March 2023

To state that the start of 2023 has been “eventful” is an understatement. Aside from the geopolitical and financial uncertainty, natural disasters, and learning to live with COVID, perhaps the most profound and significant event involves the technological advances in artificial intelligence and the upgrade of Open AI ChatGPT4 (https://openai.com/blog/chatgpt). Why is this significant? If asked, AI technology could have provided an on point, reflective narrative concerning the latest developments in breastfeeding issues, grammatically correct, in a matter of seconds, not even minutes, as opposed to the lengthy time it has taken me to weave experiential practice into this review. My days of sharing practice are numbered! Bill Gates has penned a great review of ChatGPT in his Gates Notes (https://www.gatesnotes.com/The-Age-of-AI-Has-Begun ), declaring it to be “the most important advance in technology since the graphical user interface” and is excited about the impact that AI will have on issues that the Bill & Melinda Gates Foundation works on. No doubt his Gates notes could become AI in origin, too.

I recently had the very special and positive experience of attending an elective C- section of 37-week twins, to have both babies skin-to-skin within a few minutes and, in recovery, latched on and breastfeeding beautifully, was a textbook case for zero separation and the establishment of breastfeeding; lactation undoubtedly helped by mum having already started expressing a few weeks earlier. This trend has become widely promoted in antenatal care and was one of the topics discussed at the recent online “Clinical Application of Lactation” webinar. Having a ready supply of breastmilk in the freezer certainly helped this mum to breastfeed the twins, as her lactation was already established but It made me consider the importance of colostrum as the first feed, does it matter if the frozen colostrum is administered as a supplement after breastmilk has been received? Does freezing it alter the nutritional benefit and the effect on the vital gut biome, and is it important to prime the gut with colostrum first? Questions all needing further research or for ChatGPT to answer.

The presenters were both very senior and experienced, acknowledging that they have witnessed the evolution of trends and changes in promoting breastfeeding over the course of their careers and that the one key fact to consider is that we have made breastfeeding so much harder than it must be. Our academic understanding of the physiology of lactation and the need for lactation consultants has indirectly elevated breast feeding into the “too hard to achieve without a consultant’s advice” basket. ALL midwives and nurses involved with postnatal care should be confident with supporting the establishment of breast feeding, the lactation consultant only to be sought for the more challenging situations, those cases that are often colored by perceptions that the nipple is “too big’ “too small” or “inverted”; or to pronounce the leading diagnosis of tongue tie.

This has become a hot topic and open for debate, the need to snip or laser tongue ties; particularly the cost of that snip, it is reported to be a very lucrative procedure and therefore liked by those undertaking the task, but is it liked or appreciated by the infant, who then has repeated sensory exposure to rubbing the snipped tie to prevent it from repairing? It is a question to fathom as to why so many infants are deemed to have a significant tongue tie negatively impacting their capacity to breastfeed.

Encouraging mothers of premature infants to pump regularly to establish lactation is one thing, but recently I have witnessed overzealous pumping achieve phenomenal hyper-lactation, unbelievable expressed breastmilk volumes that have paradoxically caused great anxiety. One mum was producing 200 mls every two hours from each breast! Enough to feed several babies, not just a petite 31/40. The breasts were so large and heavy, causing extreme discomfort and back ache, not to mention the overwhelming fear of potential mastitis.

Thankfully this was averted but there have been other mothers with mastitis, and we have been following the latest guidelines from the Academy of Breast-Feeding Medicine management. Pumping to “empty” the effected breast is not recommended. Antibiotics are not routinely indicated, whereas methods to reduce swelling and inflammation are. Only ice and cold compresses are to be applied, not hot, and only gentle massage to the affected area. as opposed to firm kneading or squeezing, which will only serve to increase the inflammation.

The mother was advised to pump every two hours and so she did, for the preceding four weeks before returning to the special care baby unit accompanied by a large chili bin of frozen expressed breastmilk (EBM)! No one had advised her to ease off the pumping once lactation had been established. She had a lactation app to enter the volumes that she had produced and had kept track of every precious drop. It became quite a challenge to extend out the hours between pumping to reduce the volume expressed when her goal had been to keep exceeding the previous volume or at least match it. Her daughter is the first baby I have known to have breastmilk added to her bath water by way of using the excess! Sadly, our nursery is too far away from a tertiary centre to have donated the breastmilk to be rigorously screened before giving to premature babies, whose own maternal supply may be insufficient. However, there is an online demand for expressed breast milk from athletes, cancer patients, and body builders, who recognize that it is perfect protein rich milk for their muscle building goals. it is quite a prized and unregulated commodity selling upward of $500/l !!! Mothers are reportedly pumping excessively to supplement the family income! I kid you not.

The take home message from the webinar reaffirmed it is not necessary for every mother to pump in order to breastfeed and yet this is the message being delivered, with pumps being provided as part of antenatal care (in the US), pumping is encouraged antenatally to establish lactation prior to birthing, pumping regularly after birthing for those who have not established their lactation antenatally, with ongoing pumping promoted just to keep up supply. There is NO need to pump to maintain supply. The feeding demands of the infant will ensure adequate supply. Current pumping practice aims to fast track the process post birthing to avoid an unsettled hungry baby and the often-associated discomfort from sore nipples, the irony being that mothers are experiencing anxiety associated with trying to establish early onset lactation several weeks prior to their due date, as opposed to the natural establishment of lactation that takes two to three days. As the presenters declared,

“We have made breastfeeding harder than it has to be”.

Coinciding and complimenting the webinar was the launch, in February, of the Lancet three paper series on breastfeeding, Breastfeeding 2023 (thelancet.com). It explores the value of and outlines the muti-faceted, highly effective strategies used by commercial formula manufaturers to target parents, health care workers and policy makers. Their dubious practice is in breech of the breast feeding code and preys on parental anxieties surrounding feeding their baby. This is an ongoing concern and has been a priority to address for as long as I can remember. Maybe we should ask ChatGPT4 how to resolve the often manipulative practices that milk formula companies use to influence parents to feed their infant formula. Then, how to increase global breast feeding statistics to 50% or more, (although I was pleasently delighted to learn from the recent “Maternal and Child Survival : a decade of progress and Action for the future” that 50% of infants globally are now breast fed and on target to meet the Sustainable Development Goals (SDGs) in 2030), followed by asking how to create a funding model to implement the strategy. In the meantime, the USAID update provides a clear outline of the hurdles to overcome to meet the SDGs, and the huge set backs that the Pandemic has had in thwarting progress. ChatGPT4 might just provide all the suggestions and solutions we need for an optimistic outlook for the future. Achieving the SDGs by 2030 might be in our grasp with the aid of ChatGPT.

Judy Hitchcock RN

COINN