The truth can set us free (and help us breastfeed)

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? Arch Dis Child Fetal Neonatal Ed 2002;87:F158-F162 doi:10.1136/fn.87.3.F15) explains:

The sodium content of breast milk at birth is high and declines rapidly over the subsequent days… Women who failed to establish good breast feeding did not experience the normal physiological decrease in breast milk sodium concentration compared with those who had little difficulty in establishing a good milk flow…
Today the evidence suggests that the most common cause of hypernatraemic dehydration is low volume intake of breast milk. The infant becomes dehydrated while the kidneys are mature enough to retain sodium ions. Water loss occurs predominantly through the skin and from the lungs…

Primary insufficient lactation is rare. Poor milk production is usually due to secondary insufficient lactation, caused by poor milk removal from the breast, which then becomes engorged. The child may then tire and fail to stimulate further lactogenesis. Small for gestational age or preterm infants suckle less powerfully than appropriately grown term infants. It has been suggested that the principal cause may be inadequate professional support of lactation, particularly in firstborn children who are breast fed. van der Heide et al attribute the severe weight loss of their two infants to “poor professional support of lactation and lack of weight control”. A survey of the literature shows that often the common thread is a mother who is primigravid and has a strong desire to breast feed. The problem can still occur in mothers who have previously successfully breast fed infants. Mothers may be of high intelligence and yet not identify the fact that their infant is poorly hydrated.
Note the discussion in the above paragraph regarding secondary insufficient lactation. THIS is where my heart started beating a bit faster. I didn’t experience major engorgement or see much milk until almost a week after FC’s birth, at which time I seemed to have copious amounts of the stuff. I started pumping the same day as my milk came in (or what I perceived as it “coming in”), thanks to that LC I mentioned earlier, so I suspect it was the pumping that kept my supply going. I pumped religiously, every 2 hours, round the clock. But for that first week pump-free week, FC’s feeding habits seemed to be described perfectly in this study from the Canadian Medical Association Journal (Neonatal hypernatremic dehydration associated with breast-feeding malnutrition: a retrospective survey, Livingstone et al)

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.


Efficient milk removal depends on correct maternal positioning and latching and normal infant suckling dynamics; 9 of the 21 infants demonstrated poor breast-feeding techniques, which resulted in ineffective milk removal. They breast-fed on demand every 2-4 hours for 20-90 minutes. The mothers experienced definite prenatal and postpartum breast enlargement, indicating normal mammogenesis and lactogenesis….All of these mothers had difficulty getting their babies to latch and breast-feed properly, and this resulted in insufficient milk removal by the neonate. Breast milk sodium was high in 1 of 5 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:

Breast feeding undoubtedly produces health advantages for infant and mother. We are right to promote expansion of breast feeding in the developed and developing worlds. On the other hand, it is not acceptable to gloss over individual breast feeding tragedies lest the resultant publicity discourages mothers from choosing to breast feed their babies. Rather we must address the underlying problems that may arise during breast feeding, identify resources of finance and expertise to eliminate these, and continue to recommend breast feeding as the best method of nourishing healthy infants. Given the numbers of children involved, this topic must receive a very high priority in our health strategies.

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?

Suzanne Barston is a blogger and author of BOTTLED UP. Fearless Formula Feeder is a blog – and community – dedicated to infant feeding choice, and committed to providing non-judgmental support for all new parents. It exists to protect women from misleading or misrepresented “facts”; essentialist ideals about what mothers should think, feel, or do; government and health authorities who form policy statements based on ambivalent research; and the insidious beast known as Internetus Trolliamus, Mommy Blog Varietal.

Suzanne Barston – who has written posts on Fearless Formula Feeder.


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29 thoughts on “The truth can set us free (and help us breastfeed)

  1. I honestly don't know what to think. I'm so sleep deprived at the moment that I am having trouble processing it all.

    It makes me feel better about having trusted my instincts and put him on formula at 6 days old. I know I was under a lot of stress because I had no idea when I when I would see my husband again or when I'd join him in NY because he was at a month long training.

    Either way, it makes me wonder about trying it again. I'm sure I will, but I'm sort of feeling like it won't work out. I have such a strict diet due to food allergies and intolerances. I would think that would also affect my milk.

  2. I feel like half the women I know have fertility issues. Some have struggled with multiple miscarriages, some have undergone hormone therapy in order to get pregnant, suffered through trials with Clomid, or undergone IVF. It really makes me wonder what's going on to cause all these fertility issues. Something in our environment? Birth control pills?

    Anyway, most of these moms go into pregnancy with higher stress levels anyway, I'd imagine that could cause some stress afterwards too.

  3. Hiya
    If it's a subject you are interested in reading more about, I can HIGHLY recommend the Health-E-Learning course – breastmilk constituents. It discusses the mechanisms that increase sodium levels and why/how. It also covers casien/whey/lactose etc and is an enlightening read!

    I am a little confused by the big post above (it's early and it was a late night lol) so sorry if I'm missing something really obvious.

    You say: 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.

    But your milk contains human casein, not bovine or soy protein? If you don't have CMP allergy youself, or a leaky gut for other reasons (eg candidia or other food allergies) CMP wouldn't be in breastilk at all. If you do and it is, stopping consumption removes it from milk (takes 2-3 weeks)

    Humans can't be allergic to human protein, because it's made from mothers blood (the same blood that fed the baby during pregnancy.)

    It's very wrong that TT's are getting missed, leading to no other choice but supplementation, and as per your case sensitisation to cow and soy proteins.

  4. Sorry another post as also wanted to add, you say:

    “”Another interesting and scary aspect to this is the problem inherent in diagnosing hypernatremia in the first place.””

    But this is again only if you haven't been educated on what is normal for a breastfed baby and thus miss the signs (and I include a LOT of health professionals in this) I find it staggering how many cases are missed – just because baby “appeared ok”. ALL parents and HP's should be educated about “ouput” – what is in the nappy gives a clear picture about what is going in. Not just size and frequency but also colour and the normal changes that should happen in colour, size and frequency in the first week an beyong. If this is not as expected, we should be acting! not waiting. Stools and urine are reliable early indicators as to health, along with observing the baby,speaking to mum and weight. If only going on appearance it IS dangerous! hungry babies scream and fuss, starving babies sleep.

  5. You have done great work here. This is one of those things that just makes SO much sense when someone puts all of the pieces of the puzzle together. Lactation failure is on the rise, as are fertility treatments (especially as certain treatments become better known/cheaper/more commonly funded by insurance). It just makes good sense to figure out how those two factors are connected.

  6. Yeah, in my research frenzy, I didn't even see anything about hyper/hyponatremia, I was paying more
    attention to the physiology of proper mammary gland development and function. Though clearly,
    hypernatremia is an improper functioning.

    Anyway, that's really interesting, and I agree with what I believe is your overall point: there is
    information out there that is kept from new mothers. Sure, many research papers are available for
    free, but the average woman probably wouldn't even know where to begin—I, for one, never heard of
    hypernatremia before reading this post. So yeah, it would be up to doctors and LCs to offer this stuff to
    women, and whether they don't because THEY are unaware or whether they don't because they fear
    coming across as “anti-breastfeeding”, it still should be remedied.

    Oh, and any idea why I can't post here from home, but I can from work? When I try to post from my home computer, it just eats my posts. The edit function doesn't work…is there some setting I need to change?

  7. Thank you for providing this information. I too have never heard of hypernatraemia or hyponatraemia. I do know that information was withheld from me by numerous nurses and LC's about my breastfeeding problem. I was able to conceive and give birth naturally, but no one explained until about 4 weeks after giving birth that I have an anatomical problem with my nipples. In the beginning nurses and LC's were dismissing my poor milk output and mastitis on having a lazy nurser. Had I known this in the begginning I could have bought an industrial breast pump, but didn't get one until 4 weeks after the fact and I was already having lots of problems with supply and reoccurring mastitis by then. Having thyroid issues I have come to learn that it to hurts your supply. Also as some you may experience the pump just isn't quite as effective as the actual nursing from breast. I know one of the LC's did not want me to supplement with formula, but now I am glad knowing what I know I did and I will do so in the future.

  8. I have wondered about the small-for-gestational age issue. My babe was induced at 41 weeks and was SGA. Because of this, they did glucose blood tests before every feed for the first day. This meant, however, that I couldn't feed “on-demand”. I pretty much had to wait for the nurse every 3 hours to take him away to do his heel prick for the glucose test. To comfort him after the heel prick, they of course swaddled him in warm blankets and brought him back to me sleepy, after which I had a hard time waking him up to get him to feed. In fact, I got a stern lecture after I noticed him rooting around and tried to feed him only 2 hours after his last feed because I forgot that we had to wait for the glucose test. I wonder if this contributed to my eventual inability to produce enough milk.

    No one ever really warned me about looking out for dehydration. When I thought that the little one seemed extremely hungry even after 60 minutes of nursing, the postpartum nurse said that “all new mothers think their babies are hungry”. Comments like that sure don't give new moms any confidence in looking out for health problems in their little ones.

  9. I never took a specific BFing class, but I'm sure some of you have. Does anyone remember if any information like what FFF mentions above, or information about mammary gland development/differentiation was offered? I would think a BFing class would be an appropriate forum to at least make this stuff available to women, even if they were just interested in knowing how it all works.

    I know if I was BFing, I would find it even more fascinating than I already do, to understand how the body actually makes milk. I suppose that women, LCs and doctors all having a better understanding of the normal processes AS WELL AS when things go wrong, could lead to more open communication about BFing and perhaps more women doing it for longer. Also, if they can't for some reason, then the mothers AND the support providers could all understand the physiology behind it and maybe women wouldn't get emotionally beaten up so much.

  10. You may wish to take a look at this study. It has to do with sodium levels and breastfeeding success. It found that women with elevated sodium levels in their milk had babies who didn't feed well, ex. they couldn't latch on, didn't feed at least 8x a day. It is not that these women had an inherent inability to produce milk. On the other hand, women with normal sodium levels almost always were successful at breastfeeding. The few exceptions were women who truly were unable to produce enough milk, such as women with previous breast surgery or with hypoplastic breasts. Anyway, here is the study:

    http://pediatrics.aappublications.org/cgi/reprint/93/5/802?ijkey=0a77d1f241264fe1d86fec9c4da064c6d8c5e1e0

    Emily

  11. @ Amy – I took a very intensive Bradley course that made it very clear that one of the main reasons to avoid interventions is to establish successful breastfeeding. Our instructor made it very clear that breastfeeding was natural and that supply issues were unlikely and overblown. “Because, we've been doing it since the beginning of our species.” Not much help when you find yourself unable to BF due to low supply.

  12. Very interesting post. I have lots to say on the clinical side, but for now I just want to address your comments on the “booby trap of not alerting moms to potential lactation complications”.

    I have conflicting feelings here because, while I agree that there needs to be better research/professional education around lactation, I disagree that preemptively discussing rare breastfeeding scenarios is particularly useful. Imagine you're at your childbirth class and the instructor starts a general conversation of potential birth defects. Would you find this helpful, or would it just add to your existing fears and worries? And (heaven forbid) what if your baby is born with one of these defects; do you find comfort in the fact that you already knew this was a possibility?

    Most first-time moms I meet have very little basic breastfeeding knowledge before they deliver, and even the best breastfeeding classes can only scratch the surface of general topics. I'm absolutely in favor of explaining common breastfeeding challenges, but it's simply not possible to discuss every breastfeeding scenario with new moms (as an aside, the primary clinical textbook I use on breastfeeding is nearly 900 pages http://www.amazon.com/Breastfeeding-Human-Lactation-Kathleen-Auerbach/dp/0763705454 – where would I begin addressing all of this info?).

    Breastfeeding medicine/lactation consulting is still very much in its infancy as a profession and more research into clinical breastfeeding issues and the science of lactation is imperative. As is the case with any medical specialty, not all professionals are created equal in terms of their knowledge base/bedside manner/teaching abilities. I see many hospitals put nurses with virtually zero specific lactation training in charge of teaching breastfeeding (hello booby trap!). I'd like to see more breastfeeding education for medical professionals working with moms and babies so practitioners can better understand normal nursing behavior, identify potential red flags before they escalate and refer moms to qualified lactation consultants when there is a real problem.

    In summary: yes, we absolutely need more lactation research and professional education, but I don't think broadcasting a message that something might go wrong is ultimately beneficial.

  13. @Kate/lactivista,

    I see your point. Maybe you're right – it's not so much a question of “broadcasting” it or making it out to be a huge public threat or anything; it's more about ensuring that doctors, nurses and LCs are aware and properly trained about these issues. My fear is simply that due to the current state of our healthcare system, women/babies are going to slip through the cracks…

    One of the studies I mentioned above suggests that it be standard practice to see breastfed babies or any children exhibiting certain symptoms (or weight loss) between 3-5 days postpartum, in order to “check in” and make sure everything is going well. This seems like a good first step to me, and I think it is pretty much standard in the States. But we need to make sure that these aren't just wham-bam visits – maybe we could meet with the staff LC at that time, too, and have it covered by insurance, or for free?

  14. “In summary: yes, we absolutely need more lactation research and professional education, but I don't think broadcasting a message that something might go wrong is ultimately beneficial.”

    In one sense I agree – I don't think we need to tell every person about every single little thing that could go wrong. It's like telling people about a rare birth defect that occurs in one in a billion people.

    On the other hand, I completely disagree – my first breastfeeding experience I KNOW would have gone better had people told me about the challenges and not the hearts and flowers. Too much bad lactivism is thrown at first time mothers in hopes of not scaring people off. But in doing so I think you very much set people up for failure if you don't tell them how hard it's probably going to be. Because with a few exceptions, most of my friends have had challenges breastfeeding. Easy is NOT the norm. And these are people in an area where breastfeeding is encouraged – we almost all do it. The local hospital where most of us deliver is extremely pro-breastfeeding. They have wonderful lactation consultants. Most of our pediatricians have them on staff.

    And in telling people about the challenges, I do think things like low supply should be discussed, because it's more helpful than harmful. Better to tell a mother, oh, I see you have low supply, let me help you breastfeed as much as you can and then you can supplement, no biggie – than to make them feel like they failed somehow. If people see low supply as not being something uncommon, something to make them feel weird or like they failed, I think they'd be a lot MORE likely to keep breastfeeding.

    Frankly, the only reason I'm succeeding at breastfeeding now is because of my own experience as a mother and the fact that I ignore lactivists for the most part. I don't need them or much of the judgment that goes along with them. But that kind of confidence only came to me as a second time mom. Too bad I wasn't the same way the first time around.

  15. @Mel,

    Also excellent points. I have to say that I had much the same experience – where I live, the hospitals are very pro-BF, we all took the classes, had a lot of community support… and all but two of my friends had major issues (low supply, recurrent mastitis, latching trouble, FTT, etc). It does seem more the norm than the exception. And yet the lactivists I've talked to tell me that these problems are rare or overblown. It is confusing.

  16. @FFF I think a lot of moms and babies are falling through the cracks under the current healthcare system. Many insurance companies see breastfeeding support as non-essential/elective (how is feeding a baby non-essential??), so moms struggle over whether or not to pay out-of-pocket to get the professional support they need. Last year, the California Gov. vetoed a bill that would have made visits to LCs covered by insurance. Disheartening to say the least.

    @Mel I agree that the message “breastfeeding is the most natural thing in the world” isn't particularly helpful. I'm much more inclined to tell new/expecting moms that the first few weeks of nursing can be challenging and to make sure they have a good support team (partner, friends who breastfeed, knowlegeable pediatrician, and lactation consultant) in place before giving birth to help navigate any difficulties.

    I'm sorry to hear that that you didn't seem to have very good breastfeeding support with your first baby. While I agree with your thoughts on being candid and open in acknowledging a mom's particular (and very real) challenges, I often see a disconnect between the breastfeeding advice given to a mom and her actual takeaway. An hour-long consult on a practical strategy to help a mom struggling low supply is later summarized as “the LC said I couldn't make enough milk”. Does that make sense? It's exactly here where counseling the nursing mother becomes an art rather than a science.

    On a final note, it really saddens me to hear broad generalizations of lactivism by people who've had a negative experience/felt judged by one or two individuals. The vast majority of lactivists I know are truly devoted to supporting all moms and babies.

  17. I think that a lot of the people who take breastfeeding courses are already most likely to breastfeed, and I don't think telling them about potential challenges is going to scare them off. We spent TWELVE weeks talking about the birth, an experience that takes around 12 hours. We discussed possible challenges, options for C-section possibilities, etc. And yet, that isn't increasing these particular women's c-section rates (I know that the rate is high in this country as a whole). As an informed consumer, I would have appreciated a little more information about breastfeeding challenges BEFORE. Those postpartum days are incredibly hormonal (which I'm sorry to say you can't possibly understand if you haven't been weeping on the side of the road because the light changed too soon). I think it would do a far greater service to those who want to breastfeed to not being introduced to the possibilities of problems in those days.

    Quite frankly, I believe our breastfeeding efforts are better served in trying to encourage and maintain breastfeeding in those who WANT TO than trying to convert those who are more inclined to want to start with formula.

  18. Dammit, I had a post that was relevant, but I forgot to email it to myself.

    Anyway, Brooke: I (still) agree that the curriculum of the BFing classes should change to reflect reality a little more. You bring up excellent points about the birth class, and how mention of the challenges/complications doesn't prevent people from trying to stick to their original plan, if they can. I think the same would be with breastfeeding—knowing it could be challenging won't put most people off. We all know that birth and raising children is challenging, but we do it anyway.

    I think having a better idea of the challenges would actually help women to feel less alone, should they run into problems. If they believe that BFing is as easy as falling off a log, and if it isn't, they must be doing it wrong (and then they feel like failures as mothers, and that goes down another dark road). If they believe that BFing could be challenging, they'll probably rise to meet the challenge and know what to look for, and which questions to ask, rather than just giving up.

    So here's my idea of an excellent breastfeeding class:

    Continue to teach the techniques, which are the basis of most classes today.

    Include interesting info on how the mammary glands prepare/differentiate to produce milk.

    Explain common challenges and solutions.

    Talk about combo feeding/formula feeding, so if that choice is made, it can be made from an educated standpoint.

    Offer sources to find more information, like papers about hypernatremia for example, or anything related to lactation. Also, blogs, like this one as well as BFing support.

  19. “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?”

    This. And oh, This.

    “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.”

    Oh, you said it all for me here. Said it all.

    I don't think the answer is to sit pregnant women down and give them a full briefing on all the possible things that could go wrong with breastfeeding. But I do feel that as most women experience at least one challenge it would do the classes well to go over, lets say, the 4 most common breastfeeding issues? Just so when they happen to most of us we don't think it's 'just us'.

    But even more then the info we try to get out to women before they have their babies… we need our health care providers to be armed with a heck of a lot more information. And that information should be shared with women up front. I should have been told by someone that my PCOS did put me at risk for issues breastfeeding. They should have been ready with possible options that had been studied to work on people with my medical history. There is no excuse for the lack of information out there.

  20. This issue about giving/not giving women honest breastfeeding information really hits home for me.
    I took a breast feeding class and sadly, it really was no help at all. The best part of it was that I already knew the lactation consultant (she was great, by the way) who helped me in the hospital because she taught the class. My baby had major trouble latching on and everyone I saw (multiple lactation consultants included) all had different ideas and nothing really worked. In class the LC made it sound pretty easy, that I might be sore for a while, but it shouldn't really hurt. The only problems she mentioned were engorgement, mastitis, tongue tie. No mention of potential low supply problems, latching difficulties that persist past 1 month, thrush infections, newborn nursing strikes, feeding aversions, etc.

    No one told me it would/could be AWKWARD, PAINFUL, EXHAUSTING,(mentally, emotionally and physically), DIFFICULT, (I was constantly taking my baby on and off the breast to try and fix her latch)…etc. I eventually made the choice to pump and bottle feed and it was a truly a relief for us! If only someone had warned me, maybe I wouldn't have beaten myself up so much. I felt all the problems were my fault because I clearly couldn't do it right. Not in any book or website did I find any mention of the problems I was having, let alone possible solutions. I was alone. I was a failure.

    We need to let women know that breast feeding can be (and commonly is) HARD. We need to mention specific problems and help them find more detailed information if they need/want it before the baby comes.
    With all the information (or at least a honest heads-up) we can prepare women to be more successful when problems arise. It's a bit ridiculous to think that if we tell women it's hard and they may have A or B difficulty, they won't do it. We are all fully aware that raising a child is hard and we are obviously doing it anyway.

    Will this knowledge and experience stop me from trying to nurse subsequent children? No. I will be more prepared to tackle problems. I'll still try my best and who knows, maybe the next time it will be wonderful.

    I for one, wish someone would have trusted me enough to tell the truth. Knowledge is a powerful thing.

  21. I agree, this information should be upfront. The difference between this and educating upon birth defects is that when a birth defect is diagnosed, the support is tremendous. This is not necessarily true in the case of breastfeeding. And mom's emotions surrounding nourishing her infant should not be the field where political battles are waged.

  22. You don't want to scare pregnant women with ALL of the possible complications. But I do think breastfeeding information could be targeted to women who are at higher risk of particular problems. An obstetrician who is aware of a patient's PCOS could point them towards information that could help them prepare better, for example.

    A really simple example is the relationship between antibiotics during labor, and thrush. I had antibiotics (for strep B) during labor with my first child. As we passed the 2-week breastfeeding mark, the pain was getting worse instead of better. I put it down to latch problems (which were true), and worked on correcting those, but it just got worse and worse. Finally found out at 5 weeks that I had thrush. Which was fairly quick & easy to treat, thank goodness. The LC mentioned that the antibiotics might have contributed.

    I would think it would be fairly simple to include a warning, for a patient who is intending to breastfeed and has just had antibioitics during labor, that thrush is something to watch for. How to recognize it, and how to treat it. See? It's simple. Target the information on complications to the patient most likely to need it. It could be a simple information sheet that is passed out to anyone who receives antibiotics.

    With my second baby, I again had antibiotics for strep B during labor. I'd also had 2 courses of antibiotics in the previous month for bronchitis. Again, no warning — but this time *I* knew. Thrush hit hard and fast, but I was prepared and caught it right away.

  23. I am so loving this blog. It's so much good information and reflective comments. The thing that's bugging me though is: how do you get this information out to pregnant women, who can use it the most? It seems to me that many women take breastfeeding classes as part of their maternity education, but a system isn't in place to truly be supportive of prospective nursing mothers.

    As I read through many of the comments, I'm struck by the hospital policies that many mention. I had my first son at a birthing center and my second at home with a midwife. Both the birthing center had my midwife had 100% breastfeeding start rates, and over 95% at a year. It makes me think that the current medical paradigm really isn't that supportive of breastfeeding, which, when successful, has a lot less to do with scheduling, latching and technique, but with relaxation, confidence, and support.

    Regardless, I think mamas as a community (whether breastfeeders or formula feeders) need to come together and figure out together how to create a positive mothering environment for us all.

  24. @Mama Eve,

    Thank you SO much for your lovely comments! I am always thrilled when I hear from women like yourself who are truly out there to help other women. It's amazing and deserves so much respect.

    I agree with you that our hospital policies are not conducive to breastfeeding success. That's my issue with the “baby friendly” initiatives – I think they are missing the forest for the trees. Having formula around didn't make things hard for me; it was the complete isolation I felt after giving birth, coupled with the intrusions of unfriendly doctors/nurses who came in, didn't talk to me, and checked my stitches or whatever… the LCs weren't particularly helpful, and the nurses were dismissive. We were given no guidance on anything, but also expected to “fulfill” certain criteria, like a sheet documenting how long our son fed and when… but without any help getting him to feed in the first place.

    I don't know what the solution is, b/c so much of it comes down to the state of health care in the US and other countries. I would LOVE to give birth at a birthing center, if my insurance would cover it. It sounds like bliss. 🙂

  25. @ Mama Eve-
    The challenge is that women who deliver in a birthing center or at home are low-risk and a specific population, so there will always be skewed statistics, you know? I know that there are other factors contributing to lack of breastfeeding success, but I don't think it's just that all women can do it or that “relaxation, confidence, and support” will solve some of the real problems that new moms face.

  26. FFF- Do you know which country has the highest rates of assisted conception? Do you know how our rates of fertility treatment compare to say, the Dutch? After getting all worked up about the Babble post, I started wondering if part of the reason that the U.S. sees higher BF failure rates is because there is more done to help those conceive who might otherwise not have been able. It would be interesting to look at the comparison of fertility treatments with breastfeeding success internationally.

  27. Brooke–I would also be interested in that info, but factors to consider:

    1)why the couple in question was infertile? If it was the man, then obviously, he will have no physiological impact on her milk supply.

    2)Regardless of which partner was infertile, IF treatments often lead to multiples, which come with greater risks during the pregnancy (GD and pre-E, for example). So, if a woman gets pregnant with multiples through some infertility treatment and ends up with GD or pre E AND has BFing issues, which could be related to GD or pre-E, the infertility RX is only responsible for the lactation failure in a roundabout way.

    3)Thinking about FFF's latest post, about stress, I think infertile couples are more stressed before conception, possibly moreso during pregnancy (either for fear of loss, or because of multiples) and possibly more after the birth, for any number of reasons. If stress is a big player in lacation failure, would we see higher numbers of stress-induced lactation failure among infertile couples? If so, would we include that data in the infertile lacation rate set?

    4)Would we break down the data by reasons for infertility? If we put all the women with known hormonal issues (hypothyroid, PCOS, POF, pituitary tumor, LOCAH) in one group, maybe that would give us a clearer picture of hormonally based IF vs. lactation rates?

  28. Hi – just found your site – really appreciate it! I think you hit just the right tone on an issue that all too often becomes a virtual shouting match between camps (that aren't really in opposition, but somehow end up acting like it anyway).

    I really liked this post and think that you're right about playing straight with pregnant and new moms.

    I probably would fall a bit more to the side of some of the commenters who argue that we don't need to tell new moms about ALLLLL the problems, but the really common ones would be nice.

    I know there were many breastfeeding sessions during which I wanted an LC to punch for saying “it shouldn't hurt if the baby is latched correctly!” O.rly?

    And as another commenter so perfectly said – we spend weeks and weeks discussing birth (which lasts not-so-long, hopefully) and which will happen regardless of what we do, and like 5 seconds on breastfeeding (which doesn't have to happen) and dealing with other postpartum and childcare aspects. The balance is way off.

    I would have appreciated some preparation – just a gentle, but strong and caring voice to say: “This might work out perfectly and easily for you, however, it also might present a significant challenge to you and those challenges could last for a few days, a few weeks, or even the next few months. It WILL get better in most cases, but you might have to fight like hell to get there. It might hurt. Your child might want to feed for hours at a time because she's not good at eating yet. Our culture doesn't support what your baby probably wants to do. So you get to make a decision about what is best for you and for your baby. If you stick it out with exclusive breastfeeding, I'll always answer the phone when you call with problems or just need to talk it out. If you switch to formula, I'll help you get that right too. If you want to do both, we'll work on that. And if you want to pump, we'll deal with those challenges as well. But you love your child, you know it, I know it, your child knows it. And that's what will make any decision you make the right one.”

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