Tag Archives: Breastfeeding

Introducing Solids and Baby Sleep: Yep, Early Solids Improve Baby Sleep After All

Don’t give your baby solids until 6 months of age. This is the unambiguous advice of the world’s most highly regard medical organizations, including the American Academy of Pediatrics, the UK’s National Health Service, and the World Health Organization.

Ignore the “mistaken” belief that introducing solids earlier will help your baby sleep better. Early solids could have the opposite effect, worsening your baby’s sleep, according to popular parenting sites like Kelly Mom and the Baby Sleep Site.

Or so we have been told.

It turns out that the claim that solids don’t help baby sleep was based upon the shoddiest of studies–small, non-randomized, poorly controlled–like this one, which simply looked at whether babies were eating solids and how well they slept.

(To be clear–I am not trying to knock this research as research. Small exploratory studies can be very useful for hypothesis generation and deciding on which large studies to run, but the stuff of sound public health pronouncements they are not.)

Now, we finally have much better data, from a randomized trial of over a thousand babies. And surprise, surprise, your mum (or in my case, my mother in law) was right all along: Introducing solids early, at around 3 to 4 months, does improve babies’ sleep. Not just then, but for their entire first year.

The Details

The new study is a secondary analysis of the UK-based Enquiring About Tolerance (EAT) randomized clinical trial, a trial whose main goal was to assess whether early solids lowered the risk of food allergy.

In the trial, researchers randomly assigned 1,303 exclusively breastfed infants to either begin solids at three months (the experimental group) or at around 6 months of age (the control group).

Parents in the experimental group began feeding their babies solids at around 3 months of age, with specific instructions to expose them to six common food allergens (eggs, peanuts, white fish, cow’s milk, wheat, and sesame seeds).

The randomization was highly successful. Nearly all babies in the early introduction group began taking in solids by 4 months of age, whereas almost none of the control babies started solids until after 5 months of age. Notably, nearly all these babies continued to be breastfed, almost none received formula.

Although the EAT trial’s original purpose was to determine if early solids would help prevent food allergies, the study also carefully assessed the babies sleep. Each month, parents reported how long their babies slept at night, how often they awoke at night, and if they felt their babies had mild or severe sleep problems. They also described where their baby slept and how they put their babies to sleep.

Thus, this study represents the largest, carefully constructed randomized trial of how solids affect infant sleep ever performed.

So what did they find?

Babies who received solids early, starting around 3 to 4 months, slept better than controls. They slept a tiny bit longer each night during their first year of life (an average of 6-7 minutes overall, with the biggest difference–17 minutes longer each night–seen at 6 months of age). They were also about 10% less likely to wake up at night. So good, but not really much to write home about.

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Where early solids packed the biggest punch, however, was in preventing sleep problems. While only a small percentage of babies had sleep problems (fewer than 5% overall), control babies were much more likely to be problematic sleepers.

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As shown in the graph below, severe sleep peaked at around 9 months, and then dropped off sharply at a year (good news for many a bleary-eyed sleep beleaguered parent).

Most strikingly, parents of early introduction babies were far less likely to say their babies had mild or severe sleep problems throughout their first year of life–long after the controls were also taking in solids. It appears that early solids helped babies consolidate their nighttime sleep earlier, and this benefit persists throughout infancy.

This latter point was surprising to me, but appears well supported. In fact, the more solids experimental babies ate earlier, the better they slept. (This was a follow-on analysis, and not randomized, but it does lend further support to their main findings.)

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The Bottom Line

So, does this study mean we should all give our babies solids early to help them–and us, let’s not forget us!–sleep better?

By itself, probably not. The effects on sleep are pretty small, overall, (6-7 minutes extra sleep a night; about one less night awakening a week). And before we run completely in the opposite direction and overinterpret these findings, I would really love to see at least one other randomized trial examine the same question.

And we need to note that the babies who slept best in this study (as we already know) were not co-sleeping, slept in their own rooms, and went to sleep by themselves, without parental assistance. These practices had a much bigger impact than solids on baby sleep and remain the foundation for helping your baby sleep well.

That said, let’s step back a second and consider the larger context. Many studies now suggest early solids lower the risk of allergies. This is why many medical organizations that focus specifically on allergies recommend starting solids earlier (4-6 months) than their umbrella counterparts (6 months)–creating schizophrenic, headache-inducing advice for well-meaning parents.

For me personally, speaking as a parent, I would look at these findings and choose to start giving my baby solids at around 4 months of age.

(Introducing peanuts early lowers the risk of peanut allergies. Although the EAT trial did not actually show significantly lower risk of food allergies, there was a trend in that direction.)

As I have written about earlier, the recommendation to breastfeed exclusively for 6 months really only makes sense for women living in developing countries, where access to clean water and safe food sources can be limited. There are no demonstrated benefits for women living in developed countries like the US and the UK. It’s past time for medical organizations to reconsider this misguided blanket advice.

 

Breast may be best, but why isn’t it better?

In honor of World Breastfeeding Week (yes, yes, I know–it ended yesterday), we need to talk about a widely overlooked aspect of breastfeeding, its recipients!

Nope, I am not talking about our babies. (After all, who could overlook them?) I am talking about our babies’ gut bacteria.

Breast milk contains carbohydrates (known as HMOs, for Human Milk Oligosaccharides) specially designed to nourish specific gut bacteria, particularly Bifidobacteria. Bifidobacteria contain genes designed to metabolize HMOs–implying they have co-evolved with us for a long time.

This process of seeding your baby’s gut begins not with breastfeeding, though, but before birth. During pregnancy, women’s bodies cultivate these bacteria while pruning out others, seemingly in preparation to pass them onto our babies during birth.

Why does this matter? Health benefits.

Breastfeeding may benefit health indirectly–by cultivating the right gut bacteria. Scientists now believe that having the right balance of gut bacteria helps to calibrate your baby’s immune system and metabolism, possibly with lifelong effects.

I dig into the latest research on this breastfeeding-gut-health axis in my latest post for BloomLife. Check it out!

https://preg-u.bloomlife.com/breast-may-be-best-but-why-isn…

Drinking While Nursing: 7 Things to Know

While over half of mothers in the U.S. drink alcohol while breastfeeding, many of us are foggy on how this does (or does not) affect our babies.

Can you drink a glass of wine while breastfeeding your baby? Or do you need you wait 2-3 hours for the alcohol to clear? And exactly how much alcohol is too much alcohol to nurse?

Doctors and trusted sources like KellyMom and Babycenter give wildly conflicting advice on these points.

Continue reading Drinking While Nursing: 7 Things to Know

Don’t Count on Breastfeeding to Help You Shed Your Baby Weight

Breastfeeding melts off the baby weight, right? Breastfeeding leads to an “earlier return to prepregnancy weight,” according to the American Academy of Pediatrics (AAP).

This is because “breastfeeding burns extra calories, so it can help you lose pregnancy weight faster,” as many popular websites, like WebMd claim.

Sounds pretty clear cut, right?

So when I failed to lose weight while breastfeeding my first child, I was shocked. Weren’t those pregnancy pounds supposed to be falling off? Why were my pre-pregnancy jeans still collecting dust in the back of my closet?

Breastfeeding an infant does burn an average of 480 calories a day. So why wasn’t I losing more weight?

But like so many other alleged benefits of breastfeeding, breastfeeding-aided weight loss turns out to be vastly overblown.

In other words, my experience was completely normal. For most well-nourished women, long-term breastfeeding results in only a trivial amount of extra weight loss by 6 months postpartum, usually only of 1-2 lbs.

Continue reading Don’t Count on Breastfeeding to Help You Shed Your Baby Weight

Questioning Breastfeeding’s Benefits Does Not Make Me Anti-Breastfeeding

Earlier this week, I wrote about the alleged benefits of breastfeeding being vastly overstated.

My goal in writing that post was not to nurse some long-standing grudge against breastfeeding advocates. Nor was it an attempt to justify my own parenting choices: I breastfed both my children for well over a year.

(And yes, as some readers have inquired, I know just how wonderful breastfeeding can be. How breastfeeding your baby can be calming and joyful, even magical. But whether I found breastfeeding magical or a chore–or, in actuality, both–has nothing to do with whether it lowers the risk of asthma, or heart disease, or anything else.)

In response to my post, someone shared this comment on Facebook:

“Anyone who thinks this [my post] a solid piece of work needs to read my latest book, Milk Matters: infant feeding and immune disorder. No one has to prove that breastfeeding (the evolutionary and physiological norm that provides free stem cell transplants) makes a positive difference. Those who assume, claim or promote artificial feeding as safe or adequate need to prove that deviating from such basic physiological norms is safe, that there are no short or long term harms from doing so. …”

I am sharing this comment not because I find it particularly compelling, but because I think it nicely illustrates the problem with arguments made by many breastfeeding advocates: They start with the assumption that breast is best. And then, inevitably, they fail to scrutinize the evidence, no matter how flimsy, that supports that assumption.

And the evidence is flimsy indeed. Most of the alleged benefits of breastfeeding are found only in observational studies, which are widely acknowledged as biased. On average, breastfeeding mothers have a higher levels of education, higher incomes, and live in safer neighborhoods than formula-feeding mothers, granting their children an early leg up in life. Separating the effects of breastfeeding from these other advantages is next to impossible.

How do we know that these observational studies are biased? Primarily because we do not find the same benefits in better-designed studies–sibling comparison studies and the PROBIT randomized controlled trial. The only clear-cut benefit seen in these studies is a lower risk of severe vomiting and diarrhea during infancy. (For a detailed summary, see my earlier post).

To be fair, breastfeeding advocates are right, in a way. Breastmilk does contains numerous hormonal, antimicrobial, immunological, and nutritional factors not found in formula. This is why breastmilk helps protect against vomiting and diarrhea during infancy.

Before the advent of clean water, sanitation, and modern medicine, breastfeeding was frequently life-saving. In countries where access to these resources remains limited, it still is. There’s no bigger possible benefit than survival.

But these beneficial properties do not imply that breastmilk has any long-term benefits for the panoply of modern ailments: allergies, asthma, obesity, type 2 diabetes, and cardiovascular disease. We cannot claim such long-term benefits without sound empirical evidence. And that is entirely lacking.

If the American Academy of Pediatrics, and others were to say, “We recommend breastfeeding because it reduces the risk of severe diarrhea and vomiting during infancy, and because breastmilk contains unique immune, hormonal, and nutritional factors not found in formula, the long-term benefits of which are unknown,” I would have no problem with their claims.

But instead, they have chosen to present poor quality evidence as fact. Playing fast and loose with the evidence in this way undermines their credibility. Worse, it violates the trust that women have placed in them.

Breastfeeding Benefits: The Real, the Imagined, and the Exaggerated

A good friend of mine living in Scotland, who had a baby last year, mentioned to me how disappointed he has been with the U.K. National Health Service’s promotion of breastfeeding. Calling the alleged benefits overstated, he said, is itself an understatement.

I nodded in general agreement, acknowledging that many of the alleged benefits of breastfeeding have only been found in observational studies. 

Observational studies on breastfeeding merit skepticism, because they all suffer from the same major problem: breastfed infants on average differ from formula-fed infants not just in how they are fed in infancy, but in practically every other possible way–maternal education, maternal IQ, poverty, neighborhood safety, exposure to environmental toxins, race, and type and quality of childcare. In scientific terms, breastfeeding is confounded, out the wazoo.

We cannot tell which benefits found in an observational study derive from breastfeeding rather than from the myriad other advantages linked with breastfeeding.

(The “good” observational studies attempt to control statistically for the other relative advantages of breastfed infants. Unfortunately, controlling for confounds only works well when (1) all the important potential confounds are known, and (2) when there is a fair amount of overlap between the groups being compared. Neither of which is true when it comes to breastfeeding.)

In an ideal world, we would settle this question by conducting several large randomized controlled trials (RCTs), in which new mothers would be randomly assigned to breastfeed. RCTs are the gold standard in medicine for determining whether a true cause and effect relationship exists. In practice, though, such trials are neither feasible nor ethical.

Fortunately, we have the next best thing: a handful of studies that have cleverly circumvented the problem of confounding. These fall into two categories:

  • sibling studies, which compare siblings from the same families who were breastfed for different lengths of time, or who were not both breastfed.
  • a large RCT of a highly successful breastfeeding intervention (PROBIT Trial).

(Is the PROBIT Trial an exception to the no-RCT rule? No. Women in the PROBIT trial were not randomly assigned to breastfed or not; they were randomly assigned to receive a breastfeeding intervention or not.)

After my friend and I spoke about his irritation with the medical organizations like the American Academy of Pediatrics (AAP) and NHS overstating the benefits of breastfeeding, I was dissatisfied with my vague sense that he was right. I wanted to know exactly which benefits had been oversold and exactly which were supported not just by observational studies but by better-designed studies.

The short answer: Nearly all the alleged long-term benefits are likely the result of confounding, not breastfeeding. Better-designed studies find only a handful of real benefits: a reduced chance of severe gastrointestinal infections and a lower risk of eczema during infancy, and perhaps a small boost in childhood IQ.

Alleged Breastfeeding Benefits According to the NHS

According to the NHS, breastfed infants are…

  • less likely to suffer from vomiting or diarrhea and therefore less likely to go to hospital
  • less likely to develop type 2 diabetes in later life
  • less likely to become obese in later life
  • less likely to suffer from heart disease in later life
  • less likely to suffer from constipation
  • less likely to get a chest or ear infection and therefore less likely to go to hospital
  • less likely to suffer from tooth development problems
  • more likely to have good communication and speech skills
  • more likely to have good circulation
  • less likely to suffer from wind, colic and constipation
  • less likely to develop eczema or asthma

Sounds pretty impressive, right? Until you set aside the evidence from observational studies…

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Continue reading Breastfeeding Benefits: The Real, the Imagined, and the Exaggerated

Vitamin D in Breastmilk and My Daughter’s Diagnosis with Type 1 Diabetes

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Sydney, catching bubbles at her birthday party this month.

A few weeks ago, I was all set to write about the vitamin D needs of pregnant and nursing women. Increased sunscreen use and less time spent outdoors means that few women can meet their vitamin D needs through sunlight exposure alone. As a result, many pregnant women are insufficient in the vitamin.

The medical community is clearly concerned about women’s low levels of vitamin D: The American Pregnancy Association recently raised their recommended vitamin D intake for pregnant and nursing women from 400 IU to 4000 IU, a tenfold increase. The change was precipitated by a recent randomized control trial, in which supplementation with 4,000 IUs a day was shown to be safe and highly effective at reducing vitamin D deficiency among pregnant women.

I only wish these changes had come sooner.

I say this because last weekend, my daughter Sydney, who turned two this month, was diagnosed with Type 1 Diabetes–a disease that may be staved off, in part, by high levels of vitamin D during infancy.

Continue reading Vitamin D in Breastmilk and My Daughter’s Diagnosis with Type 1 Diabetes

Introducing Solids: Is It Best to Wait Until 6 Months?

In 2005, the American Academy of Pediatrics (AAP) changed their recommendations from gradually introducing solids between 4 and 6 months of age to exclusively breastfeeding for “about the first 6 months of life. For the first 6 months “your baby”, they assert, “needs no additional foods (except Vitamin D) or fluids unless medically indicated.”

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My daughter at 9 months, eating peas and Cheerios

You might think that these recommendations were updated because of a new evidence showing substantial benefits for the baby of delaying the introduction of solids.

But, nope, this is not the case. Instead, these changes were motivated by studies showing an absence of harm to the baby and some minor potential benefits for the mother.

The World Health Organization was the first major medical organizations to recommend exclusive breastfeeding for 6 months, for reasons they outline in a 2002 research review (updated in 2007):

  1. No evidence exclusive breastfeeding for 6 months results in poor growth
  2. No apparent increase in the risk of allergies*
  3. A longer period of lactation-induced infertility, about an extra month on average
  4. Greater postpartum weight loss between 4-6 months, about a pound on average
  5. Lower risk of illness for the first six months, and possibly throughout the first year

* (Since this review was published, new evidence suggests delaying solids until 6 months may increase the risk of food allergies. More on this complex topic below.)

When weighing the pros and cons of exclusive breastfeeding for 6 months, the social and environmental context matters. The WHO crafted its guidelines to maximize health outcomes in both developing and developed nations. But benefits that have a large public health impact in the developing world, where access to basic medical care, birth control, clean water, and nutritious food is limited and inconsistent, can have little or no impact in the developed world.

Benefits of Exclusive Breastfeeding for Six Months

For mothers living in the developed world, the benefits of exclusive breastfeeding for 6 months are small, arguably negligible.

We have been blessed with access to birth control, so lactation-induced infertility is not a critical means of pregnancy prevention and birth spacing.

And, when it comes to weight loss, although almost every mother I know would gladly shed an extra pound or 2 of baby weight, the benefit is really small, just an extra a pound on average. Surely there are other activities that do not require 8-hours a day, round-the-clock efforts that would be just as effective forms of weight loss.

Certainly neither of these two benefits warrant the stress placed on introducing solids “at the right time.”

Of the reasons given by the WHO, the only truly persuasive one is a reduced risk of illness for the baby during its first 6 to 12 months of life. Here again, though, there are important differences between the developing and the developed world.

In the developing world, exclusive breastfeeding for 6 months is literally life saving. Within the 42 nations with the highest child mortality rates, widespread adoption of exclusive breastfeeding for 6 months would prevent an estimated 13% of the deaths of children under the age of 5. This is a larger percentage than would be saved with improved access to antimalarial medication or antibiotics.

Within the developed world, the picture is more nuanced. Here, completely weaning from breast milk before 6 months, or introducing solids before 4 months, or introducing formula before 6 months substantially increases the risk ear infections, diarrhea, pneumonia, and bronchitis.

But gradually introducing solids between 4 to 6 months while continuing to breastfeed does not. Studies that compare the outcomes of infants who were exclusively breastfed until 6 months (EBF or exclusively breastfed) with those who were exclusively breastfed for at least 4 months and then partially breastfed thereafter (MBF or mostly breastfed) find that 6 months of exclusive breastfeeding neither harms nor benefits growth and development.

The only apparent benefit of delaying until 6 months was a 25-50% lower risk of diarrhea in the first year of life. The effects on ear infections, pneumonia, and bronchitis were unclear: A couple of observational studies found a lower risk, but the majority of studies, including the only two randomized controlled trials, found no effect. And longitudinal study conducted in Belarus found no differences in weight, height, BMI, asthma, allergies, or other illnesses by age 6.

“Exclusive breastfeeding for six months does not seem to confer any long-term (at least to early school age) protection against obesity or allergic disease, nor any benefits in cognitive ability or behaviour, compared with exclusive breastfeeding for three to four months with continued partial breastfeeding to six months.”  – Kramer & Kakuma, 2012

Costs of Exclusive Breastfeeding

Lower Iron Status. EBF infants tend to have lower iron levels than mixed fed or formula-fed infants. Two randomized controlled trials, one conducted in Honduras and the other in Iceland, found significantly higher iron levels among MBF than EBF infants. Reassuringly, at 6 months of age, iron levels in both groups remained within the normal range, and the EBF infants were not more likely to be iron deficient or to develop anemia.

Still, iron needs rise sharply in the second half of the first year when newborn iron stores have been depleted, and lower iron status in the first six months could place EBF babies at higher risk of iron deficiency as they age. This is why the CDC considers “breastfed babies who after age 6 months are not being given plain, iron-fortified cereals or another good source of iron from other foods” to be at high risk for iron deficiency and anemia.

Increased Risk of Food Allergies. On this point, the advice given to parents has seesawed from it is best to delay solid foods, especially highly allergenic ones, to it is best to introduce these foods early, between 4 to 6 months. This is because the evidence behind the advice is of poor quality and inconsistent. A handful of observational studies find that early introduction increases the risk of allergies. A comparable number find that late introduction increases the risk. And not all of the studies find when solids are introduced matters at all.

Some researchers to speculate that there is something of a sweet spot in infancy, between 4-6 months of age, when introducing solids lowers the risk of allergies. This protective effect may be strongest for peanuts and cooked whole eggs. But until proper clinical trials have been done, it seems wise not to make too much of these findings. (UPDATE: A randomized controlled trial has now shown that introducing peanuts before 1 year of age lowers the risk of a peanut allergy substantially. More on this study here.)

The AAP no longer recommends waiting to introduce solids until 6 months or later to reduce the risk of allergies, and instead advises waiting until at least 4 months. And of course, this statement on solids and food allergies conflicts with guidance the AAP gives elsewhere to exclusively breastfeed for 6 months.

Conclusions

Like so many parenting decisions, the actual evidence suggests that we can all relax a bit. For those of us lucky enough to live in the developed world, introducing a small amount of solids between 4 to 6 months is unlikely to harm our babies, and equally unlikely to benefit them.

That said, when giving your baby solids before 6 months, it makes sense to provide small amounts. The immune benefits of breast milk are dose-dependent: the more milk the baby takes in, the greater the protection from illness. This is why solids during the first year should not be used to replace but to supplement breastfeeding. And when introducing solids, especially to exclusively breastfed babies, it makes sense to emphasize iron rich foods like broccoli, meat, eggs, fish, and fortified cereals.

Here is most sensible statement I found on the 6-month rule, from a review article in The BMJ, the flagship journal of the British Medical Association:

“From a biological perspective, the point when breast milk ceases to be an adequate sole source of nutrition would not be expected to be fixed, but to vary according to the infant’s size, activity, growth rate, and sex, and the quality and volume of the breast milk supply.”  – Fewtrell, Booth, & Lucas, 2010

When did you first introduce solids? Did the risk of allergies or infections play a role in your decision?

Let’s Face It: Formula-Fed Babies Sleep Better

Breastfeeding is a major battleground of the modern mommy wars. In her widely discussed piece in The Atlantic, Hanna Rosin called breastfeeding the “new sucking sound”–replacing vacuuming as the task that shackles women to the house, promotes the unequal distribution of childcare and household duties, and prevents women from reaching the upper echelons of professional success. The benefits of breastfeeding have been oversold, she claims, and–just as significantly–the costs to women’s sleep, time, and career progress have been downplayed.

On the other side of the debate, the American Academy of Pediatrics states that the benefits for the infant in terms of reduced risk of infection, adult obesity, allergies, and asthma are so great that breastfeeding must be viewed as an “investment in your child’s future” rather than a “lifestyle choice.” Some lactation consultants fall into this camp too, needing to be reminded to suppress their impulse to sigh when yet another mother complains of exhaustion and lack of sleep, for fear they alienate her–and thus fail to convince her to keep breastfeeding.

On both sides, well-intentioned but overzealous advocates twist the evidence on breastfeeding, cherry-picking among studies to support their preexisting views.

This is especially true when it comes to one of breastfeeding’s major downsides: Disrupted sleep.

Consider the post, 5 Cool Things No One Ever Told You About Nighttime Breastfeeding, which claims that the number 1 coolest thing about nighttime breastfeeding is “breastfeeding moms actually get MORE sleep than their formula-feeding counterparts,” and concludes with the rhetorical question: “Did you ever think, when you hear your baby rouse at 2:00am, that they are actually giving you the gift of MORE sleep…?”

To which I would like to respond: No, never, not only because it does not square with my own experience, but also because the research on this topic is clear: breastfeeding moms, on average, get less sleep, not more.

Almost without exception, studies on formula feeding, breastfeeding, and sleep find that breastfed babies wake up more often than formula fed ones at night, and breastfeeding mothers therefore get LESS uninterrupted nighttime sleep.

Nighttime Wakings in Formula-Fed Versus Breastfed Babies

Continue reading Let’s Face It: Formula-Fed Babies Sleep Better