‘Exclusive breastfeeding is endorsed for the initial six months in newborns. It is sufficient for every nutritional need…such that there is no need to give anything above breastfeeding.’
So begins a study looking at dehydration in breastfed newborns.
The study was carried out in a hospital in India. It found that 34 babies out of 2179 born over the period of a year were admitted to NICU for neonatal hypernatremic dehydration (NHD). That’s 1.56% of babies, which means NHD was not rare at all. The researchers looked at ways these babies differed from the babies who didn’t develop NHD. What they found didn’t surprise us.
Mothers of babies with NHD were more likely to be first time mothers, to have low or delayed breastmilk supply, to have problems with latching the baby on and to have mastitis or cracked nipples. Breastfeeding was more likely to have been initiated more than an hour after birth. Babies with NHD were more likely to feed less frequently, to feed for shorter or longer time periods (which suggests ineffective feeding), to pass urine less frequently and to lose more weight (the average weight loss was 11.4% of the baby’s birth weight, compared to 2.8% in the control group).
So, what did the researchers conclude? They noted two important things: firstly, that the number of cases of NHD increased after the hospital began implementing the ‘Baby Friendly’ Initiative. For those not in the know, the so-called ‘Baby Friendly’ Initiative seeks to increase rates of exclusive breastfeeding. As part of this, it discourages any supplementation of breastfeeding with formula. This is despite a body of evidence demonstrating that insufficient breastmilk production and intake is far from rare and can have catastrophic consequences. (Our friend and comrade Vera Wilde reviews this literature here.) Secondly, the researchers noted that a leading cause of NHD is inadequate milk supply to the baby.
However, the researchers didn’t take the rather obvious next step here. So-called ‘Baby Friendly’ policies explicitly seek to reduce the number of babies receiving supplementary feeds. They thereby increase the number of babies not getting enough milk to meet their nutritional needs. In other words, the researchers didn’t consider the possibility that their opening statement – ‘breastfeeding is sufficient’ – is contradicted by their own data.
They noted (rightly) that delayed breastfeeding seemed to be a contributory factor and was particularly prevalent for babies born by c-section, but they didn’t stop to consider why breastfeeding was delayed in such cases. They noted the high weight loss in babies with NHD, emphasising the importance of early weight monitoring to detect and prevent NHD. However, they don’t say how NHD would be prevented, other than ‘targeted breastfeeding education and support’. They even went as far as to question the adequacy of 10% weight loss as a standard cut-off point for concern, suggesting this might overestimate newborns’ tolerance for weight loss. (This seems reasonable given the 2.8% average weight loss in the non NHD group.)
The researchers didn’t see what was obvious: a policy that seeks to increase exclusive breastfeeding was associated with an increase in NHD and excessive weight loss. Therefore exclusive breastfeeding may not be sufficient for all babies. They failed to consider whether there might be another way to meet babies’ nutritional needs. They did not dare speak the f-word.
The researchers didn’t say whether any of the babies admitted to NICU with NHD had been formula fed from birth. We’d be willing to bet all our kids’ Christmas presents that it was very very few.