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The importance of rest in the initiation of breast feeding
THE
IMPORTANCE
OF REST IN THE FEEDING
INITIATION
C. B. DARNER, M.D., AND G. WILSON HUNTER, FARGO, N. DAK. (From St. Luke’s Hospital
OF BREAST
M.D., F.A.C.S.,
and the Fargo Clinici
A
LTHOUGH the benefits of breast feeding newborn babies have been repeatedly stressed by a number of writers, need for emphasizing this physiologic and important function continues. We had the opportunity, during 1941, to make some interesting observations concerning the possible effect of rest and isolation on nursing mothers. During the encephalitis epidemic, all visitors except husbands of patients were banned from the maternity floor of St. Luke’s Hospital. It was noted in that period that a fewer number of mothers failed to furnish a complete supply of breast milk for their babies; the authors studied the records of the last 100 patients delivered during this restriction and compared the results with 100 consecutive cases selected earlier in the year as a control group. Even in the control group a large percentage of babies left the hospital supplied by maternal feedings entirely. The authors have always stressed the importance of nursing, and mothers were given every encouragement to follow this normal function and procedure. Discussion of Data Before one attempts to evaluate the more significant statistical data (obtained from this study), he should note that all factors, other than visiting restrictions, which might be expected to influence lactation, were approximately equal in both groups of patients. All patients were discharged on the ninth or tenth day, as a rule. Average age and parity were the same. Maternal morbidity was 3 per cent in each group. There was a slightly lower incidence of operative deliveries in the control cases. It might also be pertinent to mention that the infant morbidity consisted of 3 casesof impetigo, all occurring among the controls. The authors attribute in part the high percentage of nursing mothers to the fact that they are in close association with a pediatrician who recognizes the value of mother’s milk. From Table I one notes that the babies delivered before the visiting restrictions were inaugurated suffered a definitely greater initial weight loss and were further under birth weight at the time of discharge than the babies delivered after the ban was inaugurated. This conclusion is reflected in the fact that 41 per cent of the latter group of infants regained their birth weight at the end of nine or ten days, as compared 117
118
AMERICAN
JOURNAL
OF
OBSTETRICS
AND
____
Initial weight loss (Gm.) Average Gm. below birth weight at discharge Per cent regaining birth weight at discharge
PERIOD OF VISITING RESTRICTIONS
I-
NO
1 : I
/1~
308.7 81.2 27.0 ___
GYNECOLOGY
_-.~_--__-~.-. PERIOD OF \‘I,SITIP;G HESTRICTIOKS
~.
41.1 -
_-.-
I~IFP'ERI~;LNCE
22g.bl -37.7
-__---.
-~
-----;-g;-;j
-~~-- -43.5 14.7
__--_
.--
with only 27 per cent in the former group. These differences are significant when one considers that most babies in both groups had comparable weight variations and that these average figures are the result of much greater weight difference in a smaller group of babies. The smaller group of infants who have lost, more and gained less are those babies who make up the inevitable feeding problems. The ones most. susceptible to all infant diseasesand infections are the babies who have the greatest need for an adequate breast supply.
PERIOD OF VISITING RESTRICTIONS
Average amounts of breast milk (daily) at discharge
NO
1 I
499.3 C.C. -
PERIOD OF VISITING KF,STR.ICTIONS
556.0 C.C.
DIFk-EKENCK
-
__---
---..-56.7 C.C.
In Table II are listed the average twenty-four-hour outputs of hrcast milk in the two groups of mothers. The figures tend to confirm t,hc more satisfactory feeding of infants by undisturbed mothers. The mothers who did not suffer the distractions and mental esertions of entertaining the sewing circle or bridge club were able to produce the greater breast suPPlY* TABLE
III.
PERCENTAGE
OF
BABIES I
Per cent of infants receiving artificial feedings Per cent of infants receiving complementary feedings
ON
ARTIFICIAL
PERIOD OF NO VISITING RESTRICTIONS
AND
COMPLEMENTAKY EExDrr;GS ____.-- __--..~ PERXOD OF VISITING DIFFERENCE RESTRICTIONS
12.0
12.0
0.0
22.0
4.0
18.0
___-___-_._-~~-------
~-..
There apparently is a certain percentage of women who are totally unable to nurse, either because they selfishly refuse to try, or because of a systemic disease which precludes nursing, or because of a primary agalactia. Weiss and HSlzel state that it is generally recognized that agalactia of a primary nature is a rare experience. More frequently there is a variable degree of primary hgpogalactia. Benoit has said that 90 per cent of infants should be breast fed on leaving the hospital, and the writers feel that by repeated emphasis on the benefits of breast
DARNER
AND
HUNTER:
BREAST
119
FEEDING
feeding they have approached the approximate limit of 90 per cent for several years. Consequently, the restriction of visitors has made no significant change in the group of babies receiving artificial feedings, as borne out in Table III. There are, however, less than one-fifth as many infants discharged with complementary feedings necessitated by inadequate milk supply as formerly. Note that the authors do not use complementary feedings for full-term infants during the first three days or at any other time unless the condition of the mother indicates some degree of hypogalactia. This emphasizes the apparent fact that the physical and mental fatigue induced by the efforts of the patient to entertain her visitors has the result of reducing the breast supply below the point of adequacy. Those same mothers, well rested in the hospital, might never have had to bother with the tasks of formula making plus breast feeding. This benefit is all the more significant in the light of the generally recognized fart that once a baby is well started on a complementary bottle, it often ends up on the bottle alone. TABLE
IV.
PERC'ENTAGE
OF MOTHERS
I
Mothers able to nurse with1 no complementary feeding Mothers able to nurse with complementary feeding Total mothers who nursed completely and partially
WHO
PERIOD OF NO VISITING RESTRICIYONS 66.0 22.0 88.0
NURSED
I
COMPLETELY
PERIOD OF VISITING RESTRICTIONS 84.0
I
4.0 88.0
OR PARTIALLY
DIFFERENCE 18.0 18.0 0.0
Table IV emphasizes t,he facts that certain mothers are totally unable to nurse and that complete rest eliminates the use of complementary bottles for many patients.
Conclusions
and Summary
1. The advantages of breast feeding for both infant and mother have been re-emphasized. 2. The records of 100 consecut,ive babies delivered during a period in which visitors mere banned are compared with those of 100 consecutive cases delivcrcd when no such restrictions were in force. 3. Infants delivered of mothers not disturbed by visitors more frequently regained their birth weight at discharge and suffered a smaller initial weight loss. 4. Undisturbed mothers had a more abundant supply of breast milk. 5. Although the percentage of artificial feedings was unchanged, the percentage of complementary feedings was reduced four-fifths by t,he restrictions. 6. Visiting restrictions must be taken into account when the physician considers the problem of instituting breast feedings.
120
AMERICAN
JOURNAL
OF’ OBSTETRIC8
AND
GYNECOLOGY
Bibliography 1. 3. 3. 4. 5. 6. 7.
Guthrie, Sylvia K.: Clin. J. London 65: ‘703, 191-X. Grulee Clifford G: Journal-Lancet 54: 681, 19%. Rob&on, Edith C.: Am. J. Dis. Child. 59: 1002, 19-10. Desfosses, P.: Presse mBd. 45: 601, 193i. de Petinto, M. P.: Med. Ibera 2: 29, 1928. Benoit, R.: Union m&l. du Canada 69: 175, 1940. Weiss, F., and Hiilzel, A.: Jahrb. f. Kinderh. 146: 98, 1.936.
VITAMIN
B IN B.
HEARTBURN
I?. HART, KU., (Frovn th.e Uniwrsity
OF
PREGNANCY$’
WINTER PARK, E’LA. of Louisr~iZl~ Clbaics)
IXTEEN prenatal patients complained of annoying heartburn with a duration of from two davs to t,wo months, and on an average S two weeks. All but t,hree were”in the last, half of gestation. The usual of
treatment of alkalies, as used in nonpregnant, individuals, proved notably inefficient when tried. Two of the group had previously had clinical pellagra, and they attributed their symptoms to this. They were given large doses of the B complex in the t’oun of a yeast extract plus 200 mg. of nicotinir acid daily. They were completely relieved of all symptoms but were kept on smaller maintenance doses throughout t.heir pregnancies. Eaeh was approximately seven months pregnant when first seen. Of the remainder of the patients, one received a TRNGPt tablet after meals and was relieved of a heartburn of two months’ standing wit.hin one week. Four patients received 200 m g. of nicotinic acid a day for a week, divided into four doses. One patient was relieved and the other three were unchanged. They were then given thiamin chloride, 50 mg. intravenously, followed br 2%mg. a day, orally. One had complete relief, one was partiallv relieved, and one remained unchanged. Nine patients all received &amin chloride as the initial medication. Two received only one dose of 50 mg., intravenously, and no further treatment. One reported partial relief while the other was unchanged. Four received 25 mg. daily, orally, after the initial closeof 50 mg. intravenously. 811 reported complete relief in one to four days. One patient was not, given an initial intravenous dcsc but received 25 mg. orally, twice a day. She was relieved after two days. The two remaining patients were in the hospital. One had a pyelitis at five months’ gestation and was given sulfathiazole. She complained of severe heartburn on the second day of this medication. Alkalies gave little relief. On the fourt,h da- she was given 50 mg. of thiamin chloride intravenously, and 25 mg., twice a day, orally, thereafter. She had partial relief in forty-eight and complete relief in seventy-two hours. The sulfathiazole was continued throughout and no alkalies were given after the thiamin was begun. The &her pa,ticnt who was hospit,alized -*Read at a meeting uf th(, I,ouisvillc Ohst~triral an<1 (I?;nec’ologic;tl Society January 36, 1942. tTRN6P is an experimental vitamin preparation of Merck and Co. It contains thiamin 5 mg., nicotinamide 25 mg., pyridoxine 5 mg., riboflavin 5 MB., and pantothenic acid 25 mg., per tablet.
IMPORTANCE
OF REST IN THE FEEDING
INITIATION
C. B. DARNER, M.D., AND G. WILSON HUNTER, FARGO, N. DAK. (From St. Luke’s Hospital
OF BREAST
M.D., F.A.C.S.,
and the Fargo Clinici
A
LTHOUGH the benefits of breast feeding newborn babies have been repeatedly stressed by a number of writers, need for emphasizing this physiologic and important function continues. We had the opportunity, during 1941, to make some interesting observations concerning the possible effect of rest and isolation on nursing mothers. During the encephalitis epidemic, all visitors except husbands of patients were banned from the maternity floor of St. Luke’s Hospital. It was noted in that period that a fewer number of mothers failed to furnish a complete supply of breast milk for their babies; the authors studied the records of the last 100 patients delivered during this restriction and compared the results with 100 consecutive cases selected earlier in the year as a control group. Even in the control group a large percentage of babies left the hospital supplied by maternal feedings entirely. The authors have always stressed the importance of nursing, and mothers were given every encouragement to follow this normal function and procedure. Discussion of Data Before one attempts to evaluate the more significant statistical data (obtained from this study), he should note that all factors, other than visiting restrictions, which might be expected to influence lactation, were approximately equal in both groups of patients. All patients were discharged on the ninth or tenth day, as a rule. Average age and parity were the same. Maternal morbidity was 3 per cent in each group. There was a slightly lower incidence of operative deliveries in the control cases. It might also be pertinent to mention that the infant morbidity consisted of 3 casesof impetigo, all occurring among the controls. The authors attribute in part the high percentage of nursing mothers to the fact that they are in close association with a pediatrician who recognizes the value of mother’s milk. From Table I one notes that the babies delivered before the visiting restrictions were inaugurated suffered a definitely greater initial weight loss and were further under birth weight at the time of discharge than the babies delivered after the ban was inaugurated. This conclusion is reflected in the fact that 41 per cent of the latter group of infants regained their birth weight at the end of nine or ten days, as compared 117
118
AMERICAN
JOURNAL
OF
OBSTETRICS
AND
____
Initial weight loss (Gm.) Average Gm. below birth weight at discharge Per cent regaining birth weight at discharge
PERIOD OF VISITING RESTRICTIONS
I-
NO
1 : I
/1~
308.7 81.2 27.0 ___
GYNECOLOGY
_-.~_--__-~.-. PERIOD OF \‘I,SITIP;G HESTRICTIOKS
~.
41.1 -
_-.-
I~IFP'ERI~;LNCE
22g.bl -37.7
-__---.
-~
-----;-g;-;j
-~~-- -43.5 14.7
__--_
.--
with only 27 per cent in the former group. These differences are significant when one considers that most babies in both groups had comparable weight variations and that these average figures are the result of much greater weight difference in a smaller group of babies. The smaller group of infants who have lost, more and gained less are those babies who make up the inevitable feeding problems. The ones most. susceptible to all infant diseasesand infections are the babies who have the greatest need for an adequate breast supply.
PERIOD OF VISITING RESTRICTIONS
Average amounts of breast milk (daily) at discharge
NO
1 I
499.3 C.C. -
PERIOD OF VISITING KF,STR.ICTIONS
556.0 C.C.
DIFk-EKENCK
-
__---
---..-56.7 C.C.
In Table II are listed the average twenty-four-hour outputs of hrcast milk in the two groups of mothers. The figures tend to confirm t,hc more satisfactory feeding of infants by undisturbed mothers. The mothers who did not suffer the distractions and mental esertions of entertaining the sewing circle or bridge club were able to produce the greater breast suPPlY* TABLE
III.
PERCENTAGE
OF
BABIES I
Per cent of infants receiving artificial feedings Per cent of infants receiving complementary feedings
ON
ARTIFICIAL
PERIOD OF NO VISITING RESTRICTIONS
AND
COMPLEMENTAKY EExDrr;GS ____.-- __--..~ PERXOD OF VISITING DIFFERENCE RESTRICTIONS
12.0
12.0
0.0
22.0
4.0
18.0
___-___-_._-~~-------
~-..
There apparently is a certain percentage of women who are totally unable to nurse, either because they selfishly refuse to try, or because of a systemic disease which precludes nursing, or because of a primary agalactia. Weiss and HSlzel state that it is generally recognized that agalactia of a primary nature is a rare experience. More frequently there is a variable degree of primary hgpogalactia. Benoit has said that 90 per cent of infants should be breast fed on leaving the hospital, and the writers feel that by repeated emphasis on the benefits of breast
DARNER
AND
HUNTER:
BREAST
119
FEEDING
feeding they have approached the approximate limit of 90 per cent for several years. Consequently, the restriction of visitors has made no significant change in the group of babies receiving artificial feedings, as borne out in Table III. There are, however, less than one-fifth as many infants discharged with complementary feedings necessitated by inadequate milk supply as formerly. Note that the authors do not use complementary feedings for full-term infants during the first three days or at any other time unless the condition of the mother indicates some degree of hypogalactia. This emphasizes the apparent fact that the physical and mental fatigue induced by the efforts of the patient to entertain her visitors has the result of reducing the breast supply below the point of adequacy. Those same mothers, well rested in the hospital, might never have had to bother with the tasks of formula making plus breast feeding. This benefit is all the more significant in the light of the generally recognized fart that once a baby is well started on a complementary bottle, it often ends up on the bottle alone. TABLE
IV.
PERC'ENTAGE
OF MOTHERS
I
Mothers able to nurse with1 no complementary feeding Mothers able to nurse with complementary feeding Total mothers who nursed completely and partially
WHO
PERIOD OF NO VISITING RESTRICIYONS 66.0 22.0 88.0
NURSED
I
COMPLETELY
PERIOD OF VISITING RESTRICTIONS 84.0
I
4.0 88.0
OR PARTIALLY
DIFFERENCE 18.0 18.0 0.0
Table IV emphasizes t,he facts that certain mothers are totally unable to nurse and that complete rest eliminates the use of complementary bottles for many patients.
Conclusions
and Summary
1. The advantages of breast feeding for both infant and mother have been re-emphasized. 2. The records of 100 consecut,ive babies delivered during a period in which visitors mere banned are compared with those of 100 consecutive cases delivcrcd when no such restrictions were in force. 3. Infants delivered of mothers not disturbed by visitors more frequently regained their birth weight at discharge and suffered a smaller initial weight loss. 4. Undisturbed mothers had a more abundant supply of breast milk. 5. Although the percentage of artificial feedings was unchanged, the percentage of complementary feedings was reduced four-fifths by t,he restrictions. 6. Visiting restrictions must be taken into account when the physician considers the problem of instituting breast feedings.
120
AMERICAN
JOURNAL
OF’ OBSTETRIC8
AND
GYNECOLOGY
Bibliography 1. 3. 3. 4. 5. 6. 7.
Guthrie, Sylvia K.: Clin. J. London 65: ‘703, 191-X. Grulee Clifford G: Journal-Lancet 54: 681, 19%. Rob&on, Edith C.: Am. J. Dis. Child. 59: 1002, 19-10. Desfosses, P.: Presse mBd. 45: 601, 193i. de Petinto, M. P.: Med. Ibera 2: 29, 1928. Benoit, R.: Union m&l. du Canada 69: 175, 1940. Weiss, F., and Hiilzel, A.: Jahrb. f. Kinderh. 146: 98, 1.936.
VITAMIN
B IN B.
HEARTBURN
I?. HART, KU., (Frovn th.e Uniwrsity
OF
PREGNANCY$’
WINTER PARK, E’LA. of Louisr~iZl~ Clbaics)
IXTEEN prenatal patients complained of annoying heartburn with a duration of from two davs to t,wo months, and on an average S two weeks. All but t,hree were”in the last, half of gestation. The usual of
treatment of alkalies, as used in nonpregnant, individuals, proved notably inefficient when tried. Two of the group had previously had clinical pellagra, and they attributed their symptoms to this. They were given large doses of the B complex in the t’oun of a yeast extract plus 200 mg. of nicotinir acid daily. They were completely relieved of all symptoms but were kept on smaller maintenance doses throughout t.heir pregnancies. Eaeh was approximately seven months pregnant when first seen. Of the remainder of the patients, one received a TRNGPt tablet after meals and was relieved of a heartburn of two months’ standing wit.hin one week. Four patients received 200 m g. of nicotinic acid a day for a week, divided into four doses. One patient was relieved and the other three were unchanged. They were then given thiamin chloride, 50 mg. intravenously, followed br 2%mg. a day, orally. One had complete relief, one was partiallv relieved, and one remained unchanged. Nine patients all received &amin chloride as the initial medication. Two received only one dose of 50 mg., intravenously, and no further treatment. One reported partial relief while the other was unchanged. Four received 25 mg. daily, orally, after the initial closeof 50 mg. intravenously. 811 reported complete relief in one to four days. One patient was not, given an initial intravenous dcsc but received 25 mg. orally, twice a day. She was relieved after two days. The two remaining patients were in the hospital. One had a pyelitis at five months’ gestation and was given sulfathiazole. She complained of severe heartburn on the second day of this medication. Alkalies gave little relief. On the fourt,h da- she was given 50 mg. of thiamin chloride intravenously, and 25 mg., twice a day, orally, thereafter. She had partial relief in forty-eight and complete relief in seventy-two hours. The sulfathiazole was continued throughout and no alkalies were given after the thiamin was begun. The &her pa,ticnt who was hospit,alized -*Read at a meeting uf th(, I,ouisvillc Ohst~triral an<1 (I?;nec’ologic;tl Society January 36, 1942. tTRN6P is an experimental vitamin preparation of Merck and Co. It contains thiamin 5 mg., nicotinamide 25 mg., pyridoxine 5 mg., riboflavin 5 MB., and pantothenic acid 25 mg., per tablet.