Wednesday, January 30, 2013

Who manages the mammaries?

One of the really excellent points that have come up in the recent discussions of medicine failing breastfeeding is an appreciation that human breasts, like all other organ systems, can have physiological dysregulation and difficulties. There are a small percentage of women with physiological inability to produce milk (estimated at 2-5% of the population), just as there are individuals with beta cell dysfunction (Type 1 diabetics), thyroid issues, and problems with really every other organ in the body. By comparison, including types 1 & 2, the incidence of diabetes was 8.3% in 2011 (CDC, 2011). To put it simply, breasts are organs, and have about the same rate of physiological issues as other organs (I borrowed this from the ongoing conversations). 

However, there has been a tremendous increase in recent years in the number of women diagnosed with insufficient milk syndrome (or insufficient milk supply syndrome) or “low milk production”.  While there was an overall consensus the problem was becoming more common, concrete data were hard to find.  The best I can do is the Infant Feeding Practices Study from 2006, wonderfully indexed on I recommend checking it out, as you can see tables for every possible variable and even download the raw data. But, here are the numbers:

Month stopped breastfeeding
Reason for stopping breastfeeding 3
< 1
1 to 2
3 to 5
6 to 9
My baby had trouble sucking or latching on
Breast milk alone did not satisfy my baby
I thought that my baby was not gaining enough weight
A health professional said my baby was not gaining enough weight
I had trouble getting the milk flow to start
I didn't have enough milk
Table 1: Reasons for breastfeeding cessation, as reported by US women participating in the 2005-06 Infant Feeding Practices Study. More than 2500 women participated in the initial survey; approximately 1400 women completed the survey through the first year (Shealy et al., 2008).

I think, based on the numbers presented above, it is reasonable to say that of the number of women who stopped breastfeeding during the first five months of life, more than 50% identified insufficient milk supply as a contributing factor. While this is not an overall incidence, it does support the overall idea that IMS is increasingly common.  We can also not know the number of women who were told this by a medical professional versus self-diagnosed. If we use medical diagnosis of poor infant weight gain as a measure of medical diagnosis (again, not ideal) we end up with 8.6-19.8%. Still, much higher than the 2-5% who likely have actual insufficient milk supply. 

There are numerous physiological conditions that are associated with decreased milk supply, and we cannot discount that the increase in the incidence of these conditions may be contributing to the increase in the number of women with insufficient milk syndrome. These conditions include: polycystic ovarian syndrome; maternal postpartum hemorrhage, retained placenta/placental fragments, thyroid conditions, insufficient glandular tissue (Anderson 2001; Willis and Livingston, 1995; Speller and Brodribb, 2012; Neifert et al., 1985 – in topical order), and mammary reduction, although this is not an exhaustive list (refs). Other conditions, such as obesity and diabetes may also interfere with lactation (Turcksin et al., 2012), particularly the onset of milk production, known as lactogenesis (Nommsen-Rivers et al., 2010). 

However, while these biological conditions may explain the initial 2-5%, and perhaps a small increase in the incidence of these conditions, it is unlikely they explain the dramatic difference we see in Table 1, with more than 50% of women who stop breastfeeding by five months reporting problems with supply.  Based on the 2009 Healthy People Data (released in 2012), 76.9% of women are initiating breastfeeding and 47.2% of infants are breastfed to 6 months! So of the babies who start breastfeeding, 61.4% are still breastfeeding at 6 months (but only 47.2%) of all infants. And, extrapolating from the 52.6% (average over the 3 categories) of women who report lack of milk as a reason for breastfeeding cessation, we end up with a crude estimate of 32.3% for IMS. Again, this is a crude estimate based on linking several different sources of numbers together and should be considered an approximation, not a set in stone number and should be viewed as a “back of the envelope calculation”. I’m using it as it is better than anything else I can find (if you know of something let me know and I will adjust the post accordingly). 

So, we have an estimated occurrence of IMS at 32.3% compared to an estimated biological frequency of 2-5%. That’s an excess of 27.3-30.3% women reporting low milk supply. Add in the nearly 4 million infants born in the same year, and we’re talking about more than 1 million women identifying with low milk supply.
It seems unlikely then, that this difference can be explained only by physiological issues, even adding in possible physiological factors with infants as well, including tongue tie (Kumar and Kalke, 2012), palate, latch, or vacuum issues (Geddes et al., 2008; Geddes et al., 2012). Certainly, it would be an oversight to suggest that these factors are not very real, not uncommon, and not contributing to overall increases in IMS. But these factors along cannot explain the difference.

Difficulties with breastfeeding, including poor latch, poor positioning, pain, nipple confusion, nipple cracking/bleeding, mastitis, are very real realities for breastfeeding mothers.  How many of these issues are the result of limited exposure to other breastfeeding women and a medical community largely unfamiliar with breastfeeding issues? Osband et al., (2011) reported that pediatric residents in the United States received an average of 9 hours of breastfeeding education (over a 3 year residency). Anchondo et al., (2012), in a survey of pediatricians, obstetricians, gynecologists, and family medicine physicians, reported that although physicians in their study had positive attitudes towards breastfeeding and information on the health benefits, hands-on knowledge was considerably lacking. Physicians also reported low breastfeeding rates and short durations themselves. Freed (1995) in a survey of more than 3000+ medical residents and physicians (68% response rate) reported that while 90% endorsed breastfeeding, less than 50% felt like they had the skills for counseling mothers. And the scariest information: for treating jaundice, clinical management was wrong more than 50% of the time and for insufficient milk syndrome, wrong about 30% of the time.  

Nine hours of training, and probably a little extra (maybe a half day at most) of training during medical school, is the sum total of the “average” physicians training in breastfeeding. I would suspect too, that some of that medical school time is allocated towards mammary anatomy (not that this is not important for understanding how breastfeeding works). And the vast majority of that time will probably be fair more theoretical than hands on/practical, if the reports from Anchondo et al., (2012) are any indication.
The lack of training, and the invisibility of possible issues related to breastfeeding, may be contributing to those excess sufferers of IMS. How many physicians for example, upon hearing that a woman has “low milk supply,” will address the feeding and not the supply issue?  One of the most common “treatments” for low milk supply is to supplement the infant with formula. Here, the focus is on the infant, and meeting the metabolic needs of the infant, without thinking about how the situation could be addressed from the maternal side.  Milk production is driven by milk removal and suckling from the breast. A complex series of hormones and neuropeptides regulate milk synthesis, and include Feedback-inhibitor of lactation (FIL), oxytocin, and prolactin. Suckling stimulates prolactin release, and while plasma prolactin does not scale to milk synthesis rate (Cox et al., 1999), prolactin promotes mRNA synthesis and the production of milk proteins.  More suckling stimulates more prolactin and maintains circulating plasma levels and milk synthesis (Cregan et al., 2002). FIL works in a different manner – FIL accumulates in milk as feeding intervals increase and the breast becomes increasingly full; increasing FIL down regulates milk synthesis within the mammary epithelial cells (Peaker et al., 1998). 

By providing the infant with formula, the entire process above is interrupted.  Infant hunger is met by formula and the amount of time spent on the breast, actively sucking, decreases. The decrease reduces the secretion of prolactin, accumulating milk increases local FIL and milk synthesis is down regulated.  Production decreases, increasing the need for formula because the mother is now making less milk. It becomes a self-fulfilling prophecy and compounds issues that may or may not have been present. The ideal solution here would be to use the system, not disrupt it. Instead of supplemental formula, increase the frequency and duration (a minimum of 3-5 minutes) of the feeds.  Not enough milk? Feed more – in most cases, the body will respond accordingly. If it does not, and the infant starts losing weight, then there is likely more troubleshooting needed. But here, the clinical practice (30% of the time) is a wrench in the physiology and likely contributes to further development of low milk supply. Poor clinical management may not explain all instances of low milk supply, but it cannot be discounted as a major player.

Thus far, we have been limited the emphasis to frequently used clinical strategies for managing self- perceived low milk supply. Here, perception of low supply has driven a specific treatment; this has further contributed to the problem.  And that is just clinical management – what about other common problems influencing breastfeeding, on both the mother and the baby’s side of things, that contribute to low milk supply?

Next time (week): tongue tie, poor latch, and other breastfeeding challenges  . . .

Anchondo I, Berkeley L, Mulla ZD, Byrd T, Nuwayhid B, Handal G, Akins R. (2012) Pediatricians', obstetricians', gynecologists', and family medicine physicians' experiences with and attitudes about breast-feeding. South Med J. 105(5):243-8.
Anderson AM. (2001) Disruption of lactogenesis by retained placental fragments. J Hum Lact 17(2):142-4.
Cox DB, Owens RA, Hartmann PE. (1996) Blood and milk prolactin and the rate of milk synthesis in women. Exp Physiol.  81(6):1007-20.
Peaker M, Wilde CJ. (1996) Feedback control of milk secretion from milk. J Mammary Gland Biol Neoplasia 1(3):307-15.
Cregan MD, Mitoulas LR, Hartmann PE. (2002) Milk prolactin, feed volume and duration between feeds in women breastfeeding their full-term infants over a 24 h period. Exp Physiol. 87(2):207-14
Freed GL, Clark SJ, Lohr JA, Sorenson JR. (1995) Pediatrician involvement in breast-feeding promotion: a national study of residents and practitioners.  Pediatrics 96(3 Pt 1):490-4.
Geddes DT, Langton DB, Gollow I, Jacobs LA, Hartmann PE, Simmer K. (2008) Frenulotomy for breastfeeding infants with ankyloglossia: effect on milk removal and sucking mechanism as imaged by ultrasound. Pediatrics 122(1):e188-94. doi: 10.1542/peds.2007-2553.
Geddes DT, Sakalidis VS, Hepworth AR, McClellan HL, Kent JC, Lai CT, Hartmann PE. (2012) Tongue movement and intra-oral vacuum of term infants during breastfeeding and feeding from an experimental teat that released milk under vacuum only. Early Hum Dev. 88(6):443-9. doi: 10.1016
Infant Feeding Practice Study II., accessed Jan 24, 2013. Page last updated October 1, 2009.
Kumar M, Kalke E. (2012) Tongue-tie, breastfeeding difficulties and the role of Frenotomy. Acta Paediatr. 101(7):687-9.

Friday, January 4, 2013

Is the medical community failing breastfeeding mothers? Yes - but so is the community!

This was not the original topic for this fortnight. Instead, this is yet another reaction piece to recent events in the news. Specifically, a widely circulated post on Is the Medical Community Failing Breastfeeding Moms. This post has received considerable attention, both positive and negative, and speaks to larger issues in society and mammary physiology. First off, you can have lactation failure, just as you can have kidney failure, infertility and numerous other physiological disorders. And lactation failure is probably not all that rare – the estimates floating about in the blogs are 1-2%; in the 1980s the estimates were a bit higher at 2-5%. In the study I work with, mothers in the Philippines in the 1980s had a failure rate of about 3%. 

What strikes me most about the new focus on medical professionals failing breastfeeding mothers, is the assumption that by presenting the challenges and potential problems of breastfeeding, we are somehow  setting mothers up for failure. I would argue in the fact the opposite – we have already set mothers up for failure by pretending that the act of doing is natural and natural means anyone can do it if they try hard enough.  Natural becomes a code for easy, when the reality is neither. Breastfeeding is work, it can be stressful, it can be difficult, it can be impossible. It can also be event-less, not difficult (but never easy), and successful.  Every tool should be in place to help mothers who want to nurse their babies and every tool should be in place to help mothers who do not want to nurse.

The set up for failure actually starts outside the medical community in the actual community. Take a moment and ask yourself when was the last time you saw a baby nurse? If the populations in my classroom are any index of the general public (probably not) then about 50% of people have ever seen a baby nurse. Think about a trip to the mall, zoo, or museum. Nursing moms? I usually remember them because of the rarity – the other 100s of visits to these places where I do not see a nursing women blend together.  Breastfeeding is largely invisible – think about the recent stink over the “breastfeeding doll” compared to the dolls prepackaged with bottles? 

Figure 1: The only doll I remember from my childhood that did not come with a bottle. She came with a sippy cup, because she was old enough to talk. She also had separation anxiety from said cup; my mom put the cup on a ribbon and the doll wore the cup at all times.

And I bring up the dolls as a larger illustration of how invisible breastfeeding is. It is not seen, seldom enough discussed, and certainly not normalized for most individuals. There is even the La Leche League story about failed breastfeeding in a gorilla suddenly corrected when she was shown how to nurse. Invisibility may lead to assumptions about breastfeeding that set up any number of potential problems. By not seeing breastfeeding as a common part of child rearing, we do not see its ease or difficulties and in the invisibility, we may be contributing to the marginalization of breastfeeding mothers and increasing their risk of failure.  By not seeing problems and practices, breastfeeding becomes idealized as a “natural” and something anyone can do.  This discounts any number of potential problems and may go so far as to stigmatize these problems, further leading to their invisibility. Inherent in this idea of natural is an assumption that a natural process cannot fail and if it does fail, the mother either did not try hard enough or wanted it to fail, and the child will be fine on formula.

The child will, generally, be fine on formula. Finding the right formula may take acrobatics comparable to those faced by breastfeeding moms (brand? Main ingredient? Size of the bottle nipple).  But that statement misses the point entirely: what can we as a community do to help women successfully nurse? And equally important: how can the medical community help women successfully nurse if they so choose (PART 2)!
Community level barriers to successful nursing extend far beyond the invisibility of breastfeeding, but for the purposes of this post, I am going to keep the focus on the invisibility aspect.  Mumford (2008) did a nice review of some of these issues. In particular, one of the points highlighted in both the Mumford article and the Times piece is the way in which invisibility contributes to problems. 

I would argue that invisibility of breastfeeding and invisibility of the problems that can (and often do) arise during breastfeeding actually may contribute to the severity and confusion surrounding these problems. If no one mentions mastitis, how do you identify it in the early stages? If no one mentions poor latch or tongue tie in the infant, does it exist? Is that the issue and not low milk supply?  How often should you nurse? On demand is a vague term – does it mean really whenever the infant wants to nurse or is it code for never more frequently than 2 hours? These are all questions we hear when we interview women as a part of my research or appear on breastfeeding-related online forums and Facebook groups. And yet the information is absent (either not available to the community or has simply not been done), personal (this worked for me so it should work for you), or even bad (pump while driving! – NO, drive while driving!). A brief PubMed search turns up exactly 13 papers looking at herbal supplements and breastfeeding; Lisa Davis points out in Time that the number of studies on lactation failure are even less.   The problem here is not just the medical community, but the overall environment for breastfeeding in the United States.

Next time: Part 2 – the role of the medical community.