Buckle up, dear readers. This is gonna be a bumpy, long, and convoluted ride.
In the year since this blog’s inception, I’ve “met” a vast number of intelligent, dedicated moms who wanted to breastfeed and were unable to, for a variety of reasons. Many of these women have shared their stories for the FFF Friday series, but in addition, the comment threads on any given post will often include short but heart-wrenching tales of trying, more trying, failure, and either unresolved guilt or in happier cases, redemption.
I don’t know about the rest of you, but I started seeing certain patterns emerging in these stories. Often, it was moms who had suffered from infertility or miscarriages; conditions like PCOS, hypoplastic breasts; babies with insurmountable latching problems; supply issues… there was a sameness to our experiences, beyond the obvious emotional toll that were part and parcel of these feeding troubles.
But it wasn’t until recently, when two amazing FFF readers - Amy and amoment2think – emailed me with their own admirably insightful theories about lactation failure. Both raised questions about the prevalence and cause of supply issues; we discussed possible environmental causes (Amy has some fascinating theories about the effect of phytoestrogens on breast development and lactogenesis – the process by which our breasts are able to lactate) and evolutionary/lifestyle aspects of the problem. And as amoment2think postulated in her great guest post on this very subject, it seems as if many in the medical and advocacy communities have glossed over or under-diagnosed these problems, out of (this is totally my analysis, I could be way off here) fear that it might discourage women from nursing, or sway the pendulum back to a mistrust of women’s bodies, an over-medicalization of birth/nurturing our children.
As Amy and I went back and forth trying to find studies to support a pet theory we developed, I stumbled across some papers which have completely thrown my world upside down. Now, before I get into the meat of this post, I want to be clear that I am NOT a doctor, PhD, or anything that might qualify me to professionally assess this information. I am sure I will make some amateur mistakes while discussing my theories; my point is not to diagnose or “prove” anything, but rather to start a conversation which I hope can ultimately help the women who want to nurse do so successfully.
To begin, I should give you a cliff notes version of how my own breastfeeding failure went down. FC did appear to latch immediately after birth; however, in the 2 subsequent days (while I was in the hospital maternity ward) he never could stay on the breast longer than 30 seconds or so; this kept getting dismissed as him being “sleepy” after birth by the 3 hospital-supplied lactation consultants we saw during this time. I insisted something was wrong, as I had felt him latch the right way (or what felt to me like the right way, at least) in those precious moments following his birth, but was told that it was just a matter of him being a “slow learner”, and other than offering different “holds” and reassurance, we weren’t given any other guidance. After being dismissed from the hospital, we had to see our pediatrician right away since FC had lost approximately 10% of his birth weight (up to 10% is considered “normal”, but borderline; he’d been growth restricted and stopped growing around 33 weeks, so his weight gain was a concern to begin with). We saw another LC there, then another, and finally one who diagnosed him with a tongue tie and encouraged me to pump (I credit her for allowing him to have any breastmilk whatsoever; had she not come into our lives, I doubt we would’ve lasted past the first 5 days). While he gained weight on my pumped milk, supplemented with formula, it ended up that he had a severe milk and soy protein intolerance (MSPI) and the casein in my milk was even too much for him. We switched to hypoallergenic formula, and that’s how I became the FFF you know and love/hate, depending.
A few other factors that I think are imperative to the story:
1. I had 2 early miscarriages, and it turned out that a progesterone deficiency was likely to blame. FC and my currently gestating FC2 were both conceived/sustained on synthetic progesterone supplements.
2. I had major problems with my reproductive system from the age of 12 when I started menstruating; endometriosis, horribly painful periods, debilitating PMS (I’m talking complete personality shifts, here), etc. I visited a slew of specialists through my teens and 20′s, and ended up being one of the first “test” cases of sustained birth control – I took continuous doses so that I only got my period 2-3 times a year when I would take “breaks” from the regimen, load up on heavy painkillers, and take to my bed for 2 days, writhing in pain).
3. I had some signs of preterm labor around 33 weeks (right when FC stopped growing, but we didn’t know it at that point as my OB was kind of a moron), for which I was given terbutaline. I continued taking the terbutaline periodically until 36 weeks, when my OB said it would be okay to stop.
4.. FC was born vaginally, but via emergency induction through pitocin, at exactly 39 weeks, when an ultrasound discovered that he had stopped growing around 33 weeks gestational age, and that my fluid was dangerously low.
5. I had severe PPD which began – no exaggeration – the moment I delivered the placenta.
I tell you this because in the research I’ve been doing for the past few days/nights (Fearless Husband is so fed up with me right now – like I wasn’t already obsessed with infant feeding from the book research and the blog, and now this), I’ve come across references that strongly suggest all of these factors might have played in to my breastfeeding failure. And like I said earlier, it appears that many readers of this blog share some of these attributes with me, which leads me to believe that there is something here.
I’ve seen plenty of research and citations regarding the association between poor breastfeeding success and PPD, certain drugs administered in labor, small-for-gestational-age infants… not as much on infertility, although TheLactivista pointed me in the direction of Lisa Marasco, a lactation consultant who has done a great deal of work with the PCOS community, who advises women to seek breastfeeding help prior to birth if they’ve dealt with fertility issues; I’m going to try and contact her to find out more about this, but it at least implies that others have noticed a possible link.
But in the blur of the past two research-heavy days, I came across some info that I was completely unaware of: the composition of milk, and how it relates to lactation function, latching issues, dehydration, failure to thrive, and breastfeeding failure. The scariest thing is, in all of these studies, the authors include warnings about the importance of acknowledging lactation problems, suggesting that the medical community might be adverse to discussing these things openly in fear of “discouraging breastfeeding”, but urging people to take these issues quite seriously. So why is this the first time I’ve ever heard discussion of this, despite doing a year of research on all things breastfeeding-related?
There are several elements of breastmilk and the mechanics of lactation that are interesting me right now, but for the purpose of this post, I want to focus on just one: sodium content. Breastmilk is made up of a number of components, including lipids, casein, whey, nonprotein Nitrogen, Lactose, and minerals, including potassium, calcium, magnesium, and sodium, our mineral of concern for this post. (Source: Breastfeeding basics.org)
Sodium levels are highest directly after delivery. Just for a little perspective, human milk goes through a bunch of changes. In fact, the process of lactation is divided into two phases: lactogenesis 1 and 2. The first stage happens prior to delivery; the second, which is what I’m most concerned with here, occurs in the days after birth. We laypeople tend to think of this as the stage where it’s just colostrum coming out of our nipples, versus the time when our milk “comes in” (you know, when you feel all engorged and boobalicious). The problem is, things can go wrong in either stage of lactogenesis. And if something goes awry in stage 2, it can lead to breastfeeding trouble, failure, or in severe cases, dehydration or failure to thrive in an infant.
I could go on about the scientific reasons an overabundance of sodium in milk isn’t a good thing, but all you really need to know is that ingesting breastmilk which has too high a sodium content can lead to either hypernatraemia or hyponatremia, which are basically different types of dehydration.(Please note – these same conditions are also big problems for formula-fed infants due to improper formula handling, which is why I’m a big advocate for better education and support for formula feeders. I’m only discussing how this all relates to breastfeeding failure here, though – but I didn’t want anyone jumping down my throat about how the pro-formula feeder was ignoring a “risk” of formula feeding).
According to several studies I read, high sodium content in breastmilk is related to an inability to establish breastfeeding. This 2002 study, from the ADC Fetal & Neonatal Edition (Hypernatraemia in the first few days: Is the incidence rising?
Reduction in feeding frequency is associated with a marked rise in milk sodium concentrations. This association might be related to reduced production, which could in turn be secondary to neonatal factors, such as primary suckling deficiency or poor suckling as a result of infection, or to maternal factors, such as stress, mastitis, or sore or retracted nipples. A vicious circle can develop so that when breast milk production is reduced, the infant becomes weak and sucks poorly, and the drive for lactation drops further until dehydration occurs. Factors contributing to inadequate breast stimulation and drainage included difficulty latching onto the breast (6 neonates), inverted nipples (1 mother) and ankyloglossia contributing to a suckling disorder (1 neonate). Three babies were described as very sleepy in nature and feeding, attempted every 2-4 hours, lasted up to 90 minutes. In 2 other cases the infants were feeding sufficiently often but were unsettled after feeds. Two infants received supplements for 36 hours before presentation; both had test feeds of 0 g. The breast milk sodium concentration was elevated in 3 of 4 cases measured.
Another interesting and scary aspect to this is the problem inherent in diagnosing hypernatremia in the first place. “The infant with hypernatremic dehydration secondary to breast-feeding is typically encountered somewhere between the first and third weeks of life,” claim Scott E. Rand, MD and Amy Kolberg, MD in their study, Neonatal Hyponatremic Dehydration Secondary to Lactation Failure. “A specific danger lies in the possible delayed recognition of this disorder, because most of the infants reported have nursed well and appear content. They therefore come to medical attention late, with severe dehydration, often weighing much less than 10% below birth weight….The parents may have failed to identify that the infant is ill, and professionals may also be falsely reassured by the infant’s apparent wellbeing. Signs may be non-specific, including lethargy and irritability….Evans and Davies described four breast fed infants who gave no signs of inadequate breast milk intake other than poor weight gain and poor growth in length and head circumference.”
I have no idea if our latching issues and subsequent failure to ever establish breastfeeding were related to sodium in my milk. I would say that the fact that I was able to sustain FC on mostly pumped breastmilk for a month makes this unlikely, but nearly all the studies I consulted do say that this is usually a temporary problem which can be resolved in time, so who knows. What I do know is that if an imbalance of sodium can either be caused by or cause breastfeeding and latching problems, women are not being informed of this.
There’s a lot of talk of “booby traps” (thanks to Best For Babes, a great organization that I believe truly does want to help women for all the right reasons) in the lactivist community, but most of these pertain to society’s lack of support for breastfeeding. I always said that my problems were not due to booby traps, but maybe I was wrong, Maybe it just wasn’t a booby trap anyone has acknowledged yet. Maybe this booby trap is an unfortunate side effect of all others – the hesitancy to alert women to rare (but apparently growing) lactation complications, because it might undermine confidence in our bodies – which is totally understandable, but in my opinion, misguided. In a study entitled Breastfeeding-Associated Hypernatremia: Are We Missing the Diagnosis? (Moritz et al, PEDIATRICS Vol. 116 No. 3 September 2005, pp. e343-e347 (doi:10.1542/peds.2004-2647), the authors appear to feel likewise:
Breastfeeding-associated hypernatremia should be completely preventable. Unfortunately, physicians receive limited residency training to deal with breastfeeding complications, and there is general reluctance to provide supplemental formula to breastfed infants with insufficient lactation. Most pediatric texts do not give clear recommendations regarding how to treat breastfed infants with excessive weight loss or when to intervene with supplemental feeding. Obviously, the goal is to prevent dehydration, which must begin with adequate breastfeeding assistance in the newborn nursery that continues after discharge. To this end, breastfed infants should be evaluated by an experienced health care professional at no more than 3 to 5 days of age, as recommended in the most recent American Academy of Pediatrics guidelines. Infants should be evaluated with a weight check, physical assessment of hydration and jaundice, and evaluation of breastfeeding and infant elimination patterns. Most breastfeeding-associated hypernatremia could be prevented if infants with excessive weight loss or inadequate breast milk transfer were judiciously given expressed breast milk if available and formula if necessary until breast milk production increased and breastfeeding difficulties were addressed by a health care provider well trained in lactation support….Breastfeeding is the most complete and perfect form of nurture and nourishment for infants, and all efforts should be made to promote successful breastfeeding. Breastfeeding-associated hypernatremia is a completely preventable complication that seems to be relatively common… Primiparous women in particular need additional support, education, and follow-up monitoring to ensure successful breastfeeding and to avoid complications of insufficient lactation. The judicious use of expressed breast milk or formula could prevent most cases of breastfeeding-associated hypernatremia. Both physicians and parents need better education and clearer guidelines on preventing, recognizing, and treating breastfeeding-associated dehydration. A comprehensive approach to the prevention and treatment of dehydration, hypernatremia, and hyperbilirubinemia should be part of any breastfeeding promotion campaign by the American Academy of Pediatrics or the US Department of Health.
The authors of the aforementioned 2002 study, Hypernatraemia in the first few days: Is the incidence rising?, echo this sentiment:
So why the hell isn’t it? My son might never have been able to breastfeed for very long, thanks to his MSPI. But apparently, the amount of casein and lactose in human milk can vary from woman to woman – it doesn’t appear that much attention has gone into this aspect of lactation, either. What if our initial failure to nurse altered my second stage of lactogenesis, so that my casein/lactose was out of whack? (This might explain why certain kids with MSPI can tolerate breastmilk, while others cannot, despite their moms cutting all potentially offensive foods out of their diets.) I can’t help but wonder if we are not just “missing the diagnosis”, but missing the mark altogether. Breastfeeding might be natural, but our lives are not. We have children later, are exposed to all sorts of chemicals and toxins, and spend years filling our bodies with synthetic hormones and altering our menstrual cycles. Many of us were only able to conceive with help from medical science. Is it really that impossible to believe that these factors might be increasing lactation problems, or creating new ones altogether?
I can’t speak for everyone, obviously, but the idea that knowledge of potential difficulties could undermine my confidence or dissuade me from nursing is hogwash. We are a nation of moms who over-research everything: maybe we’ve de-medicalized birth and nursing, but we’ve substituted the internet – Twitter, blogs – and parenting “theories” for the pediatrician of yore. We crave information. We seek guidance. We are equipped to handle much more complex ideas than ever before. The women I know who have tried and failed to breastfeed are a tough bunch; we can handle the truth.
This might mean allowing science and medicine back into our postpartum lives, just a little bit. It might mean admitting that breastfeeding may not work for everyone without a bit of intervention, rather than accusing women of “faking” lactation failure to assuage their guilt. That has to stop. Because when it comes down to it, a lack of knowledge, and a fear on the part of physicians and researchers of appearing “anti-breastfeeding”, is a booby trap too. By acknowledging that these problems exist; by not being afraid to bring these types of studies to light – studies that can legitimately save lives, not in a theoretical sense – we can help more women to nurse successfully.
As deliciously tunnel-visioned lactivist Jack Newman maintains, the only women who feel guilty about formula feeding are those that wanted to breastfeed, and failed. Let’s get to work making sure that they don’t fail, shall we?