How to Help Babies Stay Exclusively Breastfeeding in the First Days of Life
The World Health Organization (WHO) recommends exclusive breastfeeding for the first six months of life, and gradual introduction of other nutritious foods after six months along with continued breastfeeding for two years and beyond.
Feeding even a small volume of formula just one time has been shown to produce both temporary and permanent alterations as well as inflammation in the breastfed infant’s gut. The coating of antigen-specific Secretory IGA which lines the digestive tract of the breastfed infant can be removed by even a small amount of formula, leaving the gut lining vulnerable to pathogens. In preterm infants, this vulnerability is magnified.
Feeding even a small volume of formula just one time can sensitize a susceptible infant to cow’s milk protein and increase the risk of a baby developing Diabetes Mellitus.
Early supplementation with formula of the breastfed baby raises the risk of early weaning and does not address the source of breastfeeding problems.
911 infant and young child deaths could be prevented and $13.6B saved in the U.S. annually if 90% of mothers breastfed exclusively for 6 months.
Current rates of breastfeeding initiation and duration are well below the recommended 90%. Breastfeeding promotion and support programs and strategies are needed to increase these rates.
The risks of long-term formula feeding are well documented, yet are seldom understood by parents. Authorities and health care providers have long been averse to presenting these risks clearly and succinctly to parents lest they create feelings of guilt or shame in the non-breastfeeding population.
The First 100 Hours© is an educational strategy specifically designed to redirect attention from formula feeding to improve focus on breastfeeding. By properly and appropriately supporting breastfeeding for The First 100 Hours© of an infant’s life, mother and baby are provided the opportunity to breastfeed for as long as they choose. The strategy is comprised of a common language and strategy of breastfeeding support and promotion to be used by everyone in contact with the breastfeeding couple, from prenatal breastfeeding classes to the postpartum hospital unit to the pediatrician’s office visit after discharge.
The strategy details a plan for implementation of previously written and accepted clinical protocols and health organization recommendations, drawing upon the most current research for evidence-based care of the breastfeeding dyad. These public health statements and clinical protocols have their basis in widely accepted research, including peer-reviewed data and meta-analyses of multiple studies. Therefore, The First 100 Hours© strategy simply proposes a new workplan to implement the protocols and recommendations whose references and basis have been previously vetted.
Helping mothers and babies breastfeed through the first days until breastfeeding and milk supply are well-established should be the goal of all clinical care providers. Once a mother and baby reach 100 hours, it is reasonable to expect that baby will be attaching well and breastfeeding effectively and that mother’s milk volume will be sufficient to completely nourish her baby.
By helping mothers to avoid truly unnecessary formula supplementation in The First 100 Hours© of their babies' lives, the known risks of breastmilk substitutes can be avoided. If mother’s own expressed milk or pasteurized donor milk are unavailable, and the use of formula is required due to true medical indication, healthcare providers can properly intervene with specialized additional breastfeeding help to ensure that the mother and baby can resume a normal breastfeeding course.
Success through The First 100 Hours© strategy is defined as providing thorough and appropriate breastfeeding support through the first 100 hours of a baby’s life, thus establishing the opportunity for breastfeeding to continue for a normal course. A mother who chooses to wean completely after breastfeeding or feeding breastmilk for 100 hours has not failed. Rather, she has given her baby a healthy start and an unparalleled immune system boost. It is reasonable to predict that a mother who has successfully breastfed or fed breastmilk for 100 hours will continue to breastfeed beyond that timeframe, thus making six months of exclusive breastfeeding a markedly more realistic goal.
Common obstacles within The First 100 Hours© of a baby’s life include:
sleepiness resulting in low frequency of feedings
difficulty or pain when latching baby due to lack of experience and/or assistance
rising levels of bilirubin
weight loss
maternal pain/fatigue from labor and birth
hypoglycemia
Common misconceptions within the first 100 hours of a baby’s life include:
perceived lack of or low milk supply by staff and/or parents
expectation that infant will eat, then sleep for prescribed amount of time and at prescribed intervals
belief that offering a breastfeeding mother a pump will help her breastfeed better
belief that anyone other than mother “needs” to feed baby
expectation that infant should not lose weight after birth
expectation that infant’s diaper output directly reflects infant’s intake from breastfeeding
belief that there is a “need” to know how much a baby gets at a feeding
misunderstanding of the consequences of birth interventions on newborn feeding patterns
expectation that infants born prior to 39 weeks completed gestation behave and feed just like those born after 39 weeks completed gestation
belief that premature infants need to prove their ability to bottlefeed prior to attempting to breastfeed
belief that formula will fix any problem a mother or baby is experiencing
belief that a small amount of formula has minimal or no risks to mother and baby
belief that pacifier use does not affect breastfeeding
poor interpretation of hunger/satiety cues
poor understanding of normal nighttime feeding patterns of newborn infants
poor understanding of Stage I and Stage II Lactogenesis
Why is the list of misconceptions longer than the list of obstacles? This is primarily because most of the obstacles listed are exacerbated by the misconceptions listed, leading most to believe that breastfeeding is usually or always problematic. This inappropriate generalization of early breastfeeding being fraught with obstacles leads to the tendency to mistrust the process of breastfeeding.
When the care team mistrusts the process of breastfeeding, suddenly “problems” arise, usually “requiring” the use of formula to overcome them. The assumption must always be that breastfeeding is the only thing a baby needs. The care team must work outward from that assumption, proving that a suggested intervention is necessary because all the appropriate information and attempts at improving breastfeeding and breastmilk intake have been unsuccessful.
Often, in the early postpartum period, a care team, deliberately or unknowingly, gives parents the impression that everyone has been "waiting" for signs that breastfeeding is not working. This generally accompanies or accentuates the message that breastfeeding is hard, that many people are unable to sustain it, and that it is not valuable or important, concepts which have generally already been established to new parents by mass media and culture.
Medical indications for formula supplementation of the breastfed baby are few. Use of formula to supplement breastfeeding is common in places and situations where hand expression of mother’s milk is not practiced due to the fact that breastpumps may be largely ineffective during Stage I Lactogenesis and rarely yield “enough” milk to complete a suggested volume for supplementation. In addition, the recommended volume for supplementation is highly variable among practitioners and from case to case, leading to confusion among parents and other members of the care team.
Appropriate assessment of breastfeeding is always necessary in cases where providers are considering supplementation. In situations where specialized lactation care is not available, assistance with hand expression and feeding of mother’s expressed milk always has the potential to be advantageous and carries no known risks for infant or mother - in fact, hand expression has been shown to improve and increase milk supply. Formula supplementation, on the other hand, carries numerous documented risks to baby and mother.
Even if assessment by a lactation specialist is not immediately possible, all efforts should be directed toward assisting and encouraging the mother to express milk (by hand and/or using a high-quality electric breastpump) in order to provide the milk for supplementation.
The First 100 Hours© strategy is simple, yet comprehensive. The educational components are critical, but the experience itself is the key.
When a mother can successfully breastfeed her baby or express milk to feed her baby for 4 whole days, her confidence expands exponentially and the memory is imprinted permanently. If a mother and/or baby experience difficulties during The First 100 Hours, the likelihood of improving or rectifying lactation challenges or problems will improve if proper lactation referral is made at or around the time the baby reaches 100 hours of life.
Similar to the widespread promotion of immediate skin to skin contact (Kangaroo Mother Care) between newborns and mothers directly after birth, The First 100 Hours© can reasonably be expected to have positive results on overall health and well-being of mother and baby and to have the side effect of increasing the number of mothers initiating and continuing to breastfeed.
Christine Staricka, IBCLC, RLC, CCE
2013