Imagine if I told you that tens of thousands of babies were being hospitalized each year for a common problem and yet we weren’t merely doing nothing about it; we were actively promoting more harm. You’d be outraged, wouldn’t you?
Prepare to be outraged.
Tens of thousands of babies are being hospitalized each year, some sustaining permanent brain damage, and a few even dying, because of a common problem — insufficient breastmilk. We aren’t merely doing nothing about it; lactation professionals are actively promoting more harm by lying about the existence of the problem, its frequency, its diagnosis and its prevention.
[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The most reliable sign of neonatal dehydration is weight loss, NOT wet diapers.[/pullquote]
A new paper, Neonatal Hypernatremic Dehydration, should cause soul searching and policy changes among lactation professionals everywhere. I’m not holding my breath.
It should also give pediatricians and obstetricians renewed impetus to push the deadly Baby Friendly Hospital Initiative out of hospitals. I have far more hope that they will do the right thing and put scientific evidence ahead of ideology.
The paper demonstrates yet again how so much of what passes for “knowledge” among lactation professionals is actually lies.
1. Insufficient breastmilk is common.
Dehydration/excessive weight loss is defined as a loss of more than 10% of birth weight prior to the end of the first week of life, and is thought to occur in up to 15% of exclusively breast-fed infants.
Lactation professionals owe the Fed Is Best Foundation a deep and profound apology. The Foundation was created to highlight both the frequency and the dangers of insufficient breastmilk. Founders Christie del Castillo-Hegyi, MD and Jody Seagrave Daly, RN, IBCLC recognized years ago — through bitter personal and professional experience respectively — that lactation professionals were lying to themselves and each other about the dimensions and harms of the problem. Yet rather than receiving the thanks of the lactation profession, they have been defamed and demeaned by the very people who were causing all the harm.
2. The incidence of clinical neonatal dehydration is high.
Up to one-third of these infants will also be hypernatremic, and the reported incidence of hypernatremic dehydration in term neonates requiring admission ranges from 1% to 5%, with higher rates reported in developing countries.
Despite published statistics, the true incidence of hypernatremic dehydration is difficult to define, as some retrospective studies have included only term neonates, whereas others have included late preterm (>35 weeks gestation) neonates. None have included neonates with predispositions to feeding problems, such as cleft palate, Trisomy 21, neurodevelopmental, or craniofacial disorders.
3. The consequences of neonatal dehydration can be devastating.
Serum sodium level greater than 160 mEq/L is a risk factor for morbidity and mortality. The most commonly cited complications include seizures, bradycardia, vascular thrombosis, disseminated intravascular coagulation, renal failure, intracranial hemorrhage, pontine myelinosis, cerebral edema, and death. Seizure is the most common complication and usually occurs during correction of the hypernatremia, as do the other common complications.
4. Neonatal appearance and the number of wet diapers are NOT reliable indicators of dehydration.
Hypernatremia results in hypertonic intravascular contents, which causes fluid shifts from the cells to the intra-vascular space. Thus, the neonate may appear less hemodynamically compromised, resulting in underestimation of the degree of dehydration by as much as 5%. This also increases the chances an affected infant will present late for medical care.
It’s hard to over-emphasize the importance of this point.
As with many serious neonatal conditions, newborns can look fine right up until the moment they collapse; they have compensatory mechanisms that work until they fail abruptly and completely. In the case of dehydration, infants compensate for the low blood volume caused by dehydration by pulling water out of cells into the bloodstream. As a result, they can keep perfusing their kidneys — and keep urinating — even as they may be dying.
Many lactation professionals and lactivists owe both Jillian Johnson and Christie del Castillo-Hegyi deep and profound apologies for publicly doubting that their babies were dehydrated and for blaming medical staff for failing to recognize the “signs” of dehydration. If you wait to diagnose dehydration until a baby is no longer urinating frequently, you could easily wait past the point of brain damage to the point of death.
5. The most reliable sign of dehydration is weight loss.
Mild hypernatremia should not be considered a benign occurrence, and breast-fed infants with greater than 7% weight loss or significant jaundice should be evaluated for hypernatremic dehydration and the possible need for oral or parenteral fluid supplementation.
This is precisely what the Fed Is Best Foundation has been saying for years. As a result they’ve been vilified by the lactation professionals who are still lying to themselves and each other about the depth and breadth of the problem.
Though this paper doesn’t mention it, lactation professionals have compounded the problem and raised the risk by banning formula supplementation. Multiple scientific papers have shown that judicious formula supplementation is not merely compatible to subsequent exclusive breastfeeding, it actually improves the rate of subsequent exclusive breastfeeding. Moreover, it dramatically decreases the risk of newborn hospital readmission. Infants allowed unrestricted access to formula had a 76% lower incidence of hospitalization.
This new paper on neonatal dehydration illustrates three critical points.
First, the lactation profession as based on ideology, not science. It was ideology that led lactation professionals to claim that breastfeeding, uniquely among all bodily processes, was perfect. Science always showed the opposite.
Second, while the benefits of breastfeeding term babies range from theoretically possible to completely non-existent (no one has yet been able to show a single term baby whose life has been saved by breastfeeding), the risks are very real with literally tens of thousands of babies suffering so much that they must be readmitted to the hospital for treatment.
Third, the public discussion of breastfeeding has been controlled by lactivists to the detriment of babies and mothers. Type “breastfeeding” into Google each and every day as I do to see the latest articles and you will find a myriad of pieces bemoaning the “horror” of some woman somewhere being shamed for public breastfeeding. Yet there is rarely if ever any article in the mainstream media about the dangers of insufficient breastmilk, a problems that is affecting more than 1% of exclusively breastfeeding newborns DAILY.
There is one very obvious thing to do if we wish to help these babies and mothers, prevent tens of thousands of hospitalization a year and dramatically reduce the risk of permanent brain damage or death: allow new mothers unrestricted access to infant formula. If we care about babies, we will do it. If we only care about breastfeeding, we will continue to let babies suffer.
There is also one less obvious thing to do: eject the Baby Friendly Hospital Initiative from hospitals. There is no place in any hospital for an organization whose primary commitment is to its own ideology instead of to patients. It has indisputably harmed hundreds of thousands of babies and mothers. It’s time to end the harm.
It’s absolutely appalling how breastfeeding has been held up as the goal vs a healthy baby.
My best friend is pregnant again. I’ve mentioned her here occasionally: she successfully breastfeeds, but her milk takes 5-7 days to come in, and it’s all complicated by incompatible blood types between her and her husband, so their babies inevitably end up really jaundiced that first week. The solution, you’d think, would be formula supplementation. Except that their hospital now has a policy of “not allowing” formula supplementation EVEN FOR JAUNDICE because “formula doesn’t work as well as breastmilk for clearing out bilirubin.” Facepalm.
(The last time this happened, the pediatrician ordered formula supplementation, but the nurses refused to give it *and* told the parents they wouldn’t be “allowed” to have dad go out, purchase formula, and feed his baby with it. I #*@& you not. All hell rained down from the pediatrician once he heard about it due to baby getting readmitted, but now mom is convinced that they must be right, formula doesn’t “work” to get bilirubin out of a kid, and it’s All Her Fault, of course, because her body simply takes a bit longer to get the Hungry Baby In Vicinity, Produce Milk Now memo.)
Omg that is horrifying. Is that even legal?
That policy will come to and end probably only AFTER the first preventable death or lawsuit.
well even if it were to be true that breast milk clears bilirubin better than formula, the relevant comparison is not between formula and adequate breastmilk, it’s between formula and essentially nothing.
Yeah, that is bizarre. She WAS breastfeeding already, and that’s when the baby got the jaundice. So breastmilk wasn’t working all that well, I think we can say.
yup when breast milk alone isnt working the obvious solution must be……..MORE BREAST MILK!
Yeah, let’s keep pounding that hammer on the screw!
Precisely.
The hospital’s…solution…if we can call it that…is that the baby ends up staying on a bili blanket for several days while mom continues to breastfeed, all while mom “recovers” from childbirth by lying on a fold-out cot or some such in between nursing/pumping/etc because she, of course, isn’t a patient.
All this is further complicated by mom having been brought up in a similarly crazy homeschool situation to mine, so “don’t argue with anyone in authority, they’ll try to take your baby away” is totally ingrained in her. When they put up a bit of a fight last time on formula and the nurses got so nasty, she pretty much emotionally shut down from terror because she was convinced if they did smuggle in formula, someone might call CPS. (She’s ordinarily a fairly rational person, but when birth/hormones/stress of a sick baby hits, she reverts to her background.) I have pointed out that in the unlikely event CPS did get a call from a nurse about “EEEEE my patient is following the pediatrician’s direction and giving her baby FORMULA!”, CPS would tell the nurse to screw off, but, well, hormones/stress/etc.
At this point I really would not be surprised to hear about a nurse or lactation consultant calling CPS cause mom is giving baby FOOD.
Yes, if they’re going to make that argument then they should be supplying her with donor milk.
You really should name the hospital here
Seconding this. Name and shame. Women have the right to know this, when they’re choosing a hospital.
Honest question–my son was very dehydrated due to lack of breast milk. He was very sleepy his first three days. He lost 11% of his body weight in 75 hours and was hardly urinating. Does dehydration in that case automatically mean hypernatremic? Or are there different levels or types of dehydration? And if he was that dehydrated, would he likely have been hypoglycemic too, even if he wasn’t jittery? (The hospital did no labs when he was readmitted.)
There are three different subtypes of dehydration.
The different subtypes describe how the ratio of sodium to water is lost compared to a normal ratio – but they can all mess someone up. Your son was probably hypernatremic because his intestines and kidneys were keeping sodium in like they were supposed to and he wasn’t barfing – but he was losing more water during urination that he was getting orally.
Hypoglycemia is a different beast. Newborns are generally pretty good at maintaining their blood sugar by using whatever calories they can get from food plus burning fat and dropping their insulin production if needed until food shows up in a few days. The two exceptions are infants who don’t have fat stores from prematurity (waves at micro preemies!), poor growth before birth or lack of oxygen (which leads to breaking down of fat stores to keep the baby’s metabolism going when they don’t have enough oxygen to use glucose) or infants whose moms had poorly controlled diabetes (GD or otherwise). That second group’s body is used to producing extra insulin to break down the extra sugar that they received from their mom and they need extra monitoring until their body adjusts accordingly.
Thank you! That all makes sense. I’m only sorry that I have to ask these things of internet folks and not our medical team…
It’s all good. Honestly, the middle of a medical crisis is not a time when the patient (or loved ones of a patient) think to ask really in-depth questions about metabolics.
During the first 10 days or so after my son was born, the two “science-y” questions I asked were “What’s his blood type?” in response to his first blood transfusion* and “Have his eye(s) opened yet?” because his eyes were still fused at birth…the right one opened on the second day…and my husband and I really enjoyed making jokes about our one-eyed son until the left one opened 10 days later.
*Actually, the reason we asked about his blood type was even nerdier than that. My husband has O- blood which means all of our kids will get an O and an Rh – from him. I’m A+ – but my maternal grandfather was O- which means there’s a small chance that I can give our kids A or O and Rh + or Rh-. In genetic terms, we’re using our kids as a testcross to determine my genotype because if any of our kids have O or Rh – blood that shows that I have that trait as well. In practical terms….it shows we’re very nerdy and like genetics.
Okay! Can we stop locking up formula like it’s contraband, now?
It’s so ridiculous. I supplemented my son on day 3, when it was clear my milk hadn’t come in and he had lost 11 oz (8% of his body weight). He woke up that day crying and had brick dust in his diapers. I was extremely concerned and did what most people would do in the absence of a “breast is all you need” mentality; I gave him a bottle after nursing until he seemed full, and I did that for 2 more days until my milk finally came in on day 5. Fortunately he was my second child and I had already learned with his older sister that lactivism is crazy and formula is fine. Otherwise who knows what might have happened in the two full days before him showing signs of not getting enough and me actually getting milk.
We in the lactation promotion community are complicit because many of us were attracted to this vocation because breastfeeding and breastmilk production came relatively easy for us. We extrapolate our experiences and our ability to navigate mild obstacles/glitches as proof that all mothers produce the right amount of milk and that all full term healthy newborns are physically able to latch and suckle. When breastfeeding does not meet the newborn’s nutritional needs we look for hints of professional/pharmaceutical sabotage or worse, we blame/shame the parents for doing something wrong.
My son weighed a hair under 5 pounds at birth. When he was readmitted, he weighed 4 pounds 4 ounces, his sodium was 159 and his bilirubin was over 19.
He looked okay, at least to our untrained eyes. He was still producing urine, apparently for the reasons explained above. He appeared calm, we weren’t equipped to see that he was actually lethargic. And he was yellow, but his father’s natural skin tone is deep olive, and we didn’t know the difference between dangerous jaundice and his natural skin tone emerging.
There were so many things I learned about babies when I was pregnant, and through decades of society preparing me for motherhood. There were so many risks that I knew about, that I had been taught to handle, many of them quite rare. This one, though? Commonplace. Trivially easy to prevent. Kept utterly secret from parents.
This paper will probably be ignored or lactivists will say the usual “formula companies paid them to write this paper” and they will go back to shaming formula feeding as usual as more babies continue to die or suffer brain damage.
There is already a big push by LCs to prevent parents from weighing babies, and especially doing weighted feeds, because such things would prove that no, babies are not always getting enough milk and the apparent hunger is real. In my hospital, access to the baby scale was actively denied and the nurses (all trained LCs) explained that the numbers just confuse mums because really they might be low…
The adult equivalent of squeezing your eyes shut, plugging your ears with your fingers and chanting “la la la I can’t hear you”.
I know they are trying to do that in a lot of BFHI hospitals now but I don’t know if they have had a lot of success. Why do doctors seem to be afraid to stand up to these assholes? Doesn’t the doctor have more power than an LC or nurse?
As a former patient, I think it’s hindered by the split in care. Mostly I saw my OB in the hospital, who is NOT a pediatrician and was not responsible for the baby. Since my pediatrician did not have privileges at the hospital at which I delivered, one of the doctors making rounds did a quick check of my baby. Maybe I saw one every day, but I don’t think so. And my baby certainly didn’t see her own doctor, or even the same doctor. So …
You see a doctor maybe once a day and the feeding/care/helping mum stuff is expected to be managed by the nurses. Who then pretend that it all looks fine, no issues, everything normal. Move along, nothing to see here. No reason for a doctor to even get involved. And if a parent tries to bring the doctor in, the nurses will summarise the case as “well you know how these first time parents are, waaaay to much worrying when we all know babies are a bit fussy” and that’s usually how far it gets.
The main LC at our hospital was a pretty serious zealot and all, but not totally bonkers. She held a weekly “mom’s meeting” where the women all sat around and commiserated and breastfed, and it was like “no bottles allowed” (although I don’t know if that was explicit), but one of the most important things that they did do was to weigh the babies. She actually had a chart for each of the babies that was coming through where they would log the weight each week to make sure they were growing and developing properly.
Moreover, in the hospital, they had a scale by the nurses’ desk, and you could stop by any time you wanted to weigh your baby.
My interpretation is that their focus was on breastfeeding _successfully_. If the babies weren’t gaining weight, they saw it as a problem and worked to solve it.
The idea of actively prevent parents from weighing their babies is bad, bad, bad.
One of the most batshit lactivist statements that I ever read was “scales are notoriously inaccurate as a way of measuring a baby’s weight”. As opposed to what, exactly? Holding a baby in one hand and a bag of sugar in the other and trying to guess the difference?
I’ve also noticed lactivists online trying to coach mothers in what to say to obscure or confuse the issue of their baby’s weight loss, e.g feeding the mother a “memory” that the baby was accidentally weighed with an item of clothing or nappy on so the first weight can’t be relied on.
This is exactly it. They pretend weighing isn’t accurate, but just hoping for everything to be fine while ignoring obvious signs that it isn’t is even worse!
No surprise here – but the NICU was all about weighted feeds on former micro preemies, any baby with possible feeding issues due to congenital issues and most FTMs who wanted to exclusively breastfeed.
The most common thing I remember was a FTM who was all about EBF swearing that the scale could not have been right when it said that the baby had drank 15mL in a 20 minute breastfeed because mom pumps more than that and the baby had been swallowing and something else that I don’t remember and…and that’s when the experienced nurses would make some kind of soothing noise and offer to use the baby’s NG tube to determine how much milk he or she drank.
The mom would agree – and literally see that the kid had drank 15mL of breastmilk.
That whole “Weight by difference” thing is pretty standard across a whole crap-ton of disciplines outside of medicine because it works…and I get extremely skeptical of anyone who tells me that it doesn’t work after I’ve seen it literally be supported by a second method of checking the size of a feed.
I have NO idea how much weight my son lost in the two days we were in the hospital…I know they continued to weigh him, but I don’t remember ever hearing the result. I know that he and I were both still getting the hang of this breastfeeding thing, that he stayed latched to my boob for 45 minutes at a stretch, and that they treated him for mild jaundice at one point. And that he cried almost constantly.
Now I wonder…was his constant crying a sign that he wasn’t getting enough to eat?? As a new mom, I didn’t even know enough to ask. Breastfeeding class had taught me “Just keep putting him on your breast, and the milk will come.”
Now, it could have just been that he was a particularly fussy baby (and remains a ‘fussy’ kid at age 9!), but man, it would be nice to know for sure.
This really makes me angry because NOT ONE medical professional that I encountered during my pregnancies or post-partum period ever told me about the risks of dehydration. When will this become a priority for WHO and pediatricians / hospitals.
I’m sorry. Everything I learned about why breastfeeding was such a disaster for me and my son, and I do mean EVERYTHING, I learned from FIB and Dr. Amy. Unfortunately, my son was over a year when I found these wonderful resources. But no one in my hospital or any other medical practice was willing to tell me the truth. Disgusting.
Same thing for me. I found Dr. Amy first and then read Courtney Jung and Joan Wolf’s books as well as found FIB. Everything that I learned about breastfeeding and the associated risks was from them versus any medical provider I saw.
And there are still cultists screaming ‘babies do not need to eat first 72 hours of life’ or ‘babies should not be allowed to be full because such stuffing results in obesity’…
I would tell them to take a multivitamin in the morning and nothing else all day then at the end of the day tell me how not hungry you are cause just a little bit is all you need. Even some children know your stomach is the size of your fist and it expands 2 times that size so just a teaspoon of colostrum cannot possibly be enough for a baby.
Remember Jan Hocking on here saying that babies are born full of amniotic fluid and was enough to keep them going until mothers milk came in? Because, yes, a bellyful of pee, snot and a few squames is the perfect slap-up dinner for every newborn.
People who obsess over babies being too fat are weird. Also, I’ve known babies with so many rolls of fat that they could barely move, but that was the good “well done mama” type of fat because they were breastfed babies, apparently.
(Personally I’ve never understood how it can simultaneously be true that (a) a breastfed baby can never be overweight because it’s impossible for then to overeat, and (b) doing breastfeeding right requires you to allow your baby to comfort feed whenever they like, regardless of whether they’re actually hungry?).
If all babies had their sodium and glucose levels checked before discharge, would this be sufficient?
Even if that is done they will tell mom just keep breastfeeding. They dont care about the baby they care about their breastfeeding numbers. Some in hospital lactation consultants are trying to stop having infants weighed so the doctors will not notice how much weight the baby has lost.
Checking weight is easier, and results are immediate. But again, someone has to act on the results, and decide whether to explain the results to the parents, recommend a course of treatment, and schedule follow-up, or not discharge and immediately begin supplementing and other treatment as indicated.
I was thinking that since they don’t react to weight loss, maybe knowing there’s high sodium and low glucose would create more of a sense of urgency.
It wouldn’t even have to be all babies, just babies who have lost more than 7% of their birth weight.
Which would also require nurses to tell the truth about weight loss.
I could be wrong and/or paranoid at this point, but I am convinced that the nurses lied to me about Baby Books 3’s weight loss, or purported lack thereof, in the hospital. It simply doesn’t make sense that a baby didn’t lose weight at all–indeed, gained a tiny bit–in the hospital, and then lost weight per the doctor’s office scale at the first visit when he was getting *more* milk than he had been getting a couple of days before.
Parents would need to know a bit how to spot things like this on their own, breastfeeding may fail later too. Just don’t lie to them…
Never. I’m an ethical IBCLC and believe wholeheartedly that fed is best. Needless to say, everyone at work thinks I’m a shitty LC…except the NICU nurses bc they see the readmissions from inadequate milk intake.
My son needed electrolyte tests monthly for his first six months of post NICU life because he was on a diuretic drug that help get rid of his case of the preemie puffies – which is when your former micro preemie swells up with fluid retention and no one really knows why, but they all grow out of it – and the safest way to get him off the drug was to let him wean off slowly by keeping one constant dose from 33 weeks gestation until he was fat enough that the dose was no longer in the therapeutic range but we did need to check his kidney function regularly.
Anyways.
Getting electrolytes out of a newborn or young infant is a fraught process. Even a healthy term kid has small veins that can be hard to hit due to fat so a heel stick is the preferred method but newborn/young infant red blood cells shatter for shits and giggles which renders the electrolyte test invalid.
Even with STAT processing and experienced technicians, we averaged nearly three attempts to get one electrolyte test done each month. I remember one month where we got it done on the first try and that was when Spawn was 6 months old. The first three months were 4 tries, three tries and 4 tries respectively. I remember the three try appointment because Spawn’s monitor kept going off and an elderly woman kept thinking it was a fire alarm…and I was just plain done…so I was super-grateful when the tech let us know that he didn’t need a fourth stick.
I’m not thinking this would go over well with the EBF people who want to avoid eye drops/Vit K/HepB because of pain concerns with their infants. (Actually, the Spawn never seemed to mind the lancet prick; he became enraged, though, when they pushed on his heel because that, from his point of view, was done ON PURPOSE, unlike the fact that someone tapped his heel.)
Many of them would rather their baby get IV glucose than formula. I’m not making that up.
*blinks*
I honestly have no idea how to respond to that level of fear of formula – or the idea that a peripheral line inserted into their newborn’s vein is less problematic than formula.
My kid was on breast milk until he came home from the NICU and then switched over to a hydrolyzed formula that he tolerated well. The smell of the formula reminded me of rancid Cheese Whiz when I was on the mini-pill and like Cheese-Its once I switched back to the multi-hormone pill.
Spawn’s two-and-a-bit now and doing fine. Much better, honestly, than he would have been doing on breastmilk alone since I topped out at < 5 oz a day on 8 pumping sessions.
Both of my exclusively breastfed girls lost 10% or more of their birth weight. I was unimpressed by the lackluster response from the hospital. The nurse even discouraged me from supplementing #2 with formula on her first or second night, when I was confident that it wouldn’t interfere with breastfeeding because of the easy time I had with #1. I’m so lucky neither suffered any consequences.
I am alwys so confused by this attitude from medical professionals, “oh let’s just starve the kid for a few days, it will preserve your breastfeeding” Ummm so ensuring breastfeeding is worth possible pain, brain damage or death….because Why?
What I saw as the part that confused me is when we told the hospital that we wanted to TRY breastfeeding, if we could. Somehow, that got turned into “breastfeed at all costs,” which it was never meant to be. But that’s how they treated it.
There needs to be “I’ll try breastfeeding, and if it works out, I’ll do it but I don’t want to overburden myself or the baby to make it happen and I’m fine if it doesn’t” option.
I would imagine that the large majority of breastfeeding families are in this category, which is why it’s not offered.
But what does that mean Not offered?What happened to Don’t fcking starve the pediatric patients? It makes Zero sense.
It’s been shown that early supplementation actually increases breastfeeding rates. Likely because mothers have content babies to start breastfeeding with and I can only imagine how much better it’s going to be for a content baby who is a little hungry to learn to manage breastfeeding vs an angry screaming baby who doesn’t give a fuck about anything but their desperate hunger
That is the reason it may be better to tell hospital you are only formula feeding then just try breastfeeding when you get home.
Oh, this makes me feel physically sick. I could barely finish reading this, thinking about those babies. I can’t believe what we have done in the name of this ideology.
The road to hell is paved with good intentions.