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When should you consider implanted nerve stimulators for lower back pain?
CONSIDER IT FOR PATIENTS WITH FAILED BACK SURGERY SYNDROME. These patients can gain more pain relief from spinal cord stimulation (SCS) than from reoperation (strength of recommendation [SOR]: A, 2 randomized controlled trials [RCTs]). SCS can also treat chronic low back pain effectively (SOR: B, cohort studies). It’s indicated when conservative measures have failed (SOR: C, expert opinion).
The side effects and failure rates of SCS are well documented and should be considered before recommending the therapy to patients (SOR: A, systematic review of RCTs and cohort studies).
Evidence summary
SCS systems comprise transcutaneously inserted leads that deliver low-voltage electronic stimulation to the spinal cord or targeted peripheral nerves. The resulting dermatomal parasthesia can be preferable to chronic painful stimuli. The voltage generator is located externally or implanted internally.
SCS can be used to treat patients with chronic and intractable pain, such as the pain caused by failed back surgery syndrome. The syndrome, defined as persistent or recurrent pain after lumbosacral spine surgery, occurs in 10% to 40% of patients who have undergone lumbosacral spine surgery.1
A 2005 prospective RCT enrolled 50 patients with failed back surgery syndrome who were considering reoperation.1 Twenty-four were randomized to SCS and 26 to reoperation. Success was defined as >50% pain relief measured by a validated visual analog pain scale. The average length of follow-up was 3 years. An intention-to-treat analysis demonstrated that 9 of 24 (38%) SCS insertions were successful, compared with 3 of 26 (12%) reoperations (P=.04; number needed to treat=3.8).
Low back pain shows significant response to stimulation
A 2004 systematic review of SCS for all indications included 51 studies and 2973 patients.2 Sixteen of the studies, with a total of 616 patients, focused on low back pain, specifically chronic back pain and failed back surgery syndrome. Two of the 16 studies were prospective controlled trials, 8 were prospective trials without controls, and 6 were retrospective studies.
Both prospective, controlled trials (total of 62 patients) demonstrated statistically significant (P<.05) results with SCS. One measured subjective pain and the other used crossover to the other treatment arm (SCS vs surgery) as a marker for treatment failure.
Consider the side effects
SCS isn’t without side effects. Cameron’s systematic review of 51 SCS studies reported rates for a number of complications ( TABLE ).2 The most common complication was lead migration—displacement of the spinal electrodes that can cause pain to recur.
TABLE
Major complications of SCS
| Complication | Rate |
|---|---|
| Lead migration | 13.2% |
| Lead breakage | 9.1% |
| Infection | 3.4% |
| Hardware malfunction | 2.9% |
| Unwanted stimulation | 2.4% |
| Battery failure | 1.6% |
| Pain over implant | 0.9% |
| SCS, spinal cord stimulation. | |
| Adapted from: Cameron T, et al. J Neurosurg.2 | |
Recommendations
Evidence-based guidelines for interventional techniques to control chronic pain, published in the January 2007 edition of Pain Physician, classify indications for SCS as follows:3
Strong indication: complex regional pain syndrome (CRPS)
Moderate indication: failed back surgery syndrome, chronic low back pain, and chronic lower extremity pain.
The Society of British Neurological Surgeons lists the following conditions as “good indications” for SCS: failed back surgery syndrome, CRPS, neuropathic pain from peripheral nerve damage, pain secondary to peripheral vascular disease, refractory angina, and brachial plexopathy.4
1. North RB, Kidd DH, Farrokhi F, et al. Spinal cord stimulation versus repeated lumbosacral spine surgery for chronic pain: a randomized, controlled trial. Neurosurgery. 2005;56:98-106.
2. Cameron T. Safety and efficacy of spinal cord stimulation for the treatment of chronic pain: a 20-year literature review. J Neurosurg. 2004;100(suppl 3 Spine):254-267.
3. Boswell MV, Trescot AM, Datta S, et al. American Society of Interventional Pain Physicians Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician. 2007;10:7-111.
4. Society of British Neurological Surgeons/British Pain Society Spinal Cord Stimulation for the Management of Pain: Recommendations for Best Clinical Practice. London: British Pain Society; 2009. Available at: www.britishpainsociety.org/book_scs_main.pdf. Accessed October 3, 2009.
CONSIDER IT FOR PATIENTS WITH FAILED BACK SURGERY SYNDROME. These patients can gain more pain relief from spinal cord stimulation (SCS) than from reoperation (strength of recommendation [SOR]: A, 2 randomized controlled trials [RCTs]). SCS can also treat chronic low back pain effectively (SOR: B, cohort studies). It’s indicated when conservative measures have failed (SOR: C, expert opinion).
The side effects and failure rates of SCS are well documented and should be considered before recommending the therapy to patients (SOR: A, systematic review of RCTs and cohort studies).
Evidence summary
SCS systems comprise transcutaneously inserted leads that deliver low-voltage electronic stimulation to the spinal cord or targeted peripheral nerves. The resulting dermatomal parasthesia can be preferable to chronic painful stimuli. The voltage generator is located externally or implanted internally.
SCS can be used to treat patients with chronic and intractable pain, such as the pain caused by failed back surgery syndrome. The syndrome, defined as persistent or recurrent pain after lumbosacral spine surgery, occurs in 10% to 40% of patients who have undergone lumbosacral spine surgery.1
A 2005 prospective RCT enrolled 50 patients with failed back surgery syndrome who were considering reoperation.1 Twenty-four were randomized to SCS and 26 to reoperation. Success was defined as >50% pain relief measured by a validated visual analog pain scale. The average length of follow-up was 3 years. An intention-to-treat analysis demonstrated that 9 of 24 (38%) SCS insertions were successful, compared with 3 of 26 (12%) reoperations (P=.04; number needed to treat=3.8).
Low back pain shows significant response to stimulation
A 2004 systematic review of SCS for all indications included 51 studies and 2973 patients.2 Sixteen of the studies, with a total of 616 patients, focused on low back pain, specifically chronic back pain and failed back surgery syndrome. Two of the 16 studies were prospective controlled trials, 8 were prospective trials without controls, and 6 were retrospective studies.
Both prospective, controlled trials (total of 62 patients) demonstrated statistically significant (P<.05) results with SCS. One measured subjective pain and the other used crossover to the other treatment arm (SCS vs surgery) as a marker for treatment failure.
Consider the side effects
SCS isn’t without side effects. Cameron’s systematic review of 51 SCS studies reported rates for a number of complications ( TABLE ).2 The most common complication was lead migration—displacement of the spinal electrodes that can cause pain to recur.
TABLE
Major complications of SCS
| Complication | Rate |
|---|---|
| Lead migration | 13.2% |
| Lead breakage | 9.1% |
| Infection | 3.4% |
| Hardware malfunction | 2.9% |
| Unwanted stimulation | 2.4% |
| Battery failure | 1.6% |
| Pain over implant | 0.9% |
| SCS, spinal cord stimulation. | |
| Adapted from: Cameron T, et al. J Neurosurg.2 | |
Recommendations
Evidence-based guidelines for interventional techniques to control chronic pain, published in the January 2007 edition of Pain Physician, classify indications for SCS as follows:3
Strong indication: complex regional pain syndrome (CRPS)
Moderate indication: failed back surgery syndrome, chronic low back pain, and chronic lower extremity pain.
The Society of British Neurological Surgeons lists the following conditions as “good indications” for SCS: failed back surgery syndrome, CRPS, neuropathic pain from peripheral nerve damage, pain secondary to peripheral vascular disease, refractory angina, and brachial plexopathy.4
CONSIDER IT FOR PATIENTS WITH FAILED BACK SURGERY SYNDROME. These patients can gain more pain relief from spinal cord stimulation (SCS) than from reoperation (strength of recommendation [SOR]: A, 2 randomized controlled trials [RCTs]). SCS can also treat chronic low back pain effectively (SOR: B, cohort studies). It’s indicated when conservative measures have failed (SOR: C, expert opinion).
The side effects and failure rates of SCS are well documented and should be considered before recommending the therapy to patients (SOR: A, systematic review of RCTs and cohort studies).
Evidence summary
SCS systems comprise transcutaneously inserted leads that deliver low-voltage electronic stimulation to the spinal cord or targeted peripheral nerves. The resulting dermatomal parasthesia can be preferable to chronic painful stimuli. The voltage generator is located externally or implanted internally.
SCS can be used to treat patients with chronic and intractable pain, such as the pain caused by failed back surgery syndrome. The syndrome, defined as persistent or recurrent pain after lumbosacral spine surgery, occurs in 10% to 40% of patients who have undergone lumbosacral spine surgery.1
A 2005 prospective RCT enrolled 50 patients with failed back surgery syndrome who were considering reoperation.1 Twenty-four were randomized to SCS and 26 to reoperation. Success was defined as >50% pain relief measured by a validated visual analog pain scale. The average length of follow-up was 3 years. An intention-to-treat analysis demonstrated that 9 of 24 (38%) SCS insertions were successful, compared with 3 of 26 (12%) reoperations (P=.04; number needed to treat=3.8).
Low back pain shows significant response to stimulation
A 2004 systematic review of SCS for all indications included 51 studies and 2973 patients.2 Sixteen of the studies, with a total of 616 patients, focused on low back pain, specifically chronic back pain and failed back surgery syndrome. Two of the 16 studies were prospective controlled trials, 8 were prospective trials without controls, and 6 were retrospective studies.
Both prospective, controlled trials (total of 62 patients) demonstrated statistically significant (P<.05) results with SCS. One measured subjective pain and the other used crossover to the other treatment arm (SCS vs surgery) as a marker for treatment failure.
Consider the side effects
SCS isn’t without side effects. Cameron’s systematic review of 51 SCS studies reported rates for a number of complications ( TABLE ).2 The most common complication was lead migration—displacement of the spinal electrodes that can cause pain to recur.
TABLE
Major complications of SCS
| Complication | Rate |
|---|---|
| Lead migration | 13.2% |
| Lead breakage | 9.1% |
| Infection | 3.4% |
| Hardware malfunction | 2.9% |
| Unwanted stimulation | 2.4% |
| Battery failure | 1.6% |
| Pain over implant | 0.9% |
| SCS, spinal cord stimulation. | |
| Adapted from: Cameron T, et al. J Neurosurg.2 | |
Recommendations
Evidence-based guidelines for interventional techniques to control chronic pain, published in the January 2007 edition of Pain Physician, classify indications for SCS as follows:3
Strong indication: complex regional pain syndrome (CRPS)
Moderate indication: failed back surgery syndrome, chronic low back pain, and chronic lower extremity pain.
The Society of British Neurological Surgeons lists the following conditions as “good indications” for SCS: failed back surgery syndrome, CRPS, neuropathic pain from peripheral nerve damage, pain secondary to peripheral vascular disease, refractory angina, and brachial plexopathy.4
1. North RB, Kidd DH, Farrokhi F, et al. Spinal cord stimulation versus repeated lumbosacral spine surgery for chronic pain: a randomized, controlled trial. Neurosurgery. 2005;56:98-106.
2. Cameron T. Safety and efficacy of spinal cord stimulation for the treatment of chronic pain: a 20-year literature review. J Neurosurg. 2004;100(suppl 3 Spine):254-267.
3. Boswell MV, Trescot AM, Datta S, et al. American Society of Interventional Pain Physicians Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician. 2007;10:7-111.
4. Society of British Neurological Surgeons/British Pain Society Spinal Cord Stimulation for the Management of Pain: Recommendations for Best Clinical Practice. London: British Pain Society; 2009. Available at: www.britishpainsociety.org/book_scs_main.pdf. Accessed October 3, 2009.
1. North RB, Kidd DH, Farrokhi F, et al. Spinal cord stimulation versus repeated lumbosacral spine surgery for chronic pain: a randomized, controlled trial. Neurosurgery. 2005;56:98-106.
2. Cameron T. Safety and efficacy of spinal cord stimulation for the treatment of chronic pain: a 20-year literature review. J Neurosurg. 2004;100(suppl 3 Spine):254-267.
3. Boswell MV, Trescot AM, Datta S, et al. American Society of Interventional Pain Physicians Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. Pain Physician. 2007;10:7-111.
4. Society of British Neurological Surgeons/British Pain Society Spinal Cord Stimulation for the Management of Pain: Recommendations for Best Clinical Practice. London: British Pain Society; 2009. Available at: www.britishpainsociety.org/book_scs_main.pdf. Accessed October 3, 2009.
Evidence-based answers from the Family Physicians Inquiries Network
How should you manage an overweight breastfed infant?
There are several steps you can take. Monitor the growth of exclusively breastfed babies by plotting routine weights and lengths on the World Health Organization (WHO) growth curve (strength of recommendation [SOR]: A, systematic reviews). Reassure parents that higher-than-normal weight gain in infants who are breastfeeding easily without supplementation has no known adverse effects. Advise parents to change behaviors that result in overfeeding or insufficient physical activity (SOR: C, expert opinion). Refer parents to a lactation consultant to manage large volumes of milk that exceed the infant’s need. In the rare case of an infant who exhibits lack of satiety or dysmorphia, consider an overgrowth syndrome and seek an endocrinology and genetics consult (SOR: C, expert opinion).
Avoid comfort feeding, stress activity
Philip Reilly, MD
SeaMar Community Health Center, Seattle, Wash
I often see breastfeeding mothers who are concerned about their chubby babies, who have both a high success rate with breastfeeding and a high rate of type 2 diabetes as adults. When talking to these mothers, I first stress the importance of focusing primarily on nutritional feeding, not “comfort feeding.” I point out that evidence suggests that exclusive breastfeeding helps prevent adult obesity.
It’s also important to recognize that the epidemiologic shift toward increased obesity and diabetes has to do with the activity habits of children and adults, as well as their eating habits. As children grow, our advice should focus on encouraging activity, limiting “screen time,” and eliminating juices and other high-calorie dietary additions once an infant is no longer exclusively breastfed.
Evidence summary
An estimated 9.5% of infants and children younger than 2 years of age are considered overweight—that is, their weight is at or above the 95th percentile of weight-for-recumbent length on the sex-specific growth charts from the Centers for Disease Control and Prevention (CDC).1 The prevalence is unknown for infants who are exclusively breastfed2 or fed only human milk without any supplementation (except recommended vitamins, minerals, and medication) for the first 6 months of life.
Exclusively breastfed babies have a different growth curve
Because comparison growth studies demonstrate that healthy breastfed infants have a different growth curve than formula or mix-fed babies,3 the WHO growth curves (http://www.who.int/childgrowth/standards/en/), rather than the CDC charts, should be used to monitor the growth of exclusively breastfed babies.4 The WHO Working Group on Infant Growth studied infants whose sole nourishment was breast milk until 4 months of age.3 The CDC charts reflect a heavier and shorter sample of infants. Moreover, the WHO charts are based on shorter measurement intervals and may therefore be a better tool for measuring rapidly changing rates of growth.4
Exclusive breastfeeding reduces risk of overweight later in life
A meta-analysis showed a dose-dependent relationship between longer duration of breastfeeding and decreased risk of overweight in later life (<1 month of breastfeeding: odds ratio [OR]=1.0; 95% confidence interval [CI], 0.65-1.55; 1-3 months: OR=0.81; 95% CI, 0.74-0.88; 4-6 months: OR=0.76; 95% CI, 0.67-0.86; 7-9 months: OR=0.67; 95% CI, 0.55-0.82; >9 months: OR=0.68; 95% CI, 0.50-0.91).5 Because overweight has no known adverse health outcomes for exclusively breastfed infants, lactation experts don’t advise mothers to reduce feeding for these babies.6
Is overfeeding an issue?
Overfeeding may contribute to higher-than-normal weight gain in both breastfed and formula-fed infants.7 Maternal behavior changes that may taper unusual weight gains include cuddling rather than breastfeeding in response to all distress signals and encouraging movement and crawling.8
Expressing breast milk to increase infant intake increases weight gain (r=0.59); this effect gets stronger as the infant gets older (r=0.58).9 Referral to a lactation consultant is recommended to manage large volumes of milk that exceed infant need.7 For the rare infant who exhibits hypoglycemia, lack of satiety, or dysmorphia, consider early macrosomia or an overgrowth syndrome, such as Beckwith-Wiedemann syndrome, and seek an endocrinology or genetics consult.10
Recommendations
Exclusive breastfeeding for approximately the first 6 months of life is recommended by the American Academy of Family Physicians (AAFP), American College of Obstetricians and Gynecologists, American Academy of Pediatrics, Academy of Breastfeeding Medicine, WHO, United Nations Children’s Fund, and other organizations. The AAFP recommends that physicians help prevent and manage overweight in childhood to reduce the risk of obesity and chronic disease in later life.11
1. Centers for Disease Control and Prevention. National Center for Health Statistics. Prevalence of overweight, infants and children less than 2 years of age, United States, 2003-2004. Available at: http://www.cdc.gov/nchs/products/pubs/pubd/hestats/overweight/overwght_child_under02.htm. Accessed August 2008.
2. Sachs M, Dykes F, Carter B. Weight monitoring of breastfed babies in the United Kingdom—interpreting, explaining and intervening. Matern Child Nutr. 2006;2:3-18.
3. WHO Working Group on Infant Growth. An evaluation of infant growth. Geneva: Nutrition Unit, World Health Organization; 1994. Available at: http://whqlibdoc.who.int/hq/1994/WHO_NUT_94.8.pdf. Accessed February 19, 2007.
4. de Onis M, Garza C, Onyango AW, et al. Comparison of the WHO child growth standards and the CDC 2000 growth charts. J Nutr. 2007;137:144-148.
5. Harder T, Bergmann R, Kallischnigg G, et al. Duration of breastfeeding and risk of overweight: a meta-analysis. Am J Epidemiol. 2005;162:397-403.
6. Mohrbacher N, Stock J. The Breastfeeding Answer Book. 3rd rev ed. Schaumburg, Ill: La Leche League International; 2003.
7. Crow RA, Fawcett JN, Wright P. Maternal behavior during breast- and bottle-feeding. J Behav Med. 1980;3:259-277.
8. Lawrence RA, Lawrence RM. Breastfeeding: A Guide for the Medical Profession. 6th ed. Philadelphia: Elsevier Mosby; 2005.
9. Dewey KG, Lonnerdal B. Infant self-regulation of breast milk intake. Acta Paediatr Scand. 1986;75:893-898.
10. Jones KL. Smith’s Recognizable Patterns of Human Malformation. 6th ed. Philadelphia: Elsevier Saunders; 2006.
11. American Academy of Family Physicians. Breastfeeding, family physicians supporting (position paper). Available at: http://www.aafp.org/online/en/home/policy/policies/b/breastfeedingpositionpaper.htm. Accessed January 18, 2008.
There are several steps you can take. Monitor the growth of exclusively breastfed babies by plotting routine weights and lengths on the World Health Organization (WHO) growth curve (strength of recommendation [SOR]: A, systematic reviews). Reassure parents that higher-than-normal weight gain in infants who are breastfeeding easily without supplementation has no known adverse effects. Advise parents to change behaviors that result in overfeeding or insufficient physical activity (SOR: C, expert opinion). Refer parents to a lactation consultant to manage large volumes of milk that exceed the infant’s need. In the rare case of an infant who exhibits lack of satiety or dysmorphia, consider an overgrowth syndrome and seek an endocrinology and genetics consult (SOR: C, expert opinion).
Avoid comfort feeding, stress activity
Philip Reilly, MD
SeaMar Community Health Center, Seattle, Wash
I often see breastfeeding mothers who are concerned about their chubby babies, who have both a high success rate with breastfeeding and a high rate of type 2 diabetes as adults. When talking to these mothers, I first stress the importance of focusing primarily on nutritional feeding, not “comfort feeding.” I point out that evidence suggests that exclusive breastfeeding helps prevent adult obesity.
It’s also important to recognize that the epidemiologic shift toward increased obesity and diabetes has to do with the activity habits of children and adults, as well as their eating habits. As children grow, our advice should focus on encouraging activity, limiting “screen time,” and eliminating juices and other high-calorie dietary additions once an infant is no longer exclusively breastfed.
Evidence summary
An estimated 9.5% of infants and children younger than 2 years of age are considered overweight—that is, their weight is at or above the 95th percentile of weight-for-recumbent length on the sex-specific growth charts from the Centers for Disease Control and Prevention (CDC).1 The prevalence is unknown for infants who are exclusively breastfed2 or fed only human milk without any supplementation (except recommended vitamins, minerals, and medication) for the first 6 months of life.
Exclusively breastfed babies have a different growth curve
Because comparison growth studies demonstrate that healthy breastfed infants have a different growth curve than formula or mix-fed babies,3 the WHO growth curves (http://www.who.int/childgrowth/standards/en/), rather than the CDC charts, should be used to monitor the growth of exclusively breastfed babies.4 The WHO Working Group on Infant Growth studied infants whose sole nourishment was breast milk until 4 months of age.3 The CDC charts reflect a heavier and shorter sample of infants. Moreover, the WHO charts are based on shorter measurement intervals and may therefore be a better tool for measuring rapidly changing rates of growth.4
Exclusive breastfeeding reduces risk of overweight later in life
A meta-analysis showed a dose-dependent relationship between longer duration of breastfeeding and decreased risk of overweight in later life (<1 month of breastfeeding: odds ratio [OR]=1.0; 95% confidence interval [CI], 0.65-1.55; 1-3 months: OR=0.81; 95% CI, 0.74-0.88; 4-6 months: OR=0.76; 95% CI, 0.67-0.86; 7-9 months: OR=0.67; 95% CI, 0.55-0.82; >9 months: OR=0.68; 95% CI, 0.50-0.91).5 Because overweight has no known adverse health outcomes for exclusively breastfed infants, lactation experts don’t advise mothers to reduce feeding for these babies.6
Is overfeeding an issue?
Overfeeding may contribute to higher-than-normal weight gain in both breastfed and formula-fed infants.7 Maternal behavior changes that may taper unusual weight gains include cuddling rather than breastfeeding in response to all distress signals and encouraging movement and crawling.8
Expressing breast milk to increase infant intake increases weight gain (r=0.59); this effect gets stronger as the infant gets older (r=0.58).9 Referral to a lactation consultant is recommended to manage large volumes of milk that exceed infant need.7 For the rare infant who exhibits hypoglycemia, lack of satiety, or dysmorphia, consider early macrosomia or an overgrowth syndrome, such as Beckwith-Wiedemann syndrome, and seek an endocrinology or genetics consult.10
Recommendations
Exclusive breastfeeding for approximately the first 6 months of life is recommended by the American Academy of Family Physicians (AAFP), American College of Obstetricians and Gynecologists, American Academy of Pediatrics, Academy of Breastfeeding Medicine, WHO, United Nations Children’s Fund, and other organizations. The AAFP recommends that physicians help prevent and manage overweight in childhood to reduce the risk of obesity and chronic disease in later life.11
There are several steps you can take. Monitor the growth of exclusively breastfed babies by plotting routine weights and lengths on the World Health Organization (WHO) growth curve (strength of recommendation [SOR]: A, systematic reviews). Reassure parents that higher-than-normal weight gain in infants who are breastfeeding easily without supplementation has no known adverse effects. Advise parents to change behaviors that result in overfeeding or insufficient physical activity (SOR: C, expert opinion). Refer parents to a lactation consultant to manage large volumes of milk that exceed the infant’s need. In the rare case of an infant who exhibits lack of satiety or dysmorphia, consider an overgrowth syndrome and seek an endocrinology and genetics consult (SOR: C, expert opinion).
Avoid comfort feeding, stress activity
Philip Reilly, MD
SeaMar Community Health Center, Seattle, Wash
I often see breastfeeding mothers who are concerned about their chubby babies, who have both a high success rate with breastfeeding and a high rate of type 2 diabetes as adults. When talking to these mothers, I first stress the importance of focusing primarily on nutritional feeding, not “comfort feeding.” I point out that evidence suggests that exclusive breastfeeding helps prevent adult obesity.
It’s also important to recognize that the epidemiologic shift toward increased obesity and diabetes has to do with the activity habits of children and adults, as well as their eating habits. As children grow, our advice should focus on encouraging activity, limiting “screen time,” and eliminating juices and other high-calorie dietary additions once an infant is no longer exclusively breastfed.
Evidence summary
An estimated 9.5% of infants and children younger than 2 years of age are considered overweight—that is, their weight is at or above the 95th percentile of weight-for-recumbent length on the sex-specific growth charts from the Centers for Disease Control and Prevention (CDC).1 The prevalence is unknown for infants who are exclusively breastfed2 or fed only human milk without any supplementation (except recommended vitamins, minerals, and medication) for the first 6 months of life.
Exclusively breastfed babies have a different growth curve
Because comparison growth studies demonstrate that healthy breastfed infants have a different growth curve than formula or mix-fed babies,3 the WHO growth curves (http://www.who.int/childgrowth/standards/en/), rather than the CDC charts, should be used to monitor the growth of exclusively breastfed babies.4 The WHO Working Group on Infant Growth studied infants whose sole nourishment was breast milk until 4 months of age.3 The CDC charts reflect a heavier and shorter sample of infants. Moreover, the WHO charts are based on shorter measurement intervals and may therefore be a better tool for measuring rapidly changing rates of growth.4
Exclusive breastfeeding reduces risk of overweight later in life
A meta-analysis showed a dose-dependent relationship between longer duration of breastfeeding and decreased risk of overweight in later life (<1 month of breastfeeding: odds ratio [OR]=1.0; 95% confidence interval [CI], 0.65-1.55; 1-3 months: OR=0.81; 95% CI, 0.74-0.88; 4-6 months: OR=0.76; 95% CI, 0.67-0.86; 7-9 months: OR=0.67; 95% CI, 0.55-0.82; >9 months: OR=0.68; 95% CI, 0.50-0.91).5 Because overweight has no known adverse health outcomes for exclusively breastfed infants, lactation experts don’t advise mothers to reduce feeding for these babies.6
Is overfeeding an issue?
Overfeeding may contribute to higher-than-normal weight gain in both breastfed and formula-fed infants.7 Maternal behavior changes that may taper unusual weight gains include cuddling rather than breastfeeding in response to all distress signals and encouraging movement and crawling.8
Expressing breast milk to increase infant intake increases weight gain (r=0.59); this effect gets stronger as the infant gets older (r=0.58).9 Referral to a lactation consultant is recommended to manage large volumes of milk that exceed infant need.7 For the rare infant who exhibits hypoglycemia, lack of satiety, or dysmorphia, consider early macrosomia or an overgrowth syndrome, such as Beckwith-Wiedemann syndrome, and seek an endocrinology or genetics consult.10
Recommendations
Exclusive breastfeeding for approximately the first 6 months of life is recommended by the American Academy of Family Physicians (AAFP), American College of Obstetricians and Gynecologists, American Academy of Pediatrics, Academy of Breastfeeding Medicine, WHO, United Nations Children’s Fund, and other organizations. The AAFP recommends that physicians help prevent and manage overweight in childhood to reduce the risk of obesity and chronic disease in later life.11
1. Centers for Disease Control and Prevention. National Center for Health Statistics. Prevalence of overweight, infants and children less than 2 years of age, United States, 2003-2004. Available at: http://www.cdc.gov/nchs/products/pubs/pubd/hestats/overweight/overwght_child_under02.htm. Accessed August 2008.
2. Sachs M, Dykes F, Carter B. Weight monitoring of breastfed babies in the United Kingdom—interpreting, explaining and intervening. Matern Child Nutr. 2006;2:3-18.
3. WHO Working Group on Infant Growth. An evaluation of infant growth. Geneva: Nutrition Unit, World Health Organization; 1994. Available at: http://whqlibdoc.who.int/hq/1994/WHO_NUT_94.8.pdf. Accessed February 19, 2007.
4. de Onis M, Garza C, Onyango AW, et al. Comparison of the WHO child growth standards and the CDC 2000 growth charts. J Nutr. 2007;137:144-148.
5. Harder T, Bergmann R, Kallischnigg G, et al. Duration of breastfeeding and risk of overweight: a meta-analysis. Am J Epidemiol. 2005;162:397-403.
6. Mohrbacher N, Stock J. The Breastfeeding Answer Book. 3rd rev ed. Schaumburg, Ill: La Leche League International; 2003.
7. Crow RA, Fawcett JN, Wright P. Maternal behavior during breast- and bottle-feeding. J Behav Med. 1980;3:259-277.
8. Lawrence RA, Lawrence RM. Breastfeeding: A Guide for the Medical Profession. 6th ed. Philadelphia: Elsevier Mosby; 2005.
9. Dewey KG, Lonnerdal B. Infant self-regulation of breast milk intake. Acta Paediatr Scand. 1986;75:893-898.
10. Jones KL. Smith’s Recognizable Patterns of Human Malformation. 6th ed. Philadelphia: Elsevier Saunders; 2006.
11. American Academy of Family Physicians. Breastfeeding, family physicians supporting (position paper). Available at: http://www.aafp.org/online/en/home/policy/policies/b/breastfeedingpositionpaper.htm. Accessed January 18, 2008.
1. Centers for Disease Control and Prevention. National Center for Health Statistics. Prevalence of overweight, infants and children less than 2 years of age, United States, 2003-2004. Available at: http://www.cdc.gov/nchs/products/pubs/pubd/hestats/overweight/overwght_child_under02.htm. Accessed August 2008.
2. Sachs M, Dykes F, Carter B. Weight monitoring of breastfed babies in the United Kingdom—interpreting, explaining and intervening. Matern Child Nutr. 2006;2:3-18.
3. WHO Working Group on Infant Growth. An evaluation of infant growth. Geneva: Nutrition Unit, World Health Organization; 1994. Available at: http://whqlibdoc.who.int/hq/1994/WHO_NUT_94.8.pdf. Accessed February 19, 2007.
4. de Onis M, Garza C, Onyango AW, et al. Comparison of the WHO child growth standards and the CDC 2000 growth charts. J Nutr. 2007;137:144-148.
5. Harder T, Bergmann R, Kallischnigg G, et al. Duration of breastfeeding and risk of overweight: a meta-analysis. Am J Epidemiol. 2005;162:397-403.
6. Mohrbacher N, Stock J. The Breastfeeding Answer Book. 3rd rev ed. Schaumburg, Ill: La Leche League International; 2003.
7. Crow RA, Fawcett JN, Wright P. Maternal behavior during breast- and bottle-feeding. J Behav Med. 1980;3:259-277.
8. Lawrence RA, Lawrence RM. Breastfeeding: A Guide for the Medical Profession. 6th ed. Philadelphia: Elsevier Mosby; 2005.
9. Dewey KG, Lonnerdal B. Infant self-regulation of breast milk intake. Acta Paediatr Scand. 1986;75:893-898.
10. Jones KL. Smith’s Recognizable Patterns of Human Malformation. 6th ed. Philadelphia: Elsevier Saunders; 2006.
11. American Academy of Family Physicians. Breastfeeding, family physicians supporting (position paper). Available at: http://www.aafp.org/online/en/home/policy/policies/b/breastfeedingpositionpaper.htm. Accessed January 18, 2008.
Evidence-based answers from the Family Physicians Inquiries Network