by Nabila Hanim, BMSG Staff
Last June, BMSG (Singapore) had the honour of recording a video conferencing session with the esteemed Dr Jack Newman, paediatrician and breastfeeding expert, who is also an International Board Certified Lactation Consultant (IBCLC). During the session, Dr Newman had responded to some pertinent questions about breastfeeding and jaundice. In this article, we summarise the interview for the benefit of our readers and followers.
Many of us would have recognised Dr Newman from our own readings and research on breastfeeding. His resource pages have been very popular and widely referenced. Dr Newman is also known for helping many mothers tackle breastfeeding challenges even in the early newborn days. His video on breast compression, among others, has been shared extensively in the breastfeeding community.
What is Jaundice?
Jaundice is usually detected a few days from the baby’s day of birth. Jaundice is typically diagnosed after a blood test is done on the baby to check bilirubin levels. Bilirubin, a by-product of the breakdown of red blood cells, are in abundance in babies while in the womb. Once baby has been birthed, baby’s body breaks down these excess red blood cells because they are no longer needed. Bilirubin is one of the products of this process.
Bilirubin is also an antioxidant and can help the body to manage Group B Strep, which can cause meningitis in baby. Dr Newman suggested that this is probably a huge clue as to why bilirubin may be present in many babies, particular in East Asian babies.
Bilirubin has a Function
Dr Newman spent a significant amount of time talking about how bilirubin levels may not necessarily be an indicator that something is wrong with the baby. He explained that since bilirubin is not normally produced by the body, there must be a reason why it exists in babies. He also compared the high levels of bilirubin in jaundiced babies to the Gilbert syndrome, a disease by which otherwise normal adults experience higher than usual levels of bilirubin as compared to other adults. It was found that persons with Gilbert syndrome will experience elevated bilirubin levels when they fall ill and are also protected from atherosclerosis.
Is Breastfeeding to Blame?
Dr Newman then shared about how the problem is not breastfeeding but rather dehydration. Dehydration in jaundiced babies increases the risk that bilirubin will cross the blood-brain barrier, which is dangerous for babies.
On the question of whether formula is necessary for babies who are jaundiced, Dr Newman stated that breastfeeding does not have to stop because of jaundice. Introducing formula will affect the breastfeeding relationship since baby will not nurse as much.
In fact, Dr Newman believes the issue of hydration can be solved when breastfeeding is successful. A lot of times, jaundiced newborns are not breastfeeding optimally and therefore not drinking enough to hydrate themselves.
Birth Interventions Also Contribute to Breastfeeding Problems
Parents may also notice that some of their babies may not be interested in breastfeeding or are always falling asleep at the breast. Dr Newman explained that mothers who receive interventions during labour, such as epidurals, IV fluids (which are compulsory with epidurals) or taking other pain-killers while labouring, risk having babies born being sluggish, inactive or sleepy. This makes it difficult for babies to learn to breastfeed right after being born and he urged parents to become empowered to reject such interventions because it can obstruct breastfeeding later on.
Citing his experience of witnessing mothers giving birth in African countries while he was still working there, Dr Newman observed that mothers rarely received interventions during labour. He found that the babies to these mothers remain alert at birth and subsequently had little issues to latch onto their mothers’ breasts. In contrast, mothers in modern settings who birthed at hospitals frequently face the challenging tasks of breastfeeding sleepy babies.
While a jaundiced baby has always been thought to become sleepy because of their condition, Dr Newman, on the contrary, attributed this to the lack of hydration or being over-hydrated from the fluids that mums take during labour. Over-hydrated babies may show less interest to breastfeed because their bodies do not need excess fluids. He also added that taking painkillers such as epidurals allows the medicine to pass over to the baby through breastmilk, resulting in sleepy babies.
He emphasised that parents need to be empowered to reject birth interventions and to know that these interventions “are not without consequences” and implications especially on breastfeeding. He also urged that all mothers should have the choice of not taking epidural and understand that birth interventions can impact breastfeeding drastically.
Dr Newman was also asked if there was a need for phototherapy in the treatment for jaundice or exposing jaundiced to sunlight. Dr Newman replied that it is strange that we encourage adults and children to put on sunblock but have no issue with putting a jaundiced baby for long hours, sometimes days, under phototherapy light. He also mentioned that there is evidence that exposure to phototherapy can also alter the cells in babies’ bodies, which are precursors to cancers. There are also studies that show babies can experience DNA damage after undergoing phototherapy.
While he acknowledged that phototherapy can be helpful when a baby is already hemolysing and to prevent exchange transfusions, it does not tackle the root of the matter which is the lack of hydration or the infrequency of breastfeeding. “Jaundiced babies need to breastfeed and drink well,” Dr Newman said. He mentioned that if breastfeeding was going well in the first place, there would be no need for phototherapy. If the mother and baby are already engaged in breastfeeding, having jaundiced babies undergo phototherapy also “disrupts the routines” of breastfeeding.
Mothers’ Diet & Impact on Jaundice Levels
Some mothers had also voiced their concerns about the impact of food on jaundice levels and if certain food can cause jaundice or allow its levels to worsen. Dr. Newman responded that as long as babies are healthy, thriving and gaining good weight, mothers can continue to breastfeed their babies. Instead, mothers should troubleshoot early breastfeeding issues and ensure that babies are drinking sufficiently. “We have to remember that as long as baby is well there is no need to be concerned,” he said, emphasising the importance of good breastfeeding to help baby cope with jaundice.
Closing Remarks: Bilirubin is Not the Real Problem
As the conversation rounded up, Dr. Newman once again questioned why bilirubin is a problem when it is so abundant and normal in many babies. He believes that there is a link between this and the fact that babies who are healthy and still experiencing jaundice (also known as breastmilk jaundice in otherwise healthy babies with no other medical complications) can still thrive and grow well despite clearly still being jaundiced. At the end of the day, he urged the audience to embrace the fact that jaundice levels will rise when breastfeeding is not going well, and that to fix that first and foremost.
As told to Nabila Hanim, BMSG Staff
The Circuit Breaker (CB) was a two-month lockdown that was implemented by the Singapore government beginning April 2020. During this period, only essential services were allowed to continue functioning. This impacted accessory services (otherwise known as non-essential services), including home visits for breastfeeding support. Mothers were encouraged to visit the hospital for lactation help, which also meant exposing mother and baby to lurking viruses in the midst of the Covid-19 pandemic.
Giving Birth in the Middle of CB
Sarah Chen (not her real name), now a mother of two, gave birth to her second child on 23 May, right in the middle of the CB. Leading up to the start of labour, Sarah was naturally worried about giving birth at the hospital during that time.
“I was worried that the hospitals in Singapore might be overrun with critical Covid patients, that i would be at risk of cross contamination, or worst (actually I don’t know which is worst), being told to give birth at home instead,” said Sarah, citing her friend staying overseas who was told not to come to the hospital when her labour started.
Sarah managed to give birth at a local private hospital in the end. She felt fortunate that staff at the hospital she gave birth at were able to assure her and her baby’s safety throughout their stay there. The hospital staff were masked up and provided her with adequate information and reassurance, which allowed her “to forget about the virus for a few days and focus on giving birth and recovery.” She also added: “Truthfully speaking, thoughts of CB and Covid-19 left my mind the moment my water broke.”
Breastfeeding the Second Time
Once her baby was born, Sarah was unable to carry out skin-to-skin with her newborn due some complications. Despite that, she was adamant to ensure that breastfeeding started right and was able to latch her baby at the ward later on. “It was something I wanted to ace this time round with my second child. My goal was to ensure proper latching, thus reducing any nipple damage or blisters. I think that is the key to ensuring a smooth start to breastfeeding,” she said. Sarah was also motivated to breastfeed her second-born longer this time round after hearing the plight of hospitals in the United States. “Some people in the US did encounter formula and diaper shortages at the beginning of the pandemic, which made me consider wanting to breastfeed for longer this time in case that happened in Singapore, but alas that is not the case here.”
During her stay at the hospital, she also ensured that she obtained a visit from the Lactation Consultant (LC) and also urged the nurses in the ward to help her latch her baby correctly or to check her baby’s latch everytime she nursed. She was also happy to find that her baby was latching well and she also felt she had a good amount of colostrum.
Finding a Knowledgeable LC
Despite the positive experience in the hospital, Sarah faced other hurdles when she returned home. As her milk supply kicked in, she started to experience engorgement and had trouble latching her baby. She then decided to obtain a consult from a LC remotely to look at her problems. Although she only managed to attend one Zoom consult, she felt that she received adequate support. “She helped me to fix the problem overnight,” Sarah said, adding that she learnt a lot of things about breastfeeding just from the consult alone. “What I’ve learnt this time round is that when latching is problematic, sometimes it’s not just about textbook techniques. Physiology also comes into play – my baby had a high palate, I had a huge gushing supply, my boobs were big but nipples were not long, and so on,” she added. She was able to better appreciate what was happening because she understood what was happening to her body.
This was a huge contrast to her experience after she gave birth to her first child. “With my first child, every problem (that I mentioned before happened), but the LCs I had engaged at that time were not able to guide me properly,” she said. She ended up “Exclusively Pumping (EP) for 4.5 months with a massive oversupply and 101 clogged ducts.”
Despite the challenges of being confined at home, Sarah was more confident this time around and knew what to expect. Ultimately, she knew that she needed to be positive and reach out to others for help and support at a time when she must have felt vulnerable and overwhelmed with a new baby.
Advice for Mothers
When asked what she would change if she had to go through the experience again, Sarah admitted that she was happy with her experience. “I think despite the challenges, everything went as well as it could,” she said, adding that she was glad she was able to exclusively direct latch and has also managed to introduce the bottle to her baby.
She also added that mothers should be brave, embrace the challenges and not to hesitate to reach out for support such as talking to other mothers in support groups such as that of the BMSG. “Sleep more, shower to boost your spirits (and) read lots,” she also added, alluding to the fact that being prepared, well-recharged and knowledgeable are things that can well-equip a new mother.
Managing Expectations & Timely Responses: Keys to Positive Breastfeeding Experiences
Sarah’s story is one which reminds us that knowing what to expect and responding in a timely manner to breastfeeding challenges are important in ensuring a sustained and long-term breastfeeding journey. She also proved that seeking information and support were key to her well-being as well, both for breastfeeding and for her mental health. Despite the circumstances, Sarah was able to troubleshoot the challenges she faced early to prevent them from getting worse.
By BMSG Editorial Committee
Editor’s Note: This article is meant to help mothers recognise errant or misconceived breastfeeding advice that they may receive from individuals who claim to be breastfeeding professionals. Ultimately, we hope this article empowers mothers to discern between well-meaning and problematic advice.
What is a Lactation Consultant?
If you are a breastfeeding mother, chances are, you might have been asked to contact a lactation consultant or LC for short. This is usually the case when a breastfeeding mother is facing challenges that go beyond what a peer counsellor or lactation nurse is able to help with.
In such situations, mothers are strongly encouraged to seek help from a certified lactation consultant. Currently, International Board Certified Lactation Consultants (IBCLCs) are the only breastfeeding professionals who can provide mothers with assistance to more serious breastfeeding issues such as oral restrictions and latching difficulties. IBCLC is also the highest qualification standards for lactation certification globally.
Unfortunately, the term “Lactation Consultants” are not exactly protected. Anyone can call themselves a “lactation consultant” but to become an IBCLC, one would have completed the requirements to be eligible to sit for and passed a rigorous exam, prove continuing education every year and accumulated relevant number of hours before they can legally use the term.
Recognise the Alarm Bells
So if you are meeting someone who claims she is a lactation consultant or a lactation specialist, paying attention to this list of errant comments may help you to decide if the advice you are receiving from the individual is sound:
1) “Your milk is too thin and of poor quality.”
Breastmilk is made up of many components and unlike commercialised milk or milk powders, breastmilk will separate into many layers when settled. At the start of a feed after a letdown, milk that is expressed from the breast may take a watery texture. It may be natural for anyone who is uninformed to conclude that this is a sign of poor milk quality. But once we understand that milk is made up of part water and part fat, both of which are important as these help to quench a baby’s thirst AND keep them full all in one feed, the appearance of a mother’s milk rarely is any cause for concern. This is akin to the appetiser-main course-dessert analogy where breastmilk fulfils all the necessary nutritional needs for babies.
If you were to place a bottle of expressed breastmilk and let it stand for a while, you will notice that the breastmilk will separate into layers. The fattier layers will climb to the top (characterised by a layer of fat or oils) and the watery layers will sink to the bottom.
2) “Your baby is too lazy to latch.”
It must be heart-breaking to know that your baby has been labelled “lazy” at such a young age! Such advice can never be further from the truth. The fact is that a percentage of babies may face some difficulties or challenges to latch, either due to an oral obstruction (tongue ties, lip ties, missing palate etc.) or due to interventions that affect baby’s ability to latch (e.g. using a bottle before breastfeeding is well-established, using a nipple shield or a pacifier very early on in baby’s life, or mum having taken epidural in labour).
A baby is never lazy! But they can be taught to latch and if they have oral conditions that prevents them from latching well, their situation can be improved with medical interventions. After all, especially for a newborn, breastfeeding requires practice. Some babies may have very small mouths that may need them to put in considerable effort to latch on mummies’ breasts.
3) “You need to pump to see how much milk you are making.”
Pumping to check your supply is inaccurate as a pump is never able to extract as much milk as a baby can latch. The best way to check your supply is to monitor your baby’s wet and dirty diapers, weight gain as well as level of activity. Pumping too early can also trigger an onset of problems such as oversupply in the early days, which can inevitably lead to complications such as blocked ducts and mastitis.
4) “You must introduce bottles at 3 weeks to prevent bottle rejection.”
This is not true. Early introduction of bottles (anytime before 4 to 6 weeks) can interfere with a baby’s ability to latch at the breast. Parents should wait before introducing bottles because babies may develop a preference for the fast flow of the bottle. They may also experience nipple confusion where they are unable to latch at the breast or become too impatient to wait for a letdown at the breast. While it is true that breastfed babies can reject the bottle, there are other ways to provide expressed breastmilk (EBM) to babies when the time comes such as when mothers return to work. Alternatives such as cup, spoon, syringe and straw feedings have worked with many babies. Babies can also receive EBM through age-appropriate sippy cups.
5) “Pump after latching to prevent blocked ducts.”
There is no need to pump after each time you latch your baby. If your baby has emptied your breast during the session, you can continue to offer your baby the other breast at the next feeding session. Pumping unnecessarily after each latch can signal to your body to make more milk than what your baby is actually receiving. This can lead to complications such as oversupply and subsequently blocked ducts and mastitis. If you still feel that your breast is not fully empty after a feed, use breast compressions during the feed to activate the milk flow once you sense it has slowed down. This can be seen when baby falls asleep at the breast. Baby will automatically unlatch or fall into a deep sleep once he or she has received enough milk. Some mothers also hand express the excess milk and store them for later use. As long as your baby is feeding efficiently, there is no need to pump after every latch.
6) “Feed baby on both sides for 15 minutes each.”
The time that baby takes to feed from the breasts is not important. Latch on demand and allow baby to drink from the breast for as long as he or she wants. Limiting time at the breast (or unlatching too quickly) may prevent baby from getting a full feed from the breast, which may consequently mean preventing baby from getting the fattier part of the milk which is present towards the end of a feed (i.e. an emptier breast). An empty breast also stimulates the brain to urge the body to produce more milk, hence helping to maintain your supply.
Knowledge is Power
With all that has been said, at the end of the day, it would be helpful for mothers to seek evidence-based information and to talk to as individuals as possible before making important decisions for your breastfeeding journey. It can be overwhelming and also demoralising to receive comments that may be far from accurate but knowing how to sieve out errant information and to seek opinions from different sources will greatly help you to decide what is best for yourself and your baby.
A lot of times, advice can be well-meaning. It can also be problematic if it is actually misinformation or does not help you to make a well-informed decision. It is therefore highly important that parents understand the techniques behind breastfeeding and do some fact-checking before arriving at a decision. A wrong move can greatly impact what happens subsequently.