---------- Forwarded message ----------
From: "del Castillo-Hegyi Christie"
Date: Jan 18, 2015 12:11 AM
Subject: Fwd: Is colostrum truly enough
To: "President Aap" , "Deborah Jacobson" , "President Elect Aap" , "Mark Del Monte" , "AAP Executive Committee"
Cc:
To the members of the AAP:
It is our duty to protect our patients. Included in this is the duty to use our best knowledge of human physiology, medicine and epidemiology to guide our practice. We must check the work of those who serve as our consultants before applying their advice on our patients. I have received the following message from the authors of the Womanly Art of Breastfeeding, the manual of the La Leche League International. It is a lengthy document but I will summarize their points below and provide my insight on the major logical errors that stems from their incomplete understanding of basic human physiology.
1) They argue that exclusive breastfeeding is natural and ideal because we could not have survived as a species if it weren't. The assumption is that evolution protects our babies from death and disease so we must trust it. In fact, evolution and natural selection prunes and selects only the fittest. Babies born to mothers without milk simply failed to thrive or died or were fed by other mothers. If exclusive breastfeeding were the most advantageous and natural form of feeding, why can I not find a single example in the literature of a country outside the western world that exclusively breastfeeds from birth without the assistance of supplemental feeding or wet nurses? See link below or search "breastfeeding practices" on PubMed.
https://www.dropbox.com/sh/xkdny32gwf00goh/AADhfkXQsTHqf513irsLX6ZRa?dl=0
2) They argue that babies are adapted to eat little to no food for the first 24 hours because of their fat stores. How can this apply to every baby? How about preterm babies? How many days of fat do they have? How do they know? Why is it that a one-day-old bottle-fed baby can take the 2 oz per feed they believe can only be accommodated on the third day if their stomachs only have the capacity for 7 mL per feed? How is it possible for any organ in our body to grow 10 times its size between day 1 and day 3 of life and how did they arrive at this knowledge? The answer is, they made it up. The "small stomach" theory is built on the assumption that exclusive breastfeeding must absolutely be correct and therefore what a baby receives is absolutely what they only need. Yet as I've argued, a baby that loses weight is losing it because they are pulling from their tissue stores to meet their metabolic need. The amount of milk that is required to not lose weight is by definition the amount a child needs.
3) They launch into their theory of the dangers of early introduction of formula and how it leaks into the gut and is allergenic. How do they know this? Were there autopsy and histological studies that show a leaky gut on the first day of life? How is it that billions of children all around the world somehow survived the scourge of formula-feeding and manage not to have asthma and diabetes ever in their life? Diabetes has more to do with socioeconomic factors that lead to poor eating habits and obesity. How plausible is it that a few days of formula to keep a child from life-threatening dehydration and hypoglycemia can determine the fate of a person when it takes individuals years of poor eating and weight gain to develop type 2 diabetes? The evidence behind their fear of formula is at best flimsy. That withstanding, I absolutely support the use of banked human milk for supplementation if a mother chooses it.
4) They claim that ketosis is normal and physiologic for a newborn. In other words, starvation is normal for a newborn. This shows they clearly have little understanding of basic human physiology. Ketosis during fasting marks the end of gluconeogenesis, or protein breakdown to produce glucose, and the onset of sustained critical hypoglycemia which causes widespread brain cell death. They have normalized abnormal physiology to support their dogma that exclusive breastfeeding must always be ideal and safe regardless of the amount of milk a child is receiving. They say that a child can go with little to no intake for 1, 2 and even 7 days with no permanent consequences. If mothers knew that the people who advise them on the feeding of their children condone starvation of their child, there would be riots on the street. They even argue that we may be doing harm by not allowing children to become hyperbilirubinemic/jaundiced.
5). They oppose any attempt to prevent the accidental starvation of a child and my attempts to reduce rates of readmission for jaundice, hyperbilirubinemia and hypernatremia through pumping and weighing. They do not want a mother to be informed of the fact that there may be no milk coming from her breast and that her child may be receiving no milk for days. They are willing to have a child go hungry like my child did because they care more about breastfeeding than the immediate safety or even the human rights of that child. They are actively withholding information from mothers in order to push their exclusive breastfeeding agenda ignoring all the risks to the baby's life and their neurological outcomes. I know many children who are neurologically devastated after experiencing days to weeks of starvation in the hands of their well-intentioned mothers. These mothers deserve to know what they are feeding their child and their children deserve to be fed. We both do agree that there is absolutely no data supporting the 10% weight loss guideline. But I believe they are arguing that babies can lose even more safely. I argue the opposite.
6) They argue that a one day old cannot accommodate 2.8 oz/lb/day and that they are likely to vomit it all. They believe I am dangerously irresponsible for suggesting such a high minimum intake. If that is so, why is it that my 5-and-a-half pound twins took 2 oz every 3 hours or 16 oz total in their first 24 hours and gained only 1 ounce? The "small stomach" theory is fiction.
The questions I raise are difficult and directly challenge decades of practice. But they are important because we are facing an epidemic. Since the institution of breastfeeding-friendly practices, doctors have seen a rise in admission for jaundice, dehydration and hypernatremia. That means that my son's story is not rare. It is happening every minute of every day. One may easily become confused about what the right thing is for that baby given so much conflicting information. In my clinical practice, when there are difficult decisions to make, I always return to the question, "If I were the patient, what would I want done?" What would that baby want its parent or doctor to do? The answer is simple. The baby would want to be fed.
Christie del Castillo-Hegyi, M. D.
Begin forwarded message:
From: Diana West <@gmail.com>
Date: January 13, 2015 at 3:02:00 PM CST
To: Christie del Castillo-Hegyi <@yahoo.com>
Subject: Re: Is colostrum truly enough
Dr. del Castillo-Hegyi,
We appreciate your deep concern for babies and understand that your own experience was a difficult one. Your thoughts on the adequacy of colostrum are interesting but broader research does not seem to support your ideas.
In your subsequent email, you mentioned the fact that you’re a scientist as well as an MD. Science, of course, requires a perpetually open mind; evolution as the foundation for all biological sciences; and a hierarchy of research strength that increases from weakest (a single case study) to strongest (a meta-analysis of many carefully-done randomized control trials). It can be hard, even as a scientist, to step back from case studies and personal experience in setting policy, especially when those cases were traumatic. So as a first step, let’s look at the evolutionary background for animal propagation in general, mammalian birth and infant feeding, and human birth and breastfeeding.
Most insects, amphibians, and fish produce numerous young at a time, but since the number needed for parental replacement is low, the young’s survival rate can be – and is – very low. Mammals produce far, far fewer offspring in a lifetime. Each offspring’s chance for survival to reproductive age must therefore be much, much higher. Humans normally produce no more than one offspring a year – one every three or four years if the babies survive to a normal weaning age. There is a widespread misconception that human newborns are fragile. In fact, normal human birth and breastfeeding must be – and are – a very, very sturdy system. Our low replacement rate can’t afford high perinatal morbidity and mortality rates. The healthy beginnings of billions of babies over millions of years indicate that normal amounts of colostrum are fully adequate for normal babies in normal circumstances. Cultural habits have often interfered, from tribes that dressed the umbilical stump with dung, to birth attendants who didn’t wash their hands, to the misapplication of modern obstetric techniques. But birth and breastfeeding are, from an evolutionary perspective, robust. Now let’s look at some of the systems that give it that robustness.
The human neonate’s energy requirements change with each day of early life. Here’s a quick look at them day by day.
First 24 hours:
After the somewhat larger bolus that is normally ingested shortly after birth, colostrum is naturally low in volume. In addition, the first-time mother must adjust to handling and nursing her infant, and the infant himself must learn and adapt to his mother’s specific anatomy and handling. Since early fumbling is part of the normal process, the human infant comes protected against low or no intake during the first day or two. In fact, the standard of care in North America in the 1960s was to keep babies NPO (nothing by mouth) for the first 24 hours. There’s no evidence that we know of to show long-term consequences from this institutionalized fasting.
Human infants, unlike those of certain other mammals, are born with enough fat stores to offset the normally low intake of the first few days. The 1985 earthquake in Mexico offered a dramatic example: neonates survived seven days in a hospital nursery with neither food nor drink. They went on to live healthy, normal lives. Their survival resulted in part from the reserves of brown fat that are stored around and below the neonate’s neck. This disproportionately large amount of brown fat is mobilized by newborns as needed to keep body temperature at normal levels while calories are in short supply. It’s built-in “starvation protection” that older babies and adults lack.
Ketosis is abnormal in human adults but a normal process in human newborns. They metabolize ketone bodies at up to 40 times the adult rate – yet another adaptation to their initially low caloric intake. Measuring the blood glucose level of a normal baby who lacks external signs of hypoglycemia has not been shown to be effective. More effective is keeping the baby on the mother’s body. Removing a baby “for observation” is known to increase, not decrease, a newborn’s vulnerability.
Overfeeding can only come from a source outside the mother. In almost all situations, that means that the fluid is formula. The risks of early formula are many and well-documented. Some of the problems are potential, some – like the changes in gut flora - are unavoidable. Altering the normal flora puts the baby at significantly higher risk of infection and may become permanent. Early use of formula is especially damaging because the cellular junctions in the neonate’s gut have not closed, so seepage of this unphysiological, allergenic fluid into the baby’s circulatory system is increased. In fact, feeding formula delays gut closure. The risk of future diabetes seems to rise with the introduction of formula. Even more serious is the increased risk of breastfeeding failure and premature weaning, with a host of related short- and long-term health issues.
Some degree of jaundice is itself a normal mammalian newborn event, and bilirubin has antioxidant properties. Some doctors believe that preventing jaundice altogether may therefore be harmful. While lack of milk can result in hyperbilirubinemia, overfeeding can suppress normal levels.
Fortunately, there are ways of keeping a newborn adequately – not excessively – fed if he is unable to do it himself, while establishing the mother’s milk production and avoiding the risks of overfeeding, formula, and failed breastfeeding. Hand expression and hand feeding of colostrum, along with maintaining near-constant mother-baby body contact, can keep the newborn’s blood glucose and bilirubin levels in the normal range while he recovers from whatever interventions have prevented normal feeding. In those unusual cases in which the mother’s milk is delayed or truly insufficient, donor milk should be provided if possible. If formula is used, it should not exceed physiologically appropriate amounts.
2nd 24 hours
Sometimes overfeeding is a reaction to alarmingly rapid weight loss during the first 24 hours. Some early weight loss has been standard throughout the history of hospitalized birth as a result of restricted access to the breast; part of the current, and part of the reason currently is overuse of IV fluids. Recent research indicates that overhydration of the mother results in overhydration of the newborn, who voids most of the excess during the first 24 hours. The birthweight of an overhydrated baby is an unnaturally high weight; researchers suggest that, for clinical purposes, the baby’s weight at the end of 24 hours be recorded as his physiologically appropriate weight. Those same researchers have noted that there is no research – none at all - supporting the commonly cited 10% allowable weight loss, or any other percentage. They all seem to have resulted from “numerophilia” – our love of numbers.
Fortunately, the normally low volume of colostrum allows the neonate to call for frequent and lengthy breastfeeding without the harm of overfeeding. Some lactation consultants refer to the second 24 hours as “calibration day” – the day on which the baby’s frequent nursing sets the stage for the mother’s future milk supply. Less frequent breastfeeding seems to result in delayed lactogenesis II and fewer prolactin receptors being laid down. More nursing helps ensure that the mother will keep the baby close, unless cultural prohibitions separate them.
As your handout expresses so clearly, the only person who knows how much food a baby requires is the baby himself. It cannot be determined from a chart designed for older babies. It cannot be determined by pre- and post-feed weighing unless a suitably accurate is used. Using a conventional scale – or even an adequately sensitive one – is a recipe for maternal anxiety, unnecessary formula exposure, and premature weaning. And even the most accurate scale can’t measure a mother’s milk production. A pump doesn’t mimic a baby’s sucking, rarely removes as much milk as a well-nursing baby does, and rarely produces the near-instant milk release of a well-nursing baby. Research has shown that pumping thick, sticky colostrum usually yields significantly less than hand expression. Pumping “to see what’s there” is highly unreliable, especially in the first few weeks. Diapers, especially the amount of stool per day, are a much better predictor of milk intake, with color and amount changing daily during the first week. So are the baby’s behavior and apparent condition, which are readily assessed without intervention by anyone experienced in the range of normal newborn. The baby who appears to fall outside normal expectations is the only baby whose general health and intake need further examination.
So we’re back to the baby determining his own intake. Weighing a baby more often than every few days gives no sense of the baby’s condition.
3rd 24 hours
With each day, the baby’s stomach capacity increases, in step with the mother’s increasing milk volume. The baby who has unlimited access to the breast – the typical homebirthed baby, for instance – is likely to be gaining weight at this point, because his frequent small meals have triggered the increase in maternal alveolar lactose that causes an influx of water that results in greater milk volume.
Hospital-birthed babies are unlikely to be gaining by this point. Indeed, rather than expressing concern about the unsupplemented newborn, we should all be expressing concern about the failure of hospital policies to support the normal development of newborn and maternal feeding behaviors. Our previous Surgeon General and the American Academy of Pediatrics have both called upon hospitals to reduce the alarmingly high rate of newborn supplementation.
It is often said that formula does have its place in some situations, but that is inaccurate. Standard formula has no place in the care of normal infants. Human milk – the only food to which those infants are adapted – should be available to all newborns, regardless of their mothers’ willingness or ability to provide adequate milk. The risk of overfeeding and premature weaning would remain, but other risks to current and future health would be virtually eliminated.
As your handout expresses so clearly, the only person who knows how much food the baby requires is the baby himself. In the early days, that amount changes constantly. The appropriate intake can’t be determined from a chart designed for older babies with large stomach volumes. It can’t be determined by pre- and post-feed weighing unless a suitably accurate is used. And knowing a baby’s intake says very little about how well fed he is. Babies follow their own growth curves. Basing anything on three-hourly feeds ignores normal physiology. Newborns normally feed many times a day, often from a single breast, often no more than fifteen or twenty minutes after their last time at breast. One experienced mother who recorded her homebirthed baby’s times at breast counted 19 in the first 24 hours – a period of time in which many hospitals expect only one.
Babies can manage at first with no intake at all, but it’s eye-opening to many health professionals to realize what a healthy, unmedicated baby’s feeding style is when he has unlimited access to his mother’s breasts. As an observer in a Thai hospital with 24-hour bedding-in described it:
If you asked a mother [in hospital] how many times per day she feeds, she would look at you strangely. Better to ask whether the baby ever falls into a deep sleep and drops off the breast for a while - they occasionally do.
A far cry from what happens in the average American hospital birth. And for all that nursing, the amount of colostrum consumed is remarkably small.
We don’t know upon what Merck bases its figures, but we can’t stress strongly enough that suggesting that an eight pound baby should ingest – or his mother should produce – more than 22 oz of colostrum a day is dangerously irresponsible. The volume of colostrum consumed in 24 hours varies hugely from mother to mother and study to study, approximately within these ranges:
1st 24 hours: 7 to 380 ml, or .2 to 13 oz, with an average in the range of 2 oz per 24 hours, less than one tenth the amount shown on your handout.
2nd 24 hours: 44 to 335 ml, or 1.5 to just over 11 oz, with an average of roughly 6 oz.
A US study in 1988 found these average volumes:
3rd 24 hours: an average of about 390 ml, or just over 13 oz
4th 24 hours: an average of about 580 ml, or about 19.5 oz
The same study measured an average intake of 610 ml, or about 20.5 oz, at one week.
The newborn’s stomach is not adapted to large quantities of milk. Recent studies indicate a first-day stomach capacity of approximately an ounce. Newborns who are erroneously fed the amount needed by, say, a one-week-old baby, generally vomit most of it. Furthermore, there is some evidence to indicate that early overfeeding suppresses the newborn’s normal tolerance for low intake, ramping up his caloric need prematurely and unphysiologically and often resulting in further interventions.
Mature milk production has been shown to support thriving babies at 24-hour volumes ranging from 15.5 to 43 ounces, highly variable amounts that are regulated by the baby without the mother’s conscious involvement. A single set of numbers on a chart, even if those numbers represent averages, can’t possibly predict what a given baby needs.
So we’re back to your excellent statement: “The only person in the world who knows the need of a newborn is that newborn.” Fortunately, even with birth medications on board, babies will refuse excess food if it’s provided at breast or through responsible supplementation if needed, always with appropriate support of the mother’s milk production and always with human milk if possible.
Part of the reason so much misinformation persists is that medicine and science are two entirely different disciplines. Medicine tends to be based on carefully adhered-to policies and protocols, which are often based on outlier cases: This baby suffered kernicterus so all babies are at imminent risk of brain damage and must be supplemented. That baby developed hyberbilirubinemia so all babies are at risk and must be supplemented. Most of the procedures and drugs in the medical arsenal have their place, but when inductions, epidurals, cesareans, and supplementation reach the levels we see today, it should be clear that medicine has overreached. Science, on the other hand, is based on accumulated data and uses evolutionary history as its starting point, rather than using case studies as cautionary tales.
Medicine, in its attempt to be conservative, often lags as much as several decades behind science. That lag can put average patients and clients at higher risk than they might have been without medical intervention. American supplementation rates are one such case. Our former Surgeon General called for decreased, not increased, rates of in-hospital supplementation for exactly that reason. We urge you to follow suit and base your instructions not on high levels of intervention and monitoring but on trust in a remarkably flexible, robust system. It’s a system that is subject to failure at times, of course, just as our kidneys and lungs and circulation are, and subject to derailment through well-intentioned interventions. But human breastfeeding is robust enough that we need have no concern about the ordinary mother and baby on their ordinary start toward a life together. The system has worked for billions of babies over millions of years. In fact, we’ve managed to overpopulate without overfeeding. Our need is not for more meticulous monitoring of normal, but for more access to human milk, responsibly provided, when a situation falls too far outside the norm.
Thank you for giving us this chance to clarify some of the many reasons that unwarranted supplementation is to be avoided. Expert breastfeeding help abounds for physicians who would like to support their patients and clients responsibly. A good place to start in finding someone to help formulate a useful and reassuring handout for new mothers is the International Lactation Consultant Association. For further discussion of breastfeeding issues, we refer you to the physicians at the Academy of Breastfeeding Medicine. They can be reached by email at ABM@bfmed.org.
Respectfully,
The Authors of the Womanly Art of Breastfeeding: Diana West, Diane Wiessinger, and Teresa Pitman
On Wed, Jan 7, 2015 at 10:34 AM, Christie del Castillo-Hegyi wrote:
Dear Ms. West,
I have uncovered the most disturbing information over the holidays while calculating a newborn's minimum caloric requirements.
A newborn's requirements is published as around 110 kcal/kg /day. I believe this is derived from NICU data. A child who has the same organs to run and the same activities on day 1 vs day 2 vs day 3 of life should have a fairly constant basal metabolic rate. A child who has no change in weight has taken in the exact amount of nutrition to meet it's basal metabolic requirement.
Colostrum has 60 kcal/100 mL, which is the consensus from a 2014 meta-analysis of previous bomb calorimetric studies.
The daily colostrum requirement of a newborn is:
110 kcal/kg/day x 100 mL/60 kcal x 1 oz/30 mL x 1 kg/2.2 lbs =
2.8 oz of colostrum/lb/day
This equals 19.6 oz for a 7 lb child or 2.5 oz per feed. Exceedingly few women produce this amount. This is the reason why bottle-fed babies with free access to milk will take in much greater than the few cc's that breast fed babies are observed to receive per feed on the first day.
We have been taught that colostrum has more nutrients than mature milk and that is why a baby does not need as much. It does not. Colostrum has a total of 60 kcal/100 mL and mature milk has 75 kcal/100 mL.
Why is there such a discrepancy between how much a child needs and how much they can get from an average exclusively breastfeeding mom on the first day if mother's colostrum is enough?
Because we currently accept a weight loss of up to 10% before supplementation as normal and physiologic for all newborns. These newborns are not receiving their daily requirement and are being asked to pull from their tissue stores by gluconeogenesis and ketosis. This is otherwise known as starvation.
We are asking exclusively breastfed newborns to go without their minimum daily requirement and telling parents that this is normal. We have been taught to accept a different definition for starvation of a one day old child as we do for ourselves. They are suffering this for days to weeks that we currently allow in clinical practice. How many of those newborns are suffering undetected sustained hypoglycemia? This is a moral outrage.
Christie del Castillo-Hegyi, M. D.
