Wednesday, August 25, 2010

Volumes: a huge problem

The response to my last post on "los dos" pushed me into finally finishing this one! The volumes given to babies are a huge part of what makes "los dos" so problematic, but are a problem on their own as well. We don't know exactly why breastfeeding is protective against obesity, but a big part of it may be the part with the breast. It's harder (although by no means impossible) to overfeed a baby at the breast. When you're giving a bottle, it's much easier to overfeed a baby and to override their own feelings of satiety/being full by persuading them to just finish what's left in the bottle, or what we think they should be taking.

This problem, unfortunately, frequently starts on the first day of a baby's life. Have you ever seen the belly balls made by Ameda? I think they are a nice way to visualize the size of a newborn's stomach on days 1, 3, and 10. Day 1 is a shooter marble, representing 5-7 milliliters(ml), and Day 3 is a ping-pong ball, representing 22-27 ml. As a frame of reference for those of us not used to metric, 1 fluid ounce = 30 ml, and 1 teaspoon = 5 ml.

These are tiny volumes, as is appropriate for tiny babies with tiny stomachs designed to handle small volumes of colostrum that empty quickly (the gastric emptying time of breastmilk is about half that of formula).

These volumes mean that at one feeding, even on Day 3, a baby should be getting a maximum of 1 ounce.

And yet over and over in the hospital and out of it, I am absolutely boggled (and sometimes horrified) by the volumes that people are able to push to a baby via bottle. I walked into a room the other night and a mom had breastfed her 1-day-old baby on both sides, and THEN given him 40 ml via bottle. All of us routinely see parents who are able to get babies to take 45 ml or more at nearly every feed. Even at day 3, these babies are literally eating double what they're supposed to.

What happens when babies get fed such huge volumes? First of all, they spit up. Give a brand-new baby a 10 ml feed (and remember, this is just 2 teaspoons!) and you may find most of it spilled down her front. It can be scary for the parents and probably doesn't feel that great to the baby.

Second of all, they don't eat. New babies forced to take one huge feed may not eat again for the rest of the day, spitting up constantly with distended abdomens. Babies consistently getting supplemented after breastfeeding, even with smaller volumes, take longer to wait for the next feed -- maybe 4-5 hours instead of 2-3. Physiologically, this isn't sufficient to establish a good milk supply in most women.

Third of all, they get hungry. Forced to take huge volumes over and over again, they start expecting huge volumes. Mom's colostrum can't possibly keep up, which leads to a fussy baby, which leads to more supplements, which leads to less breastfeeding, which leads to lower see where this is going.

Huge volumes are one of the banes of the hospital LC's existence, as far as I'm concerned. And yet it's so hard to address.

I don't want to be the mean LC who tells the parents they just overfed their baby and doomed breastfeeding, but I do want to educate appropriately on volumes. I want to tell parents that this is too much for a baby's stomach, and that it can create problems with breastfeeding. I want to convince the parents that such huge volumes are a bad idea.

Unfortunately, the babies don't cooperate.

Parents seem to expect a baby who takes a large feed quickly and then sleeps soundly for at least 2 hours and preferably 3 or more, and overfed babies do this very well. "Baby doesn't wake up to feed as often" doesn't really sound like a problem to them. And yet once I cross the line into warning her "You can compromise your milk supply" that risks mom hearing what she probably already believes, which is that she won't produce enough milk. AND I hear the eye-rolling message boards of the Internets in my head. ("The lactation person in the hospital told me if I gave my baby ONE BOTTLE of formula, I would NEVER produce enough milk! Boob nazi!")

Parents also expect that if the baby is hungry, she/he will keep sucking, or will be willing to take a bottle back into his/her mouth. Overfed babies will most certainly keep sucking if they have a constant flow of liquid down their throat (the bottle will flow by itself without any help from them) -- in fact, it's hard for them to stop because then they would choke -- and they have a firm stimulus in the back of their mouths. They will do this regardless of their own feelings of hunger or satiety. You can also often get an unwilling baby to accept a bottle nipple back in if you play around long enough (less frequently true for the breast).

I know that responsiveness to hunger/satiety cues is an issue identified, and under research, by people out there in the infant feeding world. I think a key piece is being able to interpret NORMAL newborn behavior (fussy does not always equal hungry! frequent waking is not pathological!) and respond to a baby's cues instead of overwhelming them.

What do we do at the hospital to solve this? We try so hard to educate everyone at their first hi-I'm-the-LC visit if they are planning to do any supplementation. (Obviously we also try to educate them about exclusively breastfeeding, but this is harm reduction.) This takes different approaches, generally from the "your baby's stomach is only this big!" school of thinking.

I've also started taking a more direct route. If I'm the one bringing the bottle (you can't win every time) I pour out everything but what they baby should take at that feeding. (That a 2 oz bottle is considered the standard for a newborn nursery just shows how insidious the formula industry is). We would not give 4 pain pills to a mom and say "but only take one". Neither should we hand her a 60 ml bottle and say "but only give 10" especially because if baby keeps sucking they interpret that as "still hungry". This also prevents the practice of re-using the same bottle for multiple feedings (this happens all the time even though the bottle clearly says it should be discarded after an hour.)

It also helps to at least ask moms to give supplements via a supplementing tube at the breast (you can rig up a cheap, easy one with a 10 ml syringe and a 5 french feeding tube) or a similarly-sized dental syringe. The 10 ml syringe makes that amount look like a large amount, we have parents push it very slowly, and it at least keeps baby stimulating the breast.

I'm trying to get the nurses to do the same although this is more challenging -- I am winning a few interested parties over to trying it. Unfortunately, not every nurse sees these volumes as an issue, which leads me into my second group of overfeeders: the hospital staff.

Oh man, I wish with all this I could say that it was only the parents. But no, if a partially-breastfeeding (or even exclusively formula feeding) mom has asked baby to get a bottle in the nursery, there are nurses who will give 25 ml on Day 1 just like anyone else. (Or more, to the point of pathological...) One of the nurses who is now an LC told me it used to be a point of pride for her that she could get babies to finish the bottle, and I've heard similar stories elsewhere from nursery nurses -- getting that baby to eat who just wouldn't was (and sometimes still is) a valued skill, and getting them to eat a lot meant full, happy, healthy babies filling your nursery.

I will say, not all nurses do this! They will come to me and say "she asked me to give a bottle so I only gave him 10 ml, why don't you go see if he's hungry again and wants to breastfeed" or "she asked me to give a bottle before she came upstairs from L&D but I just made his bath take an extra long time, maybe you could get her started breastfeeding". They tell parents independently not to give too much and that it interferes with breastfeeding, or set them up with a dental syringe with a tiny amount of formula if they insist on supplementing, and they don't hand them 3 or 4 bottles at a time. Thank you, wonderful nurses!

How to solve this problem in the long-term? I heard the prolific and very smart breastfeeding researcher Kay Dewey speak last year, and she talked about her research trying to teach parents to interpret feeding cues correctly. Unfortunately, that education (done with WIC participants) was found to be ineffective at reducing overfeeding. It sounded like their next step with that research, to expand the education from just feeding cues to teaching parents how to interpret their babies' cues generally, was going much more successfully. I'm looking forward to reading more about it as they complete their research. I think it's the right direction to go in -- I believe a big part of the issue with volumes is the unrealistic expectations for "satisfied" baby behavior. Getting it to parents, however, will be a big step and take a long time.

In the meantime, what do you do to discourage parents from giving big volumes? Did you know how much babies were supposed to take in their early days?


Stephanie said...

I had no education with this when I was in the hospital with my newborn. In general, I had a pretty shoddy experience with postpartum anyway, but was definitely left feeling resentment toward their pushy sense to NURSE NURSE NURSE. I had a sort of intuition, having never done it before, of, "Well, my milk isn't in yet and he seems fine to me..."

I'd be interested, as a doula, in how to guide my families with this. It's hard when I have exclusively formula feeding moms take pride in how much their babies eat, whilst in my head I'm screaming, "And their heightened risk of obesity!" You would think that educating mothers on the cues of true hunger would be helpful. But unfortunately in all areas of our society, the typical response to discomfort or unhappiness is to put something in your mouth.

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Rebecca said...

My main suggestion for your breastfeeding doula families would be for them to be very informed and vigilant about any "routine" supplementation that might occur where they give birth. The nursery where I work wouldn't give a bottle without permission, but there are places that will...the more you work as a doula in your local facilities, and network with others who do, the more you'll learn about their particular policies.

With all families and formula feeders in particular, I think prenatal education is a key part of the solution. It's hard to tell a family that they've been overfeeding their baby when they're already doing it (and hard for them to believe it when "he's so happy!" = sleeping all the time because he's so overfed). Talking about normal volumes for the first ~3 days, and about how to calculate feeds thereafter based on baby's body weight, could be helpful in advance.