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)"
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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.
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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.
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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.
Nikki Lee RN, MS, Mother of 2, IBCLC, CCE
Lactation Consultant, Philadephia Department of Public Health
Maternal-Child Adjunct Faculty, Union Institute and University
Film Reviews Editor, Journal of Human Lactation
www.breastfeedingalwaysbest.com
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