Saturday, July 22, 2006

Breastfeeding


One of the many questions we ask at our hospital during the first prenatal visit is whether the mother intends to breastfeed her infant. The answer is usually some variation of “probably.” We strongly encourage moms to breastfeed, starting at that first prenatal visit and continuing throughout the pregnancy.

Regular encouragement by her health care provider(s) does seem to positively influence a woman’s decision to try breastfeeding her baby. But the encouragement of her own mother, her aunties and grandmothers is a stronger influence in whether she continues breastfeeding past the first few weeks. Extended family is a closely knit unit in the villages, often with multiple generations living under one roof. A new mom has many advisors.


Breastfeeding is strongly supported in Yupik Eskimo culture; many moms will breastfeed a child for two to five years, and some are nursing multiple children at one time. A woman came to clinic recently who was nursing a 4 year old, a 2 year old and a newborn. Many women are nursing an older child throughout their pregnancy, and only wean the older child when they have to come to Bethel for the last month of pregnancy. Cultural tradition is for a newborn to have exclusive right to breastfeeding; the belief is that the baby will not bond appropriately with the mother if the breast must be shared with older siblings. Some women lactate continuously for ten years or more, due to frequency of childbearing and extended patterns of breastfeeding.

Breastfeeding tends to inhibit ovulation, but many women do become pregnant while they are nursing. I have seen at least one patient who was nursing and already pregnant at her eight week postpartum visit. One reason for this may be the tendency of many moms to supplement breast milk with formula. The Women/Infants/Children (WIC) program supplies formula at no charge to the mother for her child’s first year of life, and most (if not all) women in our region qualify for the program. This easy availability of formula provides women a quick alternative if they have any problems with nursing. WIC does encourage nursing, and provides a free hand-operated breast pump to any mother who wants one. The WIC office here also has a grant-funded loaner program to supply electric pumps for short-term use. These machines retail for over $500, and work quickly, as they pump both breasts at once.

Southwest Alaska has one of the highest rates of initiation of breastfeeding in the entire U.S. It is rare to see a biological mom who is exclusively bottlefeeding, especially if she is more than 20 years old. Teen moms sometimes make little or no effort to breastfeed, but older moms almost always do. We have a fairly large rate of drop-off in breastfeeding when the baby is between six weeks and six months of age, but our breastfeeding rate at six months of age is still higher than most of the country. A small percentage nurse until four or five years of age. The oldest child I have seen still nursing was seven years old.

Instructions in breastfeeding are given to women who want or need them while they are admitted at the hospital for the delivery. We have one lactation consultant available; she is a family practice physician and nursing mom herself who had a strong personal interest in it and pursued certification. There is no La Leche League in Bethel or the YK Delta. Once a woman returns to her village, she has her own female relatives and the village health aides to help her. She rarely needs more.

Maternal complications from breastfeeding are most commonly cracked nipples, for which we give lanolin; and mastitis. The latter is a far more serious problem. Mastitis often develops quickly in Eskimo women and becomes severe. Deep abscesses are not uncommon, and occasionally the woman becomes febrile, bacteremic, even septic. We have very high rates of the dreaded MRSA, which is cultured from most of the abscesses we see. Cephalexin (Keflex) is essentially useless, our resistance rates to it are so high. Our most commonly used drug for abscesses is trimethoprim-sulfamethoxasole (Septra, Bactrim), but it is contraindicated in pregnancy and lactation, as is levofloxacin (Levaquin). We use ciprofloxacin (Cipro) much of the time. The deep and wide incisions needed for some of these breast abscesses can leave a woman with a very scarred breast.

Breastfeeding has been shown to reduce the rates of RSV, otitis media, and diabetes in babies who are breast fed. This is our strongest selling point to pregnant women. Our region has one of the highest rates--and greatest severity--of bronchiolitis in the world. Almost every home has a nebulizer, and almost every mom knows how to give a nebulized albuterol treatment and do effective percussion and postural drainage (P&PD)*. Yupik children have horrendous rates of acute and chronic otitis media. Draining ears are a daily staple in village clinics and in the hospital.

Overall, breastfeeding is easily accepted and widely supported in the Yupik Eskimo culture. On any given day, if you walk through the hospital waiting room, you may see a half dozen women nursing infants as they chat with family and friends around them. There is no hiding the baby under a blanket to do it, either. They are right there in the open, proud of their child, and their motherhood. It is the most natural thing in the world, and one of the most beautiful.


*Wikipedia had no entry to explain this. Many of our patients call it "pounding". The mom sits in a chair with one foot slightly elevated so that one knee is higher than the other. The child is placed face down on the lap with the butt on the higher knee and the chest on the lower knee (i.e., headed downhill). With her cupped hand, mom percusses ("pounds") the baby's back for several minutes. The vibration of this action helps shake loose the mucous plugs obstructing the baby's smaller airways and facilitates productive coughing to remove the mucus. P & PD following a nebulizer treatment enhances the effectiveness.

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15 Comments:

Blogger Intelinurse2B said...

So the challenge is how to get those statistical results (related to breastfeeding) to manifest in the lower 48. It was interesting to read how the act of breastfeeding is carried out and accepted in public and also how it is encouraged by the nuclear families of these new moms. Great post!

Saturday, July 22, 2006 11:20:00 AM  
Blogger TheTundraPA said...

IN2B--it's really wonderful to see breastfeeding in public so casually accepted. And the men are not standing around gawking, either. thanks for stopping by.

Saturday, July 22, 2006 12:53:00 PM  
Anonymous Anonymous said...

Part of the problem with superlatives, including epidemiological ones, for our region is the lack of specific information. That is, we are often characterized as having the most, least, highest, worst, etc.-- but so is New Mexico, Massachusetts, Vermont, New Zealand, Scotland, etc.

We don't have comprehensive environmental health research in our region (nor in many other areas of small, indigenous communities). The reasons include the way hospitalization / medical records are kept. Another reason is a focus on biomedical health approaches instead of biocultural ones. Biocultural Dimensions of Environment and Health

For example, the former approach would emphasize clinical presentations and the individual. The latter focusses on the population, in time and space. Large sample sizes are needed for most epidemiological studies with the former; the latter focusses on rigourous small sample size techniques.

Another reason is a reluctance to expect (and therefore work towards) holistic, high-quality, community-based research from one's own.

Otitis media does have a high latitude correlation (disease ecology) and a correlation with body type (developing structure of the face and skull, related to population genetics). These associations pre-date bottle-feeding. We really need to examine upper respiratory infections | populations | environment | use of antibiotics | cultural practices for all affected populations.

Sunday, July 23, 2006 4:30:00 PM  
Blogger John said...

I tried it and it didn't work. I guess it's the whole "being a guy" thing.

Sigh.

Sunday, July 23, 2006 8:05:00 PM  
Anonymous Leah in Fbks said...

I'm currently nursing a 6 mo little guy. Being Native (Athabascan) yet raised Urban; I quickly discovered that my greatest allies, confidants, and supporters were the other Native woman I know. I didn't have a good start with nursing (son took his time getting it figured out) and soon realized that all those months reading about childbirth would have been better spent learning about breastfeeding. We managed and I pump while I'm at work...so he still gets his "baht" while I'm gone.

I'me very open with breastfeeding among my much younger sisters because I wasn't raised around nursing mothers and largely didn't know much about it. I'm determined that when it's time for the sisters to have their babies, that they'll never even consider formula.

Friend of family (24 yo) recently had a baby at 33 weeks...and won't pump or nurse. Despite all my encouragement and pleading, she can't be bothered. Too self-centered, too lazy? Yes, in my opinion.

Even though my son is healthy and happy; I still get questions on when I'll wean him. He's a baby - what's he supposed to eat? He's not a little cow!

Monday, July 24, 2006 10:48:00 AM  
Anonymous Moof said...

This is for the previous commenter: John ...

Now really - there's no excuse to not breast feed! >;o)

Milkmen: Fathers Who Breastfeed

Monday, July 24, 2006 2:28:00 PM  
Blogger TheTundraPA said...

John--I guess Moof has got you here, hmmm? Maybe you just didn't try long enough! ;-)

Moof--pretty amazing! I had never heard of this!

Leah--good for you! We encourage nursing for the first year, though many women do stop around 6 months of age. Sounds like your younger sisters will benefit from your experience and education. Regarding the mother of the premie, it is too bad she was not willing to breastfeed. Premies need the extra protection that breast milk provides even more than full term infants.

Thanks for visiting!

Monday, July 24, 2006 8:35:00 PM  
Anonymous Philomytha said...

Love the picture! Yes, social support is IMO the most important thing of all for successful breastfeeding. I was fortunate in that both my mother and mother-in-law breastfed and had positive experiences, and my husband was willing to give me all the help he could, and that's why I'm still happily breastfeeding my 8-month-old son. But for women whose family have the instant response of 'give him a bottle' to any real or perceived problem with the baby, persisting with breastfeeding is a constant battle at an already hugely stressful time and I take off my hat to those who manage it.

Tuesday, July 25, 2006 12:04:00 PM  
Blogger John said...

I'm still laughing!

Wednesday, July 26, 2006 7:56:00 PM  
Blogger Fat Doctor said...

Fascinating. I work in an urban hospital where moms are generally young and lack support/education so important if they are to nurse their babies.

I always start the breastfeeding talk at our first prenatal visit. About 99% say "I don't know," which means "No way!" and 1% say "I'm going to do both breast and bottle," which means "No way!" It is disheartening. I encourage breastfeeding throughout the pregnancy. Of my 150 or so deliveries, probably one mom actually breastfed her infant to age one.

Add to this that I was unable to nurse my own child and shelled out big bucks for lactation consultants and all sorts of gizmos to help him latch. I pumped for eight weeks, took Reglan AND fenugreek, drank a gallon of water a day. When my milk finally dried up, I wept.

My anger when a patient says "No way!" in whatever way she says it, is anger at her and anger at myself and anger that we can't always have what we want. I'm trying to be more accepting of those committed to bottle feeding, but it still breaks my heart.

Thursday, July 27, 2006 1:04:00 PM  
Blogger TheTundraPA said...

philomytha--yes, social support from a woman's immediate circle of friends and family does seem to be the most important element in her commitment to breastfeed. The pain from cracked and bleeding nipples also plays a big part, especially for first-time moms. Fortunately, in our region, many do persevere. I am glad, for both you and your child, that you are still happily breastfeeding at 8 months of age.

fd--I agree, it is terribly disheartening when a woman is unwilling to make the effort to breastfeed. Here it is usually the very young moms who won't. There seems generally to be more acceptance in rural areas than in urban areas, probably because urban women are more likely to be employed outside the home and less likely to have close extended family nearby. Whatever the reasons, both mom and baby miss out on something very important. I can't help but wonder how much that early decision may contribute to "abandonment issues" later in the child's life.

Thursday, July 27, 2006 7:37:00 PM  
Anonymous Anonymous said...

tundrapa,

I used to work NICU so I have seen how important the breastfeeding is to newborns, especially those that are at risk for NEC or some other rather nasty intestinal disorders.

By the way, reletively new studies have shown that Purcussion and Postural drainage as well as nebulized respiratory treatments are not as effective as we would like to believe for bronchiolitis (RSV). It turns out that supportive care such as nasal suction (to clear the airways), IV hydration, and oxygen therapies are just as effective and have shown an actual decrease in hospital stays and expences.

Primary children's medical center in Utah has done a great deal of this "groundbreaking" research. I don't have a link but their website is not hard to find.

by the way, I love your blog,

Evan PA-S (BS,RRT)

Friday, July 28, 2006 7:22:00 AM  
Anonymous Moof said...

I breastfed the last 3 of my 4 children, and would have done so with all of them, except that my first husband forbade it.

Each were fed as long my milk held up ... which was between 3 and 6 months. It almost didn't work at all with my last baby, because I just didn't have enough milk.

It created a serious bonding experience ... which bottle feeding is not capable of duplicating.

I'm always disappointed when I hear that a new mom is going to bottle feed, but I think that people know what they feel capable of doing, and that limit needs to be respected.

.

Saturday, July 29, 2006 6:32:00 AM  
Anonymous wolfbaby said...

breast feeding is a wonderful thing.. i tried it with both of my children.. and was unsuccesfull..

i still don't know what i was doing wrong... my children would go pooo so often that there bottoms were fir engine cherrry red... and they were always at the breast like they weren't getting enough.. i only made it a week.

the second time i had to go back to the hospital for post partum pre-eclimsia.. and my milk dried up even though i pumped.. it was frustrating all around but i did try...

both times i felt like a total looser mom for nt succeding

Saturday, July 29, 2006 9:45:00 AM  
Blogger TheTundraPA said...

Evan--you are right. As I understand it, a small number of recent studies has indicated that nebulized albuterol did not improve outcome in RSV bronchiolitis (ie, reduced number of patients requiring intubation, decreased length of hospital stay). However, I believe a meta-analysis is yet to be done. Despite these results, it does seem that nebulized albuterol reduces work of breathing for the infants. Perhaps we are only treating ourselves and the moms. But when I see how much easier a baby breathes after neb/P&PD, I think there is value in that.

Also, we have plenty of RSV-negative bronchiolitis. Perhaps we should just call it "viral insult induced asthma". The nebs definitely help. Less wheezing, less coughing afterward.

Thanks for visiting, and for commenting--please, keep it up! Maybe you should consider arranging one of your clinical rotations up here; it is a great learning experience all around!

moof--you are so right about the bonding; for that reason alone, even if the product were not superior, I wish all moms could manage breastfeeding. Interesting that there was a significant difference in milk production for your last child; do you have an idea why? I am sorry your first child missed out because of your husband's demands.

wolfbaby--sometimes trying is all you can do, and it sounds like you made quite an effort. Many women who want to breastfeed and are not successful--for whatever reason--feel a profound sense of failure, like they are not Real Women, or they would manage this most basic of biologic functions. So many factors play into successful breastfeeding, and for some women it comes so easily. You were not a "loser mom" for not succeeding, and I hope you didn't beat yourself up over it. Thanks for visiting, and for sharing...

Saturday, July 29, 2006 10:52:00 AM  

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