- Email: [email protected]
A review of the breastfeeding literature relevant to osteopathic practice
International Journal of Osteopathic Medicine 14 (2011) 61e66
Contents lists available at ScienceDirect
International Journal of Osteopathic Medicine journal homepage: www.elsevier.com/ijos
Review
A review of the breastfeeding literature relevant to osteopathic practice Denise Cornall* Victoria University, Osteopathic Medicine, 301 Flinders Lane, Melbourne, Australia
a r t i c l e i n f o
a b s t r a c t
Article history: Received 25 June 2009 Accepted 21 December 2010
Background: A review of the breastfeeding related literature was undertaken to provide background for a qualitative study that explores how osteopaths promote effective breastfeeding. Topics considered relevant to osteopathic practice are presented with the aim of informing and stimulating discussion and further inquiry. Data Sources and Selection: Information is drawn together from the following databases: Lactation Resource Centre of Australian Breastfeeding Association, Cinahl, Cochrane Library, and Medline. Qualitative and quantitative studies of all designs, government and professional association websites, and conference presentations are included as the aim is to generate a broad background on the biological and psychosocial aspects of breastfeeding that could impact on osteopathic practise. The theoretical literature is included in areas where little research is available. Conclusions: A strong evidence base promotes breastfeeding as important health behaviour for a mother and baby; influenced by many complex and sensitive biopsychosocial factors. The theoretical literature and studies that have investigated the biomechanics of breastfeeding provide a rationale for osteopathic treatment to facilitate effective breastfeeding; however little supportive research has been undertaken. Further well designed studies are needed to determine the role that osteopaths might play in supporting a motherebaby dyad to successfully breastfeed. Ó 2011 Elsevier Ltd. All rights reserved.
Keywords: Breastfeeding Osteopathy Paediatrics Manual therapy Infant
1. Introduction Discussion of breastfeeding will undoubtedly stimulate a variety of responses as it touches people’s lives in many different ways. It is a topic that reflects all the complexity of biology and psychosocial influences. Although natural, breastfeeding can be difficult for some mothers and babies, who might seek assistance from an osteopath. This situation has stimulated a research interest in exploring how osteopaths promote effective breastfeeding. This paper relates to a qualitative, grounded theory study that is currently underway in Melbourne, as part of a requirement for a postgraduate research degree. The study aims to generate a theoretical framework of osteopathic care for mother and baby dyads with breastfeeding difficulties, from the ground up (practice to theory). A review of the breastfeeding related literature was undertaken to provide a context for the study; hence it predominantly relates to health care in Australia and other similar developed countries. It is less a critique than an overview as literature is used in specific ways in a grounded theory study. A preliminary review is used to justify a need for the study and importantly, to sensitise the * Victoria University, PO Box 14428, Melbourne City MC, Victoria 8001, Australia. E-mail address: [email protected]. 1746-0689/$ e see front matter Ó 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijosm.2010.12.003
researcher to the issues, while allowing the concepts and hypotheses to emerge untainted from the data.1 The literature presented here is drawn together from the following databases: Lactation Resource Centre of Australian Breastfeeding Association, Cinahl, Cochrane Library, and Medline. Qualitative and quantitative studies of all designs, government and professional association websites, and conference presentations are included as the aim is to generate a broad background on the biological and psychosocial aspects of breastfeeding that could impact on osteopathic practice. Systematic reviews and meta-analysis of studies are used where possible to summarise research on broad topics such as the health benefits of breastfeeding and interventions to promote breastfeeding. The purposes of this paper are to discuss how breastfeeding related knowledge may impact on osteopathic practice, alert the osteopathic profession to the potential role that it might play in supporting families and women who choose to breastfeed their babies, and stimulate further research interests in this field. 2. Breastfeeding rates and recommendations Developed countries, in the early part of the twentieth century, saw a rapid decline in breastfeeding and increased use of artificial
62
D. Cornall / International Journal of Osteopathic Medicine 14 (2011) 61e66
infant feeding methods.2,3 Growing concern over decreasing breastfeeding rates led to the development of a number of international resolutions to support breastfeeding.4,5 The World Health Organisation (WHO), for example, recommends exclusive breastfeeding for the first six months of a baby’s life, with the introduction of complementary foods and continued breastfeeding thereafter.6 From a health perspective, once the benefits of breastfeeding are weighed against the risks of not receiving human milk, there are only a few rare contra-indications to breastfeeding.7 A review of the literature by Kramer and Kakuma,8 on the optimal duration of exclusive breastfeeding in developed countries, concludes that there were no apparent risks in recommending exclusive breastfeeding for the first six months of life. The WHO recommendation, outlined above, is the widely accepted benchmark for target breastfeeding rates found throughout the literature. 2.1. Australian breastfeeding rates and recommendations In Australia, a relatively high breastfeeding initiation rate of 88% has been reported.9 However, only 49% of infants continue to receive breast milk at six months, and 25% at one year.9,10 Similar breastfeeding rates have been found in the United States of America,11 Canada,12 and the United Kingdom13; reporting slightly lower initiation rates (75%), which drop to less than 25% of exclusively breastfed infants at six months of age. Although there has been a rise in Australian breastfeeding rates since the 1970’s,14 they have not significantly changed since 198315 and fall far short of the WHO recommendation, particularly with regard to duration of exclusive breastfeeding. The Commonwealth Government of Australia has taken a number of steps to support breastfeeding,16,17 most recently releasing ‘The Best Start’ report in August 2007.18 This report is based on findings from a parliamentary inquiry into how the government could improve the health of the Australian population through support for breastfeeding. The report concludes that breastfeeding is important for a baby’s health where it is possible, putting forward twenty-two recommendations to promote breastfeeding, and launched a Support Breastfeeding Mums Initiative. As a part of this initiative, Australia’s first 24 h, seven days a week, toll-free helpline for breastfeeding mothers commenced on March 20, 2009, in Melbourne.19 The helpline is run by the Australian Breastfeeding Association (ABA) supported by funding from the Commonwealth Government. 3. Advantages of breastfeeding Given the biological specificity of human milk, the direct benefits for infant nutrition, growth, immunity and improved developmental outcomes have been well addressed in the literature.7,14,20e22 A broader spectrum of the advantages of breastfeeding for babies, mothers, families and communities has also been well established and includes health, social, psychological, economic, and environmental benefits. Some of the benefits might be less well known, but this knowledge is important to health professionals, such as osteopaths, whose interests lie with preventative medicine and health promotion. 3.1. Long-term health benefits There is a growing interest in the preventative, long-term, health benefits of breastfeeding for both baby and mother. Systematic reviews of the literature7,8,23,24 and meta-analyses of studies25,26 suggest that the incidence of particular diseases is reduced in the infant, child or adult who was breastfed. Diseases are summarised as gastrointestinal infection,8,27 obesity,28e30 hypertension,25 lymphoma,
leukaemia,29 sudden infant death syndrome, diabetes (Types I and II), Hodgkin’s disease, hypercholesterolemia, and asthma.7,24 Maternal protective effects of breastfeeding are found for pre-menopausal breast and ovarian cancer7,21 and rheumatoid arthritis.24 The lower incidence of certain diseases, and improved health outcomes associated with breastfeeding, benefits the community by considerably reducing public health expenditure.27 It has been suggested that a healthier mother and baby, results in decreased parental absenteeism from work.16,31 Environmental advantages include reduced production and disposal of artificial feeding products.32 3.2. Psychological considerations The psychological benefits of breastfeeding are improved mother and baby bonding and reduced maternal reactions to stress. This is thought to be mediated by motherebaby skin-to-skin contact and hormonal influences.14,33 The breastfeeding mother’s endocrine state has been compared to that of a person with an overall lowered neuroendocrine response to stress,21,34 which is important when considering the adjustment required to the maternal role.35 For some women, breastfeeding success is expressed in terms of maternal enjoyment and infant satisfaction.36,37 In these studies, women saw breastfeeding as more than a means of feeding a baby; it ‘symbolised nurturing and caring and the embodiment of the maternal role attainment’37 (p.125). While uncommon, an unsuccessful breastfeeding experience can have significant negative psychological consequences. Women have expressed powerful and mixed feelings about breastfeeding difficulties, such as relief versus guilt, shame, grief, and a general sense of failure.36e38 For some women, these feelings took a long time to resolve.37,39 4. Breastfeeding success and difficulties Breastfeeding is both a biological and socially determined process. Research findings regarding the mother and baby’s physical capabilities to breastfeed will be presented, followed by a consideration of how this knowledge can be used to better appreciate how difficulties can arise and direct useful interventions to promote breastfeeding. Social and cultural influences on breastfeeding outcomes are also presented. 4.1. Biological factors of breastfeeding Breastfeeding difficulties can focus on the mother or baby, but in reality they are so closely inter-related that it is somewhat artificial to separate them. Virtually all mothers and healthy term babies have a physiological capacity to breastfeed successfully.2,14 Lactation is a complex function; it is influenced by emotions and involves learnt skills. The mother must first position her baby to enable him to attach effectively to the breast. The normal term newborn is born with reflexes, which must become integrated into learned behaviour, by practise at the breast. Once initiated, continued lactation relies on the sucking of the baby, which in turn, leads to hormonal releases, and milk ejection.40 A cross-sectional study of normal, healthy, exclusively breastfed one to six month old babies over a 24 h period reports a wide range of breastfeeding behaviours, milk production and milk fat content.41 The authors conclude that demand feeding is preferable to imposing feeding regimes that might not be appropriate for the individual needs of the motherebaby dyad. Babies with breastfeeding difficulties are typically described as fussy or unsettled,42,43 often creating considerable family stress which, in turn, further exacerbates the breastfeeding difficulties. The baby may continue to gain weight at a satisfactory rate, or may clearly fail to thrive. If a breastfed baby’s weight does not increase in
D. Cornall / International Journal of Osteopathic Medicine 14 (2011) 61e66
line with recommended guidelines, a diagnosis of insufficient milk supply (IMS) could be made. Supplementation of feeding with infant formula is usually recommended, which has been shown to be associated with an increased incidence of early cessation of breastfeeding.43 It can be difficult to determine the underlying cause of IMS, which may be physiologically induced, linked to incorrect feeding practises, and is also heavily influenced by socio-cultural factors.38 Often, mothers interpret their baby’s unsettled behaviour as a symptom of hunger, related to inadequate quantity and quality of breast milk.44 Concern about milk supply is also found to be related to women’s self-confidence in their physiological capabilities, particularly as it is not possible to precisely measure a breastfed baby’s milk intake.37 IMS is the most common reason given for stopping breastfeeding earlier than intended.3,38,43,45,46 4.2. Baby’s breastfeeding capabilities The mechanics of how the baby removes milk from the breast have been investigated by numerous studies using different technologies.40,47e50 Results of these studies improve our understanding of how the breastfeeding baby coordinates latch, suck, swallow and breathing. These behaviours are also consistently noted as key characteristics of effective breastfeeding, in the development of tools to measure breastfeeding.51e54 They form the basis for analysis of problems, particularly relevant to the musculoskeletal system and by deduction, the potential for manual therapeutic interventions. Findings concerning the baby’s breastfeeding actions are briefly summarised below. A baby’s mature nutritive sucking pattern consists of a series of bursts or group of sequential sucks interspersed with pauses, swallows and breaths in a highly organised, but individual, fashion. It involves coordination between many muscles of the tongue, pharynx, hyoid, anterior cervical region, and thoracic diaphragm. In particular, electromyography demonstrates most muscle activity occurs in the suprahyoid muscle groups of breastfeeding infants.49 Some babies with breastfeeding difficulties appear to feed more proficiently from a bottle than the breast. There is general agreement that feeding actions will be affected by the method of feeding: breast or bottle,49 but the differences remain poorly understood. It is postulated that as bottle feeding involves a relatively constant milk flow rate, a more adaptive suck and swallow response is required from a breastfeeding baby where milk flow rates are more variable.55 To successfully latch onto the breast, the baby must open the mouth wide to acquire a good mouthful of breast tissue, and create a seal with the bottom lip. The tongue must move forward as the jaw opens; its movements are described as peristaltic and pistonlike.14,49,50 The body of the tongue moves along the underside of the nipple and breast tissue in a posterior direction approximating the palate. It then moves rapidly away to generate a negative pressure, which, accompanied by lowering of the jaw, draws the nipple and milk contents into the mouth.40,50 Positive pressure from contraction of the mother’s milk ducts, also known as the let-down reflex, assists in delivery of milk into the oropharynx,40 and initiates swallowing. Swallowing consistently interrupts breathing, so the suck to swallow ratio will influence respiration.55 Successful coordination of these activities is underpinned by normal anatomy and appropriate neuromotor coordination. 4.3. Suck problems It has been postulated by osteopaths,56e62 medical physicians,63 and chiropractors64,65 that a baby’s response to stressful stimuli, and unresolved physiological disturbances might interfere with coordinated neuromotor activity that underpins the key breastfeeding behaviours. This view has been supported by some lactation
63
consultants,66e68 who report that babies do not always respond to the usual breastfeeding management strategies. These babies have become generally known as having ‘suck problems’. Applying osteopathic principles; somatic dysfunction69 of anatomically related structures, described in the preceding paragraphs could be implicated in a baby’s breastfeeding problems, and vice versa. Problems can be expressed in a number of ways, such as unsettled behaviour, increased respiratory effort, fatigue, and a dysfunctional suck.56,60,61 Suck problems are closely associated with maternal problems, such as sore nipples, breast engorgement, mastitis, and IMS.2,70e72 Maternal discomfort or pain can inhibit lactation via higher brain centres as well as directly alter milk composition and secretion.70 Osteopathic treatment of the mother to alleviate congestion in the breast by releasing tension in the connective tissues and ducts of the breast, reducing neural irritation, and stimulating circulation, and lymphatic drainage is advocated in the professional literature.61,73 4.4. Social and cultural factors The many factors that influence initiation and maintenance of breastfeeding identified in the literature include the mother’s early breastfeeding intentions,74 family and partner’s views, sexual factors,3,75 the mother’s education, socio-economic status, levels of social support, and experiences throughout the pregnancy, birth and the postnatal period.3,22,74 A commonly expressed view is that breastfeeding difficulties arise largely from social rather than individual reasons.76 Common impediments to breastfeeding include: feelings of embarrassment and adverse reactions to breastfeeding in public3,77; portrayal of the breast as a sexual object3,13,75; and the challenge of combining return to work and breastfeeding in a non supportive workplace environment.14,78 At some point, some of these obstacles may be perceived as disadvantages. With fewer than 50% of Australian women exclusively breastfeeding their babies to six months of age, this behaviour is no longer the norm and it can be challenging for individuals to go against social norms. These issues are not limited to recent times; infant feeding practises, such as wet nursing, have a long history of being shaped by different beliefs and contexts. They can be viewed as part of a wider debate concerning the changing role and image of women and negotiation about women’s choices.75 5. Interventions to promote breastfeeding Experiencing some problems particularly in the early weeks of breastfeeding is common,44,46 and establishing a successful mother and baby breastfeeding relationship is strongly linked to the mother’s motivation and access to appropriate support.44,74 Due to the complexity of issues involved, a multi-layered approach to promote breastfeeding is recommended.2,13,77 The infrastructure provided by governments and health agencies is a central starting point in educating and supporting women who want to breastfeed.79 An important example is the Baby Friendly Hospital Initiative (BFHI), which is based upon guidelines, developed by the WHO after a critical review of the available evidence, known as the “Ten Steps to Successful Breastfeeding”. The ‘ten steps’ summarise the maternity practises necessary to support breastfeeding80 and interested readers are strongly recommended to review them. In Australia, there are currently 73 health services accredited by the Australian College of Midwives as ‘baby friendly’.81 Breastfeeding information and support services are primarily provided by midwives in maternity hospitals throughout the antenatal and postpartum periods. Women are usually discharged at day three after an uncomplicated birth of a normal baby. Mother and baby are then reviewed by the Maternal Child Health Nurse (MCHN) at a local health care centre at
64
D. Cornall / International Journal of Osteopathic Medicine 14 (2011) 61e66
recommended and regular intervals.43,82,83 For mothers and babies experiencing difficulties at this time, the MCHN might offer support or refer to specialised breastfeeding services,84,85 private lactation consultants, or in some cases, an osteopath. Numerous studies involving different interventions for increasing initiation and duration of breastfeeding are to be found in the literature. Generally, they include professional education programs and practical skills demonstrations in small group workshop formats and on a one-on-one basis, as well as peer support strategies. These interventions can be broadly considered within three different time frames: antenatal, hospital postpartum and later postnatal when mothers and babies return home. It is not possible to consider them in detail here, so some key points are made, with more attention paid to studies undertaken in the postnatal period as this is the time when osteopathic treatment is most likely to be relevant. 5.1. Interventions to support breastfeeding in the antenatal and hospital postpartum periods A systematic review of the literature, including seven trials involving 1388 women in America, reports that educational programs which take place before the first breastfeed are effective at increasing breastfeeding initiation rates.86 Research indicates that infant feeding decisions are made primarily before, or in the early stages of pregnancy,3 which suggests that the timing of breastfeeding education is important.74 For example, it has been suggested that school based breastfeeding education87 would promote positive social attitudes to breastfeeding and increase breastfeeding knowledge for men as well as women. This is important given the evidence that partners, fathers and families have an important influence on women’s breastfeeding decisions.3,74,77 Immediately after the birth of a baby, breastfeeding support strategies are based on implementation of hospital policies, such as the BFHI, already discussed. Midwives assume the role of teacher to new mothers43,88 and some studies have looked at how the midwife’s approach to this role can affect breastfeeding outcomes.82,88,89 The first hour of life has been identified as a time of heightened physiological responses that initiate the mother and baby bond and the start of a successful breastfeeding partnership.90 Early skin-to-skin contact is implicated in this process. A systematic review of eight studies show that babies are more likely to be breastfed, and for longer if they are exposed to skin-to-skin contact within 24 h of birth.91 5.2. Interventions to support breastfeeding in the postnatal period Systematic reviews of the literature, involving 34 clinical trials from 14 countries92 and 80 international studies93 conclude that both lay and professional support in the postnatal period, individually and combined, significantly extend the duration of any breastfeeding; however its effects on exclusive breastfeeding are less clear. Both reviews92,93 report concerns with the variable quality of included studies. In particular, reporting of breastfeeding and health outcomes is inconsistent. No definitional refinement of breastfeeding outcomes, being reported as either partial or exclusive, is offered. Further investigation into the content, timing, and delivery of support interventions is also recommended. Professional strategies, outlined in the above reviews, consist of combinations of counselling and practical support, provided face-to-face, via telephone and during home visits. They are provided at differing specified points in time by a variety of medical, nursing and complementary health professionals. Of note, clinical trials that involve support provided by manual therapists are not reported. Only a small number of studies that investigate a manual therapy treatment approach to promote breastfeeding were found.
5.3. Manual therapy to support breastfeeding Breastfeeding difficulties are discussed within the osteopathic theoretical literature, where they are implicated in the wider spectrum of somatic dysfunction and unsettled behaviour of infants, often linked to birth trauma.58e60,62,94e97 Many of the conclusions drawn from this literature are based on clinical experiences and anecdotal evidence and cannot be substantiated; however, this body of knowledge has stimulated much thought and debate. Others have postulated a link between birth trauma, particularly involving the structures of the cranium and upper cervical spine, and breastfeeding difficulties.98e100 One of these authors, Beidermann,42 proposes a model called ‘kinematic imbalances due to suboccipital stress’ (KISS). This syndrome is based on observational studies of typical developmental patterns in otherwise healthy babies and children. KISS is characterised by a sequential set of symptoms, including unsettled behaviour, breastfeeding problems and colic, in the infant up to two months of age. It is postulated that dysfunction of the upper cervical spine and associated altered proprioceptive input, reduced ability to direct head movements toward stimulatory sources, and muscular tension all influence the baby’s behaviour and development. It is also contended that manual therapy successfully alleviates many of these symptoms; however supporting evidence for all of these conclusions is missing. Investigations into chiropractic treatment for babies with breastfeeding difficulties include three case studies101e103 and two clinical trials.65,99 Studies involving osteopathic treatment involve three case studies104e106 and one pilot clinical trial.107 The osteopathic case studies share some common characteristics. They involve very young infants, aged 12 h, nine and eleven-days old; a history of a difficult labour; and a baby who demonstrated a weak or dysfunctional suck that persisted after assistance from a lactation consultant. All report that the initial findings of somatic dysfunction resolved, and the baby was able to breastfeed effectively after one or two treatments. A brief summary of two clinical trials is presented, as, although they have some limitations, these studies offer some preliminary insights into the investigation of manual therapy as a suitable intervention to support breastfeeding. Fraval107 undertook a pilot clinical trial to investigate the use of measuring and comparing differences in the pre- and post-feed breast milk fat concentration of breastfeeding infants as a means of determining their sucking efficiency. The study involves twelve healthy term breastfed infants: an experimental group of six, referred by a lactation consultant with a dysfunctional suck, and a control group of six, who were feeding without difficulty. The experimental group received osteopathic treatment over one month. The initial small difference in this group’s pre-post-feed milk fat measures increased following a course of osteopathic treatment, to a level that was comparable with the ‘normal’ group. Using linear regression and Tstatistics analysis, a significant relationship between osteopathic treatment and the changes in pre-post-feed milk fat concentrations was found. The author contended that results could be attributed to an improved infant sucking ability, and recommended that the study be extended to a larger cohort. This pilot study investigates a simple, noninvasive empirical measure of an infant’s sucking ability; however the validity of the measure as a research tool and the treatment effects of osteopathic treatment require further on-going scrutiny. The challenge of drawing conclusions about specific treatment effects on breastfeeding outcomes, which are difficult to define and influenced by many variables, is highlighted by the following clinical trial. Miller et al.99 conducted a descriptive, clinical case series study of 114 infants, who were referred by a medical practitioner to a chiropractic clinic, with suboptimal breastfeeding. This diagnosis was made on the basis that the infant could not be fed exclusively at the breast. Infants underwent a biomechanical evaluation at the chiropractic
D. Cornall / International Journal of Osteopathic Medicine 14 (2011) 61e66
clinic and clinical findings were documented and later discussed. They then received routine care plus a course of chiropractic manual therapy treatment. Outcome measures involved the mother’s report on rating of improvement in breastfeeding (or not) on a 10-point numerical rating scale. After intervention, exclusive breastfeeding was reported for 89 infants (78%) within a 2-week time period. All mothers reported some improvement. The authors concluded that cooperative multidisciplinary care was valuable in supporting women who want to exclusively breastfeed their babies, and that chiropractic treatment might be useful adjuvant therapy for breastfeeding problems with a biomechanical component. A recommendation was made for future randomised controlled study designs to more accurately determine the role of manual therapy in promoting breastfeeding. Studies that investigate manual therapy as a strategy to assist with breastfeeding difficulties share a common rationale for treatment based on an appreciation of the biomechanical component of breastfeeding. Positive breastfeeding outcomes following manual therapy have been reported; however the reliability of these conclusions requires further investigation. Research has been unable to establish the effects of specific interventions for breastfeeding difficulties, given the lack of valid and reliable breastfeeding outcome measures, the complexity of other contributing factors such as psychosocial support, the involvement of other health practitioners, and the natural course of the condition. All studies did not address long-term follow up; an important issue considering the decline in duration of breastfeeding at six months. Future studies need to be designed with these issues in mind. 6. Conclusion The literature emphasises the importance of breastfeeding as preventative health behaviour. It also highlights many biological, social and cultural factors that influence women’s infant feeding practises and decisions. Current research has identified the need for a multifaceted approach to promote breastfeeding, particularly after discharge from hospital when breastfeeding rates rapidly decline. Osteopathy is one such intervention of which little evidence based information is available. As osteopathy’s main interest lies with the neuromusculoskeletal system in health and illness, it would seem that the osteopath could play a part in facilitating a mother and baby’s physical capabilities for effective breastfeeding; however further research is needed. Up-to-date knowledge of the breastfeeding evidence base will better prepare the osteopath to offer meaningful support to breastfeeding mothers and babies in other ways. Some examples are educating parents, advising mothers of support services, building relationships with MCHNs and lactation consultants, and demonstrating a better understanding of the challenges that some breastfeeding women face, while taking into account family and social influences. Acknowledgements I would like to acknowledge the School of Nursing & Midwifery at Victoria University for supporting my postgraduate research interests and my research supervisors for their encouragement and advice. Support: This review paper was undertaken by the author as part of a postgraduate doctoral research degree, at Victoria University, Melbourne. References 1. McCann TV, Clark E. Grounded theory in nursing research: part 1- methodology. Nurse Res 2003;11:7e18. 2. Smith JW, Tully MR. Midwifery management of breastfeeding: using the evidence. J Midwifery Womens Health 2001;46:423e38.
65
3. Thomson A. Why don’t women breastfeed? In: Robinson S, Thomson A, editors. Midwives, research and Childbirth, vol. 1. London: Chapman and Hall; 1989. p. 215e39. 4. United Nations Children’s Fund. Facts for life, breastfeeding. [accessed 20.05.09]. 5. World Health Organisation. Baby-friendly hospital initiative . [accessed 20.05.09]. 6. World Health Organisation.. The optimal duration of exclusive breastfeeding, report of an expert consultation. Department of Nutrition For Health And Development, ; 2001 [accessed 22.01.07]. 7. American Academy of Pediatrics.. Policy statement, breastfeeding and the use of human milk. Pediatrics 2005;115:496e506. 8. Kramer M, Kakuma R. Optimal duration of exclusive breastfeeding (review), Cochrane database of systematic reviews; 2002. doi:10.1002/14651858.CD003517. Art. No.: CD003517. 9. Australian Institute of Health and Welfare.. Profile of the nutritional status of children and adolescents. Canberra: Commonwealth of Australia; 2007. 10. Amir LH, Donath S. Breastfeeding and the introduction of solids in Australian infants: data from the 2001 National Health Survey. Aust N Z J Public Health 2005;29:171e5. 11. Ruowei L, Darling N, Maurice E, Barker L, Gummer-Strawn L. Breastfeeding rates in the United States by characteristics of the child, mother, or family: the 2002 national immunization survey. Pediatrics 2005;115:31e7. 12. Dennis C, Faux S. Development and psychometric testing of the breastfeeding self-efficacy scale. Res Nurs Health 1999;22:399e409. 13. Hunt F. Breastfeeding and society. J Pediatr Nurs 2006;18:24e6. 14. Bodribb W, editor. Breastfeeding management. Melbourne: Australian Breastfeeding Association; 2004. 15. National Health and Medical Research Council.. Report of the working party on implementation of the WHO international code of marketing of breast-milk substitutes. Canberra: Australian Government Publishing Service; 1985. 16. Commonwealth Department of Health and Aged Care.. Balancing breastfeeding and work: important information for workplaces. Canberra: Commonwealth of Australia; 2000. 17. National Health and Medical Research Council.. Dietary guidelines for children and adolescents in Australia incorporating the infant feeding guidelines for health workers. Canberra: Australian Government Publishing Service; 2003. 18. Parliament of the Commonwealth of Australia.. Standing Committee on Health and Ageing. The best start. Report on the inquiry into the health benefits of breastfeeding. Commonwealth of Australia, ; 2007 [accessed 20.05.09]. 19. Australian Breastfeeding Association. Health minister Nicola Roxon launches first national breastfeeding helpline . [accessed 09.04.09]. 20. Riordan J, Auerbach K. Breastfeeding and human lactation. Boston: Jones and Bartlett; 1993. 21. Blincoe A. The health benefits of breastfeeding for mothers. Br J Midwifery 2005;13:398e401. 22. Dettwyler K. When to wean: biological versus cultural perspectives. Clin Obstet Gynecol 2004;47:712e22. 23. Romano A. Research summaries for normal birth. J Perinat Educ 2006;15:46e9. 24. Van Rossum C, Buchner FL, Hoekstra J. Quantification of health effects of breastfeeding. Bilthoven. The Netherlands: Ministry of Public Health, Welfare and Sports; 2006. Report No.: RIVM 350040001. 25. Martin R, Gunnell D, Davey Smith G. Breastfeeding in infancy and blood pressure in later life: systematic review and meta-analysis. Am J Epidemiol 2005;161:15e26. 26. Schlickau J, Wilson M. Breastfeeding as health-promoting behaviour for Hispanic women: literature review. J Adv Nurs 2005;52:200e10. 27. Drane D. Breastfeeding and formula feeding: a preliminary economic analysis. Breastfeed Rev 1997;5. 28. Australian Breastfeeding Association., http://www.breastfeeding.asn.au/ advocacy/obesity.html [accessed 05.11.06], Melbourne, 2002. 29. Moore ML. Research update. Current research continues to support breastfeeding benefits. J Perinat Med 2001;10:38e41. 30. Oddy W, Scott J, Graham K, Binns C. Breastfeeding influences on growth and health at one year of age. Breastfeed Rev 2006;14:15e23. 31. Abdulwadud O, Simpson M. Interventions in the workplace to support breastfeeding for women in employment (protocol), Cochrane database of systematic reviews; 2006. doi:10.1002/14651858.CD006177. Art No: CD006177. 32. Radford A. The ecological impact of bottle feeding. Breastfeed Rev 1992;2: 204e8. 33. O’Brien M. Psychology, the mother and breastfeeding duration. Topics in Breastfeeding. Melbourne. Lactation Resource Centre, Australian Breastfeeding Association; 2006. 34. Nissen E, Gustavsson P, Windstrom A, Uvnas-Moberg K. Oxytocin, prolactin, milk production and their relationship with personality traits in women after vaginal delivery or caesarean section. J Psychosom Obstet Gynaecol 1998;19:49e58. 35. Carolan M. Later motherhood, the experience of parturition for first time mothers aged >35 years. Aust Midwifery 2003;16:17e21. 36. Leff EW, Gagne MP, Jefferis SC. Maternal perceptions of successful breastfeeding. J Hum Lact 1994;10:99e104.
66
D. Cornall / International Journal of Osteopathic Medicine 14 (2011) 61e66
37. Mozingo JN, Davis MW, Droppleman PG, Merideth A. It wasn’t working". Women’s experiences with short-term breastfeeding. Matern Child Nurs 2000;25:120e6. May/June. 38. Dykes F, Williams C. Falling by the wayside: a phenomenological exploration of perceived breast-milk inadequacy. Midwifery 1999;15:232e46. 39. Mc Guire E. Feelings of failure. In: . Hot topic, vol. 24. Melbourne: Lactation Resource Centre, Australian Breastfeeding Association; 2007. 40. Ramsay D, Hartmann P. Milk removal from the breast. Breastfeed Rev 2005;13:5e7. 41. Kent J, Mitoulas L, Cregan M, Ramsay D, Doherty D, Hartmann P. Volume and frequency of breastfeedings and fat content of breast milk throughout the day. Pediatrics 2006;117:387e95. 42. Biedermann H. The KISS syndrome: symptoms and signs. In: Biedermann H, editor. Manual therapy in children. London: Churchill Livingstone; 2004. p. 285e302. 43. James J. An analysis of the breastfeeding practices of a group of mothers living in Victoria, Australia. Breastfeed Rev 2004;12:19e27. 44. Binns C, Scott J. Breastfeeding: reasons for stopping and problems along the way. Breastfeed Rev 2002;10:13e9. 45. Katsumi M, Koichiro F, Madoka S. Sucking behaviour at breast during the early newborn period affects later breastfeeding rate and duration of breastfeeding. Pediatr Int 2004;46:15e20. 46. Graffy J, Taylor J. What information, advice, and support do women want with breastfeeding? Birth 2005;32:179e86. 47. Bu’Lock F, Woolridge M, Baun JD. Development of co-ordination of sucking, swallowing and breathing: ultrasound study of term and preterm infants. Dev Med Child Neurol 1990;32:669e78. 48. Eishima K. The analysis of sucking behaviour in newborn infants. Early Hum Dev 1991;27:163e73. 49. Tamura Y, Horikawa Y, Yoshida S. Co-ordination of tongue movements and peri-oral muscle activities during nutritive sucking. Dev Med Child Neurol 1996;38:503e10. 50. Woolridge M. The ’anatomy’ of infant sucking. Midwifery 1986;2:164e71. 51. Creedy D, Dennis C, Blyth R, Moyle W, Pratt J, DeVries S. Psychometric characteristics of the breastfeeding self-efficacy scale: data from an Australian sample. Res Nurs Health 2003;26:143e52. 52. Dennis C. The breastfeeding self-efficacy scale: psychometric assessment of the short form. J Obstet Gynaecol 2003;32:734e44. 53. Moran V, Dinwoodie K, Bramwell R, Dykes F. A critical analysis of the content of the tools that measure breastfeeding interaction. Midwifery 2000;16: 260e8. 54. Riordan J, Bibb D, Miller M, Rawlins T. Predicting breastfeeding duration using the LATCH breastfeeding assessment tool. J Hum Lact 2001;17:20e3. 55. Glass RP, Wolf LS. Incoordination of sucking/swallowing, and breathing as an etiology for breastfeeding difficulty. J Hum Lact 1994;10:185e9. 56. Carreiro J. An osteopathic approach to children. Edinburgh: Elsevier Science; 2003. 57. Centres S, Morrelli MA, Vallard-Hix C, Seffinger M. General pediatrics. In: Ward RC, editor. Foundations for osteopathic medicine. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2003. 58. Frymann V. Relation of disturbances of craniosacral mechanism to symptomatology of the newborn: study of 1250 infants. J Am Osteopath Assoc 1966;65:1059e75. 59. Lay AM. Cranial field. In: Ward RC, editor. Foundations for osteopathic medicine. Baltimore: Williams & Wilkins; 1997. p. 901e14. 60. Magoun HI. Osteopathy in the cranial field. 3rd ed. Kirksville Missouri: The Journal Printing Company; 1976. 61. Mitha N. Accompanying the mother before, during and after pregnancy. In: Moeckel E, Mitha N, editors. Textbook of pediatric osteopathy. London: Elsevier; 2008. p. 15e28. 62. Turner S. The beginnings: osteopathic care of children. An overview. J Osteopathic Educ 1994;4:7e13. 63. Beidermann H, editor. Manual therapy in children. London: Churchill Livingstone; 2004. 64. Davies N. Chiropractic paediatrics. A clinical handbook. London: Churchill Livingstone; 2000. 65. Vallone S. Chiropractic evaluation and treatment of musculoskeletal dysfunction in infants demonstrating difficulty breastfeeding. J Clin Chiropractic Pediatrics 2004;6:349e68. 66. Heselev P. Infant feeding & special therapy: assessment & treatment of infants with feeding difficulties related to postural variations, Milk, Mammals and Marsupials: An International Perspective Annual General Meeting of the International Lactation Consultant Association; 2003. 67. Noble R, Bovey A. An overview of the successful management of suck problems in breastfed babies. Breastfeeding-ancient art-modern miracle, ABA International Breastfeeding Conference, 2001:152e8. 68. Palmer M. Recognizing and resolving infant suck difficulties. J Hum Lact 2002;18:166e7. 69. DiGiovanna EL. An encyclopedia of osteopathy. Indianapolis: American Academy of Osteopathy; 2001. 70. Duffy E, Percival P, Kernshaw E. Positive effects of an antenatal group teaching session on postnatal nipple pain, nipple trauma and breastfeeding rates. Midwifery 1997;13:189e96. 71. Righard L, Alade M. Sucking technique and its effects on success of breastfeeding. Birth 1992 December;19.
72. Thorley V. Latch and the fear response: overcoming an obstacle to successful breastfeeding. Breastfeed Rev 2005;13:9e11. 73. Stone C. Visceral and obstetric osteopathy. London: Churchill Livingstone; 2007. 74. Scott J, Landers M, Hughes R, Binns C. Factors associated with breastfeeding at discharge and duration of breastfeeding. J Paediatr Child Health 2001;37:254e61. 75. Carter P. Feminism, breasts and breast-feeding. London: Macmillan; 1995. 76. Renfrew M, Fisher C, Arms S. Breastfeeding: getting breastfeeding right for you. California: Celestial Arts; 1990. 77. Lavender T, McFadden C, Baker L. Breastfeeding and family life. Matern Child Nutr 2006;2:145e55. 78. Visness CM, Kennedy KI. Maternal employment and breast-feeding: findings from the 1988 national maternal and infant health survey. Am J Public Health 1997;87:945e50. 79. Thomas P. Suck on this. Ecologist 2006;36:22e33. 80. World Health Organisation. Evidence for the ten steps to successful breastfeeding,; 2007 [accessed 22.01.07]. 81. Baby Friendly Health Initiative.. Protecting, promoting and supporting breastfeeding in Australia, http://www.bfhi.org.au/ [accessed 08.09.10]. 82. Henderson A, Stamp G, Pincombe J. Postpartum positioning and attachment education for increasing breastfeeding: a randomized trial. Birth 2001;28: 236e42. 83. Victorian Government Health Information. Maternal and child health, child health record. State Government of Victoria, Department of Human Services, ; 1999 [accessed 09.05.09. 88. Fletcher D, Harris H. The implementation of the HOT program at the Royal Women’s Hospital. Breastfeed Rev 2000;8:19e23. 89. Inch S, Law S, Wallace L. Hands off! The breastfeeding best start project (1). Pract Midwife 2003;6:17e9. 90. World Alliance for Breastfeeding Action.. Breastfeeding: the first hour. WABA World Breastfeeding Week 2007;August 1e7. 91. Anderson G, Moore E, Hepworth J, Bergman N. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev; 2003. doi:10.1002/14651858. CD003519. 92. Britton C, McCormick F, Renfrew M, Wade A, King S. Support for breastfeeding mothers (review). Cochrane Database Syst Rev; 2007. doi:10.1002/ 14651858.CD001141.pub3. Art. Np.: CD001141. 93. National Institute for Health and Clinical Excellence.. Breastfeeding for longer: what works? Systematic review summary. United Kingdom: National Institute for Health and Clinical Excellence, ; 2005 [accessed 02.08.07]. 94. Frymann V. The trauma of birth. Osteopathic Ann 1976;5:197e205. 95. Sullivan C. Introducing the cranial approach in osteopathy and treatment of infants and mothers. Complement Ther Nurs Midwifery 1997;3:72e6. 96. Moeckel E, Mitha N, editors. Textbook of pediatric osteopathy. London: Churchill Livingstone; 2008. 97. Sergueef N. Cranial osteopathy for infants, children and adolescents. New York: Churchill Livingstone; 2007. 98. Biedermann H. Manual therapy in children: proposals for an etiologic model. J Manipulative Physiol Ther; 2005:28. 99. Miller J, Miller L, Sulesund A-K, Yevtushenko A. Contribution of chiropractic therapy to resolving suboptimal breastfeeding: a case series of 114 infants. J Manipulative Physiol Ther; 2009:32. 100. Smith L. Impact of birthing practices on the breastfeeding dyad. J Midwifery Women’s Health 2007;52:621e30. 101. Cuhel J, Powell M. Chiropractic management of an infant patient experiencing colic and difficulty breastfeeding: a case report. J Clin Chiropractic Pediatrics; 1997:150e4. 102. Hewitt E. Chiropractic care for infants with dysfunctional nursing: a case series. J Clin Chiropractic Pediatrics 1999;4:241e5. 103. Scheader W. Chiropractic management of an infant experiencing breastfeeding difficulties with colic: a case study. J Clin Chiropractic Pediatrics 1999;4:241e4. 104. Fraval M. Osteopathy in the cranial field, a case study. Aust J Osteopathy 1991;July:10e2. 105. Palmer C. Case study of a newborn baby with a sucking disorder treated with cranial osteopathy. Breastfeeding e The natural state. Hobart: ABA International Breastfeeding Conference; 2005. 106. Rivera-Martinez S. Practical applications of cranial osteopathy. In: Di Giovanna E, Schiowitz S, Dowling D, editors. An osteopathic approach to diagnosis and treatment. 3rd ed. New York: Lippincott Williams & Wilkins; 2005. 107. Fraval M. A pilot study: osteopathic treatment of infants with a sucking dysfunction. Am Acad Osteopathy 1998;Summer:25e33.
Contents lists available at ScienceDirect
International Journal of Osteopathic Medicine journal homepage: www.elsevier.com/ijos
Review
A review of the breastfeeding literature relevant to osteopathic practice Denise Cornall* Victoria University, Osteopathic Medicine, 301 Flinders Lane, Melbourne, Australia
a r t i c l e i n f o
a b s t r a c t
Article history: Received 25 June 2009 Accepted 21 December 2010
Background: A review of the breastfeeding related literature was undertaken to provide background for a qualitative study that explores how osteopaths promote effective breastfeeding. Topics considered relevant to osteopathic practice are presented with the aim of informing and stimulating discussion and further inquiry. Data Sources and Selection: Information is drawn together from the following databases: Lactation Resource Centre of Australian Breastfeeding Association, Cinahl, Cochrane Library, and Medline. Qualitative and quantitative studies of all designs, government and professional association websites, and conference presentations are included as the aim is to generate a broad background on the biological and psychosocial aspects of breastfeeding that could impact on osteopathic practise. The theoretical literature is included in areas where little research is available. Conclusions: A strong evidence base promotes breastfeeding as important health behaviour for a mother and baby; influenced by many complex and sensitive biopsychosocial factors. The theoretical literature and studies that have investigated the biomechanics of breastfeeding provide a rationale for osteopathic treatment to facilitate effective breastfeeding; however little supportive research has been undertaken. Further well designed studies are needed to determine the role that osteopaths might play in supporting a motherebaby dyad to successfully breastfeed. Ó 2011 Elsevier Ltd. All rights reserved.
Keywords: Breastfeeding Osteopathy Paediatrics Manual therapy Infant
1. Introduction Discussion of breastfeeding will undoubtedly stimulate a variety of responses as it touches people’s lives in many different ways. It is a topic that reflects all the complexity of biology and psychosocial influences. Although natural, breastfeeding can be difficult for some mothers and babies, who might seek assistance from an osteopath. This situation has stimulated a research interest in exploring how osteopaths promote effective breastfeeding. This paper relates to a qualitative, grounded theory study that is currently underway in Melbourne, as part of a requirement for a postgraduate research degree. The study aims to generate a theoretical framework of osteopathic care for mother and baby dyads with breastfeeding difficulties, from the ground up (practice to theory). A review of the breastfeeding related literature was undertaken to provide a context for the study; hence it predominantly relates to health care in Australia and other similar developed countries. It is less a critique than an overview as literature is used in specific ways in a grounded theory study. A preliminary review is used to justify a need for the study and importantly, to sensitise the * Victoria University, PO Box 14428, Melbourne City MC, Victoria 8001, Australia. E-mail address: [email protected]. 1746-0689/$ e see front matter Ó 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijosm.2010.12.003
researcher to the issues, while allowing the concepts and hypotheses to emerge untainted from the data.1 The literature presented here is drawn together from the following databases: Lactation Resource Centre of Australian Breastfeeding Association, Cinahl, Cochrane Library, and Medline. Qualitative and quantitative studies of all designs, government and professional association websites, and conference presentations are included as the aim is to generate a broad background on the biological and psychosocial aspects of breastfeeding that could impact on osteopathic practice. Systematic reviews and meta-analysis of studies are used where possible to summarise research on broad topics such as the health benefits of breastfeeding and interventions to promote breastfeeding. The purposes of this paper are to discuss how breastfeeding related knowledge may impact on osteopathic practice, alert the osteopathic profession to the potential role that it might play in supporting families and women who choose to breastfeed their babies, and stimulate further research interests in this field. 2. Breastfeeding rates and recommendations Developed countries, in the early part of the twentieth century, saw a rapid decline in breastfeeding and increased use of artificial
62
D. Cornall / International Journal of Osteopathic Medicine 14 (2011) 61e66
infant feeding methods.2,3 Growing concern over decreasing breastfeeding rates led to the development of a number of international resolutions to support breastfeeding.4,5 The World Health Organisation (WHO), for example, recommends exclusive breastfeeding for the first six months of a baby’s life, with the introduction of complementary foods and continued breastfeeding thereafter.6 From a health perspective, once the benefits of breastfeeding are weighed against the risks of not receiving human milk, there are only a few rare contra-indications to breastfeeding.7 A review of the literature by Kramer and Kakuma,8 on the optimal duration of exclusive breastfeeding in developed countries, concludes that there were no apparent risks in recommending exclusive breastfeeding for the first six months of life. The WHO recommendation, outlined above, is the widely accepted benchmark for target breastfeeding rates found throughout the literature. 2.1. Australian breastfeeding rates and recommendations In Australia, a relatively high breastfeeding initiation rate of 88% has been reported.9 However, only 49% of infants continue to receive breast milk at six months, and 25% at one year.9,10 Similar breastfeeding rates have been found in the United States of America,11 Canada,12 and the United Kingdom13; reporting slightly lower initiation rates (75%), which drop to less than 25% of exclusively breastfed infants at six months of age. Although there has been a rise in Australian breastfeeding rates since the 1970’s,14 they have not significantly changed since 198315 and fall far short of the WHO recommendation, particularly with regard to duration of exclusive breastfeeding. The Commonwealth Government of Australia has taken a number of steps to support breastfeeding,16,17 most recently releasing ‘The Best Start’ report in August 2007.18 This report is based on findings from a parliamentary inquiry into how the government could improve the health of the Australian population through support for breastfeeding. The report concludes that breastfeeding is important for a baby’s health where it is possible, putting forward twenty-two recommendations to promote breastfeeding, and launched a Support Breastfeeding Mums Initiative. As a part of this initiative, Australia’s first 24 h, seven days a week, toll-free helpline for breastfeeding mothers commenced on March 20, 2009, in Melbourne.19 The helpline is run by the Australian Breastfeeding Association (ABA) supported by funding from the Commonwealth Government. 3. Advantages of breastfeeding Given the biological specificity of human milk, the direct benefits for infant nutrition, growth, immunity and improved developmental outcomes have been well addressed in the literature.7,14,20e22 A broader spectrum of the advantages of breastfeeding for babies, mothers, families and communities has also been well established and includes health, social, psychological, economic, and environmental benefits. Some of the benefits might be less well known, but this knowledge is important to health professionals, such as osteopaths, whose interests lie with preventative medicine and health promotion. 3.1. Long-term health benefits There is a growing interest in the preventative, long-term, health benefits of breastfeeding for both baby and mother. Systematic reviews of the literature7,8,23,24 and meta-analyses of studies25,26 suggest that the incidence of particular diseases is reduced in the infant, child or adult who was breastfed. Diseases are summarised as gastrointestinal infection,8,27 obesity,28e30 hypertension,25 lymphoma,
leukaemia,29 sudden infant death syndrome, diabetes (Types I and II), Hodgkin’s disease, hypercholesterolemia, and asthma.7,24 Maternal protective effects of breastfeeding are found for pre-menopausal breast and ovarian cancer7,21 and rheumatoid arthritis.24 The lower incidence of certain diseases, and improved health outcomes associated with breastfeeding, benefits the community by considerably reducing public health expenditure.27 It has been suggested that a healthier mother and baby, results in decreased parental absenteeism from work.16,31 Environmental advantages include reduced production and disposal of artificial feeding products.32 3.2. Psychological considerations The psychological benefits of breastfeeding are improved mother and baby bonding and reduced maternal reactions to stress. This is thought to be mediated by motherebaby skin-to-skin contact and hormonal influences.14,33 The breastfeeding mother’s endocrine state has been compared to that of a person with an overall lowered neuroendocrine response to stress,21,34 which is important when considering the adjustment required to the maternal role.35 For some women, breastfeeding success is expressed in terms of maternal enjoyment and infant satisfaction.36,37 In these studies, women saw breastfeeding as more than a means of feeding a baby; it ‘symbolised nurturing and caring and the embodiment of the maternal role attainment’37 (p.125). While uncommon, an unsuccessful breastfeeding experience can have significant negative psychological consequences. Women have expressed powerful and mixed feelings about breastfeeding difficulties, such as relief versus guilt, shame, grief, and a general sense of failure.36e38 For some women, these feelings took a long time to resolve.37,39 4. Breastfeeding success and difficulties Breastfeeding is both a biological and socially determined process. Research findings regarding the mother and baby’s physical capabilities to breastfeed will be presented, followed by a consideration of how this knowledge can be used to better appreciate how difficulties can arise and direct useful interventions to promote breastfeeding. Social and cultural influences on breastfeeding outcomes are also presented. 4.1. Biological factors of breastfeeding Breastfeeding difficulties can focus on the mother or baby, but in reality they are so closely inter-related that it is somewhat artificial to separate them. Virtually all mothers and healthy term babies have a physiological capacity to breastfeed successfully.2,14 Lactation is a complex function; it is influenced by emotions and involves learnt skills. The mother must first position her baby to enable him to attach effectively to the breast. The normal term newborn is born with reflexes, which must become integrated into learned behaviour, by practise at the breast. Once initiated, continued lactation relies on the sucking of the baby, which in turn, leads to hormonal releases, and milk ejection.40 A cross-sectional study of normal, healthy, exclusively breastfed one to six month old babies over a 24 h period reports a wide range of breastfeeding behaviours, milk production and milk fat content.41 The authors conclude that demand feeding is preferable to imposing feeding regimes that might not be appropriate for the individual needs of the motherebaby dyad. Babies with breastfeeding difficulties are typically described as fussy or unsettled,42,43 often creating considerable family stress which, in turn, further exacerbates the breastfeeding difficulties. The baby may continue to gain weight at a satisfactory rate, or may clearly fail to thrive. If a breastfed baby’s weight does not increase in
D. Cornall / International Journal of Osteopathic Medicine 14 (2011) 61e66
line with recommended guidelines, a diagnosis of insufficient milk supply (IMS) could be made. Supplementation of feeding with infant formula is usually recommended, which has been shown to be associated with an increased incidence of early cessation of breastfeeding.43 It can be difficult to determine the underlying cause of IMS, which may be physiologically induced, linked to incorrect feeding practises, and is also heavily influenced by socio-cultural factors.38 Often, mothers interpret their baby’s unsettled behaviour as a symptom of hunger, related to inadequate quantity and quality of breast milk.44 Concern about milk supply is also found to be related to women’s self-confidence in their physiological capabilities, particularly as it is not possible to precisely measure a breastfed baby’s milk intake.37 IMS is the most common reason given for stopping breastfeeding earlier than intended.3,38,43,45,46 4.2. Baby’s breastfeeding capabilities The mechanics of how the baby removes milk from the breast have been investigated by numerous studies using different technologies.40,47e50 Results of these studies improve our understanding of how the breastfeeding baby coordinates latch, suck, swallow and breathing. These behaviours are also consistently noted as key characteristics of effective breastfeeding, in the development of tools to measure breastfeeding.51e54 They form the basis for analysis of problems, particularly relevant to the musculoskeletal system and by deduction, the potential for manual therapeutic interventions. Findings concerning the baby’s breastfeeding actions are briefly summarised below. A baby’s mature nutritive sucking pattern consists of a series of bursts or group of sequential sucks interspersed with pauses, swallows and breaths in a highly organised, but individual, fashion. It involves coordination between many muscles of the tongue, pharynx, hyoid, anterior cervical region, and thoracic diaphragm. In particular, electromyography demonstrates most muscle activity occurs in the suprahyoid muscle groups of breastfeeding infants.49 Some babies with breastfeeding difficulties appear to feed more proficiently from a bottle than the breast. There is general agreement that feeding actions will be affected by the method of feeding: breast or bottle,49 but the differences remain poorly understood. It is postulated that as bottle feeding involves a relatively constant milk flow rate, a more adaptive suck and swallow response is required from a breastfeeding baby where milk flow rates are more variable.55 To successfully latch onto the breast, the baby must open the mouth wide to acquire a good mouthful of breast tissue, and create a seal with the bottom lip. The tongue must move forward as the jaw opens; its movements are described as peristaltic and pistonlike.14,49,50 The body of the tongue moves along the underside of the nipple and breast tissue in a posterior direction approximating the palate. It then moves rapidly away to generate a negative pressure, which, accompanied by lowering of the jaw, draws the nipple and milk contents into the mouth.40,50 Positive pressure from contraction of the mother’s milk ducts, also known as the let-down reflex, assists in delivery of milk into the oropharynx,40 and initiates swallowing. Swallowing consistently interrupts breathing, so the suck to swallow ratio will influence respiration.55 Successful coordination of these activities is underpinned by normal anatomy and appropriate neuromotor coordination. 4.3. Suck problems It has been postulated by osteopaths,56e62 medical physicians,63 and chiropractors64,65 that a baby’s response to stressful stimuli, and unresolved physiological disturbances might interfere with coordinated neuromotor activity that underpins the key breastfeeding behaviours. This view has been supported by some lactation
63
consultants,66e68 who report that babies do not always respond to the usual breastfeeding management strategies. These babies have become generally known as having ‘suck problems’. Applying osteopathic principles; somatic dysfunction69 of anatomically related structures, described in the preceding paragraphs could be implicated in a baby’s breastfeeding problems, and vice versa. Problems can be expressed in a number of ways, such as unsettled behaviour, increased respiratory effort, fatigue, and a dysfunctional suck.56,60,61 Suck problems are closely associated with maternal problems, such as sore nipples, breast engorgement, mastitis, and IMS.2,70e72 Maternal discomfort or pain can inhibit lactation via higher brain centres as well as directly alter milk composition and secretion.70 Osteopathic treatment of the mother to alleviate congestion in the breast by releasing tension in the connective tissues and ducts of the breast, reducing neural irritation, and stimulating circulation, and lymphatic drainage is advocated in the professional literature.61,73 4.4. Social and cultural factors The many factors that influence initiation and maintenance of breastfeeding identified in the literature include the mother’s early breastfeeding intentions,74 family and partner’s views, sexual factors,3,75 the mother’s education, socio-economic status, levels of social support, and experiences throughout the pregnancy, birth and the postnatal period.3,22,74 A commonly expressed view is that breastfeeding difficulties arise largely from social rather than individual reasons.76 Common impediments to breastfeeding include: feelings of embarrassment and adverse reactions to breastfeeding in public3,77; portrayal of the breast as a sexual object3,13,75; and the challenge of combining return to work and breastfeeding in a non supportive workplace environment.14,78 At some point, some of these obstacles may be perceived as disadvantages. With fewer than 50% of Australian women exclusively breastfeeding their babies to six months of age, this behaviour is no longer the norm and it can be challenging for individuals to go against social norms. These issues are not limited to recent times; infant feeding practises, such as wet nursing, have a long history of being shaped by different beliefs and contexts. They can be viewed as part of a wider debate concerning the changing role and image of women and negotiation about women’s choices.75 5. Interventions to promote breastfeeding Experiencing some problems particularly in the early weeks of breastfeeding is common,44,46 and establishing a successful mother and baby breastfeeding relationship is strongly linked to the mother’s motivation and access to appropriate support.44,74 Due to the complexity of issues involved, a multi-layered approach to promote breastfeeding is recommended.2,13,77 The infrastructure provided by governments and health agencies is a central starting point in educating and supporting women who want to breastfeed.79 An important example is the Baby Friendly Hospital Initiative (BFHI), which is based upon guidelines, developed by the WHO after a critical review of the available evidence, known as the “Ten Steps to Successful Breastfeeding”. The ‘ten steps’ summarise the maternity practises necessary to support breastfeeding80 and interested readers are strongly recommended to review them. In Australia, there are currently 73 health services accredited by the Australian College of Midwives as ‘baby friendly’.81 Breastfeeding information and support services are primarily provided by midwives in maternity hospitals throughout the antenatal and postpartum periods. Women are usually discharged at day three after an uncomplicated birth of a normal baby. Mother and baby are then reviewed by the Maternal Child Health Nurse (MCHN) at a local health care centre at
64
D. Cornall / International Journal of Osteopathic Medicine 14 (2011) 61e66
recommended and regular intervals.43,82,83 For mothers and babies experiencing difficulties at this time, the MCHN might offer support or refer to specialised breastfeeding services,84,85 private lactation consultants, or in some cases, an osteopath. Numerous studies involving different interventions for increasing initiation and duration of breastfeeding are to be found in the literature. Generally, they include professional education programs and practical skills demonstrations in small group workshop formats and on a one-on-one basis, as well as peer support strategies. These interventions can be broadly considered within three different time frames: antenatal, hospital postpartum and later postnatal when mothers and babies return home. It is not possible to consider them in detail here, so some key points are made, with more attention paid to studies undertaken in the postnatal period as this is the time when osteopathic treatment is most likely to be relevant. 5.1. Interventions to support breastfeeding in the antenatal and hospital postpartum periods A systematic review of the literature, including seven trials involving 1388 women in America, reports that educational programs which take place before the first breastfeed are effective at increasing breastfeeding initiation rates.86 Research indicates that infant feeding decisions are made primarily before, or in the early stages of pregnancy,3 which suggests that the timing of breastfeeding education is important.74 For example, it has been suggested that school based breastfeeding education87 would promote positive social attitudes to breastfeeding and increase breastfeeding knowledge for men as well as women. This is important given the evidence that partners, fathers and families have an important influence on women’s breastfeeding decisions.3,74,77 Immediately after the birth of a baby, breastfeeding support strategies are based on implementation of hospital policies, such as the BFHI, already discussed. Midwives assume the role of teacher to new mothers43,88 and some studies have looked at how the midwife’s approach to this role can affect breastfeeding outcomes.82,88,89 The first hour of life has been identified as a time of heightened physiological responses that initiate the mother and baby bond and the start of a successful breastfeeding partnership.90 Early skin-to-skin contact is implicated in this process. A systematic review of eight studies show that babies are more likely to be breastfed, and for longer if they are exposed to skin-to-skin contact within 24 h of birth.91 5.2. Interventions to support breastfeeding in the postnatal period Systematic reviews of the literature, involving 34 clinical trials from 14 countries92 and 80 international studies93 conclude that both lay and professional support in the postnatal period, individually and combined, significantly extend the duration of any breastfeeding; however its effects on exclusive breastfeeding are less clear. Both reviews92,93 report concerns with the variable quality of included studies. In particular, reporting of breastfeeding and health outcomes is inconsistent. No definitional refinement of breastfeeding outcomes, being reported as either partial or exclusive, is offered. Further investigation into the content, timing, and delivery of support interventions is also recommended. Professional strategies, outlined in the above reviews, consist of combinations of counselling and practical support, provided face-to-face, via telephone and during home visits. They are provided at differing specified points in time by a variety of medical, nursing and complementary health professionals. Of note, clinical trials that involve support provided by manual therapists are not reported. Only a small number of studies that investigate a manual therapy treatment approach to promote breastfeeding were found.
5.3. Manual therapy to support breastfeeding Breastfeeding difficulties are discussed within the osteopathic theoretical literature, where they are implicated in the wider spectrum of somatic dysfunction and unsettled behaviour of infants, often linked to birth trauma.58e60,62,94e97 Many of the conclusions drawn from this literature are based on clinical experiences and anecdotal evidence and cannot be substantiated; however, this body of knowledge has stimulated much thought and debate. Others have postulated a link between birth trauma, particularly involving the structures of the cranium and upper cervical spine, and breastfeeding difficulties.98e100 One of these authors, Beidermann,42 proposes a model called ‘kinematic imbalances due to suboccipital stress’ (KISS). This syndrome is based on observational studies of typical developmental patterns in otherwise healthy babies and children. KISS is characterised by a sequential set of symptoms, including unsettled behaviour, breastfeeding problems and colic, in the infant up to two months of age. It is postulated that dysfunction of the upper cervical spine and associated altered proprioceptive input, reduced ability to direct head movements toward stimulatory sources, and muscular tension all influence the baby’s behaviour and development. It is also contended that manual therapy successfully alleviates many of these symptoms; however supporting evidence for all of these conclusions is missing. Investigations into chiropractic treatment for babies with breastfeeding difficulties include three case studies101e103 and two clinical trials.65,99 Studies involving osteopathic treatment involve three case studies104e106 and one pilot clinical trial.107 The osteopathic case studies share some common characteristics. They involve very young infants, aged 12 h, nine and eleven-days old; a history of a difficult labour; and a baby who demonstrated a weak or dysfunctional suck that persisted after assistance from a lactation consultant. All report that the initial findings of somatic dysfunction resolved, and the baby was able to breastfeed effectively after one or two treatments. A brief summary of two clinical trials is presented, as, although they have some limitations, these studies offer some preliminary insights into the investigation of manual therapy as a suitable intervention to support breastfeeding. Fraval107 undertook a pilot clinical trial to investigate the use of measuring and comparing differences in the pre- and post-feed breast milk fat concentration of breastfeeding infants as a means of determining their sucking efficiency. The study involves twelve healthy term breastfed infants: an experimental group of six, referred by a lactation consultant with a dysfunctional suck, and a control group of six, who were feeding without difficulty. The experimental group received osteopathic treatment over one month. The initial small difference in this group’s pre-post-feed milk fat measures increased following a course of osteopathic treatment, to a level that was comparable with the ‘normal’ group. Using linear regression and Tstatistics analysis, a significant relationship between osteopathic treatment and the changes in pre-post-feed milk fat concentrations was found. The author contended that results could be attributed to an improved infant sucking ability, and recommended that the study be extended to a larger cohort. This pilot study investigates a simple, noninvasive empirical measure of an infant’s sucking ability; however the validity of the measure as a research tool and the treatment effects of osteopathic treatment require further on-going scrutiny. The challenge of drawing conclusions about specific treatment effects on breastfeeding outcomes, which are difficult to define and influenced by many variables, is highlighted by the following clinical trial. Miller et al.99 conducted a descriptive, clinical case series study of 114 infants, who were referred by a medical practitioner to a chiropractic clinic, with suboptimal breastfeeding. This diagnosis was made on the basis that the infant could not be fed exclusively at the breast. Infants underwent a biomechanical evaluation at the chiropractic
D. Cornall / International Journal of Osteopathic Medicine 14 (2011) 61e66
clinic and clinical findings were documented and later discussed. They then received routine care plus a course of chiropractic manual therapy treatment. Outcome measures involved the mother’s report on rating of improvement in breastfeeding (or not) on a 10-point numerical rating scale. After intervention, exclusive breastfeeding was reported for 89 infants (78%) within a 2-week time period. All mothers reported some improvement. The authors concluded that cooperative multidisciplinary care was valuable in supporting women who want to exclusively breastfeed their babies, and that chiropractic treatment might be useful adjuvant therapy for breastfeeding problems with a biomechanical component. A recommendation was made for future randomised controlled study designs to more accurately determine the role of manual therapy in promoting breastfeeding. Studies that investigate manual therapy as a strategy to assist with breastfeeding difficulties share a common rationale for treatment based on an appreciation of the biomechanical component of breastfeeding. Positive breastfeeding outcomes following manual therapy have been reported; however the reliability of these conclusions requires further investigation. Research has been unable to establish the effects of specific interventions for breastfeeding difficulties, given the lack of valid and reliable breastfeeding outcome measures, the complexity of other contributing factors such as psychosocial support, the involvement of other health practitioners, and the natural course of the condition. All studies did not address long-term follow up; an important issue considering the decline in duration of breastfeeding at six months. Future studies need to be designed with these issues in mind. 6. Conclusion The literature emphasises the importance of breastfeeding as preventative health behaviour. It also highlights many biological, social and cultural factors that influence women’s infant feeding practises and decisions. Current research has identified the need for a multifaceted approach to promote breastfeeding, particularly after discharge from hospital when breastfeeding rates rapidly decline. Osteopathy is one such intervention of which little evidence based information is available. As osteopathy’s main interest lies with the neuromusculoskeletal system in health and illness, it would seem that the osteopath could play a part in facilitating a mother and baby’s physical capabilities for effective breastfeeding; however further research is needed. Up-to-date knowledge of the breastfeeding evidence base will better prepare the osteopath to offer meaningful support to breastfeeding mothers and babies in other ways. Some examples are educating parents, advising mothers of support services, building relationships with MCHNs and lactation consultants, and demonstrating a better understanding of the challenges that some breastfeeding women face, while taking into account family and social influences. Acknowledgements I would like to acknowledge the School of Nursing & Midwifery at Victoria University for supporting my postgraduate research interests and my research supervisors for their encouragement and advice. Support: This review paper was undertaken by the author as part of a postgraduate doctoral research degree, at Victoria University, Melbourne. References 1. McCann TV, Clark E. Grounded theory in nursing research: part 1- methodology. Nurse Res 2003;11:7e18. 2. Smith JW, Tully MR. Midwifery management of breastfeeding: using the evidence. J Midwifery Womens Health 2001;46:423e38.
65
3. Thomson A. Why don’t women breastfeed? In: Robinson S, Thomson A, editors. Midwives, research and Childbirth, vol. 1. London: Chapman and Hall; 1989. p. 215e39. 4. United Nations Children’s Fund. Facts for life, breastfeeding
66
D. Cornall / International Journal of Osteopathic Medicine 14 (2011) 61e66
37. Mozingo JN, Davis MW, Droppleman PG, Merideth A. It wasn’t working". Women’s experiences with short-term breastfeeding. Matern Child Nurs 2000;25:120e6. May/June. 38. Dykes F, Williams C. Falling by the wayside: a phenomenological exploration of perceived breast-milk inadequacy. Midwifery 1999;15:232e46. 39. Mc Guire E. Feelings of failure. In: . Hot topic, vol. 24. Melbourne: Lactation Resource Centre, Australian Breastfeeding Association; 2007. 40. Ramsay D, Hartmann P. Milk removal from the breast. Breastfeed Rev 2005;13:5e7. 41. Kent J, Mitoulas L, Cregan M, Ramsay D, Doherty D, Hartmann P. Volume and frequency of breastfeedings and fat content of breast milk throughout the day. Pediatrics 2006;117:387e95. 42. Biedermann H. The KISS syndrome: symptoms and signs. In: Biedermann H, editor. Manual therapy in children. London: Churchill Livingstone; 2004. p. 285e302. 43. James J. An analysis of the breastfeeding practices of a group of mothers living in Victoria, Australia. Breastfeed Rev 2004;12:19e27. 44. Binns C, Scott J. Breastfeeding: reasons for stopping and problems along the way. Breastfeed Rev 2002;10:13e9. 45. Katsumi M, Koichiro F, Madoka S. Sucking behaviour at breast during the early newborn period affects later breastfeeding rate and duration of breastfeeding. Pediatr Int 2004;46:15e20. 46. Graffy J, Taylor J. What information, advice, and support do women want with breastfeeding? Birth 2005;32:179e86. 47. Bu’Lock F, Woolridge M, Baun JD. Development of co-ordination of sucking, swallowing and breathing: ultrasound study of term and preterm infants. Dev Med Child Neurol 1990;32:669e78. 48. Eishima K. The analysis of sucking behaviour in newborn infants. Early Hum Dev 1991;27:163e73. 49. Tamura Y, Horikawa Y, Yoshida S. Co-ordination of tongue movements and peri-oral muscle activities during nutritive sucking. Dev Med Child Neurol 1996;38:503e10. 50. Woolridge M. The ’anatomy’ of infant sucking. Midwifery 1986;2:164e71. 51. Creedy D, Dennis C, Blyth R, Moyle W, Pratt J, DeVries S. Psychometric characteristics of the breastfeeding self-efficacy scale: data from an Australian sample. Res Nurs Health 2003;26:143e52. 52. Dennis C. The breastfeeding self-efficacy scale: psychometric assessment of the short form. J Obstet Gynaecol 2003;32:734e44. 53. Moran V, Dinwoodie K, Bramwell R, Dykes F. A critical analysis of the content of the tools that measure breastfeeding interaction. Midwifery 2000;16: 260e8. 54. Riordan J, Bibb D, Miller M, Rawlins T. Predicting breastfeeding duration using the LATCH breastfeeding assessment tool. J Hum Lact 2001;17:20e3. 55. Glass RP, Wolf LS. Incoordination of sucking/swallowing, and breathing as an etiology for breastfeeding difficulty. J Hum Lact 1994;10:185e9. 56. Carreiro J. An osteopathic approach to children. Edinburgh: Elsevier Science; 2003. 57. Centres S, Morrelli MA, Vallard-Hix C, Seffinger M. General pediatrics. In: Ward RC, editor. Foundations for osteopathic medicine. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2003. 58. Frymann V. Relation of disturbances of craniosacral mechanism to symptomatology of the newborn: study of 1250 infants. J Am Osteopath Assoc 1966;65:1059e75. 59. Lay AM. Cranial field. In: Ward RC, editor. Foundations for osteopathic medicine. Baltimore: Williams & Wilkins; 1997. p. 901e14. 60. Magoun HI. Osteopathy in the cranial field. 3rd ed. Kirksville Missouri: The Journal Printing Company; 1976. 61. Mitha N. Accompanying the mother before, during and after pregnancy. In: Moeckel E, Mitha N, editors. Textbook of pediatric osteopathy. London: Elsevier; 2008. p. 15e28. 62. Turner S. The beginnings: osteopathic care of children. An overview. J Osteopathic Educ 1994;4:7e13. 63. Beidermann H, editor. Manual therapy in children. London: Churchill Livingstone; 2004. 64. Davies N. Chiropractic paediatrics. A clinical handbook. London: Churchill Livingstone; 2000. 65. Vallone S. Chiropractic evaluation and treatment of musculoskeletal dysfunction in infants demonstrating difficulty breastfeeding. J Clin Chiropractic Pediatrics 2004;6:349e68. 66. Heselev P. Infant feeding & special therapy: assessment & treatment of infants with feeding difficulties related to postural variations, Milk, Mammals and Marsupials: An International Perspective Annual General Meeting of the International Lactation Consultant Association; 2003. 67. Noble R, Bovey A. An overview of the successful management of suck problems in breastfed babies. Breastfeeding-ancient art-modern miracle, ABA International Breastfeeding Conference, 2001:152e8. 68. Palmer M. Recognizing and resolving infant suck difficulties. J Hum Lact 2002;18:166e7. 69. DiGiovanna EL. An encyclopedia of osteopathy. Indianapolis: American Academy of Osteopathy; 2001. 70. Duffy E, Percival P, Kernshaw E. Positive effects of an antenatal group teaching session on postnatal nipple pain, nipple trauma and breastfeeding rates. Midwifery 1997;13:189e96. 71. Righard L, Alade M. Sucking technique and its effects on success of breastfeeding. Birth 1992 December;19.
72. Thorley V. Latch and the fear response: overcoming an obstacle to successful breastfeeding. Breastfeed Rev 2005;13:9e11. 73. Stone C. Visceral and obstetric osteopathy. London: Churchill Livingstone; 2007. 74. Scott J, Landers M, Hughes R, Binns C. Factors associated with breastfeeding at discharge and duration of breastfeeding. J Paediatr Child Health 2001;37:254e61. 75. Carter P. Feminism, breasts and breast-feeding. London: Macmillan; 1995. 76. Renfrew M, Fisher C, Arms S. Breastfeeding: getting breastfeeding right for you. California: Celestial Arts; 1990. 77. Lavender T, McFadden C, Baker L. Breastfeeding and family life. Matern Child Nutr 2006;2:145e55. 78. Visness CM, Kennedy KI. Maternal employment and breast-feeding: findings from the 1988 national maternal and infant health survey. Am J Public Health 1997;87:945e50. 79. Thomas P. Suck on this. Ecologist 2006;36:22e33. 80. World Health Organisation. Evidence for the ten steps to successful breastfeeding,