More evidence that breastfeeding dramatically increases the risk of newborn hospital readmission

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Another study has found exclusive breastfeeding dramatically increases the risk of newborn hospital readmission.

We’ve known for sometime that aggressive breastfeeding promotion has significant risks including hypernatremic neonatal dehydration and jaundice induced brain damage (kernicterus); indeed 90% of cases of kernicterus are associated with breastfeeding. Closing well baby nurseries in order to force infants to room in with mothers has additional harms: babies being smothered in or falling from mothers’ hospital beds.

Infants treated with phototherapy had a 72% reduction in risk of readmission. Infants allowed unrestricted access to formula had a 76% reduction in risk of readmission.

In January I reported on Health Care Utilization in the First Month After Birth and Its Relationship to Newborn Weight Loss and Method of Feeding by Flaherman et al., which appears to be the first study to quantify the harms of aggressive breastfeeding promotion.

Exclusively breastfed newborns had higher readmission rates than those exclusively formula fed for both vaginal (4.3% compared to 2.1%) (p<0.001) and Cesarean deliveries (2.1% compared to 1.5%) (p=0.025). Those exclusively breastfed also had more neonatal outpatient visits compared to those exclusively formula fed for both vaginal (means of 3.0 and 2.3, p<0.001) and Cesarean deliveries (means of 2.8 and 2.2, p<0.001)

In addition to the pain and suffering of the newborns and anguish of the parents, a tremendous amount of money was spent.

…[S]ince the cost of a neonatal readmission has been estimated at $4548.27 a potential savings of $7.8 million might be realized for a cohort similar to ours if the readmission rate of exclusively breastfed newborns approximated that of newborns exclusively formula fed.

To put that in perspective, with 4 million births each year and more than 75% hospital breastfeeding rates, that means we should expect 60,000 excess newborn hospital admissions at a cost of more than $240,000,000 each and every year. And that doesn’t even count the downstream impact of brain injuries, a consequence that was beyond the purview of this study.

A new study Efficacy of Subthreshold Newborn Phototherapy During the Birth Hospitalization in Preventing Readmission for Phototherapy was undertaken to determine whether prophylactive phototherapy could reduce the risk of hospital readmission for severe neonatal jaundice.

As the authors explain:

To estimate the efficacy of subthreshold phototherapy for newborns with total serum bilirubin (TSB) levels from 0.1 to 3.0 mg/dL below the appropriate AAP phototherapy threshold during the birth hospitalization in preventing readmissions for phototherapy, and to identify predictors of readmission for phototherapy.

Phototherapy works! But the authors serendipitously found a far simpler intervention that also dramatically reduces the risk of readmission: formula!

Among 25 895 newborns with qualifying TSB [total serum bilirubin] levels from 0.1 to 3.0 mg/dL below the appropriate AAP phototherapy threshold, 4956 (19.1%) received subthreshold phototherapy and 241 of these (4.9%) were readmitted for phototherapy compared with 2690 of 20 939 untreated newborns (12.8%) (unadjusted odds ratio [OR], 0.35; 95% CI, 0.30-0.40). In a logistic regression model, adjustment for confounding variables, including gestational age, race/ethnicity, formula feedings per day, and the difference between the TSB level and the phototherapy threshold, strengthened the association (OR, 0.28; 95% CI, 0.19-0.40)… Subthreshold phototherapy was associated with a 22-hour longer length of stay (95% CI, 16-28 hours).

Formula supplementation was equally effective:

Newborns who received formula feedings had lower adjusted odds of readmission for phototherapy compared with exclusively breastfed newborns (OR, 0.58; 95% CI, 0.47-0.72 for >0 to to <2 formula feedings per day; OR, 0.24; 95% CI, 0.21-0.27 for 6 formula feedings per day).

Infants treated with phototherapy had a 72% reduction in risk of readmission. Infants allowed unrestricted access to formula had a 76% reduction in risk of readmission.

Contemporary pediatricians are rediscovering what our ancient foremothers learned long ago: supplementation in the days after birth improves outcomes.

Our ancient foremothers supplemented with prelacteal feeds. Prelacteal feeding — feeding babies supplements like water, tea and honey in the early days of breastfeeding — is common in indigenous and rural cultures around the world.

So why have lactivists, who promote breastfeeding as beneficial precisely because it was the practice of our foremothers, discarded this “ancient wisdom”? First, it doesn’t comport with their belief in the near magical properties breastfeeding. Second, studies have demonstrated that prelacteal feeding is associated with higher infant mortality.

That’s not surprising since the supplements are often contaminated with harmful bacteria, and therefore compare unfavorably with exclusive breastfeeding for women who produce enough breastmilk. But supplements probably compare favorably with death from insufficient breastmilk production. Since insufficient breastmilk in the early days after birth is relatively common, prelacteal feeding became a widespread practice the world over.

Are we actively and aggressively ignoring what indigenous mothers have known for centuries, that a significant proportion of babies cannot survive and thrive without initial supplementation?

Are we risking babies’ lives and brain function because lactivists and breastfeeding professionals have become obsessed with promoting the process of exclusive breastfeeding, privileging it over the outcome of healthy babies?

Sure, we could prophylactically treat large numbers of breastfed infants with phototherapy in order to reduce the risk of life threatening side effects of aggressive breastfeeding promotion: severe jaundice and hospital readmission. But as the authors note:

Phototherapy is generally considered a low-risk intervention. Still, it can cause physical separation of the mother and the newborn, potentially interfere with breastfeeding and bonding, increase inpatient hospitalization costs, and increase the hospital length of stay…

Or we could just allow babies unrestricted access to formula, an equally effective intervention that is far easier to employ, far less expensive, and would have the added bonus of treating newborn hunger, thus reducing suffering for both babies and mothers.

  • VanessaB

    Lol, read the studies. Yes she’s for real. What an ignorant statement.

  • Anna Lee

    It’s sad that people push breastfeeding on mothers & babies during the newborn stage. It is a very difficult stage for Mom and a very vulnerable one for Baby. There is no scientific proof that supplementing breastfeeding with clean formula in a clean bottle can harm babies. Clearly, the evidence shows that it HELPS babies! Why aren’t lactation consultants more realistic? It would help Mothers and Babies so much more!

    • Jen

      Bullies always attack when people are at their most vulnerable.

  • Montserrat Blanco

    My premature son needed phototherapy. I would take formula a thousand times over phototherapy! (He was having formula as well, High bilirubin is common in preemies)

    • Gæst

      One of mine did as well, and boy he hated it. I think it was the eye mask that bothered him. He kept pushing it off. He was in the NICU anyway getting breast milk through an OG tube and the nurses had a strict limit on how much he could eat every three hours. Since it was all pumped milk, we knew it was enough.

      • Montserrat Blanco

        Mine hated it too. I really don’t know why, the eye mask, not being with us, I don’t know, but not a nice time.

  • demodocus

    There’s that interfering with bonding thing again. :/ Formula is still a simpler choice and lets a kid have a full stomach
    Anyway, I wonder if they rationalize prelacteal feeds by blaming colonialism, poor reporting by anthropologists, and/or if they are simply going with their mistaken gut.

    • mabelcruet

      I’ve never quite understood the bonding thing (not being a mum, unless you count the furry four legged babies). If bonding is something that is so easily disrupted simply by not being attached to your baby 24/7, surely its easier to bond with a baby who is eating happily, calmly and quietly from a bottle, rather than one who is starving, dehydrated, screaming in frustration and frantically looking for a nipple that he can’t latch onto?

      • DaisyGrrl

        I don’t recall if I’ve ever told this story, but my mother didn’t produce enough milk to feed me (took a month to regain my birth weight, diagnosed as failure to thrive). This was in the early days of “breast is best” and she thought she was doing the right thing – even though I cried non-stop for 4 months until she gave me my first formula bottle.

        Anyway, it was my first night home from the hospital and I had been crying inconsolably for hours. After everything had been tried (except, uh, formula), my parents laid exhausted in bed, and my dad turned to my mom and asked “can we kill it?” I only heard this story once, and my mom wasn’t entirely sure if he was joking…

        So yes, I agree 100% that feeding the damn baby makes it easier to bond than letting them cry from hunger for hours/days/weeks/months. Incidentally, I flat-out refused to breastfeed after I got my first bottle. The breast brigade would probably view that as proof that formula sabotages breastfeeding rather than a baby sensibly deciding that the proffered breast was inferior to the bottle.

        • Anna

          Both these stories really resonate. Its hard to really build a bond with a baby when you resent every time they wake, when your life is dreading the next damn pumping session. My youngest seemed like such a “difficult” baby but once she started formula suddenly she was sleeping through, happy and started smiling and giggling etc.

      • maidmarian555

        It’s easier to bond with a baby when you are feeling well in yourself and not exhausted or traumatised for sure. That said, even though his birth was rough on me, I am bonded just fine with my son. It took a bit longer than it did with #2 and as a consequence he’s very attached to his Daddy but then I don’t really see that as a negative thing. I also have a very strong bond with our stupid dog and I didn’t even give birth to him! It’s almost like you can have a powerful bond with other living beings without having to go through a specific set of rituals and processes!

        We’re in the process of weaning the baby (can you believe she’s almost 8months already!!) and it’s funny how once you’re watching them regularly shove whole slices of watermelon in their mouths, how futile the pressure and stress around breast/formula is. It’s for such a short time (even for those who breastfeed for extended periods) that they’re just reliant on milk and it passes so fast. It makes me so sad that so many of us are prevented from enjoying that time (seriously, every mealtime takes at least an hour right now with a weaning baby and fussy toddler). Those early months should be the easy bit and thanks to the breastapo so many parents are having that time ruined for absolutely no good reason at all.

    • Elizabeth A

      I may never cease to be angry about the use of “bonding” in obstetrics and pediatrics.

      No one defines bonding. It’s a thing we all agree is good, but we don’t actually know what it is. That makes it a potentially infinite source of anxiety.

      Further, while there are lots of ways to measure whether parents appear bonded to children (do they look at them? stand near them? hold them? is that because they’re emotionally bonded or just because that’s where the chair is in the pediatrician’s office?), there is no way to evaluate what the infant feels, and the infant capacity to do things is sort of limited.

      So even if we agreed on some measure that indicated bonding had occurred, we could only evaluate parental emotional response.

      A lack of emotional connection to other human beings is certainly harmful, but many humans will take the slightest excuse to connect with a baby. There are plentiful real world examples of adults and infants forming emotional connections with each other despite lacking any kind of genetic connection – biological parenthood sometimes kickstarts emotional connections, but the absence of that kick isn’t damaging.

      (And sometimes biological parenthood starts off by munging those emotional connections – the first time I laid eyes on either of my children outside my own body the thing I felt was TIRED. Plus, in one case, a doctor was up to her elbows in my uterus prying out gobs of placenta, which was more than slightly distracting. I looked at my brand-new babies and thought “Dear god, why did we do this?” I hesitate to take my Mothers’ Day cards too seriously – they were produced under educational supervision aimed at a certain result – but my kids are awesome, and unusually inclined to tolerate me for their ages.)

      • Sue

        What we do know from the “bonding” research is that extreme neglect (such as being largely unattended in an impoverished orphanage, or by extremely dysfunctional parents, for example) has developmental and psychological effects.

        This is worlds apart from the normal world of parenting.

      • Montserrat Blanco

        A baby/infant/toddler/child/teenager needs to feel loved and taken care of. That said, it does not look like it has to be the biological mother or the child is screwed up forever. It seems more than fathers, adoptive parents, grandparents, aunts, uncles and even older siblings are perfectly capable to do that wonderfully. And to be clearer, some biological parents have killed or tortured their own children, so it looks more like you need some commitment and love and a lot of time together and you are very much perfectly bonded for life. The two hours skin to skin, the first hour after the baby is born… I understand they might feel great but seriously I highly doubt my son and I would be more bonded with them… mostly because we needed the 24 hour separation in order to recover enough to see each other healthy in the first place.

      • demodocus

        I didn’t bond until they were here, either. Probably faster with my daughter since my boobs weren’t in the way, metaphorically speaking.

    • Ozlsn

      The whole “ZOMG must bond skin to skin immediately or doooomed!!” thing annoys the absolute crap out of me. I saw my son briefly before he was taken up to NICU, then not till the following morning. I did cares (change nappy, take temperature, gently hold him up while they rearranged his nest and sheets) but didn’t do skin to skin until he was 12 days old. After that it wasn’t for another 3 weeks as he was so unstable, and it took nearly 3 months before he was stable enough that kangaroo care became regular rather than sporadic. I left him in NICU every night for the first 17 months of his life, and wasn’t there in the night when he woke.

      And yet here we are, with him somehow managing to bond with me so that he crawls into bed in the middle of the night, won’t let me go to the toilet in peace, wants comfort when he bangs his head again, and demands cuddles and tickles at every opportunity.

      Skin to skin post-delivery is lovely if you can and want to. But it’s hardly the be all and end all, and frankly partner or grandparent or significant adult can do it just as well if the mother doesn’t want to or is being checked out. There is a lifetime to bond – something that Caroline Lovell’s second child didn’t get partly because her mother’s idiot midwives were so fixated on the magical skin to skin binding hour they failed to notice Lovell was bleeding to death. I think her daughter would have preferred a lifetime with her mum.

      • Mel

        NCB proponents get bonding backwards on top of that.

        Human babies bond to adults that show any level of interest in them because human babies are totally and utterly helpless for a really long time. Best in that case to attach yourself to adults who will work at keeping your alive. My running joke while Spawn was in the NICU was that he got worked up at 6 am and 6pm every night because his all-time-favorite nurse who had cared for him his whole life (from Spawn’s POV) was leaving! He calmed down at 6:30am and 6:30pm when he realized that his all-time-favorite nurse was being replaced by his all-time-favorite nurse! This repeated twice a day for the whole time he was in the NICU.

        Adults, on the other hand, are far more picky about which babies they bond to than babies are to adults – but it’s a much lower bar than it is for most animals. Most animals will not care for a visibly premature offspring or one with major disabilities. There’s really no way to trigger bonding in those situations because the adult is hard-wired to leave the area or kill the offspring. Humans, on the other hand, can provide care for an offspring while not feeling much (if any) of a bond – and eventually the bond forms. The best example I can think of this is Rilla from the Anne of Green Gables book “Rilla of Ingleside”. She’s a 14-year old girl who is raising an orphaned newborn that she’s completely unrelated to. During the first few months, she feels a sense of duty to care for the baby well and a mild form of pride for caring for the kid – but that’s about it. She writes in her diary that she feels like she’s caring for a breakable lizard. And yet, little Jims attaches to her long before she attaches to him. He’s being fed, cleaned, kept warm and held. Rilla’s exact feelings towards him doesn’t matter because he’s not a mind reader. And slowly, Rilla starts to attach to him as he becomes more interactive and responsive to her.

        • kilda

          yes, thank you! Babies are hardwired to bond to someone who takes care of them, because it’s their best chance of survival if mom dies, which let’s face it, was not a super uncommon event in evolutionary history.
          I didn’t even meet my daughter til she was 9 going on 10, and we’re quite well bonded.

      • demodocus

        My daughter was also whisked off to the NICU. Our bond is just fine. I detest being topless, so neither kid got much, even my bf’d, room-in eldest.