Hi all--
(and hi Becky and Jan B-- thanks for your email)

Re Becky's post to the group yesterday:
<<Jan B. --....  When you say there haven't seen any
definitive studies in the US on this issue, how about Dr. Neifert's prospective
study of "319 healthy, motivated, primiparous women who were breastfeeding term,
healthy, AGA or LGA infants" reported in Birth 17:1, March 1990?  At 3 weeks,
even using their lower study criteria of 20g/day wt. gain, 10.7% of babies had
"insufficient wt. gain."

I have long owed Jan B. a note on this very subject, so Jan, are you reading,
I'm doing it publicly!

While I heven't read the Birth article itself, I did go over Dr. Neiferts'
videotape of her talk on this subject to ILCA last year, watched and rewatched
it taking notes to prepare an outline of the talk, about half of which is about
this research.

So those of you who have access to the Birth article can do the reality check on
my comments, and respond, please.

For those of you who have access to neither, let me review briefly--
--Prospective study 319 "healthy" primips (see my note below), all normal
pregnancy, expecting a healthy singleton, planning to brfd at least one month
(do you see a problem with this definition?) attended at least 1 prenatal
class(ditto)
--Each had a prenatal breast exam, f/u at approx 5 and 10 days postpartum (exact
day varied). Given best advice and support on basis of exams, results these
visits.
--Study assumed weight loss should cease by day 5, and baby should gain 1 oz/day
thereafter. Comparing naked weights on visit 1 (about day 5--ave 5.7days ) and
visit 2 (about day 10), 69% (221/319) had gained the oz/day, 31% (97/319)hadn't.
-- they then followed the 97 who hadn't gained this oz/day by day 10 for another
10 days-- only half of these gained their oz/day, yielding a total of 85% with
"sufficient" lactation by age 3 wks, and 15% "insufficient"
--of the 15% with "insufficient" (i.e.<30 gm/day wt gain by 3 wks), chart review
suggested that 11% actually had effective lactogenesis sabotaged by probs (sore
nipples, etc) and 4% had primary failure of lactogenesis.  [Becky uses the more
conservative, and probably more appropriate figure of 20 gm/day, and apparently
in the Birth article the total "insufficiency" % with that difinition is 10.7%
rather than 15%, I'm not sure how that would affect the % found to be with
Primary failure of lactogenesis, as this appeared to be a diagnosis of
exclusion, based solely on chart review.]

I have real concerns about this data, because of the brevity of the study, the
definitions, and the study population (altho that might exactly be what you're
referring to, Becky, in that our industrialized countries our populations are
different, with infertility rxed, etc.)

To start, I would like to quote from Maryelle Vonlanthen's lactnet post from
yesterday (and thank you, Maryelle for your e-mail yesterday, too)--

<<Remember that weight is a very imprecice piece of information.  Yes, I
know most of my colleagues are hung up on it because it is a number and
we all know docs like numbers but the fact is that many weight babies
wrong or I should say inconsistently....   ... As a clinician I think it is
worthwhile for all of us who deal with small babies to be familiar with
other ways to asses a baby and in particular their hydration.  I have
trouble with people using only 1 parameter to make a decision about the
baby's status.  I think we all should get into the habit of questionning
the data and making sure all the pieces of information fit.  Otherwise
we'll be seeing a lot more of these bizarre unexplaned dehydrations or wt
loss.>>

That said, let's look at this prospective study of 319 "healthy" primips. First
of all, 8% of this healthy group had a history of "breast or chest surgery." In
the ILCA talk, Dr. Neifert said that for these women, if there was an incision
around the nipple, the mother had  4.55x risk of ending up in the "insufficient"
group, but in this talk it was not stated what fraction of these 8% had
incisions near the nipple, nor how excluding this group did or did not affect
the overall study results. Maybe those of you with the Birth article can address
this for me. Maybe it is not teased out because it really didn't affect the
overall study results, that only a few women were in this group. But there were
enough that the difference they experienced was judged to be statistically
significant. I should note that for those whose incisions were not near the
nipple, Dr. Neifert's study  found that the increased risk for insufficiency was
"insignificant"-- which may mean that there is no real increase in risk, or may
mean that their numbers were too small to draw significant conclusions, and that
further study needs to be done.

The other thing that the Birth article may address better than my videotape is
how this group was selected. I have reservations about the self-selecting
process of women who go to a tertiary care center, and wonder if this had any
play in it, or how it was controlled for.  Another concern I already mentioned
is that they were defined as mothers who had attended "at least one prenatal
class" and planned to nurse "at least one month"-- this to me does not define a
group of mothers who really expect to breastfeed, and in view of the fact that
most of those in the insufficient group had secondary, not primary failure, it
seems that motivation and management were the major issues there.

I think my biggest problems with this study:

--it's reliance on a single a parameter (wt) and it's unchallenged and
unsupported assumptions  (are their references in the Birth article?) about what
that parameter should be: What is a sufficient weight gain in the first three
weeks of life (didn't we used to say "back to birth wt by the 2 wks check (which
for some wasn't til three weeks), THEN 1/2 to 1 oz a day"? and wasn't that based
on bottle fed babies who were being fed from day 1? and what was the basis for
the claim that that had to happen anyway, does anyone know of any studies, or it
is just one of those old doctor's tales?  And are there ethnic/racial
differences, or other things we should take into acct (should a healthy fullterm
6# infant gain as rapidly as a healthy 9# infant? )

--the study only went for three weeks. Even in my meager experience I've seen
plenty of babies that took that long to get started and then did fine, and mom
did finally have plenty of milk, but if you judged them by the first three
weeks, forget it. And now we're seeing data to suggest that for some babies and
some kinds of anesthesia, babies can be sleepy and poor feeders for up to a
month (help me here somebody, I know I've read/heard this lately, and certainly
those with delayed first feedings and epidurals, etc the combination can sure
get you off to a slow start...

--even tho this is based on this single parameter, the babies were not all seen
on precisely day 5 and day 10, and I wonder if this might affect the data in any
way.  Some of them may not have stopped losing on day "5" because it isnt,
others may already have gained, etc. I dunno.  For that matter, since milk comes
between day 1 and day 5 also at a variable rate, even in those with optimal
suckling, this also would vary anyway.

--92% had a wt loss by the first visit (day "5") of <or = 7%.  From this Dr.
Neifert conludes that  the 0% figure we've always used is unacceptable, but I'm
not sure why.  Were all of the 8% of babies that lost >7% of bwt in the
"insufficent" group, and if so, were they all by day 10 or 20 gaining less than
1 oz/day or less than 20 gm, less than 15 gm a day, or not gaining at all?

--I'd love to see some data on third world moms in a breastfeeding culture. or
the data from a BF hospital. Roberta???

I have other questions about the video, but I have gone on too long. Please
Becky or those of you who have access to the Birth article, please set me
straight.  Also, could you check the article and see who funded the study?

And thanks to all of you who e'mailed me since my other post  which was just a
self intro.  I will get back to you, I hope I don't get deluged after this post.
Sorry it was so long. (But not as much as what I owed Jan!)

Also, in my last post i listed 3 internet addresses. I'm having intermittent
problems retrieving mail with AOL, CDC wonder is free, but so cumbersome, so I'm
going back to compuserve--

Tina Smillie
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