Breastfeeding Insufficiencies: A New Review of the Evidence

We would like to draw your attention to this review of the literature on breastmilk insufficiencies. It was written by a fellow mother, Dr Vera Wilde, whose baby suffered excessive weight loss as a result of insufficient milk intake, while exclusively breastfeeding.

Wilde starts with the recognition of harms associated with exclusive breastfeeding, including jaundice, low blood sugar and dehydration as a result of insufficient intake. These are in turn associated with a range of harms, including brain damage, neurodevelopmental problems, organ failure and death, she explains. Wilde points to studies that have found delayed milk production in 33–44% of first-time mothers (; And before anyone shouts: ‘Oh, but they didn’t have the right breastfeeding support!’, another study of ‘unusually compliant and well-educated first time mothers’ found that 15% had persistent insufficient milk after three weeks, despite intensive professional lactation support.

Wilde points out that such nutritional deprivation would normally be considered medically dangerous and legally and ethically unacceptable to impose on any human. How much more so a vulnerable newborn? She argues that previous civilisations recognised breastfeeding insufficiencies and had an infrastructure to resolve these, including wet nursing arrangements. She argues that Western reformers (who have long argued that families in ‘formula feeding cultures’ have forgotten how to breastfeed) were ignorant of breastfeeding insufficiencies. She claims that these reformers began to promote breastfeeding exclusivity based on flawed science and logic.

Breastfeeding began its modern resurgence in the 1970s. Since then, there have been multiple reports in the literature of breastfeeding insufficiency and associated harms (;;; Several of these authors noted that the cases they identified of malnutrition from breastfeeding occurred entirely in the firstborn children of upper middle class families, and that breastfeeding insufficiencies may progress rapidly and not be recognised by intelligent and committed parents.

By the mid 1990s, a rise in preventable newborn hospitalisations was noted. This went along with the recurrence of kernicterus, permanent and disabling brain damage as a result of jaundice (;;; At one Pittsburgh hospital, 1.9% of healthy babies were readmitted for breastfeeding-associated dehydration. Another study found that exclusive breastfeeding increased newborn hospitalisations by 2.2%, despite their caretakers seeking more outpatient care. Another found that introducing the so-called ‘Baby Friendly’ policies of rooming-in and minimising formula supplementation saw an increase in exclusive breastfeeding, excess weight loss and admissions for phototherapy to treat jaundice, even in mixed-fed babies.

Wilde argues that current policies do not reflect the evidence that breastfeeding insufficiency is common and can result in substantial harm. She looks to trials of early supplementation with formula for at-risk infants and their mixed findings on the impact of supplementation on later breastfeeding. She notes that not supplementing led to a clear increase in hospitalisations that could have been prevented. These adverse events were not reported to the appropriate channels, highlighting once again how risk of underfeeding goes unnoticed, unreported and unaddressed.

Wilde questions the ethics of continuing to implement or even study hospital policies and protocols that promote exclusive breastfeeding in the light of clear evidence this results in preventable harms to babies. She argues that ‘prelacteal feeding’ (supplementing breastfeeding with formula until a mothers milk supply is established) may have even more benefits in low and middle income countries, where severe jaundice occurs more frequently and delays to treatment are common.

A recent randomised trial (PROMISE) of an intervention to promote exclusive breastfeeding in low income countries raises concerns. The intervention arm had the highest ever measured perinatal mortality rate in Burkina Faso. And being a first time mother (and therefore more at risk for breastfeeding insufficiency) was a significant risk factor for neonatal death. The same intervention led to more wasting in Uganda and lower ponderal (a measurement of weight/length) in Uganda and Burkina Faso. Other researchers have highlighted the inadequacy of a public health policy relying on exclusive breastfeeding to ensure adequate nutrition.

Wilde also points out that researchers and clinicians are inhibited by the ‘WHO Code’ (The International Code of Marketing of Breastmilk Substitutes), which discourages free or low-cost formula donations, even in settings with endemic poverty and HIV (transmissible via breastmilk). Another study reported that exclusive breastfeeding prevalence in Burkina Faso nearly doubled between 2000 and 2017. This increase coincided with the country’s highest ever measured perinatal mortality rate. Correlation should not be taken to indicate causation even here, but… There is no data on breastfeeding insufficiencies that would enable this question to be examined. The PROMISE protocol made no mention of exclusive breastfeeding’s risks, nor the means to mitigate them. Exclusive breastfeeding is seen as unequivocally safe, ignoring the fact of breastfeeding insufficiencies and the clinical problems that result.

Wilde also highlights other less common but serious risks. These include in-hospital newborn falls due to maternal fatigue from round-the-clock early breastfeeding efforts and neonatal collapses related to prone positioning in early breastfeeding.

Wilde argues for supplementation of early breastfeeding until a mother’s milk supply is established as sufficient as standard practice. This might be heretical, but given that there is a widespread lack of recognition of breastfeeding insufficiency in parents and medical staff alike, it is hard to argue against. She argues that the current threshold, recommending formula supplements at 7% weight loss, does not acknowledge that dehydration and low blood sugar can occur at lower losses. (In the UK, formula supplementation is not usually recommended until 10% weight loss and some have argued for 12.5%!)

Wilde makes a compelling case that current policies are causing preventable harm. Given the established risks of exclusive breastfeeding, she queries whether the pendulum should swing back to prelacteal feeding as the accepted standard. She questions whether a head-to-head trial of exclusive breastfeeding vs prelacteal supplementary feeding should proceed in order to produce gold standard evidence. This might also help to establish where there may or may not be causal relationships between health outcomes and feeding methods.

Here in the UK, every NHS hospital is required to sign up to the so-called Baby Friendly Initiative’s accreditation programme. This initiative has never produced a single piece of evidence demonstrating it improves health incomes in the UK. Yet every single NHS Trust across the country is required to pay the Baby Friendly Initiative team money to inspect and accredit their services. The evidence that so-called Baby Friendly policies are causing harm is mounting. Rates of emergency readmissions for jaundice doubled between 2007 and 2017 as Baby Friendly policies have expanded. Is correlation causation? No, but a correlation between restricting newborn’s access to formula and readmissions for complications associated with insufficient intake is sure as hell suspicious.

It is time for a serious review of current infant feeding policy, so we can have an infant feeding policy that focuses on, well… feeding infants. No infant in the UK, or anywhere else for that matter, should ever suffer for lack of adequate food. How much might earlier and more frequent supplementation of formula prevent families going though the stress of a hospital admission and the stress of their baby undergoing treatment for jaundice? How much might this save the NHS?

Wake up and smell the sour milk: current infant feeding policy is based on flawed science, flawed logic and a total disregard for ensuring every baby has their full nutritional needs met right from birth. Let’s review and do better for the sake of neonatal safety and the sake of families.

This blog was adapted from a thread on Twitter.

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