Nursing and vaccines: Two good things, great together

The Pediatric Insider

© 2017 Roy Benaroch, MD

Stefanie wrote in:

My question is related to the MMR vaccine. Would it be better to stop breastfeeding at 11 months and then get the MMR 1st shot vaccine at 12 months? Or did I understand correctly that the maternal antibodies from breastmilk will not interfere with the MMR vaccine to work? If they do not have an effect on neutralizing the vaccine, I would prefer continuing to breastfeed.

Stefanie, you can continue to nurse if you’d like – there’s no recommendation for anyone to stop or delay nursing before any vaccine.

What Stefanie is talking about here are the immunoglobulins in breast milk, and whether they could somehow interfere with the effectiveness of vaccinations. There are no clinical studies that have shown this to be a problem for MMR or any other vaccine. Breast milk antibodies don’t make vaccines less effective or less safe.

One study of a different vaccine, one that protects against the diarrheal illness caused by rotavirus, confirmed that breast milk contains antibodies against the virus. The titers of these antibodies were especially high among women from the developing world, compared with women from the United States. The authors speculated that this might explain why the vaccine is more effective in more-developed countries, and proposed a study to see if delaying (not stopping) breast feeding could make the vaccine more effective. In the US, the rotavirus vaccine is highly effective at preventing severe disease and hospitalization, both in nursing and formula-fed babies. Moms can continue nursing right before or after the vaccine is given (it would be awkward to nursing during administration of this vaccine—it’s given orally. Not sure how that could be done.)

I’ve had a run of questions about nursing and vaccinations, some implying that breastfeeding is better than vaccinations, or that vaccinations and breastfeeding are somehow competing with each other, or that those that support vaccinations are somehow shortchanging or weak on breastfeeding. These kinds of stories seem to be a new “fad” among those who wish to sow an overlay of vague mistrust and doubt about vaccinations. Please, the science is overwhelmingly positive. Don’t rely on the Googlers and scaremongers. Immunizations are safe and effective. You do not need to worry. Protect your children. Vaccinate.

 

Breastfeeding and vaccinations protect your baby in different ways

The Pediatric Insider

© 2017 Roy Benaroch, MD

“Since I’m nursing my baby, she’s getting all of the antibodies in my breast milk. Doesn’t that protect her the same way vaccines do?”

There are antibodies in breast milk, and they can help protect your baby from some kinds of infections. But those kinds of antibodies are different from the ones your baby will make herself after vaccinations. Breastfeeding contributes to one kind of protection, but the protection from vaccines is more powerful and longer-lasting.

Antibodies (also called “immunoglobulins”) are proteins that are part of your immune system. They work by attaching to invading microorganisms and viruses, which helps signal your immune system to attack. Antibodies have to be specific to each kind of infection—one antibody doesn’t fight multiple germs—and your immune system learns how to make different antibodies based on your body’s exposures to infections.

There are two ways for your baby to get antibodies. She can get them passively, from mom, either across the placenta or via breastmilk. Both are important. Placental antibodies are IgGs, which circulate in the blood. These kinds of antibodies help fight off invasive diseases. After a baby is born, placental IgG antibodies fade away over several months. Moms can boost their own ability to give these IgGs by being vaccinated, themselves, during pregnancy (that’s why moms should get influenza and pertussis vaccines while they’re still pregnant.) Breast milk contains a different kind of antibody, IgAs, which aren’t found in the blood. They are a part of intestinal and respiratory mucus, protecting people from infections before they get to the blood. The effect of these IgA antibodies in breastmilk is especially important in the developing world, where safe water and food is harder to find, and where moms have especially high titers of their own antibodies from ongoing infectious exposures.

The other way for babies to get antibodies is to make them on their own. To learn to do this, they must either be exposed to the infection, or get an immune-boosting “glimpse” of the infection by receiving a vaccine. That’s the point of vaccines: to allow someone to make their own strong, protective antibodies without the risk of having to suffer through the disease. These antibodies, made after “active immunization”, are of very high titers and are long-lasting – in some cases, for a lifetime. They’re much more protective than the passive antibodies gained across the placenta or through breast milk.

Bottom line: families can help protect their babies from infection in many ways. Sick people should be kept away from newborns. Moms should get their own recommended vaccines. Nursing can help (though in the developed world, the impact of nursing on infections is modest.) And babies should get their own vaccines, as recommended, on schedule, to get the best possible protection.

The economic benefits of breastfeeding: A call for honesty

The Pediatric Insider

© 2014 Roy Benaroch, MD

Lookie here: I am a breastfeeding supporter. I regularly help new moms breastfeed successfully, and I even took special class to learn how to do a brief procedure to help babies overcome breastfeeding problems caused by tongue-tie. I’ve got a happy breast support sticker, right on my AAP card.

But I think honesty is (or should be) the breast policy. Some women and babies find nursing to be difficult, and some moms don’t want to nurse, and some moms, yes, don’t make enough milk to fulfill the health needs of their babies. Other moms or babies have their own health problems that prevent effective breastfeeding. Breastfeeding is not in any way an essential part of raising a healthy and happy kiddo—at least in the developed world, we’ve got great, healthful substitutes for mother’s milk. Babies do not have to be nursed to be loved and raised in a healthy manner, and moms who don’t nurse don’t need more pressure or guilt.

So I have mixed feelings when I read studies like this one. Researchers in Great Britain published a study in October 2014, “Potential economic impacts from improving breastfeeding rates in the UK.” They used computer models to look at the savings reached by preventing diseases in children that have higher rates in formula-fed kids, including ear infections and GI problems ($17 million a year); they also added in savings from having to treat fewer women for breast cancer ($50 million a year, estimating current exchange rates). At first glance, those savings figures look modest—that’s because the effect of breastfeeding on preventing breast cancer and childhood infections in developed countries like Great Britain is really quite small. But let’s accept those figures as they are. The bigger problem I see is that the authors made no attempt to quantify the economic costs of breastfeeding.

We should be honest, here. We know that breastfeeding is the major risk factor for hypernatremic dehydration, which has been estimated to occur in about 2% of term newborns. This is caused by inadequate fluid intake in a newborn, and can cause seizures, brain damage, and death; it usually requires hospitalization to treat. And breastfeeding is also a major factor leading to health consequences from newborn jaundice, including hearing loss and later learning problems. The authors of this paper didn’t try to quantify the costs of these health problems, any more than they tried to look at the economic impact of breastfeeding on family finances or a woman’s career.

Like all pediatricians, I think it’s best for babies if they’re breastfed. But we’re not doing anyone any favors by exaggerating the benefits of nursing, either in terms of economics or health. We do need good social supports and laws to protect the rights of women to nurse in public and at their jobs; but we don’t need formula feeding to be a mark of poor parenting. Honest information is what parents need. Can we stop the hyperbole?

Breastfeeding and post-partum depression: A possible cure, a possible cause

The Pediatric Insider

© 2014 Roy Benaroch, MD

An August, 2014 British study comes to two seemingly opposite conclusions: in some women, breastfeeding can protect against depression; while in other women breastfeeding seems to increase the risk of depression. It all depends on what mom’s intentions had been.

The study is complicated, and has a lot of tables—but they’ve kindly made it open-access, so you can read it yourself in detail (click the Download PDF button after the link, above.) Briefly, researchers looked at about 14,000 births, and tracked measures of mental health during pregnancy and periodically afterwards. They also tracked whether women tried or didn’t try to breastfeed, and how long breastfeeding continued. And, they kept track of what women had said their intentions to breastfeed had been prior to delivery. Results were corrected for things like socioeconomic factors and the health of the baby, since we know those have a big effect on the risk of post-partum depression.

The women who didn’t intend to breastfeed, and didn’t end up breastfeeding, were used as the comparison group, and the relative risks of post-partum depression were determined. What they found was fascinating:

Among women who intended to breastfeed, and who did in fact successfully breast feed, the risk of depression was cut in half. This effect was strongest for longer-duration nursing. The authors postulate that the beneficial effect of nursing in this group was conveyed by hormonal factors released during nursing.

Unfortunately, those positive hormonal factors were not seen in all women. Among women who had planned to breastfeed, but were in fact unable to nurse sucessfully, the risk of depression more than doubled. Most women who try to nurse find nursing a successful experience, but women who don’t meet their own expectations seem especially vulnerable to depression.

And: among women who didn’t plan to breastfeed, but did in fact end up breastfeeding anyway, the risk of depression was also increased. Perhaps these women, who hadn’t wanted or planned to nurse, felt bullied or coerced into nursing?

The obstetric and pediatric communities are fully in support of breastfeeding, which offers medical and psychological advantages to most women and their babies. But we need to acknowledge that nursing can be difficult, and that women who don’t nurse are still capable, good moms—they don’t need scorn or dirty looks when they use baby formula. It’s a shame that moms who are providing love, nurturing, and good nutrition though a bottle may be at higher risk of depression. We can do better than this.

Should a tongue-tie be clipped?

The Pediatric Insider

© 2013 Roy Benaroch, MD

Anita wrote in: “My little newborn has this bit of tissue under his tongue, so he can’t stick his tongue out. Should it be removed?”

I’m thinking Anita means, should the little bit of tissue be removed. Not the whole tongue. Probably.

That little bit of tissue is called a “lingual frenulum”, or a “sublingual frenulum.” What to do about these things is something that’s changed as years have gone by. When I was a baby, doctors would routinely just clip the things, right there in the nursery, as a matter of course. Probably without consent or any handwringing discussions.

Then, the pendulum swung away from clipping. By the 1990’s, the standard teaching was to leave the darn things alone. We figured that they didn’t do much harm, and seemed to go away on their own, so why mess with them?

Now, the pendulum may be swinging back towards at least considering clipping those frenula. Several small but good studies have shown that at least some mom-baby pairs have trouble nursing with a tight frenulum (sometimes called ankyloglossia, or a “tongue-tie.”) Clipping a tongue-tie in a baby who is nursing poorly can dramatically improve latching and milk transfer, and can really reduce the pain some women experience when trying to nurse a baby with a tight frenulum.

It’s less clear whether clipping has longer term benefits. Some feel that a tight frenulum can cause speech problems, or perhaps issues with eating or kissing.  Studies looking at the long-term effects of clipping on these issues haven’t been done.

Clipping one of these is a simple, safe, and quick procedure. However, few pediatricians who’ve been trained in the last 20 years have any experience with doing these. I did a CME training course that included videos and practicing on a dummy with a little pretend tongue, and it’s easy enough to learn. It is important that a good exam confirms that it’s a simple tongue-tie that can be easily clipped in the office. Some of these, if large or dense or located more towards the back of the tongue, would be better addressed by a surgeon in the operating room.

So, to answer Anita’s question: whether to clip a tongue-tie depends on what problems it’s causing. If there are nursing difficulties or pain, there’s very good evidence that clipping is a good idea. There’s not much evidence one way or the other to tell us if clipping should be done to prevent speech or language or other issues later in life. I try to judge that by how tight the frenulum appears, whether the tongue can be extended, and how much I think I can improve the tongue movement with a little snip, but that’s a call that has to be made individually for each baby.

If your pediatrician doesn’t have experience judging whether a tongue-tie needs to be clipped, ask for a referral to an ENT who can help decide if the procedure is needed, and how to do it safely.

Does breastfeeding improve the intelligence of babies?

The Pediatric Insider

© 2013 Roy Benaroch, MD

A new study published in JAMA Pediatrics shows that breastfeeding is good for your baby’s IQ—or does it? USA Today thinks so, with their headline “More evidence that breast-feeding may boost babies’ IQs”. Reuters is less direct: “Breastfeeding tied to kids’ intelligence”.  An editorialist for JAMA put the findings this way: “Breastfeeding an infant for the first year of life would be expected to increase his or her IQ by about 4 points.”

Sounds good to me. But is that really the conclusion that the study ought to have reached?

I know I’m treading on thin ice here. Pediatricians are supposed to be all rah-rah about nursing, and failing to be 100% supportive of any new finding that lends further support for nursing may be tantamount to apostasy. Hopefully I’ve got the cred to get away with this—my blog has always been supportive of breastfeeding, and I’m one of the few pediatricians I know of in my area that has been trained to treat tongue-tie, specifically to help women be successful in nursing.

So what does the study show? The details are behind a paywall, so you’ll have to take my word for it. It is a very dense and complex study, with a lot of tables and a whole lot of discussion of how scores are adjusted and covariates controlled. Basically, researches studied a cohort of about 1000 babies in Massachusetts born in 1999-2002. At six months of life, their moms filled out questionnaires regarding breastfeeding (along with their own diets, health information, and a whole lot of other things.) At 3 and 7 years, the children and moms underwent multiple tests of intelligence—not, technically, IQ tests, but tests that are thought to be good surrogates for IQ at younger ages. Then, looking backwards, the authors looked for correlations between those scores and how long the babies had been nursed. Depending on the “model” presented (there were 4 sets of data), the intelligence measures were controlled for age, sex, gestational age, birth weight, race, maternal age, smoking, parity, language, income, household income, marital status, and parents’ educational level. Not all data was available for all babies, which is understandable, so some of the information was “imputed.”

At age 3, two tests that were felt to reflect intelligence were administered, one of which was broken into 3 parts—so 4 tests were reported. At age 7, 3 tests were given, one of which was broken in to 2 subtests. So, net, 8 tests of intelligence were given to these children (remember that number.)

The results, as presented in Table 5, show that at age 3, 1 of the 4 tests showed improved scores among babies who had breastfed at 6 months (compared to babies who had never breastfed or had weaned or had mixed feedings.) At age 7, 1 of the 4 tests showed improvement compared to never breastfed or weaned babies, but not mixed-fed babies; another 1 showed improvement among weaned, but not never-breastfed or mixed-fed babies. Let’s mix those two together and say that a consistent improvement was correlated with nursing in 1 of 4 tests at age 7. Net: 2 of the 8 tests given to these children showed a difference for babies who had nursed at least some; 6 of the 8 showed no difference at all.

The authors in their conclusion, the JAMA editorialist, and the news outlets are saying that this study is very supportive of the association with increased IQ. They could have chosen any of these headlines:

1. Tests show improved intelligence in breastfed babies.
2. Some tests show improved intelligence in breastfed babies.
3. Most tests do not show improved intelligence in breastfed babies.

I think #3 is most intellectually honest. Sure, 2 of the 8 tests were positive; but 6 of 8 were not. In the aggregate, this study may provide some support for increased intelligence among breastfed children – none of the tests showed decreased intelligence – but the support isn’t strong, and it isn’t even consistent among the tests.

But that kind of nuanced message is boring. And it doesn’t fit the current narrative or what we expect of these studies, and it doesn’t fit into the message that pediatricians want to give women. We want more babies breast fed. I want more babies breast fed. But presenting this study as a slam dunk, that breastfeeding will improve your child’s IQ, is dishonest. In the long run, I think overstating our hand may end up undermining breastfeeding success. It will certainly add to the guilt of women who don’t breastfeed.

And don’t even get me started on the “correlation doesn’t equal causation” thing. JAMA editorialist and USA Today headline writer: you can’t conclude from a study like this that breastfeeding caused the increased markers of IQ seen in 2 out of 8 tests.

I have to admit: I’ve been known to tell women that nursing isn’t your only job, and it really isn’t your only important job, and it certainly isn’t your most important job. There’s far more to being a good mom than how you feed your kiddos. Moms are under tremendous pressure to nurse, and to deliver “naturally”, and to have the correct BPA-free sippy cups and the baby monitor that uses the correct frequency and the 100% certified organic fair trade avocados and the … well, the list seems to grow and grow, and it seems to be getting more and more competitive. Parenting, and nursing in particular, is not a contest. I don’t think this current study gives any further bonus points to the “winners”, and that’s OK with me.

Similac for Supplementation: Who needs it?

The Pediatric Insider

© 2013 Roy Benaroch, MD

Market segmentation gone crazy! The newest member of the Similac line of infant formulas is “Similac For Supplementation”, packaged “for breastfeeding moms who choose to introduce formula.”

I can’t imagine what specific need there could be for a formula designed for supplementation, as opposed to one for routine feeding. All of these formulas are already supposed to be the best possible substitute for human milk. On their website, the makers claim that this has “more prebiotics” than other formulas—though it’s not clear why that would be good, or why their other formulas contain less. They also note that “studies have shown that prebiotics produce softer stools”, though a recent review showed that there was no change in stool consistency when babies were fed prebiotic-containing formula.

One might guess that there really isn’t any difference in these formulas at all. The manufacturers only wanted a product out there to attract the eyes of families considering supplementation. Hey, exhausted parents might think. This one is for us!

But that would mean that Similac for Supplementation is just marketing hype, of no real use to anyone.

Can a wee drop ‘o formula help breastfeeding?

The Pediatric Insider

© 2013 Roy Benaroch, MD

It’s a tiny little study, a simple one, but could it really be? Could offering newborns just a little bit of formula actually help support breastfeeding in the long run?

Researchers in California reported this month a study of 40 newborns, all of whom were recruited from families who had planned to nurse exclusively, and all of whom got off to a little bit of a rocky start. They had all lost > 5% of their birthweight after 1 day of life, which is not a disaster, but means that they weren’t getting super-good milk transfer yet. These 40 babies were randomized to either get 10 mL of formula (that’s 2 tsp) after nursing, or to continue exclusive breastfeeding.

By the end of their hospital stay, only 2 of the 20 early-formula babies were still getting formula (compared to 9 of the 19 control babies, whose parents had decided to go ahead and give formula on their own.) And: three months later, twice as many little-bit-of-early-formula babies were nursing, 80%, compared to only 40% of the families who had been randomized into the exclusive-breastfeeding group.

Small study, but those sure are impressive results.

To a practicing pediatrician, the outcomes of this study makes some sense. Though many babies nurse well, others seem to grow impatient waiting for mom’s milk to come in. These impatient babies can get cranky and upset, and mom get all sorts of conflicting information that only adds to their guilt and apprehension. A little wee drop o’ formula does seem to settle babies down, maybe enough for them to calmly nurse, and maybe enough to give mom the confidence to keep trying.

I realize that there are a lot of pediatricians and lactation counselors who won’t be very happy with this study—it flies in the face of our typical advice for nursing moms. But we’re here to be humble and learn, and this study might just have something to teach us about the best way to support breastfeeding.

Are tattoos safe during nursing?

The Pediatric Insider

© 2013 Roy Benaroch, MD

“I’ve just recently gotten a tattoo and I’m still breastfeeding my daughter. Is it safe?”

There are two potential issues with getting a tattoo while nursing, though neither one is a huge risk.

One is that tattoo needles can theoretically transmit diseases like hepatitis C or HIV. However, legitimate tattoo artists use sterile or single-use needles along with other steps to ensure tattooing is safe. The risk of transmission if reasonable precautions are taken is very close to zero. So a back-alley tattoo is a bad idea, but a tattoo from a legit business that takes infection control seriously is unlikely to lead to unexpected diseases.

The other potential issue is from the tattoo ink itself. Tattoo inks are not regulated medically– that is, they’re not safety-tested to make sure they’re safe for injection. However, I know of no actual cases of babies being sickened from the chemicals in tattoo inks. In practice, tattoo inks have been used for many, many years and are probably safe. But there’s no medical authority watching over tattoo inks, and no one can guarantee that they’re safe for you or your breast milk.

I will say that it would be a bad idea to have a tattoo removed while nursing. Tattoo removal involves using a laser to break the ink pigment into little bits that can then be carried away and excreted by the body. That means that the tattoo ink bits will be in your blood, traveling around, and we really know even less about the safety of these little particles than we do about the safety of the intact ink. If you have a tattoo and you’re nursing, it is much better to leave it alone than try to have it laser-removed.

So: no one can guarantee that tattooing is safe while nursing, but with reasonable precautions it probably is, and if there is any risk it’s probably very, very small. The definite good health benefits of nursing both for you and your baby in my judgment mean that you ought to keep nursing, and don’t worry about it.

How much milk does a newborn need?

The Pediatric Insider

© 2010 Roy Benaroch, MD

Honk honk honk. (Traditionally, this would be “beep beep beep,” but I have my phone set to alert me with a bicycle honk for new text messages. It’s a riot at 3 am.)

“Newborn nursery.”

“Yeah, this is um… the doctor, calling back…someone.”

“The nurse needs to reach you, please hold.”

…and that’s why you shouldn’t kiss a pig. Did you know it’s bicycle safety awareness week?Your call is very important to us. Please hold for the next available…

“Yes, this is the nurse. What do you need?”

“You called me.”

“Who?”

“Me. The doctor. Doctor Me.”

“About Baby Grisham?”

“I don’t know who about. You called me. I’ll be there in the morning.”

“This can’t wait. The baby is spitting a lot, and needs a change in formula.”

“What?”

“We’ve been giving him Enfalac, but he’s spitting, so I need an order to change him to Simamil.”

“How old is this baby? What baby?”

Sigh. “Baby Grisham, born at 2300 hours.”

Doing math in my head. I can’t ever figure out those ‘hours’ times. “So he’s…three hours old?”

“Yes, mom’s not breastfeeding, and he’s spitting up his Lactosimacare.”

“How much?”

“A lot.”

“No, I mean, how much are you giving him?”

“Only 2 ounces.”

“OK, here is what I want you to do. Let the baby sleep in the room with mom, and stop feeding him so much. In two or three hours, give him just a little bit.”

“A little bit?”

“Yes, just a teaspoon. Five ccs, that’s it.”

“He’ll be hungry!”

“No he won’t. Normal newborns less than a day old barely need anything to eat. If you look at breastfed babies—and those are the babies eating the way they’re really supposed to eat—they get maybe, tops, an ounce of milk taken in over the whole first 24 hours of life. And they do fine. Just stop drowning this baby, and he’ll be fine, too.”

A study just published in The Journal of Pediatrics confirms what I’ve been saying for years: normal newborn babies need to take in very, very little over their first day of life. Ninety healthy, term, exclusively-breastfed babies were weighed very carefully with an ultra-sensitive scale before and after feedings to determine exactly how much milk was ingested. The average intake for the entire first 24 hours of life was 15 ccs—that is, one tablespoon. The range was from 1 to 30 ccs. That fits with exactly what we ought to expect from the physiology of a newborn and of a new mom. A newborn has just been through a traumatic transition, and has a gut that’s filled with sticky mucus. The normal “peristaltic waves” that push food along through the gut to help digestion haven’t yet begun. So it makes sense that a normal newborn isn’t quite ready to accept a full meal on the first day of life. It also fits exactly with what we know about a normal, healthy mom. Milk doesn’t “come in” until about 48-72 hours after a baby is born. Moms aren’t supposed to have a good milk supply during a baby’s first day of life. Now, some babies are going to get impatient and yell about this. That doesn’t mean they’re extra-hungry. It does mean that some babies, like some nursery nurses, don’t like to wait!

All of this assumes a healthy full term baby without additional risk factors for low blood sugar or other problems. If you’ve got a baby with special health circumstances, you need more specific advice and guidance.