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Subject:
From:
"Dr. Harvey Karp and Nina Montee" <[log in to unmask]>
Reply To:
Lactation Information and Discussion <[log in to unmask]>
Date:
Mon, 19 Feb 2007 19:10:57 -0500
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Dear Nikki and Fellow Lactnetters,

I am delighted to have this forum as a place to answer questions to clarify the understanding of issues that are relevant to all who want to encourage the promotion of breastfeeding.  But I do plead with you to familiarize yourself with my work and watch the DVD so that you are less likely to twist things out of context. Let us try to keep focused on being enlightening, not misleading.

Nikki, I am forced to take issue with the tone and many of the specifics of your last post.

For example, you mention that the Cochran Collaboration does not mention THBOB...of course it doesn't.  As I shared with you, the first double blind study of the 5 S's has not yet been completed (it is underway at Penn State University, funded by an NIH grant). That notwithstanding, I did supply you with over 50 reports and peer-reviewed studies that support the efficacy of the S's. You didn't mention any of those in your note. I look forward to you reviewing those and giving your feedback. 

You quote me as stating that the 5 S's may cover over early feeding cues.  This is accurate, but you are inacurate when you twist this point into a misrepresentation of my views by saying, "If an infant is swaddled 12-20 hours a day from birth (as recommended in the book, HBOTB pp. 120-121), it will not be able to show feeding cues. Dr. Karp  says this  in his lengthy post. His suggestion is to schedule feeds to compensate. Neither of these practices belong in breastfeeding." 

I never say that swaddled babies are unable to show feeding cues.  In fact, they are able to show MANY feeding cues...for example: rooting, waking, cooing, fussing, crying. 

You note your support of cue-based feeding...well I strongly support it, too (you can quote me on that).  But moms in todays modern world, need to know how to balance baby...family responsibilities...etc.  I believe they are most successful when they are taught how to gently modify their baby's feeding schedule as needed (e.g. delay a baby's nursing for a couple of hours at night).  You will see on the THB DVD, several mothers of 1-2 month old babies who are thrilled to have extended their baby's nighttime waking from q2h to a stretch of 4-5 hours.  DId they cover over early feeding cues for that short period? Certainly.  Did it have any negative consequence on the nursing? Absolutely not. In fact, the extra sleep may well have helped the mom to not be so stressed and exhausted and that may well improve her milk supply.

Regarding swaddling and waking babies up for feedings, you uncategorically pronounce that, "neither of these practices belong in breastfeeding."  Where is the proof for your extraordinary claim? The practice of swaddling HAS BEEN a part of successful breastfeeding in many cultures for thousands of years. And, waking a sleepy baby to feed may be of valuable to help establish the an adequate supply in the first 1-2 weeks of nursing. Parents around the world rarelyhave to wake their swaddled babies up to eat...that is because swaddled babies wake up and start to root and murmur when they get hungry. I only recommend teaching new moms to be aware of the need to ensure 8-12 feedings/day during the first couple of weeks.  

Let me be perfectly clear, in my opinion, during the first couple of weeks of life, as the nursing is becoming  established, babies need to be fed ad lib...and even more than that (because some babies are sleepy and the mom needs to wake the baby from sleep to promote the initiation of lactation - ...some benefit from swaddling during feeding so the mom can easily handle the flailing arms...others need to be unswaddled to help them arouse to feed adequately). So, parents need to know that if their baby sleeps a few hour more at night, they need to be thoughtful about getting some extra feedings in during the day.  Once the feeding is well established, the baby and mom get in balance.

I hope you are not blaming my work for the problems you are encountering in your practice when you say, "My private practice is full of battling dyads where the mother has been taught that she MUST wake the baby every 2 hours to feed; in such cases, breastfeeding is on the edge of collapse." I don't know who is teaching in your community, but my whole work is teaching parents to watch their baby.  As you will read in my book, I spend a chapter helping parents appreciate the distinct personality of their new baby.  Some prefer one S to another...some are passionate and some are laid-back.  My work is not meant to be a treatise on breastfeeding, but I agree with you that it is important that the reasonble recommnedation to feed 8-12 times a day during the first few weeks not be turned into an inviolable "law" that frightens parents into becoming "feeding machines" slavishly nursing every 2 hours. 

Moms need to learn sound nursing principles. They need to understand the concept of adequate flow, frequency of feeds, stool and urine output, etc (all the great things that LC's teach and that I taught each patient during my hospital visits). In fact, this is why I support prenatal/postnatal education for parents.  There are lots of misconceptions (about nursing AND baby calming) that can best be adressed in person.  As a society, we need to make an investment in our young families...and that includes helping them do the best job possible with their young children.

On another note, I am not sure if you misunderstand or are choosing to misrepresent other information, when you cite " The Cochrane reviews don't recommend loud noises for premature infants. Neither do a number of studies on babies in NICU.  So THBOTB wouldn't be good for premature infants; as we are seeing more premature infants at home these days (the result of in increase in inductions), it is good to know that shushing isn't good for them." 

Where do I begin with this one?

Let me start by saying , you are unnecessarily muddying the waters by spending so much time describing the use of swaddling and noise for premature babies.  The 5 S's are recommended for babies once they reach term...not during the preemature period.  

Further, you are completely incorrect when you say that  "it is good to know that shushing is not good for them" 

The studies on prematures and noise recommend avoiding loud noise (usually defined as over 90 dB). They DO NOT recommend against shushing or other sound (eg whooshing  bear, lullabies withheart beat, etc haave been found to be acceptible for use with preemies). 

Please be very careful not to twist other information, such as your comment "As shushing can be as loud as 90db, this is not suggested for premature infants." 90dB is as loud as a hair drier! (For those unfamiliar with the decibel scale 90dB is more than 10 times MORE intense than 75dB).  NO ONE is suggesting this intensity of sound...for preemie...or full term!  

Please review the articles I sent you on the highly beneficial use of 60-75db white noise in calming and soothing full term infants.

Even 75 dB (the sound intensity of a vacuum cleaner and the normal sound intensity inside the womb) is needed only for a few minutes to calm crying and then the sound can be lowered (Brackbill demonstrated that white noise at 60-70 dB was beneficial to a newborns sleep...increasing quiet sleep.) 

Furthermore, I am recommending swaddling only during sleep and crying/fussy periods.  Swaddling has been well proven to inecrease sleep while keeping babies MORE arouseable (Franco Peds 2005, Gerrard and Thach J Peds 2002).  Babies are not "shut down" or turned into "zombies" with these calming interventions.  Actually, swaddled babies are more EASILY awakened by external stimuli (sounds) and by internal stimuli (hunger). The swaddling is continual tactile stimulation...similar in some respects to skin-to-skin.  This allows babies who are sleeping in a crib to have a continual soothing input even when they are out of a parents arms (which by the way I recommend they be in for many, many hours/day). 

Nikki, besides sending you the list of more than 50 reports and peer reviewed articles that support my concepts, I also sent you a list of enthusiastic endorsements of THBOB and the 5 S's from illustrious child/prenting advocates such as, Jim McKenna, Penny Simkin, Kathleen Huggins, Elisabeth Bing, Sandra Steffes, Ann Grauer. My work is promoted by LLLI, API, numerous WIC centers across the country. This work has the strong potential for not just promoting breastfeeding success rates, but lessening PPD, SIDS, SBS, marital discord, unnecessary invasive lab tests and medication for acid reflux, etc, etc.

Does it need to be taught corrrectly?  Sure.  Do parents have to be educated adn guided away from any risks? Sure.  But that is no different than the use of car seats!  Car seats are great, but they can become a danger to babies if they are not installed properly.

So, please be very, very careful.  "Shoot from the hip" language like, "Seems to me that THBOTB is the exact opposite of what works in breastfeeding....It is not for all babies nor all families. Why then, is it marketed to all?" is argumentative rather than constructive. It reminds me of a quote by Lyndon Johnson "Do you know the difference between liberals and cannibals? Cannibals don't eat their own kind."  Please...I am a long time lactation and fellow advocate. Let us find ways we can work together. 

You are a professional with an academic background.  As such, I would hope that before issuing such strong comments...you would at least take the time to do more than just  - as you said - "peruse" the book.  Furthermore, the DVD is a critically important part of this most useful approach and I understand from your comments you have never even seen it.  

I am not personallly offended that your comments are so dismssive of my work (although I must admit being saddened by the several misanthropic comments about the passion/committment/insight of men regarding children made on Lactnet throughout this discussion) ...BUT I am concerned about your comments because they twist many facts and threaten to lead to polarization rather than consciliation.  Even your insistence on using the term "karpism" is unhelpful and demeaning. 

I am not being melodramatic when I say that my greatest fear is that your efforts to discourage others from considering this approach may result in the continued suffering of parents and children and even the death of infants.

  
Best wishes,

Harvey


>
>Date:    Sat, 17 Feb 2007 06:35:19 EST
>From:    Nikki Lee <[log in to unmask]>
>Subject: karpism and the value of dialogue (long)
>
>Dear Friends:
>
>Dialogue is so valuable; we all here on LACTNET value scholarly dialogue and 
>professional discourse. Dr. Karp has answered my questions sufficiently. I 
>will quote from his lengthy and informative post:
>
>1) "This leads to the obvious question, won't swaddling and white noise 
>obscure the hand to mouth cues or mild fussing that signal early hunger?  Yes, they 
>will. "
>
>2) "I would hope to persuade you that babies who sleep a little more at night 
>can easily get the 8-12 feeds/24 hours that are routinely recommended by 
>waking them every two hours  during the day.  Babies easily adapt to that 
>schedule......."
>
>3) "During the first 2 weeks of life, it is very important for parents to be 
>taught to wake their baby up out of sleep after a few hours to make sure the 
>baby is getting at least 8-12 feeds so the feeding can be established and the 
>baby does not get dehydrated"
>
> "There is a robust body of research supporting my observations and 
>recommendations (over 50 peer reviewed references that I am happy to send to anyone who 
>wishes).  They can be divided into 3 pillars of evidence" 
>".................3) The Happiest Baby video (essentially a video multiple case study)"
>------------------------------------------------------------------------------
>------------------------------------------------------------------
>
>I didn't know that DVDs were in the hierarchy of evidence. Case studies, 
>according to Greenhalgh, are the lowest level of evidence. However they are 
>valuable, and point the way to the RCTs and such that lead to the highest level of 
>evidence, the meta-analysis.
>The Cochrane Collaboration lacks any reports of THBOTB.
>I did a search of the Cochrane Collaboration on swaddling.
>Here's what it said:
>
>Pain relief in infants: "Neonates in the breastfeeding group had 
>statistically significantly less increase in the heart rate, reduced proportion of crying 
>time and reduced duration of crying compared to swaddled group or pacifier 
>group."  
>
>This review looks at breastfeeding or human milk as a way to reduce pain in 
>premature infants.
>
>Treatment of opiate withdrawal in infants: "An opiate such as morphine or 
>dilute tincture of opium should probably be used as initial treatment to 
>ameliorate withdrawal symptoms in newborn infants with an opiate withdrawal due to 
>maternal opiate use in pregnancy." "Treatments for newborn infants used to 
>ameliorate these symptoms and reduce complications include opiates, sedatives 
>(phenobarbitone or diazepam) and supportive treatments (swaddling, settling, 
>massage, relaxation baths, pacifiers or waterbeds)."
>
>The first choice of treatment is opiates. 
>
>Developmental care for promoting development and preventing morbidity in 
>preterm infants: "Developmental care refers to a range of strategies designed to 
>reduce the stresses of the NICU. These include reducing noise and light, 
>minimal handling and giving longer rest periods. The review of trials suggests that 
>these interventions may have some benefit to the outcomes of preterm infants; 
>however, there continues to be conflicting evidence among the multiple 
>studies."
>
>Cochrane Reviews meta-analysis says that noise should be reduced for handling 
>premature infants. As shushing can be as loud as 90db, this is not suggested 
>for premature infants.
>--------------------------------------------------------------------------
>
>The 4 reviews in the Cochrane meta-analyses that include the word 'swaddling' 
>recommend other methods as best to deal with infants in pain or premature 
>infants.
>
>My practice in lactation promotes cue-based feeding. The evidence shows us 
>that babies need to control the rhythm of breastfeeding. (see Anderson, Barros, 
>DeCarvalho, De Coopman, Daly (several times), Goldman, Kent, Woolridge). The 
>10 Steps to Support Successful Breastfeeding are an evidence-based blueprint of 
>how to promote and support breastfeeding. 
>
>My private practice is full of battling dyads where the mother has been 
>taught that she MUST wake the baby every 2 hours to feed; in such cases, 
>breastfeeding is on the edge of collapse. 
>
>If an infant is swaddled 12-20 hours a day from birth (as recommended in the 
>book, HBOTB pp. 120-121), it will not be able to show feeding cues. Dr. Karp  
>says this  in his lengthy post. His suggestion is to schedule feeds to 
>compensate. Neither of these practices belong in breastfeeding.
>
>I have already, since this lovely dialogue started, heard of 2 cases where an 
>older baby  (in one case, 2 years old) was unable to sleep unless swaddled. I 
>wonder what that means for a young life? And what the future will hold for 
>such a child.
>
>I was thinking that THBOB might be good for premature infants, that need to 
>be woken on schedule because they don't show feeding cues. But the Cochrane 
>reviews don't recommend loud noises for premature infants. Neither do a number of 
>studies on babies in NICU.  So THBOTB wouldn't be good for premature infants; 
>as we are seeing more premature infants at home these days (the result of in 
>increase in inductions), it is good to know that shushing isn't good for them.
>
>Seems to me that THBOTB is the exact opposite of what works in breastfeeding. 
>While it is clearly effective for some families, it has limited usefulness. 
>It is not for all babies nor all families. Why then, is it marketed to all?
>
>It is too bad, Dr. Karp, that a person that writes a book is at the mercy of 
>one's editor. I can not understand why baby-wearing would be removed from the 
>text of your book.
>
>Thank you, Dr. Karp, for answering my questions.
>warmly,
>Nikki Lee RN, MS, Mother of 2, IBCLC, CCE, CIMI

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