Monday, May 13, 2013

Why I'm Anti-ELF! (Early Limited Formula)

You've probably heard by now about the study of "Early Limited Formula" or ELF as helping more of the moms in their teeny tiny (about 40 participants) study breastfeed longer by "curbing" the babies' hunger until the mom's milk comes in. It sounds great at face value-just give your baby a little formula and then eventually breastfeeding will be so awesome and perfect! But that's just not what common sense or decades of actual research on lactation tell us, and I for one am not buying it. (This is a good time to throw in my standard breastfeeding disclaimer: if you cannot breastfeed or have decided not to, I'm not trying to pick on you or second-guess your individual reasons. I trust that you personally did what is best for your particular family! My complaints are all directed at society/the medical profession in general and about what should be promoted for typical situations. Exceptions will of course always occur. Just keep being awesome and making the right decision for your family and you are a-ok in my book!) Anyway, as a mama to a Down Syndrome baby, this is especially frustrating to me because babies with Down Syndrome tend to have a weak suck due to low muscle tone and often low energy because of heart issues, which does make nursing difficult initially and I would hate to see a bunch of fellow mamas to DS babies unecessarily supplementing with formula because of one questionable study that came out.

my son as a newborn, right before I told the nurse who rolled a pump in to roll it right back out...
Ok, so what's the story here? A group of researchers took 40 families whose babies had lost more than 5% of their birth weight by 24 or 48 hours and assigned half to continue exclusively breastfeeding and half to receive ELF by syringe after each nursing session. More of the babies in the ELF group were exclusively breastfed at 3 months of age than the non-ELF group.

I definitely don't think ELF should be routinely recommended, even for babies who require supplemenation, despite this study. One reason why is that I question the study methodology, such as the ridiculously small sample size. There were fewer than 20 families within each group, so each mama counted for a very high percentage of the overall results. This is going to result in skewed data. To be fair, the researchers have acknowledged this and are not trying to change the current medical recommendations based on their small study. But because of the media hype and the countintuitive result they got, I thought it was worth adressing the issue anyway.

The second, bigger, point is that when supplementation is medically necessary, formula is NOT the best option. Most pro-breastfeeding sites I've seen advocate ranking best options if supplementation is necessary as:
  1. Your own pumped breastmilk
  2. Donor milk
  3. Formula
The fact that these researchers completely ignored what are generally recognized by lactation experts as the two best options for supplementation makes me wonder whether formula company funding was involved, the researchers didn't do their homework, or these researchers are just not that interested in actually promoting breastfeeding.

The La Leche League, for example, states:
Whenever a non-human milk is used, alterations in the baby's gut flora occur and will cause changes in the frequency, odor and consistency of baby's stool as well as how the baby settles after a feed (Kleessen et al 1995). In order to reduce the likelihood of an adverse reaction, the baby whose family has a history of allergies should not be exposed to non-human milk if it can be avoided (Saarinen & Kajosaari 1995; Gustafsson et al 1992). In this case, the longer the delay before first exposure, the better.
We know formula is NOT optimal for babies. For me to take a study like this seriously they would need to have additional control groups receiving pumped breastmilk from the mamas in question and donor milk.

I also question their threshold determining whether supplementation was necessary in the first place. It is widely accepted that the use of IV fluids in labor inflates birth weights. If babies are otherwise healthy and nursing well (i.e. good coloring, not overly lethargic for a newborn, good number of wet diapers, etc.), I don't think any temporary supplemenation is necessary in most cases. When it is, a supplemental nursing system that encourages the baby to suck at his mother's nipple, even if weakly and with a poor latch, to get his food, is probably the best option to contine to stimulate the natural supply and demand that makes breastfeeding work, and pumping is probably second best. Letting the baby get milk in a way that does not stimulate the mother's breasts is not going to keep her supply where it should be unless she is naturally blessed with oversupply.

Formula certainly has a place in our society and has undoubtedly saved many lives. And ELF in particular sounds far superior to simply switching to bottles of formula. But it shouldn't be a first, second, or even third option, and to promote it based on this study would be unwarranted in my opinion.
In summary, I find this study to have far too small of a sample size for the findings to be reliable and I find the control group choice questionable. I personally do not think this study is consistent with other existing medical literature on breastfeeding other than the mere fact that when supplementation is necessary, supplementing will positively affect the baby, and I think futher study would reveal that formula should continue to be a last resort for optimum baby health.

*I am not a medical professional of any kind. Please do lots of research and make educated decisions with your family and doctors and not based on my opinion!

1 comment :

oldnewlegacy said...

You've made some really good points. After complications with my first birth (c-section), my milk came in way late. Without some medication that my OB prescribed at the 7 week check-up, I don't know what I would have done. I was up to giving my baby 6 oz of formula a day. My second baby, a VBAC, was quite the opposite. My milk came in as scheduled, but my baby wasn't staying latched on for very long. The pediatrician didn't say anything but thankfully the NP, during a later appointment, noticed that her tongue needed to be clipped. Anyhow, I did do ELF in the early weeks with both my babies. What mothers need to be mindful of is keeping breastfeeding a priority. I had such a strong desire to exclusively breastfeed, that I wouldn't let the bottle to win. ;) Setting clear rules for myself in using formula (or a pacifier) helped breastfeeding remain the utmost priority.