Self-Efficacy and ChatGPT

 It's been a long time and I'm really just experimenting with new information.  I took a small chapter I wrote for the Encyclopedia of Nursing Research and put it into ChatGPT, asking it to explain my chapter to a 12-year old.  I did it just to see what would happen.  This is the result.  What do you think?

Self-efficacy is like your belief in yourself and your ability to do things. It's about how confident you feel in your skills to achieve a particular goal. For example, if you believe you can do well in a school project or score a goal in soccer, that's your self-efficacy.

Imagine you want to score a goal in a soccer game. Self-efficacy is how much you believe you can do it. But it's not just about believing you can score a goal; it's also about thinking that you have the skills and determination to make it happen.

Now, there's something called "outcome expectations." This is when you think that doing something will lead to a specific result. For instance, you might believe that practicing soccer will make you better at it. But sometimes, even if you think practicing will help, you might not believe you're capable of practicing enough to get better. That's where self-efficacy and outcome expectations are different.

This idea of self-efficacy is used in nursing and other areas to understand how people's beliefs about their abilities affect their behavior and health. Researchers study how self-efficacy can be improved, and they've found that it can make a big difference. For example, if someone believes they can quit smoking or stick to a healthy diet, they're more likely to succeed.

Nurses use this information to help patients and students. They can figure out when self-efficacy is low and try to boost it. They do this through things like education, offering support, and giving people opportunities to succeed.

One interesting thing is that self-efficacy isn't just about one specific thing. It can affect different areas of your life. So, if you're confident in one area, like your soccer skills, it can also boost your confidence in other areas, like school or making friends.

In the future, researchers want to learn more about how self-efficacy can be applied to different tasks and whether having high self-efficacy in one area can help in other areas. They also want to keep testing ways to improve self-efficacy, so that people can achieve their goals and live healthier lives.

Lactation Matters Microbiome Post

Over the last few weeks I have been collaborating with ILCA to publish a blog post based on my popular lecture on the Maternal-Child microbiome.  They have agreed to allow me to cross-post that blog here.  So without further ado, here you go.  You can find the original entry at https://lactationmatters.org/2020/02/14/ten-things-ibclcs-need-to-know-about-the-gut-microbiome/

New understanding of how human milk affects the gut microbiome is helping to explain exactly how the benefits of human milk are achieved.
We hear a lot these days about the gut microbiome—and with good reason. Evidence suggests that the bacteria in our gut influence virtually every aspect of our functioning, from our stress and anxiety responses, to our metabolism and appetite, to the robustness of our immune system, to even our experience of gender and mating. And when our gut microbiome is out of balance, research suggests negative consequences can result: depression and anxiety, obesity, irritable bowel syndrome, Alzheimer’s Disease, and asthma have all been linked to microbiome disruption.
What does the gut biome have to do with breastfeeding? A lot, as it turns out. A webinar hosted by ILCA, Jarold “Tom” Johnston, DNP, CNM, IBCLC, explores that connection. Here, based on Johnston’s talk, are the 10 things lactation consultants need to know about the maternal-infant gut microbiome.

1. The microbiomes of baby and birthing parent are inextricably linked.

When a person gives birth, they pass their microbiome to their baby—first through exposure to their normal flora in the birth canal and then through their milk during breast- or chestfeeding.

2. Communication is a two-way street.

The milk ejection reflex is a muscular contraction that pushes milk out to the baby. But did you know that once the milk ejection reflex slows, muscles relax and pull baby’s saliva back in? Lactocytes respond to saliva exposure by producing particular macrophages. If the baby has been exposed to an infection, at the next feeding, he will get leukocytes and antibodies to fight that specific infection.

3. Colostrum is not really food.

You read that correctly! Babies get very few calories at the breast during the first 48 hours, because the calories in colostrum are not intended for digestion. They come from immune cells, designed to populate the immune system. Rather than thinking of colostrum as calories, think of it as an immune system transfer.

4. Breastmilk sugars are more than food.  

Human Milk Oligosaccharides (HMOs) play a key role in developing the infant’s gut microbiome. Human milk contains more than 100 types of HMOs. (In contrast, cows’ milk contains only two.) Each HMO has a specific benefit for the infant’s gut microbiome. Some are prebiotics, acting to increase good bacteria in the gut. Others block the attachment of invading viruses and bacteria like RSV and e.coli by providing harmless “decoy” attachment sites. Another type coats the baby’s gastrointestinal tract, preventing pathogens from sticking.  But none of them are digested by baby as carbohydrates until the baby is more than four months old.

5. A breasted baby’s gut microbiome is optimized for nutrition delivery.

The breastfed infant’s gut contains a specialized group of bacteria known as the phosphotransferase system. This system transports lactose and makes it available for use. Breastfed babies have higher levels of phosphotransferase then formula-fed babies. This means breastfed babies can access the maximum amount of energy available in their breastmilk. This ensures a constant source of carbohydrate for the developing, glucose-dependent brain.
Breastfed babies have higher numbers of gut bacteria that produce Vitamin A, B Vitamins, Vitamin K-2, and more. When they drink breastmilk, it feeds the bacteria colonies in their gut that make these micronutrients. Are you ever asked whether breastmilk contains enough iron, Vitamin K, or other nutrients? That question is misleading! Babies actually do not “get” these important micronutrients from the breastmilk they drink; what they get from breastmilk are the ingredients to feed a microbiome that can synthesize these micronutrients.

6. There are “bonus” calories in breastmilk.

Epithelial cells in human milk (formerly thought to be dead) are actually alive, active, and functional. They form clusters (called mammospheres) in the baby’s gut and continue to make more milk! This means that for every calorie of breastmilk a baby takes in, he gets bonus calories as the epithelial cells continue to generate milk inside his gut.

7. Exclusively breastfed babies have “less mature” gut microbiomes, and that is a good thing.

At birth, babies have very different proportions of specific bacteria in their gut microbiome compared to their birthing parent’s. Over the first 12 months of life, the baby’s microbiome shifts to strongly resemble the birthing parent’s. However, this shift is accelerated by the introduction of formula or the feeding of solid foods. As soon as the baby ingests anything other than human milk, the gut microbiome changes rapidly, and it does not go back. This may explain why formula fed infants experience more auto-immune and infectious illness.

8. Birth interventions affect the microbiome.

Cesarean section birth reduces microorganism exposure. While infants born via vaginal birth show 135 of their mother’s 187 bacteria strains after birth, infants born via surgical delivery show only 55. Antibiotics given to Group Beta-Strep-positive parents during birth also have an effect, since they wipe out good flora in the birth canal. Exactly how these interventions affect long-term health is not yet clear, but continuing to think carefully about birth interventions is key.

9. What about special situations?

Many of the mechanisms of microbiome transfer rely on birth and direct feeding. What about parents who exclusively pump, rely on donor milk, or induce lactation for an adopted baby? Exclusive pumping and the use of donor milk both impact the microbiome to some extent. Pasteurization of donor milk inactivates some of the living organisms in human milk, and exclusive pumping does not allow for the two-way communication discussed earlier where baby’s saliva is taken into the breast and informs lactocytes of the baby’s specific infection exposure. However, as you address parents’ concerns, what the science tells us now is that receiving human milk is more important than how it is the baby receives the milk.

10. Microbiome science is only a baby itself.

According to Johnston, it is important to remember that our understanding of the gut microbiome is just getting started. There is a long way to go, and much more to learn. However, for those of us who work with lactating families, the exciting news is: Understanding how the unique components of human milk interact with the infant’s gut organisms is helping us begin to understand how those benefits occur—they operate through the microbiome.

Mindfulness when working with infants

I'm sorry that it has been so long since my last post.  I suppose that my long breaks between blog posts means that I am really just talking to myself.  That said, I was talking to myself again yesterday and I was struck by a thunderbolt.  So here is my latest brain bender.  I'm sorry this is pretty heavy stuff, but its the way my mind works.  

The internet is an amazing place, this morning I was wandering through social media and I was struck by three disconnected and yet interrelated articles.  The first was an article posted by a behavioral psychologist Michael McKnight stating that children with 4 or more ACE (Adverse Childhood Experiences) were 500% more likely to become addicted to alcohol or drugs as an adult.  The second was an article on leadership written by Michael Brasseur where he quoted Peter Drucker saying “Culture eats strategy for breakfast”.  The final one was a YouTube video demonstrating the Galton Board, which shows that if you drop multiple beads from a funnel onto a peg-board they will fall with normal distribution ( https://youtu.be/Kq7e6cj2nDw ).  Each of these by themselves are interesting ideas, but in my head, I put them all together and it made me put everything else I was supposed to be doing aside until after I got these thoughts down on paper. 

What would happen if we looked at each bead on the Galton board as a child being born into the world?  As each bead falls from the funnel (birth), they strike the same peg (Mother).  From there, they bounce (react) either left or right and they move to the next bead.  How each bead strikes the subsequent peg is based by how they reeled off of the last peg.  The angle and force with which they strike the next peg will determine how they bounce and where they land next.  Now, on the Galton board every bead is the same and every peg is the same, there are no flaws or emotions that influence the fall of the bead.  But in life each child and each interaction is influenced by the people involved and how they respond to each other. 

This brings me to the psychologic work mentioned by Michael McKnight.  McKnight showed that adverse childhood experiences (ACE) negatively impact the child’s development.  Meaning that every time a child is exposed to an ACE (abuse, neglect, parental separation, divorce or incarceration etc.…) they are more likely to bounce to negative rather than the positive.  In McKnight’s study he showed that the link between ACE and addiction is stronger than the link between obesity and diabetes.  Let that sink in for a moment.  It means that every time a child is exposed to an adult (or even another child), that child has the option to bounce either right (to the positive) or left (to the negative).  The more positive experiences we can offer a child, the more likely that child is to bounce toward the positive side of the bell curve.  The same goes for the negative.  The more a child is ignored, not spoken to kindly, raised alone or in a divorced or single parent home, exposed to crime, violence, abuse and neglect, the more likely that child is to bounce to the left, and the left again, and the left yet again.   

Then there is the powerful statement by Peter Drucker “Culture eats strategy for breakfast.”  What this means is that when you establish a positive environment you will get better outcomes regardless your strategy.  Likewise, interventions (or strategy) are less likely to overcome an environment or culture of negativity.  So a child born into a home with two loving parents, who speak kindly to them, breastfeed the child, provide positive experiences throughout their life.  Parents who send their children to a positive learning environment (either home school or quality public schools) and surround the children with loving adult role models such as coaches and mentors are far more likely to see that child bounce to the positive again and again. 

Finally, I wanted to mention a crazy idea.  What happens if we shift the Galton funnel to the right?  What happens when we adults who have children in our lives focus on creating a positive environment every time, for every child?  Would we see a curve that is skewed to the right?  What if we ensured that every child had two loving adults in the home, every child was breastfed, every child was cared for and cherished through their critical developing years?  We would still have outliers, that is to be sure, but the mean is likely to shift to the right. 

What does that mean to you?  What does that mean to your patients and your families?  What does that mean for your children?  Is this an impossible day dream?  If so, why?  Who is responsible for your child’s health and wellness?

Neonatal Caloric Requirements: A response to the FIB-ers post about stomach volume

Neonatal Caloric Requirements

Selia asked me an interesting question about a recent post from the FIB folks about neonatal stomach volume.  It seems that J. Seagrave RN, IBCLC wrote a provocative piece about how our neonatal stomach volume models of the marble and the nut, and egg are not evidence based and therefore everything that we think we know about neonatal feeding is wrong.  As we usually find on the internet she is half-right, and biased, but she makes a very good point.  Our neonatal feeding estimates are probably wrong and our understanding of neonatal feeding in the first 48 hours is almost certainly wrong, but that doesn’t mean we have to change anything.  It also doesn’t mean that the babies are starving or suffering either.  To defend this, I’ll use basic nutritional theory and a little microbiome science for back up.  So, let’s dive in and I’ll tell you what I have discovered.

First, Seagrave is 100% correct, the estimate of neonatal stomach volume that suggests a size of 5-7 mL are not measures of actual stomach volume, they are a mathematical calculation where researchers took the average 24-hour intake and divided by number of feeds and came up with a number that is incorrect.  I won’t go so far as to say that they based their findings on one flawed study, but I will say that assumptions on neonatal stomach volume are flawed.  I agree with Bergman (cited by both Seagrave, and me).  The neonatal stomach volume, at which the stomach is “full” but not bloated is probably about 20 mL and rapidly expanding as amniotic fluid is replaced, first with colostrum, and eventually with breast milk.  In my practice I usually use a rough estimate of 15 mL/kg during the first month for what I can expect from a baby who is totally full.  I also understand that the average newborn between 7-21 days takes about 30 mL in a “good feed”.  Unfortunately, that last observation comes from my own practice where I have monitored about 250 adequately growing neonates.  That isn’t to say it is made up out of whole cloth, Kent and the good folks at the Hartmann lab have said the same thing in numerous studies (bibliography).  So where is the disconnect?  Neither stomach volume nor average intake tells the whole story.

I’d like to start with stomach volume.  I have no reason to disagree with Bergman or Seagrave, the average neonatal stomach volume is approximately 20 mL., but if you read the works they cite it is actually between 10-35 mL and that is an important distinction.  The stomach is an organ with a tremendous capacity to stretch, the difference between empty and full is tremendous.  In adults, the average stomach volume varies tremendously and is ultimately based on the volume of food habitually eaten (Lutz et al., 2015).  Actual measurements show that the empty adult stomach holds about 50 mL but can stretch to approximately 4 liters (Hoffman & Sullivan, 2017).  That is a stretch capacity of 8,000% (80-fold).  In his work on neonates Bergmann shows that the stretch capacity is about 350% (from 10-35 mL).  Can you imagine attempting to assess how much food you should eat based entirely on your stomach volume?  It would be impossible!  Would we limit your intake to 50 mL per feeding, or would we force you to eat 4,000 mL of food at every feeding?  Both are laughable in their simplicity. Also, it would be foolish to even suggest that you eat the same amount at every single feeding. Imagine, the same amount for all three meals and all three snacks.  Nonsense, as adults we understand that sometimes we want a snack and sometimes we want a feast.  It has nothing to do with how much is available, and everything to do with appetite.  Why then would we suggest that a neonate must eat the same thing at every feeding?  Why would we attempt to predict every single feed?  Newborns are not robots. No, they are like us they eat according to appetite, not some mathematic calculation discovered by research studies.  My answer to both the ABM and the FIB folks is that neonatal stomach volume is a useless predictor for required volume or calorie intake. 

 

So let’s talk about actual caloric requirements.  Unfortunately, I don’t have a good estimate of calorie requirements for a neonate in the first 48 hours.  I agree with FIB, what we think we know is based on myth and bad science (both ours and theirs).  But if we expand that to the first month, there is some pretty interesting stuff out there.   Seagrave reported the estimated neonatal caloric requirement of about 100 kcal/kg/day.  That is lower that the Food and Agriculture Organization (FAO- a division of WHO), which reports 113 kcal/kg/day for male neonates and 107 kcal/kg/day for female neonates, for simplicity we can average that to 110 kcal/kg/day for both male and female (FAO, 2004).  They also report that the TEE (Total Energy Expenditure) for Breast fed infants is lower than what is required for formula fed infants.  In other words, formula fed infants require more calories to survive and grow than breastfed infants.  The actual report is 12% more at 3 months, then gradually getting closer over the first year and becoming equal by 12 – 18 months (FAO, 2004).  That means that the average formula fed infant needs approximately 500 kcal/day where the average breastfed neonate needs only 430 kcal/day (FAO, 2004).  The two sets of numbers a little different, but they end up being close enough for our purposes.  If we can assume that both breastmilk and formula is 20 kcal/ounce (which is close enough), that means that the average (3.5 kg) breastfed neonate needs 385 kcal/day (3,500 g x 110 kcal = 385) or 19.25 ounces per day.  And the average formula fed needs up to 12% more (431 kcal/day or 21.5 ounces). 

That is, of course, assuming the calories taken in and the calories used are the same thing, which microbiome theory would suggest, is not actually correct.  When we look at neonatal feeding, we know that the average newborn takes only 37 mL in the first 24 hours (25 kcal), 100 mL in the second 24-hours (60-70 kcal), gradually increasing to 450 mL/day by 14 days (300 kcal) and 750-1250 mL/day from 30-180 days of life (500-833 kcal).  For references I highly recommend that you look up the collected works of the Hartmann lab from 1976-2016, but if you are lazy, they can all be found in the latest LEAARC Core Curriculum (2019).  That means that newborns are seriously lacking in calories for the first 1-2 days and even for as much as the first month of life, and yet… they thrive.  How do they do that?  It seems a mystery, but it really isn’t.  The simple answer is “because”, for a more complete answer, we will have to turn to theory.   

[I want to spend a second explaining the two different concepts, TEE vs. Total caloric requirement.  There is a world of difference between the 100-113 kcal/kg/day that is required for growth and the TEE.  The TEE is what the body expends to promote survival, not growth.  It is remarkably lower than you normally hear when talking about calorie needs.  The TEE of the average neonate is only 108-110 kcal per day (not per kilogram/day).  The TEE is calculated by a pretty high-tech method (Doubly Labeled Water or DLW, which I don’t have space to go into here, but just know that they use mass spectrometry to measure actual energy use over a period of time, rather than attempting to measure calorie intake).  Just understand that there is a difference, and that difference will be important later.]

I hope you have been keeping up so far because from here on out, we are forced to rely more on theory than actual research, because there is no reliable research out there.  First, we will talk about the normalcy of mammalian physiology.  That means that all things considered equal, the mammalian neonate is designed to survive, and that normal physiology can support that survival.  That means that even if we don’t understand it at a scientific level (and FIB certainly doesn’t not understand it), what happens naturally, is probably what is supposed to happen.  When we see that the average newborn takes in 37 mL of 18.7 kcal/ounce colostrum in the first 24 hours, we have to assume that there is a reason for that.  After all, mammalian physiology rules the known world, it must be doing something right.  My theory (and it is just that, a theory of MINE, take it or leave it).  My theory is that babies are not eating in the first 24-72 hours, they are transferring the mother’s immune system in the form of colostrum.  We all should know by now that colostrum contains almost no lactose (which is to say calories), that it is made up almost entirely of proteins, immune proteins like sIgA, and restorative proteins like human Breast Milk Stem cells (Bode, 2014).  All the calories that a healthy, term, newborn needs are delivered by their body fat through gluconeogenesis, not through breastmilk (ABM, 2016, AAP, 2012).  Like hibernating animals, they get nice and fat, then they fast for a while and live off that fat.  It is normal to lose weight in the immediate newborn period.  That isn’t a failure of the American health care system, it is normal mammalian physiology. 

Second, we need to look at basic nutrition theory.  We have all met that person who can eat whatever they want and not gain weight, and we all know those poor unfortunate souls who look at a piece of cheesecake and end up looking like the Sea Witch from Disney’s “Little Mermaid”.  I’m no Dietician, but I understand nutrition well enough to know that our daily caloric requirements and our TEE do not tell the whole story.  That manipulating daily caloric needs is a game of estimation and trial and error.  We increase or decrease our estimates by 10% until we reach the desired outcome.  For most western adults that is weight loss, for most infants that is weight gain.  That is a long-winded way of saying that we know that infants are eating “enough” when they gain weight.  The actual volume of intake is irrelevant if it doesn’t achieve the ultimate goal which is growth over time.    

Let’s go back and look at that last bit a little more deeply.  Why do some people get fat when others don’t, even when they eat the same amount of food?  Microbiome scientists have discovered that the bacterial content of our gut is ultimately responsible for the efficiency of our caloric absorption.  To put it simply, fat people have bacteria that is very good at getting calories out of food and skinny people have bacteria that is not very good at extracting calories from food. (for a very good explanation of this, I recommend Robert Knight’s TED talk on the subject, found at: https://youtu.be/i-icXZ2tMRM ) To dig a little deeper, a team of researches in Israel discovered that they could use stool samples to predict the speed and efficiency of carbohydrate uptake.  In pregnant women there is an overgrowth of a wonderful little bacteria called methanobrevibacter smithii.  This bacteria is actually why pregnant women are more gassy than non-pregnant women.  You see, it is more efficient at fermenting and digesting carbohydrates in the maternal-child gut.  So where you may get 80 kcal from your average slice of bread, the mother and baby may get 90 kcal.  Simply put, they don’t need to eat as many calories because they get more calories out of the food they eat.  This certainly helps explain why so many pregnant women gain excessive amounts of weight even when they stick to a prescribed diet.  In infants there is a phosphotransferase transporter system (a group of bacteria) that enhances carbohydrate breakdown and transport (Backhead, 2014).  It helps to explain why breastfed infants thrive with fewer calories than they should need, and why formula fed infants need more calories than breast fed infants.  Imagine what changes we may see in the future?  While we agree that pregnant women NEED an extra 300-500 kcal/day to support the increased metabolic needs of the developing pregnancy, perhaps they don’t need to EAT an extra 300-500 kcal, because they might actually get it through their enhanced digestion from good old m smithii.  It is too early to say, but there is evidence that breastfed neonates benefit from the same bacteria, and perhaps formula fed neonates do not (Backhead, 2014).  You might recall that the FAO reported that formal fed infants need extra calories (FAO, 2004).

I know, this is hopelessly long, but how can I explain sucha complicated problem in only 2,500 words?  Let me try to sum it up for you here.  1) Neonatal stomach volume estimates are probably wrong, and almost certainly useless measures that have nothing to do with caloric requirements, so both sides of the argument are wrong.  2) Newborns are not supposed to take large volumes of milk early on, they pack a lunch and take it with them.  3) Colostrum is not calories, so it is a little pointless to try to use it as such.  4)  Infants are not robots; their intake is guided by appetite and ability and those change from feeding to feeding.  The assumption that every feeding must be a specified volume is simplistic and will lead to errors.  5) The breastfed infant has a very efficient carbohydrate digestion system which may enable them to take more than 20 kcal from every ounce of 20 kcal breastmilk, so estimates of daily caloric requirements may not be accurate.  6) (AND THIS IS THE BIG ONE) Infants need “enough” calories to support growth over time and estimates of required volume are just that… estimates.  The proof is in the pudding, as they say, a baby who isn’t growing well on X amount of breast milk needs more breast milk, and vice versa.   I hope that answers your question.  For me, it only creates more questions.  But that is the joy of science, is it not?

References: 

Backhed, Roswall…Dahlgren, & Wang (2015) Dynamics and stabilization of the human gut microbiome during the first year of life. Cell Host & Microbe 17, 690-703.

Bergman, NJ (2013) Neonatal stomach volume and physiology suggest feeding at 1-h intervals.  Acta Paediatrica, 102, p 773-777.

Bergmann, RL., Bergmann, KE., vonWeizsacker, K., Berns, M., Henrich, W., Dudenhausen, JW. (2014). Breastfeeding is natural but not always easy: intervention for common medical problems of breastfeeding mothers – a review of the scientific evidence. Journal of Perinatal Medicine; 42:1 9-18.

Bode L. (2012) Human milk oligosaccharides: Every baby needs a sugar mama.  Glycobiology, 22(9), 114-1162.

Food and Agricultural Organization of the WHO. (2004). Human Energy Requirements. Chapter 3: Energy requirements of infants from birth to 12 months. Retrieved from http://www.fao.org/docrep/007/y5686e/y5686e05.htm#bm05.3 Retrieved on 01 April 2017.

Hartmann, P. (2007) The lactating breast: An overview from down under. Breastfeeding Medicine, 2(1) 3-9.

Hoffman & Sullivan (2017).  Davis Advantage for Medical-Surgical Nursing: Making connections to practice.  FA Davis Publishing.  ISBN-13: 978-0-8036-4417-5

Kent, J.C., Hepworth, A.R., Langton, D.B., Hartmann, P.E. (2015). Impact of measuring milk production by test weighing on breastfeeding confidence in mothers of term infants. Breastfeeding Medicine, 10(6), 318-325.

Kent, J.C., Prime, D.K., Garbin, C.P. (2012). Principles for maintaining or increasing breast milk production. JOGNN, 41: 114-121.

Knight R (2016).  How our microbes make us who we are. TED talks. Retrieved from: https://youtu.be/i-icXZ2tMRM

Lutz, Mazur, & Litch (2015) Nutrition and Diet Therapy, 6^th ed. FA Davis Publishing. ISBN-13: 978-0-8036-3718-4  

Seagrave, J (2018). Newborn Stomach size myth: its not 5-7 mL. retrieved from:  https://fedisbest.org/2017/06/newborn-stomach-size-myth-not-5-7-ml/