Ann, You wrote:
What do you think is the best/most useful/most enlightening way to define
amounts of breastfeeding, for survey to monitor mothers' feeding practices?
Would you go for exclusive/partial/none or full/partial/none (if so, how
would you define "full"?).
How would you define the high, medium and low subcategories of "partial"?
I've seen ">80/20-80/<20" and "more than half/about half/less than half" as
two definitions of "high/medium/low". What do you think?
This is one problem that fascinates me. It is an area where I think we need
a LOT more thinking and data-gathering. Until we have a whole lot more
mothers and babies breastfeeding exclusively, we have to deal in the Real
World with partial breastfeeding. We have to be able to define partial
breastfeeding in order to get decent research about why it's not as good as
exclusive breastfeeding---or (putting it better) why it is risky compared to
the biological norm for feeding babies.
I think the Labbok and Krasovec distinction of >80/20-80/<20 is probably more
useful than the "more than half/about half/less than half" distinction.
"About half" is a very narrow category. What is the practical difference
between "about half" and 60% or 40%? Let's do the math.
The average intake of human milk from 0 to 6 months is about 28 oz a day.
This would mean that, roughly speaking,
100% is 28 oz
80% is 22 1/2 oz
60% is 17 oz
50% is 14 oz
40% is 11 oz
20% is 5 1/2 oz
I think that we're more likely to find differences in health effects for baby
or mother when we compare the extremes. So in the >80/20-80/<20 scheme,
you'd be looking for differences between groups of babies getting either
all human milk
human milk plus 6 oz or less of formula a day
human milk plus 6-26 ounces of formula a day
human milk plus 26 oz or more of formula a day or
all formula.
What this definition wouldn't tell us is how much benefit there is when a mom
tries to maximize the amount of breastfeeding she does, even if her baby has
to have formula for two or more feedings a day---for instance, a mom doesn't
pump when she's at work but nurses 100% when she is home.
But this definition does make it easier for the mother and the healthworker
to figure out which category the mom and baby fit into. "About half" is just
too difficult a concept for me to translate into practical terms.
In any case, what we need is a script for the conversation between the mother
and the healthworker. I am very doubtful about comparing the number of times
the baby comes to the breast with the number of bottles of formula the baby
gets. We really want to be encouraging moms to make the breast available a
whole lot more than the bottle. The baby should be snacking and smooching
and nursing to sleep and nursing for comfort and nursing for thirst as well
as having "meals" at the breast. You can't really compare bottle feedings
and breastfeedings--they just operate differently.
Here's my thought..would this work? The healthworker estimates the baby's
daily requirement of human milk, based on the baby's growth curve, then gets
the mother's report of how much formula she's using, then does the math to
see whether the amount of formula falls within or outside the 20% to 80%
range. All we need for this is a reliable chart that shows how much human
milk a baby of a given birth weight needs in order to follow the normal
growth curve. Ha! Ha!
Well, WHO is working on a growth chart for breastfed babies. It is supposed
to be coming out fairly soon. I think 2002 was the target year for
completion.
But we are very far from having an evidence-based reference for babies'
caloric requirements. Look in Lawrence's chapter on normal growth (near the
beginning of Ch 12 in the red book, pp 360-361). I've written about this
before in Lactnet, and referenced an article by RG Whitehead, "For how long
is exclusive breast-feeding adequate to satisfy the dietary energy needs of
the average young baby?" Pediatric research 37:2, 1995, 239-243. Basically,
Whitehead acknowledged that RDAs (recommended dietary allowances, I think
this means) for babies are set too high, but that no one has had the guts to
lower them to match the evidence from exclusively breastfed babies. So we
have a standard that says something like 110 or 105 kcal/kg/day, in the face
of evidence that normally-growing breastfed babies may take in 71 kcal/kg/day
at four months of age.
AND...we won't get the evidence we need to fix this problem (lack of reliable
standards) unless we get more data about how women are actually feeding their
babies! So your question is SOOOO important!
Gotta run. Late for work. Eager to see what other Lactnetters say.
Chris Mulford, RN, IBCLC
Working for WIC in New Jersey
Living in Eastern PA
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