FFF Friday: “I’m grateful to the midwives who stepped out of line with hospital policies to connect with what was really going on…”

Last month, I received a PM from a woman named Sarah. She wrote: 

“It is hard to describe how depressed and lost one feels when someone takes it upon themselves to remind you of how exclusive breastfeeding halves the risk of SIDS, when they know you will be formula feeding. And when you tell them you don’t have a choice they just keep reiterating. As though you are choosing to kill your baby willfully and wantonly. And you start to doubt if you should even be a mother at all if you can’t breastfeed exclusively. It’s a lonely place.”

My heart broke for her. She was expecting her baby in the next few weeks, and I hoped against hope that when he or she arrived, all this self-doubt would wash away. 

And then, yesterday, she sent another message. She agreed to let me share it as an FFF Friday of sorts, even though that wasn’t her intent. I share this not to scare anyone who is currently expecting, because when Baby Friendly is done right, it can be a really positive experience. I share this to show that when Baby Friendly is done wrong, it’s done very wrong, and we can’t allow the good to overshadow the bad. It doesn’t matter that 20 women have a good experience if 5 are put through this kind of hell, because this kind of hell is inexcusable. End of story. And if anyone thinks what Sarah went through is acceptable, I doubt their opinions are malleable or their empathy is intact, so there’s no real reason to debate about it. 

Happy Friday, fearless ones. 


** Please note – the names of everyone involved in this story have been changed, and the author refers to her baby as “they” rather than her or him to protect the child’s identity as well. Just so you don’t think she had twins! : ) ** 


Sarah’s Story

My baby, R, was two weeks old at 9.31pm two nights ago. Yesterday I lay next to them on our bed, watching them sleep and kissing their teeny tiny face, their squishy belly, their downy head and relishing them. I am still getting to know them, and our bond is still slowly growing as each day passes. Formula is largely responsible for being able to connect with them like this.


I would like to tell you about my experience so far of motherhood and feeding my baby while it remains fresh in my mind, because formula is at the centre of my story; formula and my breasts, and the both truly negligent and outstanding care I received – all within the same hospital.


There’s background to how feeding and by association, attachment, has gone down for me. I have a difficult history around fertility and mental health. I had two traumatic miscarriages before this baby was conceived, and their conception happened after painful, invasive fertility testing. A lot of emotions rode on the creation of their new life, and my pregnancy with them felt heavy every day with fear of loss. I found it difficult to connect with them as they grew inside me, and sought counselling to help me do so.


I also have mental health issues that I take daily medication to treat; medication that, while it does an excellent job at keeping me functional and well, passes into breast-milk, with unknown long term consequences for breastfed babies (not enough studies have been done, and even short term studies are limited in number and scope). Women who take these medications are generally advised to limit breastfeeding or use formula, though that information varies depending on who you talk to. The idea that breast-milk is the elixir of life weighs heavily in the “risk vs benefit” equation which means I’ve been told by some doctors that breastfeeding would be “worth it”.


After months of discussion with my husband (who has always maintained that breastfeeding or using formula was ultimately an issue of bodily autonomy and thus, my choice – I highly recommend being married to a feminist) I decided I wanted to breastfeed a little bit after our baby was born, but mostly use formula and let my supply dwindle naturally. This was for two reasons: so I could get enough rest to mitigate the likelihood of developing post natal depression and post puerperal psychosis, which I was in a high risk category for, and to minimise how much exposure our baby was getting to my medications.


The circus around advocating for this feeding plan began well before I gave birth. I raised it with one of the midwives handling my antenatal care and she refused to tick the “not breastfeeding” box on my antenatal card, insisting I speak to the lactation consultant. I left the appointment angry and disheartened at being patted on the head in this way. However, this LC was wonderful; she listened to my concerns, and said she would work with me to teach me how to bottle feed, and how to express colostrum which I was still keen to give our baby – provided I get advice saying it was safe to do so (I did). I spoke to a leading expert who recommended I breastfeed more than I was comfortable with (because breast is best, of course) and met with the LC again, who wrote a plan that included pumping – which I’d also never wanted to do -and demand feeding during the day, using formula at night to assist sleep. This was the start of the parade of conflicting, confusing and ultimately destabilising advice around feeding that marked the next few months.


My labour with R was long, intense and difficult. I didn’t eat or sleep for three days and was in labour for around 30 hours, with my waters breaking, my labour stalling and ultimately being induced with syntocin when everything stood still. By the time my little one was lifted onto my chest – a purple, heavy, wet and warm tiny human still attached to me by our shared cord that pulsed with lifegiving blood – I was completely exhausted. But they were here, finally, after so much fear that we’d never meet. During that first hour of skin to skin, they had their first breastfeed. Looking into their face in that moment I felt such a rush of love and contentment that I’ve never experienced before and don’t think anything will ever rival again.


I wish I could say my stay in hospital ended on such a high note; unfortunately it didn’t. I was transferred to the post natal ward for a long stay, with my husband staying on the fold-out beside my bed and R in a tiny cot on wheels at the end of my bed. Nobody in those first couple of days seemed to put two-and-two together and note my mental health history, detailed in my file, and the fact that I hadn’t slept at all in days. I was, as we say in Australia, completely knackered – but I’d anticipated this happening, having brought in seven syringes of precious colostrum I’d expressed ante-natally for my husband to drip feed R, and thinking we could use formula as well. Right? Wrong.


Our precious syringes of colostrum were (apparently accidentally) defrosted all at once. What was supposed to last days had now to be used up in the next 12-24 hours, which scuttled our plan. Then, the first nurse I asked to make up a bottle of formula so I could get some sleep flatly refused. I didn’t know how to reply. She said she’d only give the remaining expressed colostrum I’d brought and when I expressed concern that this wouldn’t be enough to feed our baby she said I’d just have to wake up and express more and the baby would have to “make do with a snack” and I’d have to have a shorter sleep. Beyond tired, I agreed and walked back to my room wondering what had happened. Hadn’t they read the lactation plan our LC had written?


Over the next few days I was awake every few hours, wildly expressing, and trying to latch a hungry baby on to nipples that increasingly felt razor-shredded with shaking anxious hands. I had loved that first breastfeed and had such confidence in our plan, but now I was doubting myself, and hating breastfeeding on demand. Eventually we found a midwife that would make us up a bottle of formula but I now felt I was doing the wrong thing by giving R a bottle. A different LC visited and heavily encouraged breast-feeding even though I kept mentioning the lack of longitudinal safety data surrounding my medications. My sleep debt was growing and so was my despair at our plan going out the window.


On day three the baby blues hit, compounded by sleep deprivation, and I felt my attachment with R withering away. I didn’t want to touch them or look at them or tend to them because every cuddle had now become about providing food – and it hurt, and I struggled with the latch, and I was so so worried about how much of my medication was coming through in my milk. Expressing so often encouraged my milk to come in, big time, and soon I was painfully engorged and living with ice packs down my bra to deal with the excruciating sensations. I was not coping.


Day four came and I was officially a mess. The tipping point came when I sat on the bed watching my husband have a long, warm, stress-free cuddle with our baby while I was hooked up to the pump feeling like I was going to pass out from lack of sleep. I began to cry in that ugly-cry way you do when you feel like you’ve hit bottom. My husband began to cry too. And this is where one heroic midwife entered the picture.


Jill* walked in at that exact moment to do some observations, and seeing our faces and our tears, nestled herself into the armchair by the window and asked “what’s happening?” I explained how tired I was, how this was never our plan, how much I hated pumping, and how I felt I was losing my attachment with my baby and it scared me. She listened as I spilled forth my distress in an angry rush, and paused, considering my words carefully and choosing her own just as carefully. This after all was a Baby Friendly Hospital and she was supposed to recommend breastfeeding.


She told me then the following: breastfeeding is not motherhood. Motherhood is about so much more than how we feed our babies.


She then went on to recommend I stop breastfeeding or dial it right back, and switch to formula. She said it was time to take the stress out of feeding and that I really, really needed to get some sleep ASAP. She also said she was going to call one of the obstetric doctors and someone from the psych team to come and talk to me because she was worried about how things were going mental health wise for me.


The doctor came first after being called and brief on the situation, and there are no words to describe how negligent and inadequate she was in how she handled her care of me. When she walked in I was curled up under the covers, having cried continuously for hours and still going.


She tried to get my husband to leave the room (which by instinct I didn’t allow – and am so glad I didn’t). He sat close by, holding R and listening. She then launched into a rehearsed sounding spiel about why breastfeeding was best for babies and why formula was detrimental. I felt myself inwardly curl away from her – she was not here to help, it was very clear. I said I needed sleep, I was not coping and she replied in a patronising tone “you do know that someone needs to feed the baby every four hours, whether you’re breastfeeding or using formula, don’t you?”


What a ridiculous, insulting question – as if I had intended to starve my baby? As if I didn’t have a perfectly capable partner sitting beside me, also quite able to hold a bottle and feed our child? Clearly, in her view, feeding was entirely the responsibility of mothers. I was pretty pissed off at that point, which only intensified when she turned to my husband and said “and how do you feel about your wife stopping breastfeeding?” My husband arched his eyebrows so high I thought they would pop off the top of his forehead, and replied bluntly “I feel like it’s her choice, not mine.” She then read some compulsory questions in a bored tone off a piece of paper like “have you had any thoughts of harming yourself or your baby?” and then when she’d ticked all her boxes, she left. I was in even worse shape, now full of rage.


Then someone visited me from the psych team. He was wonderful. He suggested that formula was the best, safest option at this point and he pieced the last week together for me. The long labour. The three days with no sleep or food. The difficulty breastfeeding, the stress from pumping, the concerns about medication, the continuing lack of rest…as well as worries about our baby being jaundiced and having some investigations on a sacral dimple over their lower spine (all of which turned out fine). With all of this laid out, he said it was understandable that I wasn’t coping.


He and our midwife Jill suggested that we send our baby to the Special Care Nursery overnight so we could both “reset” ourselves with a full night of sleep. We were both pretty horrified by the suggestion that we have our babe removed from our care so young…and I felt like a failure for things having gotten this far. I didn’t want to agree to this. We both initially said no. Eventually, after a lot of discussion, we agreed – knowing that if we didn’t, things would probably get worse.


Leaving my baby in the nursery that night with the very kind, gentle nurses who would attend to R while we were apart was easily the hardest thing I’ve ever done. After nine months of fearing I would lose them, of thinking miscarriage or stillbirth would rip us apart, it had turned out that my mental health (or so it felt in that moment) was what had done it. I sat clinging to R before walking away, unable to look at or speak to the nurses with fat hot tears rolling down my face. How had we gotten here? Once we were back in my room I was given two sleeping tablets to calm me down and sent to bed to sleep. We picked R up at 6am the next morning, practically sprinting back to the nursery.


Now with some sleep under my belt, I was able to function again and advocate properly for myself. Everything looked better and I could think clearly for the first time in about a week. I knew then that I wasn’t going crazy; this wasn’t my fault. It was about the feeding and the sleep, it wasn’t about me.


After that everything improved. Another wonderful midwife – Harriet – took to the task of teaching us to bottle feed properly, showing us tips and tricks to do it well. We researched, we read, we tried to learn what we needed to know to move things forward and away from the dark place we’d been in as a family and to right what had felt like a sinking ship. Jill had barred the useless second LC from visiting again and unhelpful people were kept away. My fantastic parents wholeheartedly backed our decisions, and gave us lots of pep talks.


We’ve been at home for two weeks now. We are formula feeding 95% of the time, but I sometimes breastfeed because I want to, for a burst of ten minutes a day, once or twice a day. I lay down on the bed to do it, as it makes for an easier latch. I stop when I get frustrated, because that time is precious and intimate and I do not want it to be marred by anxiety. Such tiny periods of time also limit any effects from my medication and mean my supply is slowly fading away, and I’m getting my head around that. I know it’ll stop eventually, and I’ll find a way to be ok with it. I’m working on my bottle feeding technique, and using that time for attachment, looking into their eyes, kissing them, chatting to them. Just getting to know each other.


Reflecting now on the turbulence of that first five days, and how it nearly wrecked me, I am overwhelmed with both anger at some of the care I received around feeding, and gratitude for the midwives who stepped out of line with hospital policies to connect with what was really going on, and helped me. There’s a Carl Jung quote which feels so apt here – “Learn your theories well, but put them aside when you touch the miracle of a living person.”


If only more health care providers could set aside their theories when they touch each mother’s nuanced, lived experience, so many more women would be flourishing as mothers rather than falling apart. Hell, if they even just read the file, that would be a start. As it is, I’m going really well now, and repairing the hurts my bond with my child sustained in that first five days. It could have been very different for me if it hadn’t been for Jill though; and this is what is core to my story.


Every midwife, every doctor, every LC, should be like Jill. Promoting feeding that sustains and nourishes the child, the mother, and the bond between them – not forcing both of them into a slow-motion train-wreck neither may survive. Thank goodness for the rebels. Maybe one day they’ll be the norm.


Share your story, Email me at formulafeeders@gmail.com


FFF Friday: “My real argument is my son’s life.”


Welcome to Fearless Formula Feeder Fridays, a weekly guest post feature that strives to build a supportive community of parents united through our common experiences, open minds, and frustration with the breast-vs-bottle bullying and bullcrap.

Please note, these stories are for the most part unedited, and do not necessarily represent the FFF’s opinions. They also are not political statements – this is an arena for people to share their thoughts and feelings, and I hope we can all give them the space to do so. 

Before you read Reese’s story, I want you to do me a favor: look at your children. Reflect on their beauty, their quirks, their uniqueness. They are people – not petri dishes. They have worth beyond their statistical probabilities, beyond what your choices for them represent politically. And realize that you are not a petri dish, either. All the studies in the world can’t tell us the first thing about your story, your worth, or what is in your heart.

Now read the story below, and welcome the chills you’ll get at the end (and they will come, I promise). 

Happy Friday, fearless ones…



Reese’s Story

I might be the ultimate target for mommy judgment.  I divorced, got pregnant, and remarried at the age of 37.  I was induced at 37 weeks, then went straight to a C-section when the baby’s heart rate and my blood pressure plummeted.  Now my one-year-old son wears disposable diapers and rides in a stroller and sleeps in a crib.  He eats store-bought baby food and drinks formula.  We feed him when he wakes at night, though his pediatrician and half the internet says we should have sleep-trained him by now.

Before your fingers start itching to type, before you act on that “oh no, what if SHE DOESN’T KNOW?” feeling, before you decide it’s your responsibility to educate me, let me tell you the worst part.

I exposed my baby to prescription medication in utero. And if I’m astonishingly lucky enough to have another child, I’ll do it again.

But anonymously on the internet is the only way I will ever discuss this, outside my immediate family.  Only my doctors know.

The other day my husband was talking with a pregnant mom who wanted an all-natural pregnancy, but her headache got so bad she took a Tylenol.  She felt horribly guilty.  My husband wanted to say, “you’re totally fine.  No, trust me, you’re FINE.”  But then he would have to explain what he meant.  So instead, I’ll take this space here to explain.  Maybe some other mom who is feeling horrible will get some comfort from my story.

My son is almost one year old.  He’s achieving milestones, getting into everything, and showing signs of being an opinionated, fiendishly clever little guy.  Strangers comment on his huge eyes, always watching and absorbing everything.  He plays peekaboo and climbs on the furniture and yells “di di di di!” chasing the dog.  He “plays” piano and sings along, he giggles at jokes, he loves strawberries, and he’s obsessed with opening and closing doors.  While he’s on the small side (25th percentile), I can’t really call that a problem because I never broke the 5th percentile when I was growing up.  He’s doing a pretty darn good job of growing, given his mom’s genes.

Unfortunately my genes also gave me an unrelenting chronic disorder, one that I’ve had my entire adult life.  I always assumed I’d never be able to have kids.  I’ve earned a Ph.D, taught at a university, managed employees and programmed computers and raised funds and conducted research, all while taking the heavy-duty medication that keeps me alive and functional.  But I never thought having a baby would be among my accomplishments.

Then I met a wonderful high-risk OB, probably the best doctor I’ve ever seen (and I’ve seen a lot).  She said my hormone levels didn’t look good, that I’d likely have trouble conceiving.  But then she said “actually, we can work with your medication. We would start tapering in the second trimester, and get you down to as low a dose as you can handle.  If the baby is born with signs of drug dependence, the neonatal team knows exactly what to do, and we’ll get you both through it.”

My boyfriend and I knew we didn’t have much time.  Armed with confidence from the amazing OB, we got engaged and skipped birth control.  I got pregnant on the first try.

During pregnancy, I was able to taper down to just over half my normal medication dose.  It darn near killed me, but I did it.  Then I had to deliver three weeks early because my baby was measuring small, which might have been drug-related and might have just been his genes – we’ll probably never know.  After my son was born I had to adjust back up to my normal level, so breastfeeding was not an option.  I never even considered it.

My son had one sign of neonatal abstinence syndrome: he had a little diarrhea the first few days, but he was breathing and eating well, never developed other symptoms, and never had to go to the NICU for extra treatment.  This is the last thing you might expect to hear from a woman with a C-section scar, but his birth went as well as we could have dared to hope for.

His pediatrician says there are no controlled studies on exposure to this particular medication.  The anecdotal literature suggests a slightly higher risk of dyslexia and learning disability.  If our son turns out to have a learning disability, we’ll handle that as it comes, like any parents would.  I’ve seen students with learning disabilities graduate from college, maybe even some whose mothers had risk factors before they were born.

Don’t get me wrong, I’m right there with the lactivists in condemning corporations marketing formula over breastfeeding, especially in developing countries where water quality is iffy.  Especially when they could have spent those millions of marketing dollars on donations that actually feed starving people.  At the same time, I will always be thankful that formula is readily available.  If formula were outlawed or locked away by a well-intentioned but inflexible “breast is best” initiative, I would never have attempted pregnancy in the first place.  My son – with his curls and big saucer eyes, his sneaky attempts to escape through the doggie door, his personality quirks, his squeaks of excitement when he learns he can pull himself up on the furniture – would never have existed.

We humans need rules to make sense of the world.  We want to nail down moral absolutes – breast is always best, prenatal drug exposure is always unforgivable.

But when I read that first comment on Suzanne Barston’s contact page, when I read “If a mom isn’t willing to do the best possible thing for her baby, then why even have a baby”… I realized, I can’t combat that kind of ignorance with a post on the internet.  This post isn’t even my real argument.

My real argument is my son’s life, as he grows up and makes his way in the world, and maybe even makes the world a better place because he was in it.


Feel like sharing your story? Email me at formulafeeders@gmail.com.


FFF Friday: “Formula is fun”

Welcome to Fearless Formula Feeder Fridays, a weekly guest post feature that strives to build a supportive community of parents united through our common experiences, open minds, and frustration with the breast-vs-bottle bullying and bullcrap.

Please note, these stories are for the most part unedited, and do not necessarily represent the FFF’s opinions. They also are not political statements – this is an arena for people to share their thoughts and feelings, and I hope we can all give them the space to do so. 


I think Amanda Koppelman-Milstein, the author of the following post, should make a video of her “Formula is Fun” song and put it on YouTube. 

Just sayin’.

Happy Friday, fearless ones (and for once, you might actually feel happy after reading an FFF Friday rather than wanting to stick your head in the oven, thanks to Amanda’s awesome sense of humor),



 Formula is Fun

by Amanda Koppelman-Milstein

When it turned out I could not exclusively breastfeed, I felt that I needed to launch a mini-publicity campaign for my son so that he would appreciate the benefits of formula. No sucking on manure-contaminated goat’s teats, being farmed out to wet-nurses, or starving to death for my baby—formula exists! We live in a community saturated with breast-is-best messages, and I didn’t want him to feel inferior. In addition, I wanted to cheer myself up in the face of well-meaning advice about increasing my milk supply that made me sob uncontrollably. As I prepared the bottle of formula for my baby’s three AM feeding, I sang my son one of the pro-formula songs I wrote for him:

Breast is best but formula is fun!

Breast is best but formula is fun!

Formula is made by giant evil corporations

But without the formula, you would face starvation.

I had always imagined myself breastfeeding my kids for years, giving them all possible benefits they could obtain from breast milk regardless of the costs to modesty or sanity. Unsurprisingly, I had never dreamed of singing “Yakety Yak (Similac)” while cleaning bottles and praying for a bigger milk supply. However, when I got ulcerative colitis in my second trimester of pregnancy, it became clear that at some point, post-birth, that I was going to want to take some drugs that neither I nor my doctor thought were compatible with breastfeeding. I thought I’d try and get a few months or weeks in of exclusive breastfeeding in before what I referred to as “bringing in the good drugs,” but it turned out I made next to no milk.

In the weeks after he was born, my dedicated son nursed for up to twenty hours a day. My husband held him to my body as I attempted to sleep. After five consecutive hours of nursing, he was still rocking his head back and forth and screaming in hunger. My mother, who was staying with us, announced that this was actually not how breastfeeding was supposed to go, and called in a lactation consultant who arrived the same day our pediatrician said it was time to start supplementing with formula. The lactation consultant mixed him his first bottle, and told us our first priority should be getting our kid fed, and that I had many risk factors for not making enough milk.

We decided to partially breastfeed and hold off on my treating my colitis properly for a few months. Waiting wasn’t a brilliant decision in terms of my own health, but I found breastfeeding addictive. It made the baby so happy! It was so snuggly!  It made him stop crying! It made him go to sleep! It was magic.

Not being able to breastfeed him fully made me feel inadequate. My husband grew entirely bored with the nights when I sat around pumping and crying, saying “We are so fortunate that we have a healthy child (sob). I am so grateful that he is so wonderful and that you are so wonderful, I just wish we didn’t also have to use (sob) formula.”

“WAHHH!” added the baby,cheerfully sucking on whatever was presented to him.

While breastfeeding is magic, formula has a certain amount of magic to it as well. There is a reason public health campaigns need to push breastfeeding in a way they don’t need to push activities that are more compatible with working, sleeping, eating, or running to the subway. Formula is, to some extent, fun. You can give it to the baby anywhere without taking your boobs out, which is endlessly convenient at funerals, police stations, and other places where wearing a shirt is just objectively better. 

I didn’t think I was the sort of feminist who thought formula feeding was good for feminism–I always thought that was an extremist point of view that disregarded the health of infants–until I experience the joy of my husband being responsible for half of the night feedings, and saw what being just as good of a food source as I was did for his relationship with our son. This is not to say I don’t support breastfeeding–just that since I couldn’t, I was able to appreciate the upsides.

Eventually, I hit the illness wall and had to start weaning the baby, which he was extremely gracious about. By this point his appetite massively exceeded whatever milk I could make, and he grinned and bounced a bit when I unlatched him to give him the bottle.

His positive attitude about weaning dissipated when we ran out of the milk I had pumped and frozen before starting with my new medicine. The mainstay of his diet is a vile tasting hypoallergenic formula that turned him from a colicky grump into the happiest and most gregarious baby I have ever met. It smells like rancid mac and cheese. Once that was the only thing going into him, he began inspecting visiting females for signs of lactation, and in a moment of misplaced hope, gave my father-in-law a hickey on his arm. Even once we introduced solids, he pulled down the shirts of visiting females and looked at them as if to say, “Please, would you consider being my wet-nurse? I know this is a sensitive issue for my mom,but we could keep it just between the two of us… Have you seen this soy-free lactose-free stuff they’re giving me? Did you know breast milk is best for young babies, such as myself? Wanna give it a go?”

Due to my months of sadness about only partially breastfeeding, I am more than a little defensive about my “choice”—although I don’t really consider not trying to treat my illness in the long term or letting the kid starve to have been reasonable options. The other week a houseguest made a relatively innocent remark (“At least you got to give him colostrum”) and I ran to the other room to cry. 

Writing this now, when my son is the happiest baby to ever exist, it’s hard to channel the incredible sadness I felt when I couldn’t make enough milk and when I weaned him.  However, recently my doctor suggested switching my medicines, with perhaps a short hiatus between drug-that-has-not-been-shown-to-be-safe and drug-that-you-wouldn’t-breastfeed-on-unless-you-truly-were-insane. “I had a drop of milk come out the other day—maybe I could pump for like two days straight and then breastfeed him for a week or two and then wean him again…” I said to my husband, the days of sobbing while pumping nearly forgotten. However, after I thought about it, it seemed like instead of two straight days of pumping, or whatever it would take to restart the milk supply of someone who has done nothing milk-related for months, my time is perhaps better spent playing peek-a-boo. Formula isn’t the only thing that is fun.

Bad medicine: Why the AAP’s new statement on breastfeeding & medication is puzzling

“The benefits of breastfeeding outweigh the risk of exposure to most therapeutic agents via human milk. Although most drugs and therapeutic agents do not pose a risk to the mother or nursing infant, careful consideration of the in- dividual risk/benefit ratio is necessary for certain agents, particularly those that are concentrated in human milk or result in exposures in the infant that may be clinically significant on the basis of relative infant dose or detect- able serum concentrations. Caution is also advised for drugs and agents with unproven benefits, with long half-lives that may lead to drug accumulation, or with known toxicity to the mother or infant. In addition, specific infants may be more vulnerable to adverse events because of immature organ function (eg, preterm infants or neonates) or underlying medical conditions.”


– Source: The Transfer of Drugs and Therapeutics Into Human Breast Milk: An Update on Selected Topics Hari Cheryl Sachs and COMMITTEE ON DRUGS. Pediatrics; originally published online August 26, 2013; DOI: 10.1542/peds.2013-1985

The preceding is the conclusion to a new report released by the American Academy of Pediatrics, which has given birth to a number of ecstatic headlines – “Most medications safe for breastfeeding moms”. “Medications of nursing mothers do not harm babies”. “Top Pediatrician’s Group Assures Most Drugs Safe While Breastfeeding”. Reading these, one might assume that a plethora of new research had been released, provoking the AAP to make a blanket statement about risk and benefits.

One should read the actual report before one gets too excited.

Other than the introduction and conclusion, which basically explain that studies are limited on most medications and how they affect a nursing infant, but that the benefits of breastfeeding outweigh the risks, the report reads like one giant warning.

Let’s start with antidepressants:

“Previous statements from the AAP categorized the effect of psychoactive drugs on the nursing infant as “unknown but may be of concern.” Although new data have been published since 2001, information on the long-term effects of these compounds is still limited. Most publications regarding psychoactive drugs describe the pharmacokinetics in small numbers of lactating women with short-term observational studies of their infants. In addition, interpretation of the effects on the infant from the small number of longer-term studies is confounded by prenatal treatment or exposure to multiple therapies. For these reasons, the long-term effect on the developing infant is still largely unknown…Because of the long half-life of some of these compounds and/or their metabolites, coupled with an infant’s immature hepatic and renal function, nursing infants may have measurable amounts of the drug or its metabolites in plasma and potentially in neural tissue. Infant plasma concentrations that exceed 10% of therapeutic maternal plasma concentrations have been reported for a number of selective serotonin reuptake inhibitors…”

As stated in the first sentence of this section, the evidence hasn’t really changed from when the last AAP statement on drugs and human milk was released, circa 2001. But the conclusion sure has. In 2001, the authors advised that “(n)ursing mothers should be informed that if they take one of these drugs, the infant will be exposed to it. Because these drugs affect neurotransmitter function in the developing central nervous system, it may not be possible to predict long-term neurodevelopmental effects.” In 2013, the author states “Mothers who desire to breastfeed their infant(s) while taking these agents should be counseled about the benefits of breastfeeding as well as the potential risk that the infant may be exposed to clinically significant levels and that the long-term effects of this exposure are unknown.”(p. e799)

This is where I start getting nervous. The last thing I ever want to do is discourage someone who needs antidepressants or another lifesaving medication from breastfeeding – especially considering I personally chose to take the small risk and feed my newborn breastmilk while I was on Zoloft (one of the many SSRIs that are categorized in both reports as “Psychoactive Drugs With Infant Serum Concentrations Exceeding 10% of Maternal Plasma Concentrations”, meaning that the levels of the drug getting into a newborn via breastmilk are clinically significant and of potential concern for a growing neonate). These are the risk/benefit scenarios we often discuss here on FFF – decisions that parents need to make (and deserve to make), armed with solid information and free from paternalistic admonishments that don’t have real world meaning. But I don’t feel that the new AAP statement – or the way that the media is reporting it – is allowing for a truly informed decision.

Notice the emphasis of the newer AAP statement – the advice given is to counsel the mother on the benefits of breastfeeding first, and then inform her of the potential risks and unknowns of nursing on her medication. Anyone with a grade-school understanding of psychology can figure out what that would sound like. (“Breastfeeding is extremely important and will save your child from every ill imaginable! But I should warn you that if you choose to nurse while on Zoloft, we can’t confirm or deny that your baby may turn into a werewolf when he reaches puberty. Your choice!”)

Maybe I’m arguing semantics here, but why couldn’t they avoid the paternalism of both the 2001 and the 2013 statement and simply advise doctors to inform parents of the risks and benefits of both feeding options, as well as the risks of nursing on medications, in an accessible, understandable way? And then help them mitigate the risks, no matter what path they choose?

Moving on… painkillers. The AAP is now agreeing with what I freaked out about in Bottled Up – Vicodin and newly postpartum, breastfeeding women are not a match made in heaven. And before you post-C-section mamas beg for the Darvocet, that won’t fly, either. Turns out that infants whose mothers used these commonly prescribed drugs  for managing postpartum pain have popped up with cases of unexplained apnea, bradycardia, cyanosis, sedation, and hypotonia; one infant died from a Vicodin overdose after ingesting the drug through mother’s milk. But hey- you can take (moderate) doses of Tylenol and Advil to manage that post-surgical pain, so no worries.

Are you starting to see why “Medications of nursing moms do not harm babies” might not be the most accurate headline?

Ummm…. Herbal remedies! Those have to be okay, right? They’re natural, after all!

Not so fast, sugar.

“Despite the frequent use of herbal products in breastfeeding women (up to 43% of lactating mothers in a 2004 survey), reliable information on the safety of many herbal products is lacking…The use of several herbal products may be harmful, including kava and yohimbe. For example, the FDA has issued a warning that links kava supplementation to severe liver damage. Breastfeeding mothers should not use yohimbe because of reports of associated fatalities in children…Safety data are lacking for many herbs commonly used during breastfeeding, such as chamomile,black cohosh, blue cohosh, chastetree, echina- cea, ginseng, gingko, Hypericum (St John’s wort), and valerian. Adverse events have been reported in both breastfeeding infants and mothers. For example, St John’s wort may cause colic, drowsiness, or lethargy in the breastfed infant…Prolonged use of fenugreek may require monitoring of coagulation status and serum glucose concentrations. For these reasons, these aforementioned herbal products are not recommended for use by nursing women.”

Wait. It gets worse. You know those galactagogues you were prescribed to increase your milk supply? Flush them down the toilet, says the AAP. The safety of Domperidone, for example, “has not been established.”

“The FDA issued a warning in June 2004 regarding use of domperidone in breast- feeding women because of safety concerns based on published reports of arrhythmia, cardiac arrest, and sudden death associated with intravenous therapy. Furthermore, treatment with oral domperidone is associated with QT prolongation in children and infants.”

The authors aren’t overly enthusiastic about other galactagogues, either, and instead encourage moms struggling with supply to “use non-pharmacologic measures to increase milk supply, such as ensuring proper technique, using massage therapy, increasing the frequency of milk expression, prolonging the duration of pumping, and maximizing emotional support.”

I’ve read the report 10 times now, trying to see where they could possibly come to the conclusion that this is a game changer; that it is at all newsworthy; that this is what counts as progress. To my untrained eye, it appears to be little more than a re-framing of old information to fit in better with the “breast is best at all costs” mantra, rather than a landmark “update” of an antiquated policy paper. Based on this report, how are pediatricians supposed to tell patients, in good conscience, that there is adequate evidence that it’s safe to breastfeed on “nearly all” medications?

For most of the meds in question, it probably is safe- similarly to how the risks of infant formula are scary on paper and far less daunting in real life, I honestly believe that we’d be seeing a lot of seriously messed-up kids if your absolute risk of nursing while on antidepressants was high. Just like many of us have made carefully weighed decisions to formula feed, feeling the weight of misery in one hand and balancing that with an increased risk of ear infections in the other, so shall we handle questions of breastfeeding and medications. The problem is not with moms making choices based on the facts we have- the problem is when respected, policy-creating organizations create false narratives that render us unable to make those choices in a truly informed way.

The report leans heavily on the work of Thomas Hale and LactMed, fantastic resources for research on these issues. I’m grateful there are people dedicated to focusing on this research – research that matters so much more than yet another associative study attempting to show that breastfed babies are smarter than formula fed ones. We desperately need more research on how commonly prescribed medications affect breastfeeding infants, not so that we can “forbid” women from breastfeeding, but so that we can help them reach their breastfeeding goals. This might mean timing medications so that they are mostly metabolized prior to nursing, or pumping for some feeds, or even -god forbid- using a little formula or donor milk for the feeds that have a higher amount of the drug coming through milk (these are tough things to figure out, sometimes, as people metabolize differently, as do babies, but it’s a good goal to have on the horizon). Maybe it means finding better medications. Or it might just mean allowing parents to ponder their own risk/benefit scenarios and respecting their decisions, whatever those may be.

Before we can do that, though, someone has to remind the AAP that they are doctors first, breastfeeding advocates second. Let the science speak, not the zealotry, and maybe we can start helping parents make truly “informed” choices.


FFF Friday: “I wonder how many other mentally ill mamas fall through the cracks…”

Welcome to Fearless Formula Feeder Fridays, a weekly guest post feature that strives to build a supportive community of parents united through our common experiences, open minds, and frustration with the breast-vs-bottle bullying and bullcrap.

Please note, these stories are for the most part unedited, and do not necessarily represent the FFF’s opinions. They also are not political statements – this is an arena for people to share their thoughts and feelings, and I hope we can all give them the space to do so.

This week’s story addresses something that is often ignored or dismissed in conversations about choosing whether of not to breastfeed: mental illness. For someone who struggles with any number of psychiatric disorders, pregnancy and lactation, with all the hormonal and emotional upheaval they bring, can be downright toxic. Or, as Caitlin puts it, a “living hell”. Making the choice to formula feed can be a matter of survival; while some medications are compatible with breastfeeding, others aren’t – and it’s overly simplistic to tell women (as many popular breastfeeding resources do) that “if your medicine is contraindicated, you should probably be able to find one that isn’t”. Treating psychiatric conditions medically often requires “cocktails” of drugs; it can take years to find the right meds, the right doses, and the right combination. We can’t allow the rhetoric to drown out the voices of women who are struggling, and who are trying to tell health care providers (and other members of the peanut gallery) that breast simply isn’t best for them or their babies.

And I won’t even start in on the lack of education and assistance Caitlin was given, because it may well drive me to drink. I’m already *this* close to cracking open a bottle of wine and I still have three hours of “day job” work to do, so that will end badly for everyone. I think Caitlin’s story does an excellent job of making the point I’d want to make, anyway, so I’ll let her go to it.

Happy Friday, fearless ones,



Caitlin’s Story

I wanted to share my story – the story of someone who knew from the very beginning of her pregnancy that she would not be able to breastfeed her child.

To say that psychiatric problems have plagued me my entire life would not be far off course – I was diagnosed with bi-polar disorder at the onset of puberty at the tender age of eight. It was a long, hard struggle for me and my care providers to find just the right medications that would work for that, along with my anxiety disorder and my later-acquired post-traumatic stress disorder.

When I found out I was pregnant, that carefully-sought combination of medications had to stop. The psychiatric medications that were safe for pregnancy – and subsequently breastfeeding – would not work on their own without careful balancing by other non-baby-safe medications. In fact, they make my issues worse.

So I knew I was in for a rough haul, but never expected my nine months of pregnancy to be a living hell with daily battles against suicidal ideations. That said, my care providers knew from the beginning that it was of paramount importance that I start my medications, as one doctor put it, “as soon as the placenta hit the bucket.”

Despite the fact that it was well-known I would not be able to breastfeed my child, I was given no support or education on how to properly formula feed her. I was met with comments ranging from pity – “It’s a shame you won’t be able to breastfeed. You’ll miss out on some important bonding” – to outright derision, with one nurse even outraged that I would dare put my “imaginary” mental health problems above the well-being of my child.

At the time, I was too tired and too miserable and too out of my right state of mind to be outraged. Every time I think back on those moments, my blood boils. My care providers KNEW for nine months that I would be unable to formula feed. I spent several days in the hospital (courtesy of a crash C-section) wherein I was given no advice on how to feed anything other than the pre-packaged, already mixed formula that came, at great frustration and humiliation, from asking a nurse each time my child was hungry because they would not stock formula in the rooms.

But I endured. And my daughter endured. And everyone who was closely involved with my pregnancy knew that the best thing for my daughter was to have a healthy mother to care for her. So I tried my best to keep my chin up and remember that I was doing what was best for both me AND my daughter.

And lest I be accused of not advocating for myself, every time I asked for guidance or education, I was met with a brush-off, or a “we’ll talk about it later” or even just that withering look that said I was barking up the wrong tree. Or even just a shrug and an “I don’t know what to tell you.”

I was lucky – I had a team of mamas at my disposal who had “been there, done that” with their own children, and their children’s children. They were able to guide me and teach me the ins-and-outs of what to do and what not to do when it came to properly formula feeding my child after we left the hospital.

But sometimes – like now – I wonder how many other mentally ill mamas fall through the cracks, like I almost did? I wonder how many others don’t have that same support network to bolster them and give the education needed to properly formula feed their child? At a time when hormones and serotonin and dopamine are already imbalanced, how many other mentally ill mamas just snapped under the pressure?

I made it through – and almost a year later, my daughter (who is also lactose-intolerant and was fed exclusively soy formula) is thriving and ahead of her development, both mentally and physically. And most importantly, she has a sane mama to help her grow into a wonderful human being.

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