Saturday, September 27, 2008

On Wet Nurses and Non-Species Specific Milk

Someone asked me the other day if a pregnant woman could act as a wet nurse. Short answer - sort of. Pregnant women make a substance called "colostrum" in their milk glands. Colostrum is a thick, golden-yellow, nutrient rich substance that is the precursor to milk. It is powerfully packed with antibodies that help the baby's immune system, and with enough nutrition to keep the baby healthy until the mature milk comes in, around 3-4 days after the birth, thanks to the fall off of a hormone called progesterone that the placenta manufactures to keep the pregnancy going. Until the progesterone falls off, the body will continue to make colostrum and prepare the breasts for milk production. Colostrum is great stuff. Unfortunately, there isn't a lot of it. The amount of colostrum in a breast is measured in drops to a teaspoon, not in ounces. Which makes feeding a baby problematic beyond the first few days of life.

Further, it's a bad idea for a very pregnant woman to try to nurse a baby. Stimulating the nipples releases a hormone called oxytocin that does two things. First, it stimulates the body to release the milk from the breast glands. Secondly, it stimulates the uterus to contract, which means it's a significant risk of sending Mama into preterm labor. Handy thing to know in a pre-medical society if the pregnancy is overdue and the midwife needs to induce though.

So then what? If the baby's mother isn't around to nurse and the pregnant woman won't work, what about giving it milk from a cow or goat?

Attempts have been made in the past to feed babies milk from non-human species - cows, goats, etc.. Those attempts have mostly failed. There are proteins and substances in human milk that are specially formulated for human babies. Feeding cow's milk that hasn't been processed into baby formula is a surefire way to kill the kiddo or at least make her dog sick, as many of the proteins and substances in cow's milk is formulated specifically to feed baby cows, which aren't much like baby humans. The same goes for goats, cats, dogs, ferrets, and any other mammal out there. Species-specific milk is the best way to feed a baby in any species, even in today's world.

Shoot, now what?

In an era before commercially prepared baby formulas, you've really got one choice for keeping a baby alive and healthy in the absence of it's mother following birth - a wet nurse. Like I said in the post on what happens to babies in famines, anybody with nipples can breastfeed, whether or not they have ever had a baby of their own. It's easier to get things going if pregnancy has already made the changes to the breast that are required for nursing, but even a woman who has never been pregnant can breastfeed if she works at it hard enough. Finding a wet nurse who is already lactating (making milk) might be the easiest option though. Getting supply going is going to require days to weeks of stimulating the nipples, a lot. Babies nurse approximately 140 minutes in a day, and that's about how much time a woman would have to spend stimulating her nipples to get a supply of breastmilk going. Around the clock, every 2-3 hours for 10-20 minutes at a time. It's not easy, but if you're talking the life of a child, it's worth doing. In the modern age, a double, hospital-grade, electric breastpump is woman's best friend, but in the age before all those gadgets, grandmothers and aunts and neighbors still wet nursed by getting supply going the old fashioned way - literally milking the breasts until milk was made.Hand expression, the act of "milking" the breast, involves putting the fingers behind the colored portion of the nipple, press toward the chest, then compress toward the nipple, but not down toward the tip. A woman with a good supply of mature milk should be able to shoot milk across the room if she hasn't fed the baby in a few hours. Point the nipple down into a container, and you can store breastmilk for bottle, cup or spoon-feeding a baby (yes, you can cup or spoon feed a newborn).

Colostrum will "bud" out from several spots on the end of the nipple as droplets and can eventually be collected in a spoon or small cup. When a woman is starting to get a supply of milk for the first time to wet nurse, putting a baby to the breast, even another baby who already is being fed by another woman before the baby eats, will be more effective than hand expression, but with proper technique, hand expression can be more comfortable and more efficient than even the double electric breast pumps used primarily in the US today.

Standford Medical School has an excellent video that shows women with various breast types hand expressing milk for their babies, both well and premature/ill.


Friday, July 18, 2008

What would happen to a nursing baby in a famine?

The answer: nothing, if the mother was smart enough to just keep nursing (assuming baby is under 6 months old).

Breastfed babies die in famine situations all the time though right? Yep. Because the mother is so desperate, so unable to believe that she can provide adequate nutrition when she herself is wasting away, that she will feed the baby anything. Women have been known to chew tree bark and grass on the side of the road and feed the nutrition-less pap to their babies because of that insecurity.

The truth is, nature is a smart cookie and survival of the species is a pretty strong genetic need. Baby gets the choicest nutrients and the composition of breast milk changes to give baby the best chance of survival, even over the mother. Nursing takes so few calories from the mom that even if she is skeletal and malnourished, baby will be fat, healthy, and happy if nursing continues. Women even managed to nurse babies and keep them alive in the Nazi concentration camps, under the absolute worst conditions.

If, however, mom decides to supplement baby on whatever food can be found, then baby will likely become as malnourished and skeletal as the mom and may die rather quickly. Artificial baby formulas aren't a safe bet either, in modern famine situations. Diarrheal illness is widespread during famine, and without clean water, refrigeration, and proper handling, formula can be every bit as deadly as famine.

Older babies >6 months need some supplemental nutrition, but breastfeeding is still vitally important, as mom's immune system continues to help baby to fight off any pathogens mom is exposed to - including those diarrhea producing bacteria that can rage through refugee camps and the like.

In your fantasy stories, if mom is lost, baby can still survive these conditions if someone is willing to become a wet nurse. Anyone female with breasts will do for starters - any woman can breastfeed. However, pregnant women will only produce colostrum - an immature milk in tiny volumes that won't support a growing baby's needs fully. Establishing a milk supply in an individual who has never been pregnant is a little harder than in someone who has made milk before, but it can still be done. Putting baby to breast frequently, stimulating the nipples, and some herbs (with limited efficacy) have been long-known to restart or start lactation. In modern times, the American Academy of Pediatricians recommends that adoptive mothers of young infants breastfeed. However, wet nursing and milk exchange is highly discouraged in the US today because of the risk of spreading diseases like HIV.


Monday, June 30, 2008

How premature does a baby have to be to have trouble breathing?

Any baby can have trouble breathing after birth, regardless of prematurity or size, but breathing problems are much more common in babies who are very early, very small and underdeveloped, or very large. Some common reasons for respiratory distress syndrome (breathing trouble requiring oxygen or other support) in newborns include:

  • Prematurity - lungs are underdeveloped. Typical pregnancies last 38-42 weeks gestation (how long the baby is cooking from the mother's last menstrual period). Respiratory distress syndrome is generally mild to moderate from 34-37 weeks in healthy babies and becomes increasingly severe if the baby comes earlier. Babies less than 28 weeks very often require special medication delivered right into their lungs call Surfactant, to help keep their lungs from collapsing between breaths.
  • Infection - infection in the mother can be passed to the baby. Babies who have respiratory distress that lasts more than a few hours or is severe at or shortly after birth are generally screened for infection (also known as sepsis) and given 48 hour courses of Gentamicin and Ampicillin (antibiotics) even if no infection is identified. Because of immature immune systems, even if the baby has no outward signs of infection other than respiratory distress and the cultures come back negative, the baby could still have a hidden infection.
  • Heart and circulatory defects - there are many kinds of heart defects and circulatory problems that can result in poor perfusion to the lungs or to the body, resulting eventually in breathing problems. Some heart problems don't cause noticeable problems until the baby's body starts to accommodate to life outside the womb by closing down special circulatory pathways that the fetus needs, but a breathing baby doesn't. This can take several hours or even days.
  • Diabetic mothers - these babies are usually very large - >9lb at birth and can be very large even if born early. Because of mother's chronic high blood sugar, baby doesn't develop in quite the pattern expected and can suffer respiratory distress, low blood sugars soon after birth, heart problems, and multiple birth defects, particularly if the diabetes was poorly controlled during the pregnancy. Gestational diabetes - a form that goes away after the baby's birth, can cause the same problems.
  • Anatomical defects - certain birth defects which are rare but can cause severe respiratory distress include anything that prevents the lungs from fully forming or expanding, anything that impairs circulation, brain or brain stem malformations, and anything that causes severe pain or nervous system irritability.

A photo of acrocyanotic feet. Acrocyanotic means a bluish tinge on the periphery of the body - the hands and feet. Notice the purplish heels especially

And since this is for writing and I'm assuming you'll be describing the scene and the problems, here's a quick rundown on how a normal respiratory effort looks and some of the trouble signs:

  • Respiratory rate 30-60 breaths per minute - too fast or too slow can be bad. As a nurse, I'd rather see too fast than to slow, though. Breathing too slow (or not at all) is an ominous sign of trouble.
  • No grunting noises - babies in distress often make a little grunting sound at the end of each breath. The reason for this is they are trying to keep a little pressure in their lungs at the end of the breath, to keep their lungs from collapsing. It's imperative that lungs stay slightly open after a breath, because lungs that are completely closed require many times as much effort to open back up.
  • No nasal flaring - The sides of their noses will flare out if they are trying hard to get more oxygen. Think of someone you've seen about to launch into a tirade and how their noses widen a bit as they get their breath to blow like Mount Vesuvius.
  • No head bobbing - Babies in distress will bob their heads with each breath in an effort to open the airways wider to breath in and narrow them down a bit when breathing out.
  • Breath sounds clear and equal - breath sounds may sound a little "wet" or crackly in some babies, particularly if born by C-section as there isn't a lot of squeezing to get that excess water out of the lungs like a vaginal birth. If the breath sounds are decreased or absent on one side, this could indicate that the baby has a collapsed lung, or is having a problem called pnuemothorax, which means baby has developed a hole in the lung which allows air to collect in the cavity between the lung and the chest wall, compressing the lung more and more with each breath and not allowing it to re-expand. This can lead to a life-threatening condition known as "tension pneumo" in which so much air has built up in the chest cavity that it is pushing everything over - the lungs and eventually the heart - and pressing so hard it's decreasing circulation. Pneumothorax and tension pneumos are treated by inserting a "chest tube" into the chest cavity that allows the air to be slowly pulled back out and gives room for the lung to re-expand and heal
  • No central cyanosis (blue tinge around face, lips, or the center of the body). It's ok for baby's hands and feet to be blue or purplish for the first 24-48 hours, but an overall pink color (pink as in a healthy coloring, not as in salmon or caucasian) is preferred. Babies with very dark skin can be assessed by looking at lips and tongue - if those are pink, no worries

Treatment for respiratory distress in the newborn is pretty organized. If breathing, baby would first be given oxygen either by nasal cannula (see photo at right), by "blow-by" which means blowing oxygen across the baby's face, or by face mask. If that doesn't work, hand-bagging would start, which means using a mask and bag with a special valve to force air into the baby's lungs. A baby being hand-bagged will quickly be intubated (have a small plastic tube inserted past the vocal cords and into the lungs) and would either continue to be bagged through the tube or be hooked up to a ventillator. Deep suctioning through the breathing tube is likely to occur and Surfactant may be given to help the baby keep the lungs open between breaths. Unless the lungs are seriously malformed, this is usually sufficient. In some very rare cases, if the baby was born at a fetal care center or a center that was prepared for an unusual defect, a baby unable to be helped by hand-bagging or ventillator might be put on ECMO which is a long-term (up to 3 weeks, sometimes) heart-lung bi-pass machine. This has MANY risks and about a 50% chance of survival, depending on the reason it is used.

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