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What Every Nursing Mother Should Know
You have decided to breastfeed your baby! Congratulations. You are carrying on a tradition which has continued almost uninterrupted since the beginning of mammalian life on earth, some 200 million years, give or take a few million. Not only that, of course, you are doing the best for your baby and for yourself, as no artificial baby milk (formula) has even come close to breastmilk in duplicating its variety of ingredients and the complexity of the interaction of these ingredients. There are hundreds of ingredients present in breastmilk that have specific functions and are not present in artificial baby milk, despite what the formula makers’ marketing will try to make you believe. And breastfeeding is not just breastmilk. It is a whole behaviour, a special relationship between the mother and her child that is more than breastmilk, in the same way that love is more than sex.
Almost uninterrupted? Almost. Until about 150 years ago almost all babies were breastfed, though not necessarily by their own mothers. In some societies, notably in Europe, the mothers of aristocratic, and even middle class families, often did not breastfeed, giving their babies away to wet nurses to feed. It is, of course, a sign of status to be able to pay others to do things for you-gardening, cooking, feeding your child, raising your child-and showing you are above the common herd seems to be important for many people. Furthermore, the birth spacing effects of breastfeeding, largely forgotten in our day and age, were well known in those times, and aristocratic families wanted to have many children, so that breastfeeding by the mother was definitely discouraged amongst the nobles. But generally, almost all babies in the world were breastfed, sometimes for several years in most societies. Only in some societies was milk other than human milk used to feed small babies.
Then, business started getting interested in selling milk to mothers. There was a market, a lucrative one as it turns out. With the industrial revolution, people moved to the cities, and more and more women went to work in factories and could not breastfeed their babies the way they did when they worked in and around the home in the rural areas. Women lost touch with the traditions of breastfeeding and depended more and more on “professionals” to guide them with childcare, including infant feeding. So more and more women started feeding their babies with breastmilk substitutes. Marketing techniques have changed, but the message of the manufacturers has always been the same: “Our milk is almost the same as mother’s milk”. This is the message now, and it was the message 100 years ago, when we hardly knew what was in breastmilk. And the message is just as wrong today as it was 100 years ago.
At about the same time as business became interested in infant feeding, so did the medical profession. For both altruistic and financial reasons. There was always the problem of how to feed orphaned babies. In some societies orphaned babies were nursed by relatives of the mother. Some orphanages hired wet nurses, but often there were not enough available to feed all the orphans. Also, what were the factory workers going to feed their babies? There seemed to be no question of maternity leave in this money driven society, or, except rarely, having day care on the premises of the mothers’ work. Feeding straight animal milk was often associated with severe illness and death of the baby, either because the milk was not clean due to lack of refrigeration or infected with tuberculosis, or the ingredients were unsuitable for human infants, present in too large or too small quantities. As well, milk was often fatal because it was diluted with water, or the cream was skimmed off by the unscrupulous trying to make a little more money.
So physicians began to become involved and tried to make infant feeding “scientific”, by studying the ingredients of human milk and trying to adapt animal milk to the needs of infants. Cow’s milk became the main source for the base of milk “adapted” for babies, not because it had any special properties, but simply because it was most abundant and least expensive. Some physicians became wealthy by inventing their own formulas, but most physicians saw a new source of income from patients coming to see them to help them with infant feeding. At the time, women would never have imagined going to a physician (almost all of whom were men) for advice about breastfeeding. But with the advent of artificial feeding, they became dependent upon the physician for guidance.
By the 1920’s, artificial feeding was no longer a rarity, and a cozy relationship had developed between the medical profession and the manufacturers of artificial milks for babies that has continued to this day. The formula companies agreed to encourage mothers to go to physicians to get advice about infant feeding, and not advertise directly to the public (though this part of the understanding has fallen by the wayside recently), while the physicians helped market the new products. By the 1950’s many physicians truly believed that artificial feeding was better than breastfeeding, because it was “more scientific”. By the early 1970’s, artificial feeding had become the rule, and the model by which both lay people and health professionals understood infant feeding. Unfortunately, even in the 1990’s, despite an upsurge in breastfeeding in the affluent world starting in the mid 1970’s, the formula fed baby and formula feeding mother are still considered the model for infant feeding, and breastfeeding babies and mothers are generally forced to conform to this model. Often with disastrous consequences for the breastfeeding relationship.
So what should every breastfeeding mother know? You need to know that what’s true about bottle feeding is not necessarily true about breastfeeding. You need to know that many of the people who will be advising you, relatives, friends and health professionals, understand breastfeeding only in terms of artificial feeding and that they understand artificial feeding much better than they do breastfeeding. You need to know that very few health professionals, even, especially, pediatricians have had even the rudiments of the theory of breastfeeding during their training, and even fewer have had any practical training. You need to know that many health professionals or their wives did not breastfeed their own babies and too many of them thus feel justified in not being supportive of breastfeeding, though they may still say they are. Luckily, things are changing, though slowly, and health professionals you encounter may be extremely supportive and helpful. But be wary. You need to know that if everything goes well with the breastfeeding, as it often does, everyone will support your breastfeeding. But if the breastfeeding is not going so well, you may be bombarded with advice to stop or supplement, despite the fact that usually a little knowledgeable advice will help overcome even some seemingly insoluble problems. And finally you need to know that you may be deluged by free samples of formula and “educational” materials from formula companies and their health professional collaborators who say they support breastfeeding. But never forget, there is only one purpose for your getting samples and “educational” materials-so that you will buy the products.
What are some examples of using the artificially fed baby as the model for infant feeding and forcing this model on the breastfeeding baby?
“There is no milk in the first few days”
On the very first day you may be told that your baby needs to be supplemented. Though this is very occasionally necessary, most of the time this has more to do with the fact that formula fed babies will take a lot of formula from a bottle than breastfed babies get from the breast in the first couple of days. Instead of making the deduction, true, of course, that formula fed babies are drinking too much, it is often assumed there is not enough milk in the first few days, as if the formula fed baby sets the standard. But if there is enough, why do so many breastfed babies seem to want to feed so much in the first few days? Because the baby who is not latched on well has difficulty getting milk, especially when the supply is not abundant. Once the supply is abundant, the baby may get milk very well, even with a poor latch, though there is often a price to pay-sore nipples, long, frequent feedings, blocked ducts, colicky baby. Unfortunately, so lacking in breastfeeding training are so many of our postpartum staff (not all by any means, but many), that you may be told the baby’s latch is very good, when in fact it is not at all. One of the best ways of knowing whether the latch is good or not is whether breastfeeding hurts or not. In the first few days, many mothers do experience some nipple tenderness, but severe pain is not normal, and is due almost always to a poor latch.
“There is no such thing as nipple confusion”
You can almost always force a baby to take a bottle nipple, though even this becomes difficult eventually if the baby breastfeeds well. But even strong breastfeeding advocates will argue about this one. The fact of the matter is that babies are not stupid. They want milk, and they will go to where the milk comes from. And if they do not get it easily from the breast, but get it well from a bottle, they will prefer the bottle. Why might they not get it easily from the breast? Because breastfeeding is hard work for the baby? No, it isn’t. But if the baby is not latched on well, he may not get milk easily. When a baby latches on poorly, it is, using an analogy easily understood in our bottle feeding society, similar to giving him a bottle with a nipple hole that is too small. The bottle is full, but the baby will not get it easily. However, when a mother has an abundant supply and the baby drinks well at the breast, he may accept both breast and bottle well.
There are now however, methods to supplement, if supplementation is truly necessary, which do not require a bottle. If there are alternatives, why not use them instead? Because the bottle is natural? It says volumes about our society that so many people find the bottle natural, and a cup or nursing supplementer “unnatural”.
Babies need to feed x number of times a day for y minutes”
This is a perfect example of how even breastfeeding advocates can get mixed up. It is not how often or how long a baby is at the breast. It is how well he feeds. A baby who feeds well five times a day is better off than a baby who feeds poorly 10 times a day. A baby may be “at the breast” but not actually getting milk. A baby who drinks at the breast for 20 minutes is getting a lot more milk than a baby who drinks for 2 minutes but then sucks without getting milk for 2 more hours. The better the latch, the more likely a baby is to get milk during a longer part of the feeding.
“Jaundice is bad and requires the interruption of breastfeeding”
Actually it is almost never necessary or desirable to interrupt breastfeeding because of jaundice. Jaundice which is due to the rapid, abnormal destruction of the baby’s blood cells often resulted, in the past, in serious injury or even death for the baby, but this is different from what most babies are now experiencing. Though causes of abnormal jaundice still obviously occur, the majority of cases of jaundice in the breastfed baby are due, at least in the first three or four days after birth, to an inadequate intake of breastmilk. The approach to dealing with this is to fix the breastfeeding problem which results in inadequate feeding, not stop the breastfeeding.
If you look carefully at any well gaining, exclusively breastfed baby, you will see that even at 6 or 8 weeks of life, chances are he is still slightly yellow (jaundiced). Because this is common, and breastfeeding is, after all the normal, physiologic method of feeding, jaundice is normal, and what is not normal is the absence of jaundice in artificially fed babies. We don’t think that this absence of jaundice harms the artificially fed baby, but there is no proof that it is harmless. The so called “prolonged” jaundice of the breastfed infant is not a reason to interrupt breastfeeding even for a single feeding.
If there is an abnormality causing the jaundice, it is extremely unusual that stopping breastfeeding, even temporarily, is required or helpful. In such a situation, the treatment is to treat the abnormality, not interrupt breastfeeding.
“When a baby or his mother is sick, it is better not to breastfeed”
On the contrary, when the baby or is mother is sick, breastfeeding is more important than ever. It may not always be possible, because of the severity of the illness, but that does not diminish the importance of breastfeeding. Health professionals or hospitals which have enlightened policies will do all they can to encourage the continuation of breastfeeding, and it is amazing what can be done even in very difficult circumstances. Premature babies need breastmilk, and breastfeeding, more, not less. Babies who have diarrhea need breastfeeding more, not less. Mothers who have mastitis should breastfeed their babies on the affected side so that the mastitis resolves more quickly. Mothers who take medication can almost always continue breastfeeding, because most drugs come out into the milk in such tiny quantities that it is extremely unlikely to be clinically significant for the baby. But if a drug really is truly of concern, it is rare that there is not an alternative that can be used safely. A physician who is supportive of breastfeeding will make every effort to prescribe medication that is compatible with breastfeeding.
These are just a few of the myths of breastfeeding, some of them propagated by people very supportive of, but not knowledgeable about, breastfeeding. Myths and misinformation about breastfeeding abound. You may be fortunate to have a supportive milieu and supportive health professionals. But you may not be so fortunate either. Remember then, that breastfeeding is best, not just “preferred”. It is best for the mother and for the baby, and the substitute for breastfeeding is only adequate, and for too many babies not even adequate. Supplementation is occasionally necessary, but not as often as it is suggested, not by a long shot. Many health professionals do not know how to help, even when they would like to. But more and more help is available, and more and more physicians, nurses and lactation consultants are developing the expertise to help even when problems seem insurmountable.
Jack Newman, MD, FRCPC