Friday, June 13, 2008

Breastfeeding -- Almost Always Possible

From the moment that a woman announces her pregnancy, she is bombarded with unsolicited advice and opinions from well-meaning relatives, friends, and doctors—and the topic of breastfeeding is no exception. By the time baby is born, the new mom has heard all kinds of nursing horror-stories about babies that wouldn’t latch or wanted to nurse non-stop, or moms who had to supplement with formula and simply could not make enough milk. As soon as the first difficulties arise, the mother begins to wonder whether she is cut out to breastfeed, or if she is one of the many women who just can’t successfully nurse. Given the misinformation so often recited on the topic, there isn’t much mystery as to why so many women fail to meet the important breastfeeding milestones.

Evidence of the typical nursing outcome can be seen in the CDC’s 2007 reports, which showed that breastfeeding rates were at a 20 year high with nearly three quarters of mothers nursing their babies. However, at six months of age only one third were still nursing and a mere 11.2% were following the World Health Organization (WHO) and American Association of Pediatrics (AAP) recommendations of exclusive breastfeeding for the first half year . However, despite what these statistics and mainstream knowledge suggest, almost all women (and babies) can successfully nurse.

In a Department of Health news release [May 10, 2004], several myths about breastfeeding were laid to rest. Among them, that, “Nearly all (95%) women believe that breastfeeding comes naturally to some and not to others,” and “Nearly all women (87%) believe that some women don't produce enough milk to be able to breastfeed.” These opinions were rebuffed by explaining how, like many other aspects of parenting, breastfeeding is a skill that must be learned, and that difficulty in the beginning is not a reason to stop. A direct quote from the WHO is also given, explaining, “Virtually all mothers can successfully breastfeed provided they are given proper information and support.” Although there are many mothers who did not nurse their children for a full year who believe there is nothing they could have done differently to increase their success, numerous studies support the WHO’s sentiments and have proven that outside support is a tremendous influence on duration of breastfeeding.

The Journal of Human Lactation reported in their March 2008 article entitled “Breast-feeding: support interventions associated with increased practice” a Singapore study which concluded that additional post-partum support significantly increased nursing duration. The test subjects included 450 women who were randomly split into three groups, receiving varying levels of pre- and post-partum guidance on breastfeeding. Randomization kept factors known to affect nursing duration (such as age, income, and education levels) from skewing results—which showed that additional support roughly doubled rates for nursing and exclusive nursing at six weeks of age. The results from later intervals were similarly impressive, which shows that when mothers are given the help they need, they are more likely to continue breastfeeding.

In addition to seeking help from others, women can increase their chances for success by learning the ins-and-outs of nursing before baby arrives. Many moms wait until they experience troubles at home to seek out information, and blindly accept the advice of their pediatrician rather than going to a breastfeeding expert. Quite often, pediatricians can do more harm than good to a nursing relationship—especially if they were not quizzed on how knowledgeable they are about breastfeeding before being hired.

When interviewing a pediatrician, they should be asked their position on extended (beyond one year of age) nursing, as well as when they believe solid food should be introduced. If their answers do not echo WHO and AAP guidelines—that there is no age limit to the benefits and that exclusive nursing for the first six months is ideal—they are not the pediatrician for a mother who intends to successfully nurse. Also, inquire as to under what circumstances they would recommend that a mother supplement with formula or wean. A general rule of thumb is that babies can lose up to 10% of their birth weight while waiting for mother’s milk to fully come in, and have until they are two weeks of age to regain that weight. In the meantime, provided that baby is having six or more wet diapers a day and several soiled diapers, colostrum is plenty to sustain baby and is the ideal food for newborns. Finding a doctor who understands these breastfeeding basics should be first on every expectant mother’s to-do list.

Other things that moms can do to prepare before baby is born include finding an International Board Certified Lactation Consultant (IBCLC), and attending both Le Leche League (LLL) meetings and a breastfeeding class. Most metropolitan hospitals have IBCLCs on staff, but it can be luck of the draw whether they are any good or if they are on-call at the time of delivery. Breastfeeding advocacy websites (such as often have forums that list recommendations, and can be a good starting point for finding an IBCLC. While many women are comfortable attending a class for other mothers-to-be, joining Le Leche League—an international organization for breastfeeding support—can be a bit daunting. Some new moms are intimidated by the idea of being in a roomful of women who have already breastfed successfully for months or even years. However, group meetings are a wonderful way to meet women in person who have nursed their children and to get knowledgeable advice from other mothers. Also, LLL has “leaders” who organize the meetings and who can be contacted 24 hours a day with questions.

No matter how well-prepared an expectant mom feels while rubbing her belly, it’s another thing entirely once baby arrives. It is important that baby be put to the breast as soon after birth as possible, preferably within the first half hour. The “breastcrawl” technique, in which a still-naked newborn is placed on mom’s bare chest and allowed to latch themself by instinct, is one of the simplest and most effective ways to get baby to latch. If this doesn’t work, there is no need to panic—mom should keep trying and give her IBCLC a call for advice. Even after a difficult birth or c-section, latch issues can most often be remedied by trying different nursing positions. For latch issues that cannot be remedied by changing position, such as flat or inverted nipples, a nipple shield may be recommended. A nipple shield is a thin piece of silicone that fits over the areola and draws out the nipple. Hand expression or a breast pump can also be used to make flat nipples easier to latch onto, as well as to relieve engorgement.

To prevent nipple confusion—in which baby learns to prefer the fast, easy flow of a bottle over the breast—and to encourage a healthy milk supply, it is important that there be no supplemental bottles of formula in the hospital or while waiting for mother’s milk to come in. Mother can prevent nurses from giving their baby formula against her wishes by “rooming in” rather than having baby kept in the nursery. This keeps mom from stressing over having to rush the feeding and encourages her to offer the breast unlimitedly—which is key to helping her milk come in quickly. Most often, even babies with jaundice do not need to be supplemented with formula. Although mild jaundice is more common in breastfed infants, Dr. Jack Newman—one of the leading American pediatricians for breastfeeding and natural family living advice—says that:

“Breastmilk jaundice is normal. Rarely, if ever, does breastfeeding need to be discontinued even for a short time. Only very occasionally is any treatment, such as phototherapy, necessary. There is not one bit of evidence that this jaundice causes any problem at all for the baby. Breastfeeding should not be discontinued ‘in order to make a diagnosis’. If the baby is truly doing well on breast only, there is no reason, none, to stop breastfeeding or supplement with a lactation aid, for that matter. The notion that there is something wrong with the baby being jaundiced comes from the assumption that the formula feeding baby is the standard by which we should determine how the breastfed baby should be. This manner of thinking, almost universal amongst health professionals, truly turns logic upside down.”

Dr. Newman’s mention of the need to view breastfed babies as the standard against which all infants are judged is relevant in more ways than one. Many women believe that because their infant is nursing around the clock that their milk isn’t filling enough and that they should start solid food early, or that their supply is too low to meet baby’s needs. In reality, human milk is higher in both fat and calories per ounce than formula or cow’s milk, and frequent nursing is not only common, it’s also very normal.

Breastmilk is produced on a supply-and-demand basis, and the more often baby nurses, the more milk mom will make. The idea that babies should go three or more hours between feedings comes from the formula-feeding standard that Dr. Newman mentioned. Since breastmilk is the only food that newborns are born able to fully digest, the proteins in soy or dairy based formula take longer to break down, requiring baby to eat less often. Also, the average baby is born with a stomach the size of their fist, so frequent feedings of a few tablespoons at a time let them fill up appropriately for their size. Another way that the waiting period for mature milk helps baby is that it allows them to learn how to “suck, swallow, breathe” before they are faced with big gulps of mature milk.

It might seem like once the mother’s milk fully comes in, that the problems are over. However, the time between leaving the hospital and three months of age is when most moms either begin to supplement or stop breastfeeding altogether. As babies grow and mature, they tend to put themselves on a schedule and begin to space out feedings—and (hopefully) let their parents get more rest at night. When a baby who has been sleeping in several-hour blocks at night begins waking hourly wanting to nurse, all-knowing mother-in-laws tend to suggest that baby be left to “cry it out” so mom can sleep at night. Pediatricians are notorious for this suggestion as well, but if one has been chosen based on their answers to the questions mentioned earlier, they will know that not only would it be cruel to leave an infant to cry out without response from their mother, it’s also unnecessary.

Several times during baby’s first year they go through “growth spurts”—periods of a few days where they put on weight faster than usual or begin developmental milestones—during which they tend to sleep less than usual and nurse a great deal more. Rather than training baby to ignore their body’s cues to eat¸ many parents find they are able to get more rest by moving the crib into their room, or by co-sleeping (maintaining a safe bed for the whole family to sleep in so both baby and mom can nearly sleep through the feedings). Frequent feedings during the day can be equally tiresome, but by wearing baby in a carrier such as the Ergo or Bjorn, mom can continue to nurse baby while getting other things done.

There are some babies that even outside of growth spurts simply like to nurse more often than a bottle-fed baby would need to eat. Other than a lack of privacy for the mother, this shouldn’t be considered a problem. Nursing is about much more than getting calories into the baby, and who can blame them for wanting to enjoy their favorite food while snuggled up close to their mother’s skin.

Some “experts”, like the authors of the controversial book On Becoming Babywise, suggest that tactics such as leaving a hungry baby to cry themselves to sleep or refusing to let them fall asleep at the breast trains them to adhere to a schedule from as early as three to six weeks of age. Although a full night’s sleep within a month of giving birth may sound tempting, even if their approach does work, it comes with many risks. As early as 1998 the American Association of Pediatrics released statements linking the On Becoming Babywise techniques to “dehydration”, “involuntary premature weaning”, “low milk supply”, and “failure to thrive”. One important reason why feeding schedules shouldn’t be used with infants (especially those who are exclusively breastfed) is that babies are born with a sucking instinct that goes beyond simply understanding their own hunger cues.

Pacifiers were invented so bottle-fed babies could enjoy the comfort that usually comes from the lazy fluttering-suck at the breast that babies do when they aren’t actually trying to get milk. This “comfort nursing” provides additional stimulation to mom’s breasts and keeps her milk supply bountiful. Scheduling feedings denies her body this trigger to make more milk, so in addition to the damage done to her supply by limiting the frequency with which milk is removed from her breasts, she isn’t getting the built-in bonus that comes from using her body as her baby’s primary source of physical comfort.

In addition to nursing on demand, there are other things that mom can do to ensure an adequate supply. Some women believe that they must have a perfect diet in order to make milk, but most often all that is needed is for mom to listen to her body. Every ounce of breastmilk that baby drinks is an ounce of fluid that comes from mom’s body, so it’s important that she drink to thirst. Tracking intake to make sure a full 64 oz of water are consumed daily is unnecessary, but a good rule of thumb is to drink a glass of water each time baby nurses. Anecdotal evidence also suggests that sugar can help supply, which makes sense given that human milk has the highest concentration of lactose (milk sugar) of any mammal. Breastfeeding burns anywhere from 300 to 500 additional calories a day, so if mom is dieting she will need to make sure not to dip low enough that her body thinks it can’t spare the calories to make milk. In general, women can lose up to two pounds a week without risking supply issues.

Sometimes even with the best diet and offering the breast unlimitedly, the mother may have difficulty meeting baby’s demand. The first step would be to identify the reason—like the return of menstrual cycles, taking birth control pills or other hormones, or starting any medications (cold medicines in particular are notorious for drying up milk supply). If the problem cannot be solved by stopping a medication, there are several herbs that can be taken to boost supply naturally. Fenugreek, blessed thistle, and alfalfa have been used for centuries to help mom make more milk. If they are not effective, a prescription can be written for Reglan or Domperidone (the later is not FDA approved for use to increase supply, but it has been studied and approved by the AAP for that purpose).

There are, however, some times when nay-sayers are correct, and mother will be unable to successfully nurse. Women who have had breast surgery that severed the ducts, such as an augmentation or reduction, and those with hormonal disorders, will experience difficulties. Also, there are a number of medications—like those used for heart conditions, rheumatoid arthritis, and some anti-depressants—which pass through the milk. If the mother is on a medication that is not compatible with nursing, she has no choice but to bottle feed infant formula. It may also be challenging for stay-at-home mothers with other children to make time to nurse on demand, or for mothers with taxing jobs to find the time and privacy to express milk at work. In these cases, it is important for the mother to remember that any breastmilk is a wonderful gift, and that even if she must supplement to meet baby’s needs that it is still worth it to nurse as much as her schedule will permit.

Overwhelmingly, the reasons that might be offered to a mother as to why she can’t or shouldn’t nurse are issues that can be overcome with the right help. The statistics for women who have nursed until their child’s first year are not an accurate measure of how many women could have. Most women can successfully breastfeed for a year or more if they choose. Hopefully, more women will choose to get informed ahead of time and surround themselves with the support they need, so more babies enjoy the full year or more at the breast that they deserve.

Breastfeeding is an instinctual and natural act, but it is also an art that is learned day by day. –Angela White, J.D., breastfeeding counselor

1 comment:

Kaisha said...

You should publish this in pamplets to be handed out at hospitals/doctor offices! SO many ppl I know say they "couldn't" bf. I think hearing it is almost always possible would be a great thing!