come from a developing country and a real malnourished mother has little or no breastmilk for her newborn. When I see new mothers drinking coffee and eating only a bagel for the whole day while breastfeeding nonstop and they think they are nourishing their newborn, I think someone should step in and tell them the truth, not perpetuate a myth. A paediatrician once told me that the breastmilk sucks all the nutrients from my body for my baby. But what if the mother’s body does not have sufficient nutrients, then what?
With all the breastfeeding initiatives, I fear some mothers breastfeed at the expense of the newborn’s health. What is most important is the newborn’s health. Indeed, breastfeeding initiatives are for the newborn’s health, citing all the research that breastmilk is best for the newborn. But are we (healthcare providers as well as mothers) losing sight of the fact that the newborn needs adequate nutrition for good health? Ultimately, the goal is a healthy newborn. This should always be priority and considered in all that is done for the newborn. Does being exclusively breastfed and in an isolette under phototherapy lights for days as a result of jaundice outweigh being both breastfed and formula fed and not being separated from the mother? As a postpartum nurse, I feel torn between my care for the newborn and the mother when I see a screaming, close-to-dehydrated newborn, who is exclusively breastfed. I want to support the mother’s choice to exclusively breastfeed but I feel compelled by the newborn’s hunger cry.
One might think I am against breastfeeding but I am not. I am a mother and I breastfed my children. I am all for breastfeeding when the mother has adequate milk supply and the newborn latches onto her breast well and feeds well at least 8 times a day. My questions are how do we achieve this for all mothers? And can we? The truth is not every woman can breastfeed. No one wants to say it but there, I said it.
Breastfeeding starts before birth. Eating a healthy balanced diet and staying well-hydrated are paramount to breastfeeding. Expectant mothers must be educated about breastfeeding including its challenges and potential dangers, not to scare them but to prepare them and develop solutions before the problems occur. Parents need to understand the gravity of the situation and be active participants in the care of their newborn. Here are a few strategies for new mothers to keep in mind:
· Breastfeed within an hour of delivery to make it the first experience the newborn has of feeding.
· Go to breastfeeding class during your hospital stay so a lactation consultant can observe you breastfeed your newborn. The importance of this cannot be overstated. The lactation consultant will detect any problems and help you then and there. Lactation consultants are great resources so utilize them!
· Breastfeed your newborn 8 – 12 times daily for at least 20 – 30 minutes for the first several days. I have encountered mothers who breastfeed their newborn for 5 – 10 minutes and think it is a sufficient feeding. Nothing could be further from the truth. Let newborn breastfeed for as long as s/he wants but make sure it is at least 20 – 30 minutes for each feeding.
· Know your newborn’s daily weight during your hospital stay. Weight loss > 7% of birth weight signifies breastfeeding problems and requires prompt evaluation according to AAP guidelines.
· Have a newborn follow-up appointment within 1 – 2 days of hospital discharge. The AAP recommends that all exclusively breastfed newborns be evaluated by a paediatrician at 3 – 5 days of age to examine for adequate fluid intake, any evidence of jaundice or dehydration, to identify any breastfeeding problems and to provide additional support and/or resources to parents as needed.
· Discuss Vitamin D supplementation for your newborn with your paediatrician. Vitamin D supplementation of 400IU daily is recommended for all exclusively breastfed newborns beginning at hospital discharge .
Lastly, I would like to ask all my readers to ponder this question: Is breastfeeding with supplementation with formula so wrong? What is imperative is that the newborn is nourished. Dehydrated and many jaundiced newborns are fed formula as a result of inadequate breastfeeding. Why wait until the newborns are sick before supplementing when there are signs of inadequate breastfeeding? Some experts talk of nipple confusion but everyday I see newborns who exclusively breastfeed well all day even though they take formula at night. I did both and my children still preferred my breast. As long as the mother offers her breast first for each feeding before she supplements, there is no such thing as nipple confusion. My main point here is supplementing with formula should not be so stigmatized that mothers whose newborns need supplementation feel they have failed as mothers. I have seen mothers cry for choosing to supplement even though it was the right decision because of this. This perception of failure could contribute to postpartum depression. A mother should never feel she made a wrong choice or failed for assuring her newborn is nourished. Amidst the push for all mothers to breastfeed, let’s not forget the newborn and its most basic need: adequate nutrition.
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2. Chen, Y., Chen, W., & Chen, C. (2011). Risk factors for hyperbilirubinemia in breastfed term neonates. European Journal of Pediatrics, 171, 167-171.
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4. Boensch, M., Oberthuer, A., Eifinger, F., & Roth, B. (2011). Life-threatening hypernatremic dehydration in a 7-week-old exclusively breastfed infant as a cause of a decline in breastmilk volume and parental language barriers in a North African family. Klinische Padiatrie, 223, 40-2.
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6. Naveed, M., Manjunath, C., & Sreenivas, V. (1992). An autopsy study of relationship between perinatal stomach capacity and birth weight. Indian Journal of Gastroenterology, 11, 156-158.
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