Birth Planning for Future Health

Birth Planning for Future Health

There comes a point in your pregnancy when you realise that this baby actually has to come out. You might laugh thinking back, but often we are so excited to be pregnant that we haven’t thought further than being pregnant. When you type “Birth Plan” into your search engine, immediately there are 13 300 results. Each of these has excellent advice on preferences and options that you should think about in order to make a positive birth experience. Some are very practical in the sense of what to pack, who should be allowed into the labour ward and when should you have an enema so not to poop on the table; but what if some of these decisions could impact the long term health of your unborn baby. Suddenly, how scary that we not only have to plan for beyond the pregnancy, but the responsibility of decisions made at birth could have far reaching impact.

Recent terminology that is starting to filter into these plans is the Microbiome. "Two amazing events happen during childbirth. There's the obvious main event which is the emergence of a new human into the world. But then there's the non-human event that is taking place simultaneously, a crucial event that is not visible to the naked eye, an event that could determine the lifelong health of the baby. This is the seeding of the baby's microbiome.” (1). The human microbiome consists of trillions of microbes – bacteria and viruses—the balance of which largely determines our health and well-being throughout life. The largest microbiomes in women are located in the mouth the gut, the uterus, the vagina, and the skin. Breastmilk also provides a vital microbiome for the infant.(2). The microbiome is normally transferred from mother to baby via the placenta during pregnancy; the vaginal canal during birth; and the mother’s skin, breastmilk, and lips in the hours, days and weeks after birth. The microbes and their genetic material play an essential role in the child’s health, development, and metabolism. Disruption in the transfer of the microbiome in the perinatal period due to changes in the way  pregnancy and birth are managed in the hospital have led to the increase in many diseases, such as allergies, asthma, diabetes, gastrointestinal diseases, obesity, autoimmune disorders, and some mental disorders. Until the past few years, the connection between the altered microbiome and poor health was virtually unknown. With newer technologies that allow for the study of microbes that were previously impossible to study, these connections are beginning to be discovered. (3).

Let’s go back to looking at just a few things on our birth plans while keeping the maintenance of the microbiome as our heading:

Mode of delivery – Unfortunately cesarean delivery (CD) is no longer reserved for medical reasons, but the massive increase in elective CD sitting in the 80% in some private clinics, has put this on the list of birth planning. During vaginal delivery, the contact with the vaginal flora is an important start to the infants colonization, this is absent in CD. Studies are showing that babies born vaginally are colonised with lactobacillus, whereas cesarean delivery babies were colonized by a mixture of potentially pathogenic bacteria typically found on the skin and in hospitals, such as Staphylococcus and Acinetobacter. The effect of this appears to be most robust in the area of immune mediated diseases. CD has been associated with a significant increased rate of asthma and allergic rhinitis.(4).

Skin to skin (STS) – Placing the baby immediately on the mother’s chest and leaving the baby there is what is needed. Almost all necessary interventions can be performed with the baby on the mother’s chest. Wrapping the newly born baby in hospital blankets and placing in an incubator means the baby has no chance to acquire the skin microbiome of the mother, through direct contact, including skin to skin holding, licking and nuzzling. Instead the baby is exposed to the hospital microbiome via the blankets and the handling by the nurse. (5). Even if CD is necessary, immediate STS should be done.

Antibiotics, widely used for the mother during pregnancy and birth and for the infant afterwards, destroy helpful microbes. Even though this is not usually the choice of the mother, as prescribed, but by just discussing risk vs reward with prescribing physician can go a long way to avoiding unnecessary usage.

Breastfeeding / Formula feeding and the consistent use of the formula top up. Infant formula deprives the baby of the rich breastmilk microbiome, and impairs the normal development of the newborn’s immune system and maturation of the baby’s gut microbiome. (5). Exclusive breastfeeding has a protective role of breast-feeding against the development of diarrhoea and necrotizing enterocolitis in the newborn and allergic and autoimmune diseases in childhood, including coeliac disease type I diabetes and atopic dermatitis. Later in life, breast-feeding has been associated to a reduced risk of inflammatory bowel diseases, cardiovascular diseases, obesity, and type-2 diabetes. (7).

Many woman are exclusively breastfeeding, oh ja, except for that top up or 2 that baby received in the hospital, or some choose for various reasons to mix feed. Breastfed and formula fed infants have different gut flora. The science bit: Breastfed babies have a lower gut pH (acidic environment) of approximately 5.1-5.4 throughout the first six weeks that is dominated by bifidobacteria with reduced pathogenic (disease-causing) microbes such as E coli, bacteroides, clostridia, and streptococci. Babies fed formula have a high gut pH of approximately 5.9-7.3 with a variety of putrefactive bacterial species. When formula supplements are given to breastfed babies during the first seven days of life, the production of a strongly acidic environment is delayed and its full potential may never be reached. Breastfed infants who receive supplements, develop gut flora and behavior like formula-fed infants, the dominance of bifidobacteria during exclusive breastfeeding decreases when infant formula is added to the diet. (6). Exclusive and partial formula-feeding have been shown to alter the gut microbiome toward adult patterns, increase proinflammatory bacteria,  and increase gut permeability, and result in lower concentrations of fecal short-chain fatty acids compared with exclusive breastfeeding. (8).

Now you are thinking so what? What all this leads to is that just one bottle can have a long-term consequence on immune health as well as reduced protection against overweight and obesity.

These are just a few examples of how the microbiome can be altered at birth, and as research in this field expands, there will be an impact on our birth plans and how we are treated in maternity care facilities. You are the advocate for your baby, when you are putting together your birth plan, add microbiome to the google search, and insist that your health care team THINK GUT.

Samantha Crompton RN.RM.RCM.RP. SACLC

References

1.    http://articles.mercola.com/sites/articles/archive/2014/12/27/seeding-baby-microbiome.aspx. The Importance of Reducing Your Toxic Burden When Planning to Start a Family. December 27, 2014. Dr. Mercola

2.    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3340594/. The Human Microbiome and Its Potential Importance to Pediatrics Coreen L. Johnson, PhD^a and James Versalovic, MD, PhD^b

3.    https://healthfinder.gov/News/Article.aspx?id=711974. Antibiotics, Formula Feeding Might Change Baby's 'Microbiome'. C-section birth may also diminish diversity of these colonies of helpful microbes, study shows.

 

4.    Cesarean versus Vaginal Delivery: Long term infant outcomes and the Hygiene Hypothesis. Josef Neu, MD^a,b,a,b and Jona Rushing, MD^. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3110651/

 

5.    How the 'Microbiome' Affects Your Baby's Birth and Health. https://www.bastyr.edu/news/health-tips-spotlight-1/2015/06/how-microbiome-affects-your-babys-birth-and-health. By Penny Simkin, PT, CCE, CD(DONA)

6.    Supplementation of the Breastfed Baby “Just One Bottle Won’t Hurt”---or Will It? Marsha Walker, RN, IBCLC. January 2014.

 

7.    Effect of Breast and Formula Feeding on Gut Microbiota Shaping in Newborns. Federica Guaraldi¹ and Guglielmo Salvatori², https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3472256/

 

Double Trouble: Tongue and Lip Tie Twin case study

Double Trouble: Tongue and Lip Tie Twin case study

Introduction

Ankyloglossia and shortened maxillary frenula (tongue and lip tie) often cause difficulty with breastfeeding. Poor latch with subsequent maternal nipple pain, poor milk transfer, failure to thrive and symptoms of reflux and colic have been described in the literature.

 

 

 

Ankyloglossia (tongue tie) is a congenital anomaly observed in newborns and children, and is characterised by an abnormally short lingual frenulum. The tight frenulum can cause decreased tongue mobility to varying degrees. (2). In order for a breastfeeding infant to properly latch onto the mother’s breast, the infants tongue must be able to thrust to the edge of the lower gum and cup around the areola and the mothers elongated nipple. The infants tongue movement may be restricted by an abnormal lingual frenulum. In breastfeeding the infant is unable to form an appropriate seal. This frequently results in sore nipples for the mother. Ineffective sucking in the newborn may also result in insufficient milk drainage in the mother, which in turn may lead to mastitis, decreased maternal milk supply, and eventually poor infant weight gain secondary to non-nutritive sucking. (3). A frenotomy, simple “snip” with a blunt-ended scissors is usually all that is needed and bleeding is minimal. It is less traumatic than ear piercing, and much less invasive and painful than circumcision. Immediately after the frenotomy is done, the infant is placed back on the breast, and the latch adjusted. There is usually immediate improvement in milk transfer and maternal comfort. (8).

During latching onto the breast, is also the importance of the upper lip flanging outward. The normal breastfeeding motion is best achieved when the baby can widely open the mouth. This wide opening is best achieved when the baby is able to flange the upper lip outward, allowing the mucous membrane portion of the lip (rather than the dry outer portion) to contact the breast. This allows for a better seal, which is the first step in generating the negative pressure for breastfeeding. (7). If the upper lip tie is tight enough the infant may also have trouble feeding from a bottle. Dr. O'Callahan and colleagues (2013) found that 37% of babies with tongue tie also had a current upper lip tie (ULT). Those ULTs were treated routinely as part of the study. While they were not specifically separated out and studied, it shows the importance of treating the baby to maximize breastfeeding outcomes. Many practitioners who routinely treat tongue-tied babies feel that this number likely underestimates the number of babies who would benefit from a lip tie revision. (7)
Reflux in infants poses many challenges for the parent/infant relationship. Aerophagia is a poorly studied but commonly seen phenomenon in breast and bottle fed infants. Aerophagia from the Greek “aerophagein” means “to eat air”. Post-feed aerophagia can be seen with higher rates in infants with tongue tie and possible lip tie. When the infant attempts to latch and has an ineffective flange/seal and dysmotility of the tongue on swallowing, there may be an increase in swallowing of air, leading to post-feeding gastric distention, colic and possible reflux. This is often seen clinically in infants with ankyloglossia and/or shortened maxillary labial frenula (tongue and lip tie). Aerophagia is often seen after feeds and is diagnosed by auscultation (examination with a stethoscope) during feeding, presence of colic-like symptoms after feeding, and gastric distention immediately after feed and can be seen on flat plate X-ray with enlarged gastric bubble. The increase in gastric pressure may overcome the lower esophageal sphincter pressure and gastric contents may reflux into the upper airway. This may be confused with other types of reflux disorders and result in misdiagnosis and improper treatment. (9).

Case Study

Kate and Patrick parents to 4 boys were referred to me for feeding concerns of their twin boys Dyson and Cadan by their chiropractor.

Dyson and Cadan mono di twins were born at 32 weeks weighing 1.8kg and 1.7kg. They were in the NICU for 4 weeks, on CPAP for 2 days. Kate expressed breastmilk for the boys for the duration of the NICU stay where they were tube fed initially then moved onto bottle. Exclusive pumping without the baby stimulating the breast, Kate started having some supply concerns. Kate had breastfed her previous 2 boys, but decided with the inconsistency of supply and there being 2, she decided not to continue breastfeeding.

Dyson was posseting and actually vomiting 2-3 of his feeds per day. The pediatrician diagnosed both boys as having reflux. They were put onto Gaviscon for a few days and then moved onto Nexium, which Kate was not very keen on. Kate and Patrick took the boys to a chiropractor for the reflux. The reflux did improve but still had concerns. The boys were having trouble latching onto the bottle. It was taking around 90min for the boys to drink a bottle, and it was getting worse. Chiro suggested that they contact me, to assist with feeding concerns.

On seeing the boys, they would fatigue quickly while drinking bottle. Battling to maintain latch onto the bottle. Examining their mouths, I suspected that they had posterior tongue ties and lip ties. This was potentially the reason for the feeding difficulties and reflux. I referred them to a paediatrician for evaluation. I discussed suck training exercises in order to increase the muscle tone, as well as different teats to use and paced bottle feeding techniques.
Parents took the boys to an ENT that their family has been seeing for many years. The ENT told the parents that there is no such thing as posterior tongue ties. Kate phoned me, as now having concerns. She can see that there is a problem, but the twins were seen 3 times per day in ICU for 4 weeks and the pediatrician seeing them never once said anything about tongue / lip tie. There trusted ENT says there is no such thing. Now she must trust the word of a nurse over 2 specialized Drs. I sent her all the information that I had on the topic, with my rationale for why I think that Dysan and Cadan have posterior tongue ties. Kate and Patrick were now sitting with 3 different diagnoses; reflux; tongue tie; and no tongue tie. An extremely stressful and confusing situation.  She decided to pursue it with an ENT at Parklane Clinic. In the 6 weeks between seeing me, and seeing the ENT, the twins only gained 300g.
This ENT confirmed and diagnosed posterior tongue tie and lip tie. He performed a frenotomy, lip revision and put in grommets. As the boys came around from the anaesthetic, she was advised to feed them immediately. Kate said that there was a definite difference already in how the boys latched onto the bottle. Over the next few weeks there was a dramatic improvement, they were different babies. Much more content, and they gained 400g in 1½ weeks. The twins’ weight gain has steadily improved; they are now “klapping” their bottles. Kate also describes the difference in feeding them, where previously not even wanting a bottle, to now getting excited when they see it coming. They have recently started solids and are doing well.

Discussion

Parents want to do the best for their children and prevent or fix anything that prevents them from thriving. In order to do this, they rely on health care professionals to assist them. If we look back through the case study, Dysan and Cadan were compensating, when this became too difficult, they started presenting with symptoms. The symptoms were treated, not the reason for the symptom. Kate and Patrick and other parents seek help from various health care professionals. Paediatrician may treat the reflux with PPI, chiropractors, physiotherapists, sleep trainers, dieticians, clinic sisters, pharmacists etc. each doing best to help the parents and the baby. This all comes at a financial cost, putting parents under strain as well.
Reliable information about how tongue tie truly disrupts latch quality wasn’t available until 2008, when an ultrasound study showed what the tongue does during breastfeeding. This information presented a paradigm shift in the understanding of infant anatomy and physiology with respect to breastfeeding and had a huge implication for how restriction of normal tongue movement could impact successful breastfeeding. (10).
Tongue ties are not always obvious, especially posterior tongue ties. It takes training, reading and practice in diagnosing tongue ties. Education of health care professionals on the signs of potential tongue and lip tie needs to be done. In twins case:

-          Reflux

-          Poor weight gain

-          Fatigue during feeding, taking long to feed.

-          “colic”, fussy babies, fussy eaters

As well as training more health care professionals on how to assess a baby for tongue tie, and if a health care professional has the knowledge, to actually be assessing for ankyloglossia routinely. Cadan and Dyson’s tongue & lip tie could have been picked up in the NICU. If more babies were diagnosed with tongue-tie properly, not only would moms who want to breastfeed have a better chance of succeeding, but the long term complications of tongue & lip ties could be prevented. (5).

Samantha Crompton RN.RM.RCM.RP. SACLC

References

1.     Guidelines to the writing of a case study. Dr. Brian Budgell, DC, PhD*.J Can Chiropr Assoc 2008; 52(4) 199.

2.     http://www.cps.ca/documents/position/ankyloglossia-breastfeeding. 20/9/2015. Ankyloglossia and breastfeeding. Anne Rowan-Legg MD, Canadian Paediatric Society , Community Paediatrics Committee. 2015;20(4):209-13.

3.     Newborn Tongue-tie: Prevalence and Effect on Breast-Feeding. Lori A. Submitted, revised, 15 October 2004.From the Regions Family and Community Medicine Residency Program (LAR, DJM-K), Department of Family Medicine and Community Health (NJB), University of Minnesota Medical School, St. Paul, and the HealthPartners Research Foundation (TAD), St. Paul, MN.

4.     Tongue-Tie and Breastfeeding: a review of the literature. Janet Edmunds. Breastfeeding Review 2011; 19(1): 19–26.

5.     http://www.bestforbabes.org/booby-trap-docs-who-wont-snip-tongue-tie-thousands-of-breastfeeding-moms-babies-suffer/. 22/9/2015. Booby Trap: Docs Who Won’t Snip Tongue-Tie, Thousands of Breastfeeding Moms & Babies.

6.     http://www.perioimplantadvisory.com/articles/2012/7/ankyloglossia-tongue-tie-release-using-dental-lasers.html. 12/10/2015. Ankyloglossia (tongue tie) release using dental lasers. Dr Laurie Kobler.

7.     http://www.drghaheri.com/blog/2014/3/6/how-does-an-upper-lip-tie-affect-breastfeeding. 7/9/2016. How does an upper lip tie affect breastfeeding. 16 march 2014.

8.        CONGENTIAL TONGUE-TIE AND ITS IMPACT ON BREASTFEEDING. Elizabeth Coryllos, MD, MSs, FAAP, FACS, FRCSc, IBCLC. American academy of paediatrics.

9.       Aerophagia Induced Reflux in Breastfeeding Infants With Ankyloglossia and Shortened Maxillary Labial Frenula (Tongue and Lip Tie). Scott A Siegel. Int J Clin Pediatr. 2016;5(1):6-8.

10.   http://www.drghaheri.com/blog/. How the system can fail breastfeeding families. 8/9/2016.

Tongue Ties and Colic/Fussy/High Needs Baby's

Tongue Ties causing Colic/Fussy/High Needs Baby's

Infant colic is a common but poorly defined and understood clinical entity and, while several causative factors have been suggested, a unifying theory of its pathogenesis is still required. A definition that I have begun to adopt is one where stimulus irritates the baby and gets to a place where the caregiver is no longer interacting positively with the baby.
Parents go on an endless quest to sort out baby's colic/wind/reflux/random discomfort. Conflicting and numerous advice is given across a range of health care professionals and well meaning support systems. A large focus of this conflicting advice is around feeding and winding. Mom has an inherent instinct to nourish her child, and a disruption in that desire, coupled with conflicting advice can have a profound impact on mother and the mother/infant relationship. One of the most basic human instincts of the baby is the need to breastfeed, demonstrated by the breastcrawl soon after birth. When this is disrupted, it can effect how the baby feeds, and cortisol level studies suggest that the baby suffers stress.
One of the reasons for this disruption could be a Tongue Tie. The medical term for this is Ankyloglossia. It results when the frenulum (the band of tissue that connects the bottom of the tongue to the floor of the mouth) is too short and too tight, causing movement of the tongue to be restricted. There are many signs and symptoms that point you in this direction, which is why always a good idea to consult with a certified lactation consultant SACLC or IBCLC if you are having concerns. I am just going to focus on the fussing/windy/colic baby.
The Tongue Tie baby will try to latch on the breast with a "small mouth". They don't open widely, and that narrow opening allows small amount of the breast tissue into the oral cavity. This results in a shallow latch that can predispose the mom to significant pain and inefficient milk intake by the infant, leading to a cascade of problems. When you are told to get the baby to open the mouth wider, may need to investigate why baby is not opening wide. If there is indeed a restriction, a wide latch can cause baby discomfort and tension and possibly migraine, the baby responds by closing the mouth until the tension dissipates. The shallow latch leads to a high needs fussy baby; and excessive air swallowing due to the poor latch and seal can lead to reflux.
This is leading into our definition of colic/fussy/high needs baby: Fussing, windy, reflux, constantly on the breast, appearing to be in pain, irritable. A baby with colic may experience hyperalgesia, previously described in infants subjected to procedural pain due to routine medical care such as heel pricks. This can lead to something like a wind being unbearable, causing long inconsolable bouts of crying. Parents overtired, feeling inadequate, painful breastfeeding and no longer having positive relationship with the baby. These parents seek help from various health care professionals. Paediatrician may treat the reflux with PPI and often putting bandaid on the issue by suggesting formula, chiropractors, physiotherapists, sleep trainers, dieticians, clinic sisters, pharmacists etc. each doing best to help the parents and the baby. This all comes at a financial cost, putting parents under strain as well.
Tongue ties are not always obvious, especially posterior tongue ties. It takes training, reading and practice in diagnosing tongue ties. This is why it is ideal if you are having feeding issues to consult a lactation specialist. May help get a clear reason as to why baby has colic and direct the efforts of health care team, paediatrician to do frenotomy, lactation specialist assist post frenotomy exercises and breastfeeding post frenotomy, chiropractor / physiotherapist assist with body work. This helps to avoid uneccessary medications, unfocused consultations, stopping breastfeeding and all comes with it.

Samantha Crompton RN SACLC

References:

1. Update on infantile colic and management options. Curr opin Investig Drugs, Nov;8(11):92-6.
2. Dr Michael Marinus presentation. Abbot Nutritional Forum. 18/08/2016.
3. Dr Bob Ghaheri. www.drghaheri.com
4. Breastfeeding basics: Tongue Tie. www.breastfeedingbasics.com
5. Born to breastfeed Born to be Breastfed. Hettie Grove. 2016. p114-116.
6. Influence of repeated painful procedures and sucrose analgesia on the development of hyperalgesia in newborn infants. A. Taddio. www.yorkspace.library.yorku.ca KAT107.
7. Dr Michael Marinus Easy Baby Podcast Episode 3. www.marinuschiropratic.co.za. August 23 2015.