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.

Many medications are safe for nursing moms

The Pediatric Insider

© 2016 Roy Benaroch, MD

An exhaustive new review should provide reassurance for nursing moms: many medications are safe for you to take, and genuinely serious reactions are very rare. Moreover, most serious reactions that do occur are to just a handful of medications. Common sense can be a good guide to keeping nursing babies safe when their moms take medication.

In this study, from February 2016, the authors did a truly comprehensive search of the literature for all studies and case reports of problems caused by medications in breast milk. The same authors had done a similar study in 2002, and decided it was time for an update.

Some of the findings:

• About 60% of reported reactions occurred during the first month of life; and 80% during the first two months. This makes sense—the youngest babies consume the most milk per weight, and also have the least ability to metabolize medications.
• 70% of adverse reactions were to medications that affect the brain, including narcotic pain medicines, antidepressants, and antipsychotic medications.
• All of the deaths reported (there were only 2) involved one or more narcotic pain medications.
• The use of multiple nervous system depressants at the same time increased the risk of serious reactions.

The bottom line: be careful especially with the youngest babies, especially when using multiple medicines, and especially when using medicines like narcotics that are known to cause slow and shallow breathing. That doesn’t mean nursing moms can’t take these medicine, but it does mean that they ought to take advantage of non-narcotic pain medicines, first, and if they do take narcotics their babies need to be monitored closely. A “pump and dump” strategy can be employed if mom needs potent pain medicines for a short time. It is not reasonable to expect nursing moms to live with untreated pain.

A great resource for nursing moms and the doctors who give them advice is the Lactmed database from the National Institutes of Health. You can look up just about any medication there, and see what studies are available to give you real and reliable information on milk transfer and potential issues with nursing babies. Some of the information is quite technical, but it’s better than the vague handwaving found in other places.

Speaking of which: one of the worst places to look for safety info for breastfeeding moms are the official “product inserts” of medications. They pretty much always say that nursing moms can never take any medicine (I don’t think they’re allowed to eat any food, either. Just water and rocks. Safety first!) Remember: product inserts are written by lawyers, for lawyers. They’re there to fulfill the crazy byzantine regulatory framework of the FDA. And to ward off lawsuits, and possibly vampires too. They’re not there to give parents or doctors useful information.

The health of moms is important, too. Often, moms stop taking their own medications out of fear that it may harm their nursing baby. Reviews like this, looking at what’s actually published and documented, provide some useful reassurance for moms and babies alike.

Can more vitamin D improve the health of nursing moms and babies?

The Pediatric Insider

© 2016 Roy Benaroch, MD

“Breast is best” is a simple, catchy phrase—but to be honest, it’s one that should be followed by a bunch of asterisks and qualifiers. Some mother-baby pairs have a hard time with nursing, and need support and understanding (rather than a simple dismissal of their concerns.) And breast milk, we know, isn’t a great source of absorbable iron, which is especially an issue for premature babies. But the biggest drawback of human breastmilk, compared with commercial formula, is that it is an inadequate source of vitamin D.

A new study shows that this doesn’t have to be the case. Perhaps insufficient vitamin D isn’t really a fundamental problem with breast milk, but a problem with mom’s vitamin D intake.

Backing up a second – we’ve known for a long time that breast-fed babies are much more at-risk for nutritional rickets than formula-fed babies. This is especially true for families with dark skin. Rickets is caused by insufficient vitamin D, and can lead to poor growth, bowed limbs, and other health problems. For most of human history our vitamin D came from sunlight exposure. The skin of babies and mothers can manufacture vitamin D, though it requires sunlight to do it. Darker skin is less efficient at making vitamin D than lighter skin.

To combat the risk of insufficient vitamin D in breast-fed babies, the AAP has recommended a daily vitamin D supplement, starting from birth. In practice, this recommendation is followed maybe 20% of the time. Parents don’t like to give their newborns medicine, and I think pediatricians are reluctant to focus on the possible inadequacies of human breast milk.

In the current study, researchers sought to determine if giving higher doses of vitamin D to nursing moms could result in enough vitamin transfer in their milk. 334 mother-infant pairs were recruited, and randomized into three groups. In group one, moms were given an ordinary vitamin supplement, and their babies a vitamin D supplement (400 IU/day, matching the current recommendation.) In group 2, the babies were given no extra D, but moms took 2400 IU/day; in group three, moms were given 6400 IU each day. Babies and moms underwent regular blood and urine tests to see if these doses resulted in good vitamin D levels in the babies, and to see if these doses caused any metabolic problems with vitamin D, phosphorus, or calcium metabolism.

There was a relatively high drop-out rate—of the original 334 pairs, just 148 stuck with the plan for exclusive breastfeeding, and were thus able to complete the trial (families who discontinued breastfeeding or added formula supplements were not included in the final analysis.)

All of the babies who received regular supplementation had robust vitamin D levels and normal biochemical testing – we know, if that 400 IU a day for babies is given, it works. That was group 1. Group 2, where moms were given vitamin D 2400 IU/day,  was a failure—they actually stopped this arm of the study early, because many of the babies in this group did not have adequate vitamin D levels on their blood tests. But the babies in group 3 – who themselves received no direct vitamin D supplements, but whose moms got 6400 IU/day—did as well as group 1, with perfectly good vitamin D levels and no evidence for any side effects or problems. And, bonus, their moms also benefitted, with normal vitamin D levels and no side effects.

A reasonable question, though—is 6400 IU of D a day safe for moms to take? A prior guideline from the Institute of Medicine had suggested an upper limit of 2000 IU/day (though that has since been increased to 4000); the Endocrine Society now sets their upper limit at 10,000. During the past decade many studies have used adult D supplementation in the range of thousands of units per day, and according to the authors of this paper not a single adverse event was observed.

This study supports a safe alternative for families, and perhaps one that’s easier to do. Moms are used to taking prenatal vitamins, and continuing to take them while nursing. Adding 6,000 IU of D to the typical 400 in a prenatal isn’t expensive, and seems to be safe and effective at making sure their babies get enough D. Breast milk can have enough D – but only if mom gets her own supplement.

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.