Breastfeeding in the first days of life and when do we need to intervene with formula? Transcript of 2020 Baby podcast with Melbourne neonatologist Dr Dani Freeman

Introducing Melbourne neonatologist Dr Dani Freeman

Pam:

I'm Pamela Douglas and my guest today is Melbourne based neonatal paediatrician Dr Danielle Freeman drdanifreeman.com.au. We're planning to have a chat about breastfeeding in the first days and weeks of life. Dani, thank you so much for joining me today.

Dani:

Hi Pam, thank you so much for having me. So I'm an neonatologist, that is, a paediatrician who specializes in newborn babies.

Pam:

I wonder if you could address for a minute what you really like about being a neonatal paediatrician?

Dani:

Neonatology is a broad field, so it can cater to all sorts of interests and niche things that people like. For me, the things I love about it is that it involves genetics, and it involves ethics, and it involves communication, and also some very precise medical procedures, which I do really love.

It's a real privilege to work with families, and it's also a privilege to be able to make a difference, particularly from a medical perspective, that could have a lifetime impact. I feel really lucky to be involved with parents at one of the most important times in their lives. But of course there can be some really tragic moments, and I think it's an important part of my role to help families through these as well.

Pam:

So Dani, how many newborns would you say you've worked with over the years?

Dani:

The answer to that, Pam, would be lots. If I stopped to think about it, it's probably something around 8,000. I've also been lucky to look after many siblings from the same family, so it's nice to be part of a growing family's journey and story as well. After spending a lot of time working in intensive care and looking after mainly very sick babies, my career evolved sort of on its own, and it eventually led me to looking after mainly normal babies, and I did this mainly in private maternity hospitals. These days, while I still look after some really unwell babies, my passions are now focused on helping parents and babies in the first days and weeks of life, normalizing newborn behaviour, avoiding conflicting advice and information, and very importantly, empowering mothers to achieve their feeding goals.

Gaps in health system knowledge concerning breastfeeding support in the first days after birth

Pam:

Dani, we know that at birth in Australia, 96% of women are wanting to breastfeed their baby, and yet by the end of that first seven days of life, only 80% of women are able to do this exclusively. What do you think needs to be done differently? What are you seeing happening in these first hours and days of life?

Dani:

I guess firstly it's important to say that there are some babies who do have serious illness straight after birth, or in the first days and weeks of life. And this is obviously a really stressful time for parents. But this is not the topic of today's conversation, and fortunately that scenario is quite rare as most babies are normal.

What's really interesting, Pam, is that I didn't learn very much at all in my medical training about normal babies, and the vast majority of what I do know has been purely learned through observation. And I also realize that there are big gaps in knowledge for the parents and the staff on the ward. I would see mothers in tears, and sometimes fathers, on the second or third morning with their normal, healthy baby. Having spent many years looking after really sick babies, I said, "Why are you crying?" Because they had a lovely, normal, healthy baby!

I found the same repeated answers: that they were worried that the baby had been awake all night and that it had been wanting to feed all night and it mustn't be getting enough milk. These new mums were exhausted, and they were really confused by all the different things that they were being told by the staff on the ward.

So after I looked after 100, 500, 1,000 babies ... you start to notice patterns and similarities in babies’ behaviour after birth. But I also realized that they're all unique individual and that normality is an extremely diverse condition.

I guess it's not possible to write a protocol about how a baby should behave after birth, just like it's not possible to write a protocol for every woman's pregnancy and childbirth. I think it's really important that people caring for mothers and babies are able to realize that, and provide individualized care for the mother and the baby and the family in front of them.

But we seem to be caught in a medical model where we're tempted to look for what's wrong. I personally try, wherever possible, to look for and celebrate what's right. I tell my patients that I'm doing that. I teach them about the bell curve of normal, that little curve that can sit a lot of stuff underneath it. And I try to paint a general picture of what to expect in the coming days while establishing breastfeeding, rather than list something very didactic that is often going to lead to some sort of failure in expectation.

Pam:

It sounds to me as though your patients are really fortunate!

Dani:

Thank you, Pam. Simply speaking, breastfeeding requires two things, the milk and the technique. I like to call the technique the dance, and I tell new mums that the milk comes if there's lots of dancing in the first days of life. Of course like any new skill, it takes time and patience and lots of practice.

In order to help new mothers achieve success with their breastfeeding intention, we need to provide a calm and supporting environment. We need to educate and inform mothers of what they should expect, which might also mean we need to educate our healthcare providers, and we need to, wherever possible, avoid giving conflicting advice.

This conversation particularly relates to a first-time mum, because again, provided that there's nothing significantly going on in terms of illness of the baby or the mother, I generally tell mothers who have breastfed successfully in the past, "you will succeed again with your new dance partner."

Newborns need to suck (which doesn't mean they're hungry)

I think there is some idea that babies are starving with hunger when they're born. But I don't think babies are born with a sense of hunger in the way you and I might think of hunger. Because from a logical point of view, if they were, our highly evolved human race would have actually organized it so that women would be producing bottles full of milk straight after birth, but they're not. They're only making a drop or two. There must be a reason for that.

Pam:

Introducing an evolutionary perspective, really.

Dani:

Yes. If we really were supposed to make that much milk on day one, we would. So I don't think it’s hunger, but babies certainly are born with a desire to suck, and that desire is not a conscious, "I want to suck". It’s a primitive reflex and it's a response to smelling their mum's hormones, the pheromones.

When babies come out and they want to suck, everyone's like, "Oh my God, they're hungry!" But a lot of babies have undergone a very long labour and sometimes an instrumental birth or an emergency caesarian section and they're racing with adrenaline and sucking actually soothes them.

The other thing I’ve noticed is that the mothers who had a little bit of trickling of blood after birth, their babies were also really awake and looking to suck. And that also makes sense because sucking on the breast contracts the mother's uterus. Perhaps, again, that initial suck is to protect the mother's life by preventing bleeding. Of course, these days, most of us have our babies in a hospital where that's not going to work. But it makes sense from an adaptive point of view.

So babies want to suck after birth. And when they're born, if we think about it logically, the baby has just come out of the bag of fluids. The baby's guts are full of amniotic fluid, and meconium, and all sorts of other stuff, literally full from their mouth to their bottom. So there's no room for lots of milk there. Only one or two drops of milk are needed initially for that baby's stomach and the bowels to start working, so that they can vomit up the fluid and poo out the meconium and get everything out. So that when the milk does come in, in a couple of days, there's room for it.

I think that straight after birth skin-to-skin contact and access to the breast as soon as possible is really important, but we shouldn't mistake that for the baby being hungry or needing food immediately. If we take it back to the basics, newborn babies enjoy sucking and they enjoy the warmth, and the smell, and the feel of their mothers, and it just so happens that this has the rather ingenious side effect off bringing in milk which provides hydration and nutrition to the baby.

Pam:

This is very interesting to me Dani. I'll let you continue on.

What is a normal amount of weight for a term newborn to lose in the first days after birth?

Dani:

The next few days after birth are quite predictable because a normal, healthy, full-term baby goes into a programmed or a physiological dehydration in the first days of life while waiting for the milk. So, as I've alluded to, the baby needs to get all of that amniotic fluid and meconium out, and that, of course, then results in some weight loss and some mild jaundice. So all of the babies, to a degree, have a form of weight loss, usually between five and 10%, depending on a variety of factors which I'm sure we'll touch on a bit later, and most of the babies also have a bit of jaundice or yellowing of the skin.

In the first days of life, most babies also, I've observed, are very sleepy during the day. When I do my ward rounds during the day, the babies are wrapped up and nice and quiet, but the mothers have told me that the baby has been up all night feeding or trying to learn how to feed. That’s because the mother's producing high levels of prolactin at night.

I think that pheromones are produced at night and the baby can smell this and it wakes the baby who wants to cluster feed through the night. In the middle of the night this is mistaken as unsettledness or severe hunger. But in my opinion, the evening and night-time when the baby is awake and looking for the breasts, that's when the mother and baby have the best opportunity to practice the technique or the dance with breastfeeding, provided she's had some rest during the day.

If you've ever visited a postnatal ward, you've probably seen why getting rest during the day could be quite tricky because there are so many visitors, and the doctors or nurses are doing their rounds, and the physio times, and the meals are being dropped off and picked up. It's really hard for the mothers to rest while the baby's in the corner sleeping. I've always thought that in the ideal world, there'd been minimal interruptions during the day on the ward. At night, we would allow the mums to learn how to breastfeed with lots of support because that is when the baby is awake and looking for it.

So Pam, the breasts are stimulated more and more in the first days of life, when you and I know that a baby's sucking on a mainly empty breast. But those first few drops of milk turn into a few drops more, which turn into a few more millilitres, and a few more millilitres after that, until the milk comes in.

And my observation after seeing all these babies is that the vast majority of babies cope very well through this period. Despite everyone being worried about them, they are often sucking voraciously with good stamina, despite us knowing that they're relatively dehydrated.

There are some babies who do become too sleepy, or too jaundiced, or lose excessive weight. Those babies need to be assessed clinically, as should the breastfeeding technique and the milk supply.

But I've actually found that it's quite rare that a normal full-term baby to require supplementation with formula in the first week or so of life. Often they are getting formula, though.

So in my practice, if mothers or midwives are feeling worried during this period, rather than starting formula, unless that's requested, I generally suggest that the mother commences expressing because I have noticed that some mothers feel very happy and relieved when they can see the milk coming out.

Maternal nipple pain and damage is a serious breastfeeding problem in the first days of many babies' lives

And breastfeeding, as you well know, is not always easy in practice. I hear of a lot of perceived problems with breastfeeding in the first few days. So for example, "Is it something to do with the baby's mouth? Is it something to do with the shape of the breast? Does the baby have pain in its tummy? Is my baby too sleepy? Am I making enough milk?" These are legitimate concerns which typically require reassurance, but the serious breastfeeding problem I see is nipple damage.

It’s the midwives who are dealing with this and the lactation consultants, but the mums complain to me that their nipples are in pain and bleeding. This needs to be tackled because all of that cluster feeding, the dancing that I've told you about. If they're doing that with improper latching or suboptimal attachment, then it really can cause a lot of damage.

And by the time the milk comes in two or three days, the breasts are so sore and they're bleeding that the mother has to fully express and have time resting the breasts, which can also be tricky because that baby still wants to be on the breast all day.

Pam:

Yes.

Dani:

So if the baby's receiving expressed breast milk and say there's 10 millilitres or something, and it drinks it in two minutes, we've got an hour trying to cuddle the crying, unsettled baby.

Pam:

I might jump in there, Dani, because of course this issue of nipple pain and damage is huge, isn't it? And is a very important topic, which we won't try to deal with in too much detail in our conversation today.

But I'd just like to flag that women may be told to breastfeed through the pain or to count to 20 through the pain. And there may be a certain percentage who are lucky enough to count to 20 to just tolerate initial pain and eventually the nipple pain subsides. But there'll be many other women for whom the damage to the nipples gets progressively worse and worse. And then this whole physiological dance that you're so beautifully describing is profoundly disrupted, isn't it?

Dani:

It sure is.

Pam:

So of course, this is where I have the view that women have the right to be informed about the biomechanics of the suckling and what to look for. And if there's any discomfort at all, to deal with that breast tissue drag and get rid of it right from the very beginning, so that we avoid this terrible trajectory of nipple pain damage and seriously disrupted breastfeeding.

Dani:

I completely agree with that. On that note, when we ask the mum to express because her breasts are very sore or for any other reasons, suddenly she sees that there's five millilitres, and either she's worried that that's not enough, or a midwife is worried that's not enough. And that is often when that slippery slope of complementary formula feeding starts.

The baby still wants the hour of cuddles. So it might be that the mother has to give the expressed breast milk and then cuddle the baby for an hour, put a finger, or even a dummy in the mouth so the baby can have an hour of sucking, or send the dad out to do laps of the postnatal ward, because it's not necessarily because there was ever a supply issue, but we've suddenly seen the amounts of milk, which then we start intellectualizing. I've seen that happen time and time again.

Going back to what you originally asked me about what we can do differently, my observation is that if a mother and baby are kept together in a calm and supportive environment, the vast majority will successfully establish breastfeeding within seven to 10 days of life. That's my true belief. Whilst lots of deviations occur on that pathway, when a mother tells me that her intention is to exclusively breastfeed, that's where my empowering language comes in, because in the absence of something actually being wrong, I think that it's achievable in the vast majority.

How much weight is safe for a newborn to lose in the days after birth?

Pam:

Thanks Dani. I guess that brings us then to this grave and protective concern that the health professionals there on the wards have about weight loss. So it's that balance, isn't it, between what's acceptable, and what's placing the baby at risk. Could you speak to that concern, Dani?

Dani:

Sure. So the weight loss is a big thing. And also can lead to a whole lot of interventions.

Pam:

I noticed you were saying 5% to 15% is normal, but in fact, of course, 10% is the figure that we as doctors and midwives have drilled into our brain as the threshold for needing to introduce supplementation.

Dani:

Absolutely. I very purposely said 5% to 15% because, first of all, I don't really like rules when it comes to something that we know has such a diverse range of normality, such as occurs in newborn babies. So again, by observing lots and lots and lots of different babies, I realized that there are some babies who lose 5% and some who lose 15%, and we have to look at the baby.

As we mentioned earlier, when a healthy baby is born, it's full of fluid and meconium. The birth weight is the figure that we put on the cot card and send around to all of the relatives, but it's false in many ways. It's a wet weight.

Pam:

And IV fluids? I presume that amplifies this issue?

Dani:

Absolutely. I don't think the birth weight is necessarily a true indication of the baby's weight percentile, and then every single baby loses weight. Some mothers are very shocked to hear this, which again shows that we've got a gap in knowledge, perhaps because of what we’re saying as health care professionals. As a result, they're all very worried about the weight loss.

But we know that all babies lose weight, and from my observation, it's usually around 7% to 10% in the first 48 hours of life. Sometimes more, sometimes less, and as you mentioned, it's affected by many different factors.

For example, a baby born by ceasarean section will usually lose more weight because it's more full of water after that type of birth, rather than a vaginal birth, where some of that fluid has been wrung out of the baby. As you mentioned, if the mother's had an epidural or had lots of IV fluids during the labour, the baby will lose a higher percent. And I've even observed that in the mothers who were extremely puffy with high blood pressure and swollen faces and ankles around the time of delivery, their babies are also a bit puffy and will lose a lot more weight.

I do think that it's reasonable for there to be a percentage at which a medical overview of the baby is triggered. 10% is perfectly reasonable, but we have to then manage that on an individual basis. So we have to assess the baby in front of us. 20% of babies lose more than 10% of their birth weight. So how could something that's so common possibly be abnormal all the time?

It's looking at the baby, it's looking at the breastfeeding techniques, the milk supply, the clinical condition of the baby. And personally, if I had my way, and this might be controversial, I don't think we should weigh healthy babies in the first two days of life at all. Often we say, "Let's see if your baby's put on weight," but there’s actually no realistic expectation for any baby to put on weight in the first three or even five days. The anxiety that's caused for the mothers and the staff lead to all of the interventions.

I'd rather that we focus on improving breastfeeding techniques, looking for signs of supply, and actually looking at the baby's clinical condition rather than the numbers on the scale.

Pam:

Hmm. Thanks Dani. So what would flag concern? What would make us worried about the degree of weight loss? This just might be useful for any health professionals listening in as well as parents. And I understand we're talking about something complex here, complex clinical judgment, aren't we?

Dani:

I think from a weight point of view in a healthy, full-term baby, there's not much relevance, really, of the weight in those first couple of days in hospital.

I tell this to all my parents, because most babies will get weighed three times if they're staying for four or so days. They'll have their birth weight and they'll have two more re-weighs. Even a fully formula-fed baby will have two weight losses. I'm expecting a loss, and a loss. So when mums are going home from hospital, I'm expecting them to be still going home with weight loss. But of course we do need to see weight gain happen soon.

The way that I prime my parents, because I'm not going to see them the next day, is that the feeding needs to continue to be improved on in terms of the technique of the dance. There needs to be more sign of milk i.e. she might see milk coming out of her breast. The baby's poos will start turning yellow and we will see a weight gain soon. I generally like to see a weight gain at either the first or second weight done after discharge from hospital. So by the next day after discharge when the health nurse comes, it's nice if there's a plus.

Pam:

That's about day four. Is it day four, day five, that we're saying?

Dani:

Yes. But certainly by the second weigh done at home. And when I say a plus, I mean only plus 5, plus 20 grams, plus 40 grams, just a plus. Not prescriptive, just a plus, meaning that you've reached your nadir of negative and then suddenly we've got a plus. But of course they're all on different scales as well. And most of the funny weights I've seen have been because the scale has been non-calibrated.

Newborns and meconium

Pam:

So Dani, what do parents need to know about meconium and the baby's stool in these first days?

Dani:

Meconium is that dark-green, tarry poo that babies pass in the first days of life. It’s actually made up of all of the things that have been swallowed by the foetus while in the womb. Skin, hair, amniotic fluid. Most babies will pass their first meconium in the first 24 hours of life, and then the vast majority within 48 hours. If that first meconium occurs after 24 hours, that's labelled as delayed passage of meconium. And that can rarely, but sometimes, be caused by a problem with the bowel. I find that most babies who don't pass it in the first 24 certainly do within 48 hours. And then there are some babies that pass the meconium in the womb, and that's usually a sign of foetal distress.

From looking at all these normal babies over the years, some babies only have one really large meconium. Others have 20. And both of those and everything in between are normal. Because again, we start counting and measuring and having an expectation of what it should be. I tell parents that your baby was born with all of this meconium in them, and whether it takes twenty dirty nappies or five dirty nappies to clear it, it was already there.

Then there is a period where there's a back-up of milk behind the meconium in the gut. When the baby starts swallowing and digesting his milk, that milk mixes with the dark tarry green meconium so it becomes a lighter green. After the meconium is cleared, then it's just milk stools, which are usually yellow. And that usually occurs by about day four or five of life. But again, there's a vast range of normal in terms of the colour, the amount, the consistency, the frequency. So everyone is worrying about their poo, but some babies poo 20 times a day, and then some babies poo every few days. And on its own this doesn't necessarily mean it’s abnormal, we need to look at the whole picture.

Newborns and wees in the first days after birth

Pam:

Thank you. And then what about the amount of wee, the amount of urine that these little ones pass in those very first days?

Dani:

Yeah, so I've been told by lots of parents that they were told in their antenatal classes or read somewhere that there needs to be one on day one and two on day two and three on day three. But I'm sure you've gathered from our discussion that I don't really believe in rules when it comes to things like this because of the anxiety it causes if you don't fit into the rules.

So firstly, I've never seen a healthy baby who does not pass urine. They all pass urine. It's really hard to see it amongst all the meconium sometimes, in the first couple of days of life. And we talked about the programmed dehydration. So while a baby is going into that phase, they hold on to the urine. They're holding onto every drop of hydration, which is a normal response to being a bit dehydrated.

And once the milk is in, the urine output increases. So healthy babies, once the milk is in, are having multiple wet nappies per day. But I generally tend to encourage parents not to count or measure them.

Newborns and jaundice

Pam:

Thank you. And then that other important topic around the jaundice that you mentioned and sleepiness and how that might impact on the little one coming to the breast. Could you talk to that for a minute, Dani?

Dani:

There are some babies that become extremely jaundiced and require treatment with phototherapy or the blue light. That's quite rare in the first days of life. When it does occur, it's most commonly due to a mismatch in the blood group between the mum and the baby. And that type of significant jaundice can cause sleepiness as a symptom.

Then that baby is often then separated from the mother, by going to the special care nursery or being placed in isolation in the room, which can obviously make establishing breastfeeding a bit challenging. Sometimes those babies do need to be supplemented with either expressed breast milk or with formula.

But most of the other babies have mild jaundice. And in fact, it's extremely rare to have no jaundice at all, but sometimes it's really subtle. Sometimes it's just the whites of the eyes, but if you did a blood test on every single baby on a postnatal ward, I don't believe you would find a jaundice level of zero on any of them because it's actually a physiological jaundice.

The best way to understand it, I guess, is that while the liver and the bowels start to kick in, they're waiting for milk in order to go through it’s digestive processes. A simplistic way of making sense of this is to say that the yellow stuff which should be excreted into the poo often gets a little stuck in the bloodstream while the gut is kicking in, and it stains the skin, if there is not enough milk passing through the gut yet to absorb it.

The midwives and paediatricians will be assessing that physiological jaundice, shift by shift. If there are concerns about the level of jaundice, we can measure it, but mild jaundice, in my opinion, doesn't usually cause sleepiness per se. Babies are generally sleepy in the day anyway, and wakeful at night due to their circadian rhythm and due to their mum’s pheromones. I encourage those babies with mild jaundice is to be near their mother as much as possible.

Pam:

You're meaning they're either in arms or indeed skin to skin, am I right Dani, when you say that?

Dani:

Yes. Or even just so that the cot is literally right next to the mother so that the baby is as near as possible. So especially at night, when those smelly pheromones are coming out, the baby can smell the mother’s pheromones and wake up looking to suck.

What needs to happen when a baby has lost 10% of birth weight?

Pam:

I'd also like to check in with you about the rule, I suppose, that we have as health professionals in our brain around needing to regain the birth weight by two weeks. Sometimes we'll watch closely and it'll be three weeks, but I'm interested to hear your reflections on this, Dani. It's hard, isn't it? Because as health professionals, we’re so anxious to protect safety, but we can also be unduly aggressive too with interventions, can't we?

Dani:

Well, as I mentioned before, I like to see a plus at the first or second weight after discharge. So, if they go home and the baby has just started to gain, though not necessarily back to birth weight, it’s a sign that we've passed the hump. Most babies do experience a plus at the first or second weight after discharge.

Pam:

Sorry to break in, but that second weight, roughly, when are you thinking that happens? Because I think the home visits occur differently between states.

Dani:

Well, I think it's also different within Victoria. So, if you're in the public system, often you're visited by a hospital midwife, daily or second daily after you're discharged. Whereas the private ladies will go home on the fifth or so day and usually be visited by their health nurse within the next few days.

So again, I'm not putting a day limit on it. If the baby is still on a minus when they go home from the hospital, I'm happy with one more minus, but it would be very nice if the next one is a plus, without being too prescriptive, if that makes sense. Most babies do achieve that and most babies do regain their birth weight by about two weeks of age. That is true. But again, no rules here.

And I think that every mother and baby needs to be individually assessed rather than using a one size fits all approach. If the baby looks healthy, however we define that which is another topic of conversation, if the mother appears to have good milk supply and the baby's latching well, then I think we should feel confident that weight gain will occur if it hasn't yet. And we should continue to monitor it.

What are some red flags for newborn safety?

However, in terms of the safety thing and the risks, there are two really big red flags that shouldn't be ignored, and that's static weight and weight loss. So static weight, in my experience, is most often due to a supply issue.

But weight loss, if the scales are indeed correct, is never, ever normal, and it could actually be the sign of an infection or a metabolic condition. And those babies should be assessed as soon as possible by their GP or their paediatrician or in the emergency department. Those two red flags are really important.

And sorry, I should clarify, when I say weight loss, I'm talking about weight loss after we have already gained weight. So once we start having weight gain, any plus, then that should be followed by plus and plus and plus and plus throughout childhood. We shouldn't see weight loss unless the baby is sick.

Those two are really big red flags, but there is also a whole subset of babies who are "slow to gain weight." And lots of people quote to me that they were told that their babies didn't gain enough grams or didn't gain enough weight or didn't gain the expected amount of weight. So again, I like to celebrate the fact that we've gained weight rather than not gained enough weight.

What is adequate weight gain in a newborn?

My approach to reviewing weight gain in those early days and weeks of life is a combination of looking at the feeding history, examining the babies, and the actual weight on the scale. It's an overall picture, rather than looking at grams per week.

I much prefer to plot the weights on the growth chart and look at the trends and patterns, which in those days and weeks is a tick shape because you have your initial wet birth weight, you then decrease, and then you start to increase. It’s often like a nice tick.

I say to my parents, when I'm quoted grams per week, I say, "If you're on the third percentile, you need to gain far less grams per week to stay on that percentile than if you're on the 90th." So we can't categorize every single baby. Likewise, you can be really chubby and healthy growing on the third percentile, and you can be really skinny and have poor weight gain but you're on the 90th. It really needs to be an individualized approach.

Pam:

Yes, and we're talking about the WHO percentile charts here, I assume.

Dani:

Yes, I do prefer to use the WHO charts wherever possible, but some medical practice software use the CDC, I believe.

Pam:

Yes, it's true. I must admit, over the years, I'll then do my own plot on the side. Dani, how do we do that dance between ensuring safety for the newborn and not unnecessarily introducing formula?

Why is formula sometimes used unnecessarily?

Dani:

Well, that's a very, very good question, Pam, and I, like you, am probably quite concerned about how much unnecessary formula is given in the first days of life. And by unnecessary, I mean, as a protocol-driven or direct response to, for example, a weight loss of greater than 10%. Because of course I told you and I am quite passionate that I do empower mothers' feeding goals.

So if a mother needs to or wants to formula-feed her baby, I will just as passionately help her introduce that, which is again a topic for another day, because there's lots of pitfalls of introducing formula in the first days of life. But where a mother requests formula, as long as she has received the support and education, that's absolutely fine with me.

But with the unnecessary use of formula in mothers who intend to breastfeed, I think that we need to be really careful, because this is all about the gut microbiome, which is really important. The gut microbiome is the environment of organisms inside the healthy gut, extremely important for our immune system, and it's also thought to be linked to our health in general. This is an emerging field. There's lots of studies being done about the gut microbiome and it's all rapidly evolving.

Everything we put into a baby's body, particularly in those very first few days and weeks, has an effect on the microbiome. And wherever possible, I think that breast milk should be the only thing we put in there unless we have a good reason not to. I think that formula could have a negative effect on the gut microbiome and needs to be used with good reason.

We're seeing a lot of childhood allergy currently and increasing in recent years, and I think that's due to a lot of possible causes. But of interest, it seems that early sensitization of the gut to cow's milk protein in formula might play a role.

There’s a lot more we can do to educate midwives caring for others on the postnatal ward, and more importantly, education of the mothers themselves, preferably in the antenatal period, rather than in that exhausted, confused haze in the first couple of days of life.

Pam:

Yes, absolutely. And in fact, in Neuroprotective Developmental Care of the Possums programs, we have a two-hour when baby comes home program that compliments the usual antenatal classes [When baby comes home, starting here], and is particularly focused on our evidence-based NDC approach to supporting the breastfeeding and infant care more generally from birth going onwards. Helping parents get oriented to what they might expect when that baby arrives in the world and then comes home.

Concluding remarks: one-size-fits-all approaches let breastfeeding women down

So Dani, did you have any comments you'd like to offer in conclusion? This has been such a rich conversation. Was there anything else you might add?

Dani:

Oh, look, it's a massive topic, Pam, and you know that we could probably talk about it all day and night and over a glass of wine or two.

Pam:

Absolutely.

Dani:

I guess my concluding remarks about all of this, if we had to summarize, is that there can't be a one-size-fits-all approach to something that has such a range of diversity.

I think that the healthcare professionals caring for women and babies in the first days of life should be very mindful of this in their approach, because it would allay their own anxiety too. If we're looking at things and saying, "well, if it's more than 10%, could they still be normal?" the answer is yes, most of the time, yes.

So we need to focus on educating parents and healthcare professionals about normal baby behaviour so that we don't unintentionally introduce these unnecessary and potentially harmful interventions.

Pam:

Dani, it's been such a delight to speak to you. I'd like to thank you very much for giving me the time.

Dani:

It's my pleasure, Pam.