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Breast feeding is not extinct
Letters to the Editor
Breast feeding is not extinct
To the Editor: I am afraid that there are numerous misleading statements in the article by the Woodys on breast feeding (J. PEDIAT. 6g: 344, March, 1966). 1. " I n lying-in hospitals . . . demand feedings are impractical." Why are they? For many years the Jessop Maternity Hospital at Sheffield has employed self-demand feeding. What is the difficulty? I should m a k e it clear that at the Jessop Hospital all full-term babies are at the mother's side, so that as soon as they express a desire for food, the mothers pick them up and oblige. 2. "Uterine contractions with feeding are 'good' for the figure." I cannot see the connection. Uterine contractions during a feed in the puerperium are due to the action of oxytocin liberated as part of the draught reflex. 3. "Breast-fed infants are notoriously free of 'colic.' " If this refers to "3 months colic" or "evening colic," it is untrue. They are just as liable to colic as any other baby. 4. "When the infant is satisfied and can go 2 to 3 hours between feedings he is getting enough." This is untrue. Some babies are quite
of sufficiency of milk, neither is the "let-down." 8. "Chocolate, shellfish, nuts, some legumes fruits and tomatoes [taken by the mother 1 cause distress in the infant." What is the evidence for this statement? 9. "They [early neonatal (transitional) stools] are likely to cause excoriation of the buttocks." Surprisingly enough, they are less likely to cause it than the stools of bottle-fed babies. What is the rationale of using vitamin A and D ointment for the soreness? 10. There is confusion about the number of stools fully breast-fed babies may produce. The range is anything from 24 per day to one every 12 days. It does not depend just on the age. 11. Why put the baby on to the bottle after the fourth week? It seems extraordinary advice. What is wrong with weaning him gradually with cup and spoon (or just cup) when he is 4 or 5 months o l d - - i f there is enough breast milk? T h e r e are many good points in the a r t i c l e - but many misleading ones. 9
.
.
R. S. I L L I N G W O R T H D E P A R T M E N T OF CHILD I-IEALT~I T H E U N I V E R S I T Y OF S H E F F I E L D T H E C H I L D R E N ' S HOSPITAL
See E d i t o r ' s C o l u m n , p. 506
WESTERN BANK, SHEFFIELD, l 0 ENGLAND
content to starve without showing their dissatisfaction by crying or frequent feeds. It is essential to weigh a breast-fed baby regularly (e.g., once a week). The advice that scales should be forbidden is wrong. It is because of the danger that a breast-fed baby may underfeed that it is wrong to say that "the mother's ignorance of the quantity taken is another virtue of breast f e e d i n g " unless the baby is weighed regularly. 5. The advice about engorgement of the breast is dangerous and impractical. The mother cannot just pull out the nipple and express if the breast is severely engorged. 6. "Breast-fed babies swallow relatively little air while sucking." They swallow just as much as bottle-fed babies--and swallow a lot more if they suck too long on the breast or suck when the breast is empty. Why shouldn't they? 7. Leakage of milk (lactorrhea) is not a sign
To the Editor: There are so few articles on breast feeding in current medical literature that those of us who are friends of the practice are grateful for each addition; I am therefore hesitant to write critically of Norman and Hannah Woody's paper which appeared in the JOURNAL in March. A number of specific details do seem to bear comment. The authors state that inverted nipples and premature birth are contraindications to nursing. Inverted nipples can often be brought forward by the use of a Woolwich nipple shield worn during pregnancy. Healthy premature infants of about 4 pounds or more can nurse nicely. The mothers of smaller prematures can pump their milk for bottle feeding until the baby is old enough to nurse.
500
Volume 69
Number 3
"... at least one breast should be emptied at each feeding." It is a rare mother who can satisfy her baby on unilateral feedings. Most mothers should be taught that the baby should nurse about the same length of time at both breasts every feeding. The Woodys suggest that the baby be starved 12 hours, then given water, and first meet the breast at 16 hours. Why not start with an initial breast feeding as soon as mother and baby feel like it? In our local hospitals, mothers not infrequently nurse the baby in the first hour of life and it works fine. They further suggest limiting the nursings to 3 to 5 minutes until the third or fourth day. The Newtons 1 showed that prolonged early nursing did not increase the incidence of nipple soreness, and it decreases the incidence of engorgement. " . . . mild soap may be used before and after feedings." This would amount to 12 to 18 washings a day; quoting the Newtons again, they showed that this increased the incidence of sore nipples. T h e Woodys describe a hitherto unknown phenomenon of nurslings, " T h e Hungry Age," at 10 to 20 days of life when the mother is advised to supplement her nursing with bottles. I don't see this in the babies in my practice, possibly because they nurse for long periods at both breasts from the first days of life. What experienced nursing mothers often report is that breast milk diminishes if supplements are regularly offered, first because the baby who is satiated by bottle feedings nurses less often and so stimulates milk production less, and, second, because some babies learn that bottle milk comes rapidly and with less effort. They then nurse only briefly and turn away, expecting the bottle. This is probably the m o s t frequent cause of nursing failure after the first weeks of life. It can usually be avoided by using sugar water if a supplement is really needed to quiet a hungry baby on occasion. Milk supplements should be kept to an absolute minimum. "Breast-fed infants are notoriously free of ' c o l i c . ' " I wish this were true; my practice includes about 90 per cent breast-fed babies and I see all the colic I care to. "When the infant is satisfied and can go 2 to 3 hours between feedings, he is getting enough milk." Unfortunately, some babies are too docile for their own good. My partners and I have seen half a dozen babies calmly starving at the breast for weeks at a time. The changes in their
Letters" to the Editor
50 1
growth curves upon weaning to the bottle were startling. "Abdominal cramping shortly after feedings suggests that some maternal food is not agreeing with the baby." This is stated so often that it deserves rebuttal; I believe this is an exceedingly rare event, hard to prove, and deserving only a very skeptical hearing. "An old rule for duration of nursing is still good: It is urged for 3 months, encouraged for 6, permitted for 9." What arrogance for the doctor to "permit" nursing for 9 months! And why 9 months? Scores of mothers in our practice n u r s e for 1 or 2 years; the Sioux nursed for 5 or 6! Last, a comment is due about the excellent grandmother substitutes who may support the nursing mother in the absence of a knowledgeable physician. T h e LaLeche League of nursing mothers (Franklin Park, Illinois) is a superb source of information and help, authoritative in a way we mostly male pediatricians cannot match. Karen Pryor's book, Nursing Your Baby and Niles Newton's chapter on nursing in her Family Book o[ Child Care also deserve recommendation; doctors as well as mothers can read them with profit. EL/~ER R. GROSSMAN~ M.D.
1650 WALNUT ST. B E R K E L E Y 9~ C A L I F . ,
REFERENCE
1. Newton, M., and Newton, N.: The normal course and management of lactation, Clin. Obst. & Gynec. 5: 44, 1962. Reply
To the Editor: An article that fails to provoke letters to the editor is probably not worth writing and we are pleased to have stimulated Prof. Illingworth and Dr. Grossman. Since the former neatly enumerated his objections and the latter fonnd congruent areas for discontent, we will use Prof. Illingworth's numbers to identify our specific comments. 1. The difficulty, in the United States, is lack of nursing staff. 2. This natural stimulus for nursing mothers causes their uteri to involute quickly. 3. The problem here is one of semantics and both critics should have read on to the subsequent section on "evening fussing and crying." Breast-fed babies will fuss in the evening when they do not get enough milk; but "colic," which
Breast feeding is not extinct
To the Editor: I am afraid that there are numerous misleading statements in the article by the Woodys on breast feeding (J. PEDIAT. 6g: 344, March, 1966). 1. " I n lying-in hospitals . . . demand feedings are impractical." Why are they? For many years the Jessop Maternity Hospital at Sheffield has employed self-demand feeding. What is the difficulty? I should m a k e it clear that at the Jessop Hospital all full-term babies are at the mother's side, so that as soon as they express a desire for food, the mothers pick them up and oblige. 2. "Uterine contractions with feeding are 'good' for the figure." I cannot see the connection. Uterine contractions during a feed in the puerperium are due to the action of oxytocin liberated as part of the draught reflex. 3. "Breast-fed infants are notoriously free of 'colic.' " If this refers to "3 months colic" or "evening colic," it is untrue. They are just as liable to colic as any other baby. 4. "When the infant is satisfied and can go 2 to 3 hours between feedings he is getting enough." This is untrue. Some babies are quite
of sufficiency of milk, neither is the "let-down." 8. "Chocolate, shellfish, nuts, some legumes fruits and tomatoes [taken by the mother 1 cause distress in the infant." What is the evidence for this statement? 9. "They [early neonatal (transitional) stools] are likely to cause excoriation of the buttocks." Surprisingly enough, they are less likely to cause it than the stools of bottle-fed babies. What is the rationale of using vitamin A and D ointment for the soreness? 10. There is confusion about the number of stools fully breast-fed babies may produce. The range is anything from 24 per day to one every 12 days. It does not depend just on the age. 11. Why put the baby on to the bottle after the fourth week? It seems extraordinary advice. What is wrong with weaning him gradually with cup and spoon (or just cup) when he is 4 or 5 months o l d - - i f there is enough breast milk? T h e r e are many good points in the a r t i c l e - but many misleading ones. 9
.
.
R. S. I L L I N G W O R T H D E P A R T M E N T OF CHILD I-IEALT~I T H E U N I V E R S I T Y OF S H E F F I E L D T H E C H I L D R E N ' S HOSPITAL
See E d i t o r ' s C o l u m n , p. 506
WESTERN BANK, SHEFFIELD, l 0 ENGLAND
content to starve without showing their dissatisfaction by crying or frequent feeds. It is essential to weigh a breast-fed baby regularly (e.g., once a week). The advice that scales should be forbidden is wrong. It is because of the danger that a breast-fed baby may underfeed that it is wrong to say that "the mother's ignorance of the quantity taken is another virtue of breast f e e d i n g " unless the baby is weighed regularly. 5. The advice about engorgement of the breast is dangerous and impractical. The mother cannot just pull out the nipple and express if the breast is severely engorged. 6. "Breast-fed babies swallow relatively little air while sucking." They swallow just as much as bottle-fed babies--and swallow a lot more if they suck too long on the breast or suck when the breast is empty. Why shouldn't they? 7. Leakage of milk (lactorrhea) is not a sign
To the Editor: There are so few articles on breast feeding in current medical literature that those of us who are friends of the practice are grateful for each addition; I am therefore hesitant to write critically of Norman and Hannah Woody's paper which appeared in the JOURNAL in March. A number of specific details do seem to bear comment. The authors state that inverted nipples and premature birth are contraindications to nursing. Inverted nipples can often be brought forward by the use of a Woolwich nipple shield worn during pregnancy. Healthy premature infants of about 4 pounds or more can nurse nicely. The mothers of smaller prematures can pump their milk for bottle feeding until the baby is old enough to nurse.
500
Volume 69
Number 3
"... at least one breast should be emptied at each feeding." It is a rare mother who can satisfy her baby on unilateral feedings. Most mothers should be taught that the baby should nurse about the same length of time at both breasts every feeding. The Woodys suggest that the baby be starved 12 hours, then given water, and first meet the breast at 16 hours. Why not start with an initial breast feeding as soon as mother and baby feel like it? In our local hospitals, mothers not infrequently nurse the baby in the first hour of life and it works fine. They further suggest limiting the nursings to 3 to 5 minutes until the third or fourth day. The Newtons 1 showed that prolonged early nursing did not increase the incidence of nipple soreness, and it decreases the incidence of engorgement. " . . . mild soap may be used before and after feedings." This would amount to 12 to 18 washings a day; quoting the Newtons again, they showed that this increased the incidence of sore nipples. T h e Woodys describe a hitherto unknown phenomenon of nurslings, " T h e Hungry Age," at 10 to 20 days of life when the mother is advised to supplement her nursing with bottles. I don't see this in the babies in my practice, possibly because they nurse for long periods at both breasts from the first days of life. What experienced nursing mothers often report is that breast milk diminishes if supplements are regularly offered, first because the baby who is satiated by bottle feedings nurses less often and so stimulates milk production less, and, second, because some babies learn that bottle milk comes rapidly and with less effort. They then nurse only briefly and turn away, expecting the bottle. This is probably the m o s t frequent cause of nursing failure after the first weeks of life. It can usually be avoided by using sugar water if a supplement is really needed to quiet a hungry baby on occasion. Milk supplements should be kept to an absolute minimum. "Breast-fed infants are notoriously free of ' c o l i c . ' " I wish this were true; my practice includes about 90 per cent breast-fed babies and I see all the colic I care to. "When the infant is satisfied and can go 2 to 3 hours between feedings, he is getting enough milk." Unfortunately, some babies are too docile for their own good. My partners and I have seen half a dozen babies calmly starving at the breast for weeks at a time. The changes in their
Letters" to the Editor
50 1
growth curves upon weaning to the bottle were startling. "Abdominal cramping shortly after feedings suggests that some maternal food is not agreeing with the baby." This is stated so often that it deserves rebuttal; I believe this is an exceedingly rare event, hard to prove, and deserving only a very skeptical hearing. "An old rule for duration of nursing is still good: It is urged for 3 months, encouraged for 6, permitted for 9." What arrogance for the doctor to "permit" nursing for 9 months! And why 9 months? Scores of mothers in our practice n u r s e for 1 or 2 years; the Sioux nursed for 5 or 6! Last, a comment is due about the excellent grandmother substitutes who may support the nursing mother in the absence of a knowledgeable physician. T h e LaLeche League of nursing mothers (Franklin Park, Illinois) is a superb source of information and help, authoritative in a way we mostly male pediatricians cannot match. Karen Pryor's book, Nursing Your Baby and Niles Newton's chapter on nursing in her Family Book o[ Child Care also deserve recommendation; doctors as well as mothers can read them with profit. EL/~ER R. GROSSMAN~ M.D.
1650 WALNUT ST. B E R K E L E Y 9~ C A L I F . ,
REFERENCE
1. Newton, M., and Newton, N.: The normal course and management of lactation, Clin. Obst. & Gynec. 5: 44, 1962. Reply
To the Editor: An article that fails to provoke letters to the editor is probably not worth writing and we are pleased to have stimulated Prof. Illingworth and Dr. Grossman. Since the former neatly enumerated his objections and the latter fonnd congruent areas for discontent, we will use Prof. Illingworth's numbers to identify our specific comments. 1. The difficulty, in the United States, is lack of nursing staff. 2. This natural stimulus for nursing mothers causes their uteri to involute quickly. 3. The problem here is one of semantics and both critics should have read on to the subsequent section on "evening fussing and crying." Breast-fed babies will fuss in the evening when they do not get enough milk; but "colic," which