Analytical Armadillo: 10/01/2016

Note: This is long and I apologise in advance - I know we all love 10 bullet point, read and run style entries ;) however I think it's a really important subject and I hope it helps to protect even one baby from what this dyad experienced.

As an International Board Certified Lactation Consultant (IBCLC), the first rule of practice is to always feed the baby. Always, always, always, without exception.

Despite this, some feel IBCLC is synonymous with "hardcore breastfeeding fanatic"; someone who wants your baby at the breast at any cost, because formula is poison and should never be used by anyone trying to breastfeed. As I've pointed out numerous times, and demonstrate daily in practice this simply isn't true- at least not for me or the practitioners I know.

Recently some have suggested that if there's a chance baby could become dehydrated, it's safer to bottle-feed; that more hospitals implementing the UNICEF Baby Friendly Initiative (BFI) standards, could put babies at increased risk of insufficient milk intake.

Around the same time, I also read a gut-wrenching blog post by Dr Christie del Castillo-Hegyi, MD, describing her journey when her newborn suffered hypernatraemic dehydration. This is a severe condition when baby's serum sodium level becomes elevated, sometimes to dangerous levels which can result in long-term consequences and even death.

I contacted Christie who kindly agreed to let me use her story for educational purposes. I thought we could start by looking at their journey and the support they received - before exploring typical weight patterns in the early days, rates of dehydration and how likely it is that baby will suffer dehydration. We also need to know how to identify families at risk, what tools are available and how to resolve problems as they arise; highlighting the significance of infant feeding education to all healthcare professionals involved in the care of a young baby.

Let's take a read:

"My son was born 8 pounds and 11 ounces after a healthy pregnancy and normal uneventful vaginal delivery. He was placed directly on my chest and was nursed immediately. He was nursed on demand for 20-30 minutes every 3 hours. Each day of our stay in the hospital, he was seen by the pediatrician as well as the lactation consultant who noted that he had a perfect latch. He produced the expected number of wet and dirty diapers. He was noted to be jaundiced by the second day of life and had a transcutaneous bilirubin of 8.9. We were discharged at 48 hours at 5% weight loss with next-day follow-up."

Normal uneventful delivery, baby was a healthy weight and fed immediately after birth before a pretty typical cue feeding pattern followed. All sounds pretty standard at this stage, but newborns aren't born ravenously hungry as they've been nourished continuously via the placenta. The feed initiated typically within an hour or so after birth is primarily to deliver antibodies, immune agents or "baby's first vaccine" as many call it via colostrum - as this prompts rapid closure of the open junctions in baby's gut. Many then take a longish sleep to recover from being born, before starting to search or "root" for food in earnest. In practice I find if baby doesn't get enough during day two, boy will they let you know day 2 night...

Nappies: if we consider on the day they're born, newborns typically only need around 5-7ml per feed, producing the expected number doesn't require huge amounts in terms of intake. How wet or soiled a nappy is can be tricky because parents may have no frame of reference as to what to expect in terms of output.

The amount baby needs increases rapidly after the first day, and so closely examining output at this time becomes far more informative - I often ask parents to send me photographs (which makes for an interesting camera roll alongside damaged nipples ;)) because I've known "3 soiled nappies" to be in effect 3 wet bottom burps.

Jaundice is noted which again doesn't and shouldn't really cause much concern at this stage:

"Approximately 70% of term newborns present with jaundice in the first week of life, and in most cases this jaundice it is a transient and benign phenomenon." here.

Christie's son had a level of 8.9 at this stage, which for those in the UK is 152µmol/L and below treatment levels (> 237µmol/L @ 42 hours) according to NICE.

Weight check: You would expect a loss at this stage, with the lowest point typically being around day 3 or 4 before regain starts. 5% is nothing that would typically ring any alarm bells and they were having a follow up the next day.

"We were told by the lactation consultant before discharge that he would be hungry and we were instructed to just keep putting him on the breast."

I don't know whether this was an IBCLC as unfortunately the title "lactation consultant" isn't protected - often people (including hospitals and other healthcare professionals) use it to refer to those who aren't IBCLC certified - heck I've known parents call their keen friend "my lactation specialist"; however what is clear is that there was a missed opportunity in terms of ensuring parents were familiar with how to identify whether baby is taking enough versus signs that may suggest additional milk is needed. Whether the lactation consultant intended to infer what she did or whether this was a misunderstanding in communication, it's concerning.

"Upon getting home, he became fussy and I nursed him longer and longer into the night. He cried even after nursing and latched back on immediately. He did not sleep."

This is the first red flag something isn't quite right - but how are parents to know this if they're not told? On the contrary I find a lot of information talks about very frequent feeding in the first few days, how newborns like to be held and it's normal if they feed all. the. time.

I recognise what people are trying to highlight is that, particularly as a newborn, a breastfed baby may want to feed more frequently than the 3-4 hours often quoted based on formula fed infants; they may not have a set pattern and may take a few closely spaced feeds before settling for a nap. As more babies are formula fed than breastfed, the behaviours of formula fed babies are often held as the norm to which those breastfeeding are supposed to conform - despite research consistently demonstrating this isn't the case (2).

However we also need to clarify that doesn't mean constantly, or not settling in-between, or crying and feeding all night - this tells us something is wrong. Be that inadequate milk intake, illness or as per one baby recently, an unidentified dislocated shoulder from birth - it's not typical. We need to be able to identify normal versus not to know when to seek help.

"By the next morning, he stopped crying and was quiet."

This is the second red flag and it's extremely concerning as it suggests baby may have exhausted his energy supply signalling for food, and so is "shutting down" to protect his vital systems. As babies start to become "dry" and after a long period of crying, the sound changes and becomes hoarse until it resembles the noise made by a pterodactyl - anyone familiar with the sound hears it long before they've even clapped eyes on the baby in question. If baby continues not to receive milk he will gradually become sleepier and more lethargic until he struggles to rouse.

"We saw our pediatrician at around 68 hours of life (end of day 3).

Despite producing the expected number of wet and dirty diapers, he had lost 1 pound 5 ounces, about 15% of his birth weight. At the time, we were not aware of and were not told the percentage lost, and having been up all night long trying to feed a hungry baby, we were too exhausted to figure out that this was an incredible amount of weight loss. He was jaundiced but no bilirubin was checked. Our pediatrician told us that we had the option of either feeding formula or waiting for my milk to come in at day 4 or 5 of life."

In the UK anyone who weighs your baby at this stage will calculate the percentage loss for you and 15% is an incredible amount of weight to lose. We know baby had lost 5% at the end of day 2 and so this equates to a further 10% bodyweight loss in 24 hours! Nappy output would be reduced with this sort of loss (it can't come out if it hasn't gone in), however as discussed above it's not uncommon for confusion to occur even amongst health professionals.

It's also important to understand that this was a critical point in terms of intervention. Some key things I would expect from a doctor running checks on a newborn at this stage:

Ask the parents how baby had been since discharge, including his feeding and sleeping patterns.
Recognise they were presented with a dehydrating infant, who would by now have dry lips and the inside of his mouth would feel the same. He would be quiet, listless and more difficult to rouse.
Recognise this was a huge weight loss for a newborn. To put this in perspective it's like an adult weighing 10 stone one day and 8 1/2 the next.
To check bilirubin levels following excessive weigh loss and jaundice
Admit the baby to hospital immediately

I was stunned to read that waiting until milk comes in was presented as a viable option, in fact I read it twice to ensure I had understood correctly.

Many UK hospitals have now implemented breastfeeding management plans, and such a drastic weight loss would trigger NHS management plan 3:

Baby who has lost >12.5 – 15% of birth weight on day 3, or no/minimal improvement following management plans 1 and 2

Refer immediately to paediatric staff – this is mandatory (baby may be admitted to S.C.B.U) – if baby is at home – baby will have to be admitted to hospital.

Blood tests for fbc, U&E’s, SBR, septic screen and urine microscopy.

CRP and blood cultures if clinically indicated.

Breastfeeding management as per plans 1 and 2. Supplement with formula via cup only if breast feeds are ineffective and EBM volumes poor, if EBM volumes are good give EBM via cup. Top-ups may be instructed by paediatric staff for all feeds.

Ensure this baby is receiving adequate volumes of milk intake for age.

Frequent breastfeeding and use of electric pump to further increase milk supply. As the breastmilk supply increases; decrease the volume of artificial milk.

May require naso gastric feeds or I.V fluids, but continue frequent breastfeeds and expressing if baby in SCBU.

Observe urine and stool frequency.

Re-weigh in 24 hours, then twice weekly weights, if weight has increased after 24 hours, until clear trend towards birth weight is demonstrated.

Ensure that you are aware of any issues specific to the individual mother and have considered any potential impact on that individual situation.

This is a far cry from go home and wait for milk isn't it?

The problem when young babies don't consume enough milk, is they can easily fall into a cycle of: signalling, trying to feed, running out of energy and falling back asleep again - rinse and repeat. As this continues and the deficit between what baby needs and what they're taking increases, baby becomes more disorganised and less effective at the breast, falling asleep more and more quickly. Once energy levels fall sufficiently that baby is unable to signal and initiate feeding - things can quickly become dangerous.

"Wanting badly to succeed in breastfeeding him, we went another day unsuccessfully breastfeeding and went to a lactation consultant the next day who weighed his feeding and discovered that he was getting absolutely no milk. When I pumped and manually expressed, I realized I produced nothing."

"I imagined the four days of torture he experienced and how 2 days of near-continuous breastfeeding encouraged by breastfeeding manuals was a sign of this. We fed him formula after that visit and he finally fell asleep.

It's good the lactation consultant thought to test weigh the baby, but again I'm confused as to why none of the healthcare professionals supporting this family, appear to recognise or respond to the urgency of this situation, seemingly not picking up on any of the red flags or acting to trigger safeguarding protocols?

By this stage it isn't as easy as just "feeding the baby", as after such rapid and excessive loss a baby is very likely to be suffering hypernatraemic dehydration - meaning simply giving milk now have disastrous consequences.

The Royal Children's Hospital Melbourne state:

"Treatment can be complicated and potentially dangerous. Seek expert advice early. Too rapid reduction of the sodium in hypernatraemia can cause cerebral oedema, convulsions and permanent brain injury. Close monitoring is critical."

As you can see on their page, rehydrating safely is a careful balance of delivering glucose and electrolytes at the correct level; this balance of fluids may need adjusting frequently to ensure rehydration isn't too fast or slow.

"Three hours later, we found him unresponsive. We forced milk into his mouth, which made him more alert, but then he seized. We rushed him to the emergency room. He had a barely normal glucose (50 mg/dL), a severe form of dehydration called hypernatremia (157 mEq/L) and severe jaundice (bilirubin 24 mg/dL). We were reassured that he would be fine, but having done newborn brain injury research, knowing how little time it takes for brain cells to die due to hypoglycemia and severe dehydration, I did not believe it, although I hoped it. "

I can't even imagine the panic and trauma of such a situation; it must be utterly horrifying, terrifying to find your baby unresponsive before seizing. 157mEq/L is a level most of us in the UK will never see in practice and the potential implications of such high levels are well documented. The Royal Children's Hospital Melbourne state:

"In children with acute hypernatremia, mortality rates are as high as 20%.

Neurologic complications related to hypernatremia occur in 15% of patients. The neurologic sequelae consist of intellectual deficits, seizure disorders, and spastic plegias. In cases of chronic hypernatremia in children, the mortality rate is 10%.

Complications
Although seizures can occur because of hypernatremia per se, this is rare. They usually occur during the treatment of hypernatremia because of a rapid decline in serum sodium levels.

Therefore, slowly correcting hypernatremia is important.

Other complications include the following:

Mental retardation

Intracranial hemorrhage

Intracerebral calcification

Cerebral infarction

Cerebral edema, especially during treatment

Hypocalcemia

Hyperglycemia"

"At 3 years and 8 months, our son was diagnosed with autism spectrum disorder with severe language impairment. He has also been diagnosed with ADHD, sensory processing disorder, low IQ, fine and gross motor delays and a seizure disorder associated with injury to the language area of the brain."

This is where we can see the impact of a formula feeding culture really biting us on the behind. Were this mum and baby harmed because they tried to breastfeed, or because they were failed by a system where they seemingly fell through the cracks of inadequate knowledge and a lack appropriate protocols? When it comes to paediatric health, does any other field of medicine function this way?

Term, healthy babies will try and alert their caregiver to the fact they're not receiving enough milk long before the situation becomes a dangerous one.

Normal weight loss:
According to current guidelines, a typical newborn feeding well can be expected to lose up to 5-7% of their birth-weight in the first 2-4 days. It used to be widely accepted up to 10% was acceptable, but this was based on schedule feeding, routine separation of mothers and babies and so on. As further research was completed it suggested a good amount of babies at 10% were showing early indicators of mild dehydration and overall, more went on to experience further problems than babies who lost smaller amounts.

However it gets much more complicated than this for a number of reasons.

The 5-7% is based on studies exploring mean weight loss, which may not allow for standard deviation (1,2). We also know some babies lose more weight or for longer than typical and yet are perfectly healthy (3). We need to tease apart the details of an individual dyad's situation, rather than making assumptions; factoring in the birth and what has taken place since. As one example, extremely large amounts of IV fluids may be passed by baby as urine after birth (5,6,7), leading to excessively wet nappies and a larger than typical loss that does not mean more food is needed.

We then need to know what to do with that information. Is mum not producing or is it (as is much more common) that baby isn't transferring enough? Whether it's the former or the latter, the next question is why? This means people need to be appropriately skilled to examine the big picture and identify those who need additional help, and be able to provide or direct them to someone who can help resolve the issue.

Tools also exist that practitioners can use to monitor at risk babies, for example nomograms that show hour-by-hour percentiles of weight loss have recently been developed. This compares the data entered to that recorded for over 100,000 breastfeeding newborns along with subsequent outcome, to quickly identify those on a trajectory for greater weight loss and related morbidities- and so unnecessary intervention isn't forced upon a healthy dyad. You can see an example in practice here.

Official Guidelines:
The American Academy of Pediatrics states:

“Weight loss in the infant of greater than 7% from birth weight indicates possible breastfeeding problems and requires more intensive evaluation of breastfeeding and possible intervention to correct problems and improve milk production and transfer.”

The International Lactation Consultant Association and the Registered Nurses' Association of Ontario specify that a loss of more than 7% of birth weight, continued loss after day 3, or failure to regain birth weight within a minimum number of days (i.e., 10 days or 2–3 weeks, respectively) are signs of ineffective breastfeeding.

The Academy of Breastfeeding Medicine advises "Possible indications for supplementation in term, healthy infants [include] weight loss of 8% to 10% accompanied by delayed lactogenesis (day 5 or later).” (1)

Rates of Hypernatraemic Dehydration in the UK
A 2013 study analysing almost 1,000,000 births in the UK and Ireland found just 62 cases of severe neonatal hypernatraemia, equivalent to just seven in every 100,000 births and an individual risk of 0.007%.

No baby died, had seizures or coma or was treated with dialysis or a central line. At discharge, babies had regained 11% of initial birth weight after a median admission of 5 (range 2-14) days and none had long-term damage. (3)

NHS guidance also notes that excessive weight loss is a a late indicator of poor breastfeeding - we need to identify and address these cases before this point. A number of factors are shown to increase risks, whilst technologies now exist to closely monitor those presenting with red flags (2,8,9,10) - all relevant health professionals should fully understand the process. There needs to be protocols that trigger action from appropriately qualified and experienced specialists, including identifying babies who need urgent medical care.

If we explore the 62 babies in the above study:

Infants presented at median day 6 (range 2-17) with median weight loss of 19.5%
58 presented with weight loss ≥15%
25 babies had not stooled in the 24 h prior to admission

The answer isn't to short change women by telling them how they feed their baby doesn't matter - outpourings from emotional mothers all over the world clearly demonstrates that's simply not the case. You can't quash the primal, instinctive drive a mother may have to nurture her young because of the inadequacies of those providing her care.

What's more as numerous researchers highlight, there are risks to not receiving breastmilk and to early supplementation with formula (2, 11); so it's as important to prevent unnecessary intervention when a mum wants to exclusively breastfeed, as it is to ensure those who need it receive it. It's our job to support families to meet their feeding goals and ensure their babies thrive and meet their optimal genetic potential.

In the context of not having any food, then of course "fed is best" - the risks of formula are miniscule compared to starvation. However the wider implication of this statement is that as long as baby is fed, it doesn't matter what it is - which isn't the same thing at all is it?

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3091615/
http://digitalcommons.uri.edu/cgi/viewcontent.cgi?article=1009&context=nursing_facpubs
https://www.ucsf.edu/news/2014/12/121546/study-shows-some-newborns-lose-weight-much-faster-previously-recognized
http://www.ncbi.nlm.nih.gov/pubmed/23512226
http://internationalbreastfeedingjournal.biomedcentral.com/articles/10.1186/1746-4358-6-9
http://www.ncbi.nlm.nih.gov/pubmed/22834720
http://pediatrics.aappublications.org/content/127/1/e171
http://pediatrics.aappublications.org/content/112/3/607.short
http://pediatrics.aappublications.org/content/135/1/e16
http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0100-879X2006000400015
http://ajcn.nutrition.org/content/98/2/521S.full

Nomograms:

http://pediatrics.aappublications.org/content/135/1/e16

https://www.ncbi.nlm.nih.gov/pubmed/26565592

Analytical Armadillo

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Fed is Best? Infant Dehydration & the Consequences of Ignorance