Infant Feeding: Science, Safety, and Support – PediaCast 609

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Show Notes

Description

Dr Anuja Sriparameswaran visits the studio as we consider the science, safety, and support of infant feeding. From breasts and bottles to microplastics and guilt, we take a comprehensive look at the first feeding decisions moms and dads must make. We hope you can join us!

Topics

Breastfeeding
Bottle Feeding
Infant Formula
Infant Feeding Support

Guest

Dr Anuja Sriparameswaran
Hospital Medicine
Nationwide Children’s Hospital

Links

WHO Guidelines for Complementary Feeding of Infants and Young Children 6-23 Months of Age
AAP Breastfeeding Guidelines
CDC Breastfeeding Guidelines
Contraindications to Breastfeeding (CDC)
Breastfeeding and Maternal Mood: Exploring a Complex, Bidirectional Relationship

Comprehensive Nutritional Review of Infant Formula
Infant Stomach Capacity
Approach to Nutrition in the Premature Infant
Infant Feeding and Long-Term Metabolic Health
Does Paced Bottle-Feeding Improve the Quality and Outcome of Bottle-Feeding Interactions?
Supporting Mothers’ Feeding Choices: A Key Role in the Prevention of Postpartum Depression?

Challenges and Opportunities for Reduction of Single Use Plastics in Healthcare
Public and Environmental Health Effects of Plastic Wastes Disposal
Decentralized Production Concepts for Bio-Based Polymers
Detection of Microplastics in Placentas, Meconium, Infant Feces, Breastmilk and Infant Formula
An Overview of the Possible Exposure of Infants to Microplastics
Environmental Impact of Feeding with Infant Formula in Comparison with Breastfeeding

Episode Transcript

[Dr Mike Patrick]
This episode of PediaCast is brought to you by Hospital Medicine at Nationwide Children’s Hospital.

[MUSIC]

[Dr Mike Patrick]
Hello, everyone, and welcome to another episode of PediaCast. We are a pediatric podcast for moms and dads.

This is Dr. Mike coming to you from the campus of Nationwide Children’s Hospital. We’re in Columbus, Ohio. It’s episode 609.

We’re calling this one Infant Feeding Science, Safety, and Support. I want to welcome all of you to the program. We are so happy to have you with us.

You know, feeding a young baby seems like it should be simple, but for many families, it’s one of the biggest sources of questions, uncertainty, and even guilt. Breastfeeding, bottle feeding, pumping, formula, combination feeding, what is best, what is safe, and what really matters the most. Today, we are separating fact from fiction and exploring the science, practical realities, and the emotional side of infant feeding as we strive to help parents make informed decisions with confidence.

Of course, in our usual PediaCast fashion, we have a terrific guest joining us in the studio to discuss the topic, Dr. Anuja Sriparameswaran. She is with Hospital Medicine at Nationwide Children’s Hospital. And just to warn you right up front, this particular episode really is going to focus on young infant feeding.

So, as we think about breast milk and breastfeeding, infant formulas and bottle feeding, that’s really where we’re going to be concentrating. So, if you’re looking for an episode that goes into details on adding complementary food or solid food starting around six months of age, this is not going to be the episode for you. We’re really going to focus on breastfeeding and infant feeding in today’s episode.

And before we get to that, I do want to remind you the information presented in every episode of our podcast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So, if you are concerned about your child’s health, be sure to call your healthcare provider.

Also, your use of this audio program is subject to the PediaCast Terms of Use Agreement, which you can find at pediacast.org. So, let’s take a quick break. We’ll get Dr. Anuja settled into the studio, and then we will be back to talk about infant feeding, the science, safety, and support. It’s coming up right after this.

[MUSIC]

[Dr Mike Patrick]
Dr. Anuja Sriparameswaran practices newborn medicine at Nationwide Children’s Hospital, and she is an associate professor of pediatrics at The Ohio State University College of Medicine. She holds a master’s degree of public health.

She’s an international board-certified lactation consultant and a fellow of the American Academy of Pediatrics. Dr. Anuja has a passion for helping newborns thrive, supporting families through their first feeding decisions, and bringing together parents, pediatricians, public health experts, and lactation science. She is a firm believer that informed parents are empowered parents, and we certainly aim to inform and empower today as we discuss infant feeding.

Before we dive into our topic, let’s offer a warm PediaCast welcome to our guest, Dr. Anuja Sriparameswaran. Thank you so much for being here today.

[Dr Anuja Sriparameswaran]
Thank you, Mike, for inviting me, and I’m excited to talk about this topic with you today.

[Dr Mike Patrick]
Yeah, I am really excited to talk about it as well. And this is, you know, for new parents, feeding your baby is one of the big things that you do, you know, that and changing their diapers and watching them sleep. But it is an important thing, and so many parents have questions.

Why do you think it is that feeding creates so much consternation sometimes?

[Dr Anuja Sriparameswaran]
So, I’m going to tell you, I’ve been practicing pediatrics for nearly two decades. So, from my years of experience, it comes down to a very simple fact, you know, for the first six months, liquid food is the only source of feeding for an infant. And AAP explicitly recommends that we do not introduce any complementary solid foods, at least up until six months of age.

So, for half a year, the liquid is everything. And when we look at the data, it is stated that approximately 80% of mothers initiate breastfeeding here in the United States. But as time goes on, about 70% or more of those infants will also receive infant formula.

And for the vast majority of families, the standard infant formula they use is the cow milk-based formula. So simply due to its production in large quantities across the country. So, because these numbers, it is so important for parents to know what the benefits are for breast and bottle feeding and why we choose one over the other and what are the benefits to the infant.

Now for the breast milk, it’s readily available. It does not need anything else. And biologically, there is no true substitute for breast milk.

However, we have to look at the clinical reality. There are various circumstances related to the mother or infant where this natural route may not be feasible for all maternal infant diets. Therefore, it’s equally important for parents to understand infant formula, to know first the true benefits, to understand if there are risks involved with infant formula, and to know what steps they can take to mitigate these risks.

And I hope our discussion today, I hope to shed some light on some of these issues, peel back some of the confusion and give parents the clear facts they need.

[Dr Mike Patrick]
Yeah, yeah. It’s really so important because you do see lots of different information online. You’re going to have as a new parent; you’re going to have relatives who want to give you advice.

And so, as a parent, it’s like, what do I do when I’m hearing different things from different people? And we would say, always listen to the advice of your child’s pediatrician for sure. And then, following the advice of trusted organizations like the World Health Organization, the CDC, the American Academy of Pediatrics, what do all of those folks actually recommend for breastfeeding?

[Dr Anuja Sriparameswaran]
Yeah, those sources that you cited are the sources that we as pediatricians go to as well. And if you ask the parents how long do they intend to breastfeed, you will probably get variety of answers. So therefore, we’ll stick to what these organizations are recommending.

So, the World Health Organization and the Center for Disease Control and Prevention and the American Academy of Pediatrics, they are all aligned on the gold standards. Their recommendation is exclusive breastfeeding for the first six months of life, followed by introduction of solid food, where they recently changed this to total duration. The AAP and the CDC updated their guidelines to recommend continuing breastfeeding for two years or beyond, matching what the World Health Organization have recommended.

And these organizations are recommending breast milk because, obviously, it has incredible amount of ingredients that cannot simply be duplicated in infant formula. However, one area that WHO and the American Academy of Pediatrics have a different perspective is regarding pacifiers. So, the World Health Organization doesn’t recommend offering pacifiers or artificial nipples.

And their assessment is that early pacifier use can mask hunker cues and potentially disrupt the establishment of a robust milk supply. However, AAP and CDC, they take a different approach based on sleep safety. They recommend introducing a pacifier once breastfeeding is firmly established, and that is typically between three to four weeks of life because their data shows that offering a pacifier at naptime or bedtime provides a powerful protective benefit against sudden unexpected infant death or sudden infant death syndrome.

But I just want to point out that perfect as human milk is, there are two things that I wanted to clarify for our listeners. First, breast milk is naturally low in vitamin D and vitamin D is crucial for preventing rickets. So, the AAP recommends that all exclusively breastfed infants receive an oral supplement of 400 international units of vitamin D daily starting within first few days of life, unless the mom is already taking a high dose of supervised oral doses of vitamin D themselves.

Second and most critically is the vitamin K. Babies need them for blood clotting. So, infants are born with pretty much close to zero amount of vitamin K and the breast milk contains very low level of vitamin K.

So, in order to prevent a life-threatening internal or brain bleed known as the vitamin K deficiency bleeding, the AAP strictly mandates a single IM intramuscular injection of 0.5 milligram to one milligram of vitamin K within six hours of birth. And sometimes parents ask why not vitamin K oral drops. Well, it is common practice in Europe but for our listeners I wanted to emphasize there is no FDA approved vitamin K option for newborn as a prophylaxis in the United States.

Besides vitamin K, oral vitamin K is poorly and not well absorbed by the infant gut, and it does not prevent late onset brain bleeds. So, the single IM shot remains the safest most reliable gold standard worldwide. Although human milk is a marvelous evolutionary product, the recommendation is to stick to what are these great organizations like American Academy of Pediatrics and CDC and World Health Organizations are doing in order to make sure that our infants are thriving and remain healthy.

[Dr Mike Patrick]
Yeah, yeah. We definitely want them to do those two things. A couple of points that I just want to emphasize that you talked about.

First, going all the way back to right after birth, that vitamin K shot is so important, and we really do see babies who do not get it. It’s rare but it does happen and when it happens it’s just devastating that they can have a brain bleed and it’s not always like right after birth that that brain bleed happens. It can be a couple months down the road and so that vitamin K shot really does a fantastic job of preventing that rare event from happening.

But even though it’s a rare event, when it happens it’s a really bad event and usually life-changing for the family. So, a vitamin K shot is really, really important right after birth. The other thing that I wanted to emphasize that you’ve said a couple of times here, there’s going to be a lot of grandparents and aunts and uncles who say, oh, you should start feeding your baby at four months.

That’s when you’re supposed to start feeding a baby. And really, even when I was training, you started cereals around four months of age and there may be some providers who still recommend that. But it is important to note that the organizations that we’re talking about, they’re basing their decision on science that it really is best to wait to introduce solid foods until six months of age.

So, the four months of age, that’s old stuff. Six months is evidence shows us that that’s the best time to start solid foods. And then I wanted to go a little bit deeper into the advantages of breast milk.

And I think one of the bottom-line things that we’re going to be saying is breast milk is best, but we also understand that there’s other circumstances for individual families. And if breastfeeding is not possible for one reason or another, don’t feel guilty about it. Choose a great infant formula that’s out there and we’ll talk way more about that.

But first, I just wanted to kind of home in on why do we consider breast milk is best? How is human breast milk really uniquely designed for our babies?

[Dr Anuja Sriparameswaran]
Great question. And as far as just to touch a point on that vitamin K, yes, I mean, the baby’s vitamin K deficiency bleeding is divided into early, classic, and late. And these things can go on and happen up until six months of age.

And typically, the late-onset vitamin K deficiency bleeding, which is commonly seen in exclusively breastfed infants, typically present with intracranial bleed. And so, I’m glad that you reemphasized the importance of vitamin K. So as far as this uniquely designed infant formula, let’s talk about start off with the protein composition.

The breast milk has two types of protein. They’re called the whey protein and the casein protein. And it’s so natural for these protein ratio to keep changing according to the needs of the infant.

So right after delivery, it is colostrum. It’s the first milk that’s present. And in that milk, there is about 80% whey protein and 20% casein because the protein is easily digestible, highly soluble protein.

So, it just makes sure that the immature digestive tract can easily process this formula without forming curds. And then you have this transitional milk, which happens somewhere between day 4 to 14. And the milk volume is increasing.

And then the ratio changes to about 70% whey to 30% casein protein. And once the milk supply is established, the ratio is about 60 to 40, 60% whey protein to 40% casein. So, to put that in perspective with the standard unmodified cow milk, it is exact opposite.

Cow milk has 20% whey and 80% casein. And we’ll talk a little bit more about how infant formula adjusts for that. And then I just wanted to emphasize how breast milk is made and how it is made in a way that the proteins are present to provide this fantastic immune protection for these infants who don’t have a robust immune system at the time of birth.

So, it provides secretory IgA, the primary antibody that will coat the infant’s intestinal wall, and it prevents viruses and bacteria from binding. It also has an iron-binding protein that’s referred to as a lactoferrin. And this basically takes out the ion that’s needed by the bacteria.

So, it kind of stops out the bad bacteria from growing. And then you have the enzyme called the lysozymes that actively breaks down the cell walls of the harmful bacteria. Then obviously the human milk is flooded with a ton of hormones like epidermal growth factor and that is very helpful in maturing and sealing infant’s gut that is not, it’s kind of porous at the beginning.

I also wanted to talk about a little bit about the other carbohydrate that also provides this defense mechanism for infants. The primary source of carbohydrate is lactose. It provides the main fuel for the infants.

But then there’s this complex carbohydrate called the human milk oligosaccharides that infant completely lacks the enzyme to digest it. It passes through the stomach entirely untouched, and it’s designed to exclusively feed a specific beneficial bacteria in the colon called the Bifidobacterium infantis. By feeding the good bacteria, it essentially crowds out the pathogen.

It just optimizes the gut pH and trains the infant’s immune system from inside out. So, this is why we describe the human milk not just as a food but as a uniquely designed living biological system.

[Dr Mike Patrick]
Yeah, yeah. So important to understand that there’s, it’s far more than just simple proteins and the carbohydrates that that you mentioned in the sugars. That there’s also, there’s also antibodies and there’s hormones and things that you really can’t replicate in an infant formula that’s beneficial for babies.

And then we also hear about the fats that are in human breast milk that are really great for babies. Tell us about those and why they’re important for infant development.

[Dr Anuja Sriparameswaran]
Yes, it’s amazing. So, if you were to just look at a drop of human milk under a microscope, you’re looking at a very complex dynamic suspension of fat droplets. So, I would like to kind of break this down into the co-micronutrient distribution of the breast milk, the structural architecture of the, what’s referred to as the milk fat globule, and how these lipids are important in our neurodevelopment in these infants.

So, let’s look at the breast milk. By total weight, breast milk is about 87 to 88% water. And then you have these 12 to 13%.

That kind of carries all of the solid energy, the macronutrients. So, we talked about lactose. It makes up about 7% primary source of glucose energy for what the infant brain is demanding.

And then when we come to the lipids, that makes up about 3.5 to 4.5% by weight but provides greater than 50% of the infant’s total caloric intake. And then the protein is about 0.9 to 1%. It is intentionally nature made this low to accommodate infant’s immature kidneys, but it’s highly bioavailable.

And the fat in the breast milk, they just don’t float around loosely. They exist in a highly sophisticated structure called the milk fat globule membrane. So, triglycerides make up 98% of these lipids.

They’re packed tightly inside the core of the milk fat globule to deliver the dense energy. And then you have phospholipids and sphingolipids that are making up 1% to 2% of the lipid fraction forming the actual outer layer of this milk fat globule. So, this membrane structure is crucial because it protects the fat from premature digestion and interacts directly with the infant’s gut mucosa, again, to support the structural gut maturation.

Now we are coming down to these powerful long chain polyunsaturated fatty acids. They’re called DHA and ARA. You would have seen that in the infant formulas as well.

So, let’s talk a little bit more about this. So, there are two essential fatty acids that human body cannot synthesize from scratch. One is the linoleic acid, and the other one is alpha linoleic acid.

And these must come from diet, and they serve as a metabolic precursors to synthesize ARA which is called the arachidonic acid and DHA which is referred to as a docosahexaenoic acid. A little bit difficult to say but we simply say that as ARA and DHA. So, they both serve dual roles.

In a structural role they accumulate in the lipid bilayer of the neural membranes. DHA is seen to dominate in the cerebral cortex and the retina, driving the visual acuity. They are important for the wiring of the photoreceptors and then they play a high level of development of your infant’s brain development and cognition later on in their lives.

When we talk about the biochemical role, they serve as a precursor for prostaglandins, leukotrienes, and resolvins which are very important for infant’s immune system. And they also serve as precursors for endocannabinoids which influence safe gut motility, sleep-wake cycle, and appetite regulation. So, the absolute concentration of ARA and DHA in human milk vary significantly around the globe because it’s highly dependent on maternal diet.

But the raw unmodified cow’s milk contains low to non-existent concentration of long-chain polyunsaturated fatty acids. So, decades of research have shown that older standard formula without these lipids had lower retinal and cognitive testing scores compared to in infants compared to the breastfed infants. So today nearly all infant formulas are fortified with plant or algae-derived DHA and ARA to mimic the natural cognitive advantage of human milk.

So, whether an infant is receiving human milk with a naturally variable long-chain polyunsaturated fatty acid profiles or strictly fortified modern formula, ensuring a reliable source of these structured lipids is crucial. And clinician understanding this lipid math allows us to appreciate how early nutrition is important for structural brain development.

[Dr Mike Patrick]
Yeah, yeah. And I can’t say how important that is, you know, when we think about brain development and also eye development, that you really need those fatty acids available for babies, and it is not available in cow’s milk. That’s really, really important.

So that’s why we recommend cow’s milk for baby cows, and we recommend human milk for baby humans, because they really are designed for the baby that’s being fed with that milk. And breast milk is often called a living tissue, and it is so different from one species to another, and even from one phase in a baby’s life to another phase in their life. Why do sometimes we call that a living tissue?

That’s an interesting way to put it.

[Dr Anuja Sriparameswaran]
It is. I mean, it is very, very, you know, mind-blowing when you look at this breast milk and how nature has created this beautiful architecture. So, the reason is that the studies have shown that breast milk carries a substantial load of live bacteria.

And then, you know, plenty of research done in the last two decades have shown that these microbes are not infectious or pathological in origin. Instead, they are very beneficial. They migrate from the maternal gastrointestinal tract and directly into the memory gland, and then they are kind of referred to as infants’ very first probiotic food.

And they are transferred directly, vertically, to colonize the infant’s gut, which studies have shown that the bifidobacterium species heavily found in the feces of breastfed infants kind of matches the mom’s bifidobacterium. And also, further studies have shown that these microbial populations are diverse. They have shown that greater than 200 distinct bacterial phylotypes within the healthy human milk.

Another reason is that breast milk is considered a living tissue is that it’s rich supply of active maternal immune cells. So, they have done this ultrasound and fluid dynamic studies where they have shown that, you know, in the nursing infant, there’s a retrograde flow of the infant’s saliva back into the maternal memory ducts. And this backwash as a direct line of communication stimulates the immune receptors in the breast tissue to sample the infant’s environment.

And if the infant has been exposed to a pathogen, the mother’s breast book is like literally reading the microbial signature in that saliva and customizing targeted antibodies and upregulating like specific secretory IgA for their next feed. And further interesting is that it was assumed that the live cells in human breast milk were entirely limited to these immune cells and basic epithelial cells. But incredible research has shown that human milk actually contains highly active subpopulation of maternal stem cells.

What’s truly mind-blowing is that these stem cells express markers of pluripotency, meaning that they hold a potential to differentiate into cells from all three layers. So, in animal models, science have tracked these exact milk stem cell as they survive the acidic environment of the infant’s stomach, migrating directly into the bloodstream and crossing the blood-brain barrier and functionally integrating into infants developing brain, liver, pancreatic tissue and produce organ-specific proteins. So yes, I mean human milk is absolutely a living communicating tissue.

A formula can provide an excellent baseline of proteins, essential fats, but it can never replicate the stem cell blueprint nor the dynamic read in infant saliva to synthesize the customized antibiotic on the fly. It’s truly a living biological bridge between mother and child.

[Dr Mike Patrick]
Yeah, that really is amazing. So incredible. Now one other little piece of breastfeeding that I wanted to talk about is that it really is also sustainable as we think about the planet.

There is a lot of waste that goes into bottle feeding in terms of packaging and plastics and those sorts of things. Can you talk a little bit about how breastfeeding is great for the environment?

[Dr Anuja Sriparameswaran]
Yeah, and you touched on the point of packaging because the standard formula on the market is basically cow milk-based protein. So, if you think about it, there’s a massive environmental impact just comes from raising these livestock and then you have to feed the livestock and that uses extensive land use and deforestation and these all have direct impact to the greenhouse gases from methane excretion from the livestock. Beyond raising these livestock, you have to think about energy and transporting these raw materials and when you have to procure all of the components required to make these formulas and what takes place in making the formula.

You have to use a spray dried to convert a liquid milk into a dry powder. That specific industrial method has a tremendous impact on energy consumption. Then you have to look at like all of the water that needs to be used to manufacture this formula itself.

Then we have to look at what happens after consumption. Whether a family is using a single ready-to-use infant feeding bottles or powdered infant formulas, these are containers. Whether they are made of like plastic or other materials, they all need to be disposed and very little of these materials actually gets recycled and majority of these materials are ending up in our landfill, ultimately polluting our soil, air, and water from various type of chemical leaches during the long process of degradation.

On top of that, there is an economic and environmental cost in simply transporting all of this physical waste that’s created from single-use bottles and powdered cans. And look at that breast milk in contrast to this and breast milk is kind of considered a true circular economy. There’s no waste.

Everything that’s produced naturally by the mother and it’s also rich in micro and micronutrients, microbes, and other living cells like we just discussed. In terms of sustainability, direct breastfeeding operates with like very little carbon footprint. In fact, the data shows that global warming impact from infant formula feeding is roughly double of that breastfeeding.

Now some studies would refute this by kind of pointing out that when mothers are not solely offering direct breastfeeding but instead offering express breast milk, the carbon savings may drop due to electricity used for pumping, plastic storage bag, and continuous bottle sterilization. But the bottom line here is pretty clear. Breast milk is natural, it’s healthy, and deeply sustainable choice for infant feeding and provided that there’s no medical indication that prohibits consumption of maternal breast milk, it is the most sustainable choice.

[Dr Mike Patrick]
Yeah. Now you mentioned when it’s medically not indicated to breastfeed, what are some situations where breastfeeding is not recommended?

[Dr Anuja Sriparameswaran]
So, there are listed indications and American Academy of Pediatrics, Center for Disease Control, they all have this list. So, let’s look at like absolute contraindications. So, when the infant is diagnosed with classic galactosemia, which is a very rare genetic metabolic disorder where baby cannot metabolize galactose, which is the breakdown product of lactose, so this can make the human milk toxic to their system.

From the maternal standpoint, breastfeeding is not recommended if a mom is infected with human T cell lymphotropic virus type 1 or type 2, or if she has suspected or confirmed Ebola virus. Then we also strictly discourage breastfeeding if a mother is actively using illicit drugs such as opioid, PCP, or cocaine. However, a crucial clinical distinction must be made here for mothers who have discontinued these illicit substances and are stable on methadone or buprenorphine maintenance therapy, breastfeeding is not only safe but actively encouraged.

Now let’s come around to the HIV. Historically, the American Academy of Pediatrics had maintained a strict absolute contraindication for breastfeeding if a mother was HIV positive. Today, both the CDC and the AAP have shifted to align with the patient-centered approach, so mothers living with HIV can be supported to breastfeed as long as they meet a sustained viral suppression, which is defined as viral load less than 50 copies per milliliter, and they maintain this suppression throughout the pregnancy at minimum during the third trimester and consistently after giving birth. If a mother is not on antiretroviral therapy or if she’s unable to maintain sustained viral suppression, breastfeeding is not recommended due to risk of vertical transmission. But I just wanted to make sure that our viewers understand that the risk is never zero.

It’s less than 1%, but the risk is never zero. And then there are other infectious and medical scenarios. The mother may temporarily suspend breastfeeding and stop giving express breast milk.

This includes untreated brucellosis or when undergoing diagnostic imaging with radiopharmaceuticals that emit radiation or it applies when mom has an active herpes infection if the lesion is present on her breast. However, mother can still breastfeed directly from the unaffected side of the breast as the lesions are covered on the side that it’s active. For monkeypox, breastfeeding must be delayed until isolation criteria are met, meaning all lesions have resolved and scabs have fallen off and fresh layer of intact skin is formed.

Finally, there are cases where milk itself is completely safe, but precaution requires temporary separation of the mother and the infant to prevent spreading the infection through air or contact. And this includes untreated active tuberculosis or active varicella chickenpox infection that developed between five days before delivery and two days following. During this time, express breast milk should be given to the infant by another care provider.

For tuberculosis, the mother may resume direct breastfeeding once she has been treated approximately for about two weeks and the doctor documents that she’s no longer contagious. But the bottom line is clear. Outside this highly specific clinical guardrail, breast milk still remains the safest, healthiest, and most natural nutrition baseline for maternal infant diets.

[Dr Mike Patrick]
Yeah, yeah, yeah, for sure. And I think it’s going to be really important to realize that those the conditions that you mentioned are rare. They’re really very rare.

They do happen, but they’re not common. And so, if you are attempting to breastfeed and having difficulty, it really is worth it to get some help to continue to breastfeed for as long as possible. Where are some places that parents can get help if they’re having difficulty with breastfeeding?

[Dr Anuja Sriparameswaran]
So as far as like if the parents are having difficulty breastfeeding, all of our hospitals are staffed with lactation consultants and they are IBCLC trained. So, they provide hands-on help with these mothers who are having difficulty with breastfeeding. We do also have lactation clinics once they leave the hospitals so they can continue seeing them while they are working on breastfeeding.

And even if you don’t successfully direct breastfeed at the beginning, you do have options of expressing breast milk and offering that to the infant. And then, you know, while you’re working with your lactation consultant or patient, most of these infants can successfully transition eventually to directly breastfeed. Obviously, meanwhile, if the mother is unable to meet recommended volume through just or express breast milk, then obviously there are options for donor human milk.

And then we do have a milk bank here in the city of Columbus. So that is highly safe and well-tested and pasteurized human donor milk that’s available. Parents do have to pay out of pocket for them.

That’s what we recommend. If not, then there are other choices that until they are able to fully establish this direct breastfeeding, then there are several choices of formulas that are out there that they can choose from.

[Dr Mike Patrick]
When you say there are several choices of formula out there, there are so many. It can be very confusing for parents who are going that route. And again, before we move on to infant formula, I just want to say I hope we’ve made the case for why breast milk is best for babies.

Just so, so many reasons and makes it worth the effort to get human breast milk into your baby. But at the same time, there are parents who really do try, and they have one difficulty or another. They may be seen lactation consultant, maybe family life, and they’ve got so many things going on that it just doesn’t work.

And then the fact that they aren’t breastfeeding then can cause some mental health challenges for moms in terms of anxiety because they really tried hard. And now they feel like their baby’s not getting what’s best for them. And you can understand why that could create anxiety and depression.

So, we want to say that there’s sort of this middle ground of yes, it’s best. There’s no question that human breast milk is best. But if it’s not working out, please don’t feel guilty.

Like you’re still doing the best you can for your baby. And that’s an important thing, right?

[Dr Anuja Sriparameswaran]
Yeah, correct. I mean, we say that all the time to our parents. And obviously, you know, formula is used as a bridge because it’s not always going to work out the same for all mothers for various reasons that I’m sure we’re going to address later on.

And so, in that reasons, the formula does act as a medicine, a bridge. For some people, it’s a medicine or a bridge. But some people, that is their choice of feeding if that’s what they chose to feed.

Or like you said, if the breast milk for various reasons is not working out. Or in some instances, the mother may want to breastfeed, but there are medical contraindications like we talked about or anatomically, if she’s not capable of breastfeeding or other issues that might prevent her from breastfeeding, then a formula is out there and is the best choice. And it provides the nutrients that infant need to grow and thrive.

[Dr Mike Patrick]
Yeah. So, when we’re thinking about infant formula, you know, the aisle at the grocery store is long with lots of different types of formulas out there. What types are available and why are there so many options?

[Dr Anuja Sriparameswaran]
So, yeah. So, in the United States, historically, just about like four companies, manufacturers that produced infant formula. We are pretty familiar with Abbott.

And then you have Enfamil, Meet Johnson, Gerber, Nestle, and Perrigo. However, in 2022, there was a major manufacturer that had an infant formula recall. And as we all know, we were just coming out of the COVID pandemic and there was a severe supply chain disruption.

So, this resulted in FDA fast-tracking approval of trusted international brands to sell here. So now there’s like a lot of choices. And so, you know, just kind of like to understand what you’re looking at.

Obviously, you know, most of them are imported from Europe and Australia. There are certain slight differences between formula manufactured here in the U.S. and formulas imported from Europe. In European Union, the lactose is the primary sugar for standard formulas.

In contrast, like some of the formulas here uses corn syrup or maltodextrin. And then in Europe, high level of DHA, the long-chain polyunsaturated fatty acid, essential for brain and eye development, it’s required. Although here in the United States is optional, but it’s widely adopted in the U.S. And then, you know, there is the market for fortified goat’s milk, which has smaller protein droplets and can ease on the infant’s stomach. So, what I wanted to emphasize is that, you know, when you are buying these formulas, just pay attention to the direction on how to mix these formulas, because it’s very crucial to follow these directions so you don’t end up causing caloric dilution or electrolyte imbalance, which can cause, you know, hyponatremia, which is really bad for the infant. It can cause seizures. So, we highly, highly emphasize to pay attention to how these, for the directions on how to mix these things.

And also, when you’re buying this, you know, the formulas that are sold at the supermarket or pharmacy are tightly regulated, inspected by the FDA. So just be careful when you’re buying, you know, your formula from a, not directly from this, but a third-hand vendor. Just make sure that, you know, you might not be able to verify that, whether that’s FDA approved, and if there’s a recall, that is not communicated to you.

So just stick to the ones that are sold at our local supermarket and tightly regulated by the FDA. And also, just kind of, I want to throw out some of these acronyms there that are because of a variety of choices of milk out there. Now, like I said, most of the infant formulas are based on cow’s milk.

And we talked about a little bit before, although the cow’s milk protein is adjusted to mimic the breast milk, you know, it does have a high amount of casein compared to the breast milk. So, there is a tendency for infants to develop a cow milk protein allergy. So, for those reasons, then you have this partially hydrolyzed formulas.

These are where the proteins are like gently chopped up, but it’s not exactly recommended for a true cow milk protein allergy. But then there is this extensively hydrolyzed formula. This is a gold standard for managing cow milk protein allergy.

Here, the proteins are broken down into a small peptide that infant immune system doesn’t recognize them as a foreign threat. And then you have the amino acid formula. Here, there are no protein chains.

They’re just individual isolated amino acids. Then you have a choice of like soy or pea protein options. These are for like if a family is a vegan, or for instance, if you have congenital lactase enzyme deficiency, which is very rare, then that would be a choice.

Or like we talked about before, if an infant is diagnosed with galactosemia. But the bottom line is clear. While there are like seamlessly endless options there and can be overwhelming, it’s all of these formulas, as long as they’re FDA approved, and they are created to provide what is needed for this infant to grow and thrive.

[Dr Mike Patrick]
Yeah, yeah. And I think if families are confused, and it’s understandable because there are just so many options that are out there, talk to your pediatrician. You know, if you have questions about what’s going to be the best formula to use for your particular baby in your situation, please do talk to your pediatrician and they can guide you in which one is going to be the best for your baby.

Now, to be fair, there are some advantages to formula feeding compared to breastfeeding. What are some of those advantages?

[Dr Anuja Sriparameswaran]
I think that we just kind of talked about before, you know, obviously, this provides an alternative to breastfeeding. And like we said, breastfeeding is the gold standard. Breast milk is the gold standard.

But it may not be the case for all of the mothers for a variety of reasons, like we mentioned before. If the mother does not have adequate glandular tissue or if she has undergone mastectomy, direct milk production is impossible. And then she could have other issues, the hormonal issues.

If she has issues with all of the hormones that are important into a milk letdown, like prolactin, oxytocin, or dopamine, then that would impair her milk production. Sometimes there are unseen things that happen at the time of birth, like if mom suffers a severe postpartum hemorrhage, or if she has polycystic ovarian syndrome. These can interfere with milk production.

So sometimes, you know, obviously, if an infant is being given up for adoption, or if the mother is using illicit drugs, then direct breastfeeding is off the table. Or sometimes, you know, mothers are on certain medications that are contraindicated. Under those circumstances, we would refer to our colleagues, the lactation consultants.

We do have LactMed that we refer to see which medications are absolutely contraindicated and which are okay. And the other instance of absolute contraindication is if mom is undergoing chemotherapy. So, as we said before, in the ideal world, donor human milk is a wonderful bridge, but it may not be feasible for every mother.

So, you know, in this instance, the formula does provide a unique alternative choice. So, to summarize this, whether a family is relying on breast milk, donor milk, or a standard formula or specialized soy formula, our goal as clinicians is to ensure that every infant is receiving safe, biochemically sound, and sufficient nutrition, obviously to thrive and grow and become productive adults.

[Dr Mike Patrick]
You know, regardless of how a baby is fed, I think what matters most is that we are participating together in the feeding experience, that this is also, infant feeding is also a social time, and babies are learning all sorts of new things as they’re developing. And one of those things that they learn is that they are getting nutrition from their parents. It’s really a bonding time for mom and baby, and hopefully for the father and the siblings as well.

So, what principles really matter the most as we think about healthy feeding in terms of the whole family?

[Dr Anuja Sriparameswaran]
So, yeah, I mean, like you said, no matter how a baby is fed, whether a mom is choosing to breast feed, bottle feed, or do a mix of both, the most important principle is that we support her with a choice of feeding, starting right at the birth hospital and continuing that in their medical, pediatric medical homes. If mother chooses to bottle feed, and if there’s no true medical contraindication to offering breast milk, our role as pediatrician is to gently offer her education on lifelong benefits of breastfeeding for both mother and child and provide immediate assistance if she is open to initiating breastfeeding. If mother is choosing to bottle feed, we must provide appropriate practical education on the types of formula present in the market, how to safely prepare, how closely they must follow the guidelines and instruction on preparation.

Parents need to know how often to feed the infant, what is what is the recommended volume are per feed based on the day of life, and then how to gradually scale that up. Typically, we say that after first five days of life, a stable infant requires about 150 to 180 ml per kilogram per day of fluid intake, that’s formula. Of course, this volume of milk intake will go down gradually once the infant is introduced to complementary food, and the recommendation is at six months.

On the other hand, if the mother is breastfeeding, we educate that a breastfed infant needs to be fed every two to three hours or completely on demand and teach mother how to monitor the infant’s urine and stool output in the early days. And then we make sure that she has available lactation clinic to follow up with. So, you know, whether a mom is breast or bottle feeding, the feeding time is fundamentally a sacred time for the infant to bond with the parent, especially the mother.

So whichever route that she’s choosing, we always encourage the mother to offer her infant what is referred to as a skin-to-skin time. This can happen before or after feeding. We also want to educate mothers on safe sleep practices.

It’s very important to discuss that never co-sleeping with the infant in bed, couch, or chair. If a mother is feeding her baby in bed and feels herself like she’s falling asleep, she should safely transition the infant back to their own separate crib or basinet to protect against sleep-related tragedies. Last but not least, every family needs an established medical home and close partnership with their pediatrician to address any ongoing concerns regarding the infant’s growth.

And I also want to emphasize this to my families. Mothers must take care of themselves. They need to follow up with their own physician, seek help immediately if they’re feeling overwhelmed or severely fatigued or experiencing signs of postpartum depression, because mom’s health is crucial and paramount for an infant to thrive, grow, and remain healthy.

Mother must be supported and remain healthy. And that is the foundation for a healthy infant, mother, and family.

[Dr Mike Patrick]
Well, this has been a fantastic and informative and really interesting conversation as we think about breastfeeding and the importance of breast milk for young babies. We are going to have a ton of links for you in the show notes, links to the World Health Organization, the American Academy of Pediatrics, the CDC, and all of their breastfeeding and infant feeding guidelines for you. We are also in the show notes.

Again, just head to pdacast.org, look for episode 609, and you’ll find the show notes for that episode. And then look in the links section. And again, we’re going to have a ton of stuff for you.

To those organizations, yes, but also a lot more on the science of breastfeeding and breast milk and why it’s so important for young babies. We also have some information on infant formula, comprehensive nutritional review of infant formula. We also talk about infant feeding and long-term metabolic health, also supporting mothers feeding choices, a key role in the prevention of postpartum depression.

We kind of hinted on that a little bit, but there’s an article in the show notes there that goes into that in a lot more detail. Also, you know, we spoke about the environmental impact of that decision of breastfeeding versus bottle feeding. And so, we do have some resources there, including environmental impact of feeding with infant formula in comparison with breastfeeding.

So, if you want to learn more about that. And then as we think about microplastics, we also have some interesting articles in the show notes for you. For example, detection of microplastics in placentas, meconium, infant feces, breast milk, and infant formula.

If you want to learn more about microplastics, if that’s a too deep of a dive for you, at least check out an overview of the possible exposure of infants to microplastics. So, if that’s of interest, that went way beyond our topic of conversation today, but we really could do an entire episode on plastic disposal and microplastics. I think that’d be an interesting conversation for a future episode of the podcast.

But I digress. So, leave it to say that there are lots of links for you to useful resources in the show notes as we think about breastfeeding and infant feeding in general. So once again, Dr. Anuja Sriparameswaran, hospital medicine at Nationwide Children’s Hospital. Thank you so much for stopping by and visiting with us today.

[Dr Anuja Sriparameswaran]
Thank you for having me.

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[Dr Mike Patrick]
We are back with just enough time to say thanks once again to all of you for taking time out of your day and making PediaCast a part of it. We really do appreciate your support. Also, thanks again to our guests this week, Dr. Anuja Sriparameswaran with hospital medicine at Nationwide Children’s Hospital. Don’t forget you can find our podcast wherever podcasts are found. We’re in the Apple podcast app, Spotify, iHeartRadio, Amazon music, Audible, YouTube, and most other podcast apps for iOS and Android. Our landing site is pediacast.org.

You will find our entire archive of past programs there along with show notes for each of the episodes, our terms of use agreement, and the handy contact page if you would like to suggest a future topic for the program. Reviews are helpful wherever you get your podcasts. We always appreciate when you share your thoughts about the show and we love connecting with you on social media.

You’ll find us on Facebook, Instagram threads, LinkedIn, X, and Blue Sky. Simply search for PediaCast. And then don’t forget about our sibling podcast that is PediaCast CME.

It is similar to this program. We do turn the science up a couple notches and offer free continuing medical education credit for those who listen. And that includes not only physicians, but also nurse practitioners, physician assistants, nurses, pharmacists, psychologists, social workers, and dentists.

And it’s because Nationwide Children’s is jointly accredited by all of those professional organizations that we can offer the credits you need to fulfill your state’s continuing medical education requirements. Shows and details are available at the landing site for that program, PediaCastCME.org. You can also listen wherever podcasts are found.

Simply search for PediaCast. So, thanks again for stopping by. And until next time, this is Dr. Mike saying, stay safe, stay healthy, and stay involved with your kids. So long, everybody.

[MUSIC]