Posted on January 8, 2017 January 7, 2017 by Jessica
"Autoimmunity and Breastmilk as Epigenetic Medium"
Sylvia Metzger, MPH, MSN, RN, CNL, IBCLC, LCCE is a clinical instructor for maternal-child health nursing at the University of Colorado Colorado Springs. Metzger will present "Autoimmunity and Breastmilk as Epigenetic Medium" at the upcoming International Breastfeeding Conference in Orlando, Fla. This week on Our Milky Way, she joins us for a Q&A. Prepare to be amazed!
Q: How did you become interested in maternal child health?
A: It began with lots of love. I am truly blessed to have very caring Slovak parents who endowed me with unconditional love throughout my life, and through their consistent nurturing and support lasting into adulthood, showed me how wonderful it feels to have that emotional stability. I wanted to share some of it; I got plenty extra and I wanted to pass on this imprinted fortune hoping it may one day make a difference in someone else's life. Maternal-child health provides myriads of opportunities to nurture: to me, this field is all about nurturing. I call it epigenetic nurturing. I don't think that it is a proper scientific term, but I like it. I believe that compassionate care rooted in the client-nurse connection can truly nurture our DNA. It's not that we can change the sequence of our DNA (how our genetic ladder was initially built based on the parental blueprint), but we can modify the environment, which among many factors includes the nurturing of a mother and her infant. So, there are mechanisms beyond our DNA powerful enough to turn on or off certain genes. Epigenetics can steer the wheel of our health trajectory in both a positive and negative way. I feel that in this field, I can make the most difference. So, maternal-child health was just a natural fit. It never feels like a job. I love caring for babies, moms and dads. It's the best field ever, and a true privilege to work in!
I was actually a biology teacher in Slovakia, and then became a childbirth educator for many years before choosing nursing as my second career. Although biology gave me a comfortable foundation to navigate through basic sciences, I think the real catalyst of my desire to become a maternal child health nurse came with my own motherhood. Becoming a parent changes every fiber of your being, I think for the better. Everything you do, every decision you make, is suddenly dependently intertwined with your instinct for putting the child's needs first. Not that it's always easy, but it is absolutely worth every bit of self-sacrifice. And it also somehow makes you stronger and more able to see what actually matters the most in life.
I have two children and had diametrically opposite birth experiences — the first in a intervention-focused military hospital in the US, and the second in a midwifery-led low-key hospital in Germany. I was initially disheartened with how my birth plans, or better birth dreams, went out the window in the military setting, but I grew to appreciate the experience. Holding my daughter erased any remnants of disappointment with the lack of birth options. Plus, it gave me just the right impulse to become a childbirth educator. I wanted to not only empower women to help them believe in the wisdom of their own body, but also include future dads in the childbirth preparation. Once you are in this field, you are hooked for a lifetime, and it is only reinforced when you get a chance to meet and hear some of the most inspiring pioneers in the field: Dr. Cadwell, Dr. Brimdyr, Penni Simkin, and Henci Goer, to mention a few. They continue to be my inspiration, and I only wish I could express my gratitude for their commitment and contributions in the field.
Q: You're in the home stretch of your family nurse practitioner training! That's wonderful. How has this experience added to your maternal child health advocacy?
A: It's hard to believe I am done, and it's wonderful to have more time for my family and get more sleep, but secretly I think I will miss being a student. There is so much to learn in family practice, and I am just at the beginning. But I do believe that the rigorous training has helped me become a stronger maternal child health advocate. The clinical setting is its own natural laboratory. Even as a novice, one begins to notice the pattern of complaints patients come in with. You cannot help but wonder about the origins of certain diseases, especially when seeing them in transgenerational patterns- but even more, you want to know what can be done to prevent them or modify their course.
When parents hold their infant, they are not just looking into the mirror image of their own DNAs. Certainly, genes play a huge role in an infant's future health, but fortunately and sometimes unfortunately, the infant's DNA does not completely inform his or her destiny. Many diseases cannot be explained by genetic variation alone, and twin concordant studies show fascinating discrepancies in disease development reflecting the power of the environment. Every baby's destiny can actually begin before conception, reflecting both the paternal and maternal health status. Dad's lifestyle and health before conception actually matter, and can also pre-program a baby's health trajectory. It is not just the mom's intrauterine environment. Paternal obesity prior to conception, for example, can increase the incidence of obesity and metabolic disorders in offspring, independently from the maternal status. But how much do we focus on fathers during preventative care visits? I would love to change that. Epigenetic effects can also be passed on from grandparents to grandchildren. PTSD, for example, seems to have a transgenerational effect, with parental stress exposure prior to conception influencing stress reactivity of offspring, and increasing the risk of PTSD in future generations. I feel that the translational research from epigenetics has such a great potential to help clinicians refocus priorities from treatment to prevention. I would love to be a part of that.
Q: Your work with military families helped mitigate the risk of child abuse. Do you have any favorite memories you'd be willing to share of your work in Germany?
A: I feel so blessed having had the privilege to care for military families living overseas. It's hard to be in another country without close family when you have a new baby, and at the same time adjust to a new culture, often parenting alone while your spouse is deployed. Transitioning to parenthood is like stepping into a foreign land….there is that excitement but also a bit of fear of the unknown, and of being scrutinized by others. You try to sort through well meant and sometimes unwanted advice, constantly struggling with the worry that you aren't doing everything you can for your baby. The military recognizes these challenges, and offers home visiting services to support new parents prenatally and until the age of four.
You asked about my favorite memories, there are so many. I had a hard time leaving when our tour ended. It was the most rewarding job because it allowed me to really connect with families. My clients taught me so much more than I could have ever given them in return. They showed admirable resilience and a willingness to grow from their past, often traumatic, experiences.
Best moments? Talking young soldiers into wearing a pregnancy empathy belly to better understand their wives (of course, with a few push ups and pull ups), but also to more appreciate their wife's changing body. Waking up to an early morning phone call and reassuring a soon-to-be-dad that what he just described are early contractions, and all will be ok. Having the privilege to be at my client's birth after hours and hours of walking outside in the dusk and dawn to get the labor started. Sharing the first moments of tears and joy. Seeing a tough military dad confidently place a baby skin-to-skin when mom had an emergency C section. Hearing a dad who attended every breastfeeding class proudly encouraging his wife, "Honey, it's ok, you are supposed to have just a few drops of colostrum, that's plenty for him!" Witnessing the transformation of young pregnant teens to amazingly caring moms. Receiving a recent email from a mom who had a difficult childhood, who overcame breastfeeding difficulties, and shared that she wants to become a lactation consultant and support new moms. A 10 pm phone call with lots of crying – both mom and her 6 week old newborn — who just needed reassurance that this is the normal peak of crying. Jogging with postpartum moms while carrying at least 2 babies to make it easier on the moms, and seeing the moms' glow through the sweat of accomplishment.
Q: Please tell us a bit about your work with Baby-Friendly Hospital Initiative (BFHI.)
A: I absolutely love being in the midst of a major change at our hospital and embracing its natural ups and downs. Our lactation team and maternal child management have so far received encouraging feedback from our families, and this is really why we are all here – for moms, babies and dads. When you hear, " I never had anybody spend this much time teaching me about breastfeeding…", or,"I cannot believe that this time it doesn't hurt. Thank you for staying with me for so long to help with the latch", or, "I wasn't sure if I can breastfeed twins, but the laid back position you showed me made me believe I can…and I did!" The effort is more than worth it. As with any significant change, the initial waves of resistance among staff, who are required to complete quite an intensive program of theoretical and skill-based training, can be understandable. As we began to teach BFHI to our mother/baby, labor/delivery, and NICU staff, however, we learned that listening and validating nurses' concerns went a long way. I consistently tweaked the curriculum based on the reaction of the previous class. For example, one of our NICU nurses voiced concern about the safety of donor milk because of legalization of marijuana in Colorado, and felt more comfortable with formula supplementation. All it took was a bit of a research and a phone call to a manager of the Mother's Milk Bank, who kindly explained the strict screening criteria, which includes THC, for donor milk. My only disappointment is not having had the opportunity for our lactation team to provide such face-to-face BFHI training for our obstetricians, anesthesiologists, pediatricians and neonatologists. They have to complete online training only, and although I understand the hardship of time and commitment of their professions, I think it is a missed opportunity to hear their concerns and brainstorm ways to overcome their resistance. I was fascinated with the talk of Dr. Flacking from Sweden – their neonatologist was involved in the actual environmental design and redesign of the NICU which helped promote skin-to-skin contact and thus subsequently led to much earlier exclusive breastfeeding outcomes of their neonates. We are lucky to have many supportive physicians, especially neonatologists, and are very close to getting our designation, which is so exciting!
Q: What is your response to the recent JAMA editorial that criticizes system-level intervention like BFHI?
A: The commentary "Unintended Consequences of Current Breastfeeding Initiatives" in JAMA Pediatrics is a hot topic making headlines. It focuses on Step 4 of the BFHI– Help mothers initiate breastfeeding within one hour of birth. Although this step promotes uninterrupted and continuous skin-to-skin contact immediately after birth and until the first feeding is complete, it clearly leaves room to utilize clinical judgement. It specifically states, "….unless there are documented medically justifiable reasons for delayed contact or interruption." It encourages, but does not mindlessly mandate skin-to-skin contact throughout the hospital stay, no matter what the situation.
Guideline 4.2 states:"After cesarean birth, mothers and their infants should be placed in continuous, uninterrupted skin-to-skin contact as soon as the mother is responsive and alert, with the same staff support identified above regarding feeding cues, unless separation is medically indicated." This step also leaves significant room for decisions based on clinical judgment, and thus should not be interpreted rigidly. I do not interpret this rigidly as black and white, but rather as an effort to promote what mother nature intended for us in the first place. And here is where I think the authors agree with the BFHI – rigid adherence to the Ten Steps may inadvertently promote potentially hazardous practices. So, it is not the 10 Steps that are faulty, but rather incorrect interpretation or lack of compliance with the guidelines. But if the public reads the subheadlines such as, "Doctors write commentary saying an initiative designed to make hospitals safe for newborns might actually be endangering them," they may think – run away! Don't have your baby in the Baby Friendly Hospital!
The authors write, "Unfortunately, there is now emerging evidence that full compliance with the 10 steps of the initiative may inadvertently be promoting potentially hazardous practices and/or having counterproductive outcomes." Here, I must disagree. I actually think that FULL compliance would minimize the risk of adverse outcomes. Full compliance with the BFHI steps respects critical thinking and sound clinical judgment.
So, if a mom is absolutely exhausted after a medicated birth, and is perhaps on magnesium sulfate, it would likely not be safe to keep the baby skin-to-skin if there is no continuous supervision available, but this is accounted for, in my opinion, in this BFHI step.
I think we have to be careful about how we interpret not only available data, research articles and editorials, but how we can be subconsciously selective, and naturally read what fits our belief system. Yes, clinicians cannot ignore case study reports, no matter how rare, because one loss of a baby's life is too many. I believe that we have to remain humble about the fact that we do not have all the answers and are deciphering complex issues in small increments, and may never find the answer to all the questions. But the issue has to be placed in a broader context, with the focus on prevention. Herlenius and Kuhn in 2013 (Translational Stroke Research), for example, reviewed published reports regarding the sudden unexpected postnatal collapse in infants who appeared absolutely healthy. They found that SUPC, although rare can result in death, with 1/3 of the events occurring in the first 2 hrs after birth, and the remainder in the first week of life during skin-to-skin contact in the prone position. But does this mean we should undermine the importance of BFHI, or should we place serious focus on increased clinical supervision of the mother/baby dyad during the first hours of skin-to-skin contact? Could this be more of an issue of understaffing rather than a flaw in the BFHI design, which clearly outlines, "direct continuous observation by medical staff during skin-to-skin contact"? Even if unobtrusive continuous monitoring was available, were the SUPC events really preventable? Infection, cardiac disorders, and metabolic defects were listed as the most common possible etiology for the SUPC.
As for Step 9 (24 hr rooming in) – I think that the key word the authors are using is again "rigid." In my opinion, being rigid is never good. The concerns of bed falls, hospital liability, and role-modeling unsafe sleep practices, are justified.
In regards to concerns of sudden unexpected postnatal collapse, the focus might shift towards maximum compliance with one of the key concepts of direct continuous observation by medical staff during skin-to-skin contact, as well as reinforcing safe sleep practices in the breastfeeding mom-baby dyad, rather than questioning the efficacy of the entire initiative.
We have to see the bigger picture, and that is that any systemic effort to promote feeding breastmilk, ideally exclusively, far outweighs the risks on an epigenetic level.
Q: You'll be presenting "Autoimmunity and Breastmilk as Epigenetic Medium" at the upcoming International Breastfeeding Conference. Could you please share a few teasers from your presentation?
A: I think that a majority of new parents do not receive adequate and clear information about how breastmilk affects health outcomes. It may also seem daunting to try to present complex findings from the field of molecular biology to a parent with minimal background or interest in basic sciences. But I want to try because I think we should. I am actually finding that the majority of my patients are fascinated with and open to this concept, and I am trying to overcome scientific jargon with lots of fun visual teaching aids. I hope to help them view breastmilk as a live biological system directly capable of modulating gene expression (meaning having the ability to turn the genes on or off). They typically do not expect to see live moving cells (and yes, I am a geek, I do have a picture), and they certainly are not thinking of some strange epigenetic mechanisms that can boss our DNA around, commanding specific genes (say those predisposing the child to autoimmune diabetes) to activate or not. Yet, breastmilk is capable of sending dynamic epigenetic messages to our DNA during critical periods of an infant's development, and contributes greatly to long-term health outcomes.
I also introduce my patients to the breastmilk microbiome with my pink stuffed model of Lactobacillus. These friendly types of bacteria (there are a great variety), exert their own gene-modulating capability which can affect our immune, endocrine and metabolic systems, and even our neuro-behavioral development. We now have some amazing research showing how breastmilk might influence the initial bacterial colonization of the infant's gut through epigenetic mechanisms, which is unique when compared to formula.. Many autoimmune conditions such as Crohn's disease, Lupus or Celiac disease, show dysregulation of our healthy microbiome as one of many complex etiologic factors, and share similar epigenetic alterations. Breastfeeding, for example, has been shown to decrease the risk of autoimmune Diabetes type I, among many other benefits, and epigenetics may help explain how.
I am excited to share some bits and pieces of new information that can hopefully shed new light on the incredible design of human breastmilk, and maybe appreciate The Creator's masterpiece at a new level.
Q: Epigenetics has brought to light that some things seemingly irrelevant, have a profound impact on babies. Will this information add to the stress of mothers? How do we present this information to parents without totally freaking them out?
A: An excellent and valid point. I can certainly see how some concepts of epigenetics, especially when presented as isolated concepts, can increase parental anxiety. Emerging evidence on the developmental origins of health and disease implies that what happens in the uterine environment matters. Intrauterine signals can "program", just like in a computer, the pathways of fetal growth and neurodevelopment through epigenetic mechanisms, increasing the risk of developing a disease later in life. So, yes, parental anxiety is a valid concern, but epigenetics is not an all or nothing phenomenon; it's more like a sliding scale. Many chronic diseases, including autoimmune ones, take many years to develop, and although often familiar in origin, they are also multifactorial. This can be good news, because at least some risk factors can be modified or avoided all together. So, I actually think that we can embrace new findings of prolific research as opportunities to modify what we are capable of. There is a myriad of opportunities to care for our genes, and counteract some of the unavoidable adverse effects a growing baby inadvertently may encounter, so luckily it's not all gloom and doom. We can, to a great degree, override some of our DNA's destiny.
Q: How do we market this information to health care providers?
A: I believe that a major shift needs to take place at both the micro and macro system level. In my studies I saw how much a clinician is expected to accomplish in 20 minute increments with patients and between patients. The documentation is insane, and takes so much time away from patient interaction and teaching, which I believe is the foundation to connect with the patient and increase therapeutic success. So, unless the primary healthcare focus shifts more towards prevention rather than disease management, and more time is allotted for patient education, I think providers cannot be held wholly responsible. I see, however, several avenues where epigenetic concepts could be integrated into our healthcare. My goal is to keep learning about the emerging epigenetic research applicable to clinical practice, and incorporate key concepts of epigenetics into maternal-child health curriculum for every nursing and medical student.
Q: It has been estimated that it takes 17 years for science to be applied to practice. Because epigenetics is an emerging science, do you worry about this phenomenon?
A: I think we are already applying some concepts in clinical practice, so I want to say no, but in reality, I think that there is still a long road ahead. As clinicians and educators, we need more training to understand the current translational research in epigenetics with practical applications to direct patient care. We need to understand the meanings and the limitations of the available epigenetic tests which, from my experience, are not yet generally available at a primary care level. The reimbursement for these services, of course, will also be a challenge, as the healthcare focus would truly have to shift towards preventative care. Although such changes inevitably face some initial skepticism and resistance, I believe that we have enough evidence-based knowledge to take the first bold steps, especially in the field of maternal-child health. I believe that there are critical windows of opportunity to influence an infant's health outcomes without expensive new tests. Why not begin with what's doable? Let's start by shifting our focus to health promotion and prevention of non-genetic diseases, such as preconception health counseling (and not leaving out fathers), promoting maternal wellbeing and resiliency during pregnancy, advocating healthy birth practices, encouraging parental skin-to-skin contact, and providing timely and ongoing breastfeeding and nutritional support to new families. That we can do today!
Q: What are you most looking forward to at the conference?
A: There is so much! You can literally feel the shared enthusiasm and passion for breastfeeding support from every corner of the world. Yet, nobody is pushy and judgmental when breastfeeding is not the parental choice. The room is full of loving oxytocin, energizing exchanges of ideas, and opportunities to gain eye-opening perspective through the lens of international experts. Last year, for example, helped me so much to prepare training for the hospital staff, especially for NICU. Even though the healthcare infrastructure and cultural norms in Scandinavian countries may be different from ours, I believe that we actually can, in small increments, adapt some of their successful strategies to promote earlier breastfeeding success. These concepts, for me, are often born right here. When I first shared the Scandinavian NICU successes from the last year's conference with our NICU nurses, some were initially skeptical, but it planted the right seed. The 24/7 skin-to-skin contact, or the environmental adaptations of the NICU layout to send a message to parents: "Please stay here with your baby all you can, you are welcome and this is your bed, your chair…," were energizing and endlessly inspiring, but above all doable in our setting.
Now, had you asked me about the pre-conference, I can barely wait to go to Sea World again to soak in every bit of information about lactation strategies of aquatic mammals, behind-the-scene, up close and personal! Slovakia is beautiful but has no ocean, so forgive me for behaving like an Alice in Wonderland. Last year, I was glued to the display glass, mesmerized with the beauty of beluga whales, and the innate wisdom of our mammalian sisters. Cetaceans, such as dolphins, have shown remarkable similarities with humans. They can provide milk on average from 12 to 18 months (up to 3 yrs), even though young dolphins are ready to eat "solids" (fish) just about the same time as human babies – about 6 months! Yet mom and calf often maintain close proximity until 4-5 years. And, just in case you are wondering, you will not find visible "breasts" but rather mammary slits. A baby dolphin can roll its tongue like a straw and the sides of its tongue have little finger-like projections that help keep the thick milkshake-like milk in the calf's mouth, but salt water out. The nursing only takes 5-10 seconds, so they snack many times during the day, no schedule! Isn't that an accomplishment?
Q: Any current projects you'd like to highlight?
A: Definitely The Human Microbiome Project! It's a National Institute of Health initiative with the goal to study our microbiota (we have plenty, almost 5 pounds of our body weight), and its emerging and shockingly significant impact on human health and disease. We will hear more about the acquisition of the early infant microbiome and its impact on neonatal health, such as prematurity, which is fascinating! Our gut microbiota work for us really hard. They are slaving away, affecting our immunity, metabolism, endocrine system, and even our neural pathways. I had no idea that an obese patient can have very different gut bacteria than a lean counterpart, and that these microbiota can epigenetically influence the patient's metabolism. The wrong bacteria can literally reprogram our metabolism towards obesity. I look forward to learning more about how to feed our microbiota right – for now, my understanding is that they love to munch on prebiotics, which is why I would like to touch on this topic during the conference. Breastmilk serves as an excellent prebiotic and is full of human milk oligosaccharides, which can, for example, decrease the risk of necrotizing enterocolitis, a devastating condition affecting predominantly premature infants. The therapeutic potential in treating illness with underlying dysbiosis through manipulation of the enteric microbiome, which would also include autoimmune conditions (Crohn's, diabetes type I) may be tremendous.
Please join us at the International Breastfeeding Conference! More info here.
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