Do Breastfeeding Babies Need Extra Iron at 4 Months?

Susan Burger, MHS, PhD, IBCLC, my guest poster today, maintains a private lactation practice in New York City.  She is one of my favorite scribes on Lactnet, our professional listserv.  Her doctorate in nutrition and her work with breastfeeding mothers and babies in developing areas of the world add weight to her insights into this controversial topic . 

Should exclusively breastfed babies be routinely supplemented with extra iron?  Yes, according to the Committee on Nutrition of the American Academy of Pediatrics (AAP) in its recently issued Clinical Report.It justifies this recommendation by citing its “concerns that iron deficiency anemia and iron deficiency without anemia can have long-lasting detrimental effects on neurodevelopment.”  

As a mother myself and as someone who worked for many years on large-scale public health nutrition programs for mothers and children in developing areas, I certainly want the AAP to fully investigate and make solid recommendations about the potential impact of iron deficiency on cognitive development. 

In the late 1980s when I did my doctoral studies in nutritional sciences at Cornell, it was common knowledge that much of the iron that is stored by the fetus occurs in the last trimester of pregnancy. The closer to 40 weeks of gestation, the better the iron stores at birth.  More recent evidence has been accumulating that clamping the umbilical cord sooner than 2 minutes after delivery may deprive infants of a last and relatively substantial contribution of iron from the placenta to the newborn’s iron stores. 

Over 20 years ago, we knew that the iron in human milk is easily absorbed and that the iron added to formula is not and that extra iron may even interfere with absorption of iron from mother’s milk.  From the evidence at that time, we generally accepted that healthy full-term babies did not need additional sources of iron until they were around 6 months old.  In fact, a 2009 study reinforces this assumption.  The prevalence of iron deficiency was only 3% among otherwise exclusively breastfed infants who were randomly assigned to receive a placebo between 1 and 6 months of age.

So, I was expecting the AAP Committee on Nutrition to recommend ways to reduce preterm deliveries and premature cord-clamping and to remove barriers to exclusive breastfeeding for the first 6 months. Instead, the Committee’s ONLY recommendation was to start supplementing term breastfed infants with iron at 4 months. 

In puzzlement, I thought perhaps the Committee was privy to some new information of which I was unaware.  So, I carefully read the rationale for the recommendation and was surprised to see that it cited one study.  Again puzzled, I thought perhaps this one study was so astoundingly thorough that it upended all the other evidence I had read.  So, I read its methods section carefully. 

My expectations were dashed.  The sample size was small; only 77 babies were randomly assigned to receive either an iron supplement or a placebo at the start of the study. The drop out rate was high; 43% of the infants had dropped out by the time that developmental tests were administered at 13 months of age.  Compliance was low; study babies received the iron or placebo only 56% of the time they were supposed to receive these.

Furthermore, the study subjects do not match the population considered by the AAP Committee on Nutrition. The study babies were not “exclusively breastfed” as mentioned by the Committee; the researchers classified these babies as “breastfed” even though a few were given up to a bottle of formula a day from the start of the study and most were drinking formula by 6 months of age. The study babies did not start iron supplementation at 4 months as recommended by the Committee; the researchers started iron supplements or placebos at 1 month of age and continued for another 5 months.  So we really don’t know if the results would hold up among a group of infants who were started on iron supplement at 4 months of age and otherwise receiving nothing but mother’s milk until 6 months of age.

Finally, the sample size was not nearly sufficient to evaluate some of the potential harmful effects of iron supplementation among babies with healthy iron levels that were found in other studies, such as increased risks of infection and slower linear growth.

To the authors’ credit, they did not extrapolate beyond the findings of their own study when they wrote that a “larger study that focuses on the long-term developmental outcomes is needed before recommendations can be considered regarding the whole population of breastfed infants.”  Yet, the Committee went ahead and made a blanket recommendation anyway. 

I thought perhaps I was alone in my thinking when I read the long list of committees and groups cited as contributing to the report.  Then, I looked at the e-letters responses and discovered that others actually had similar objections, including the Chairperson of the AAP Section on Breastfeeding, Dr. Richard Schanler who stated:

 “…. the authors acknowledge that this report was submitted for review to the Section on Breastfeeding of the [AAP]. It did not mention that we disagreed and provided our additional recommendations, 2 years ago. The manuscript infers that the Section, along with many other groups, endorsed this report. This is wrong and will mislead the medical community.  We would welcome a discussion of science and changes in recommendations that are evidence-based.  We do not have issues with screening at-risk populations. We further request that the section “Development of this Report,” be retracted and removed from publication.”

I agree with Dr. Schanler that a discussion of the science is important. In the meantime, I have far more confidence in the previous recommendations of the American Academy of Pediatrics that iron supplements should not be routine for exclusively breastfed babies before 6 months of age.  As solids are introduced, selecting an appropriate mix of foods that include those rich in iron may circumvent any need to use supplements even after 6 months of age.

Is Infant Feeding Really a Choice?

Many of us talk about breast or bottle as a choice.  I used to think that way, too.  But I’m beginning to see it differently. 

On November 1, I had the privilege of speaking to a group of amazing and inspiring British women who work with breastfeeding mothers as peer counselors.  The night before this talk in West Bromwich, England I stayed with Anne, one of the Training Coordinators of La Leche League of Great Britain’s Peer Counsellor Programme (LLLGB/PCP). 

Anne told me a story I will never forget.  It began when Anne’s son’s partner, Kelly, moved into her home while pregnant with her second child.  Kelly became involved with Anne’s son during this pregnancy, so her unborn baby was not Anne’s biological grandchild. 

Kelly had bottle-fed her first child and was planning to do the same again.  In preparation, she bought a sterilizer and an array of feeding bottles, which one day Anne came home to find covering her kitchen counter.  Knowing that many young mothers would be coming there for breastfeeding help, she asked Kelly to keep her purchases on a shelf out of view.  Anne was concerned about giving one message with her words and another with the obvious bottle-feeding paraphernalia.  Kelly did not really understand Anne’s concern (in Kelly’s mind babies, bottles, and sterilizers all just went together), but she agreed. 

After her baby was born, surprise!  Kelly gave birth in a Baby-Friendly hospital where after delivery all newborns are placed skin-to-skin with their mothers.  When this happened, Kelly’s baby crawled up and attached to her breast.  Kelly responded, “Well, I guess she’s breastfeeding after all.”  She went on to exclusively breastfeed and nursed her for several years.  No doubt her exposure to Anne and the breastfeeding mothers she met helped Kelly make breastfeeding a reality. 

When the baby was about a week old, Kelly said to Anne, “Why don’t they tell you about breastfeeding?  It’s easy, isn’t it?  If I’d known that, I would’ve done it before.”  She had only ever thought of breastfeeding as hard work and a source of problems.  Then Anne asked Kelly something she’d been wondering for a while: “Why did you choose to formula feed your first baby?”  Kelly’s response startled her: “I didn’t choose.  I just did what I thought you did to feed babies.  It was not a choice as such.  I didn’t think of it that way.” 

Kelly had only ever seen babies bottle-fed.  She didn’t know anyone who had breastfed and she knew nothing about it.  To Kelly, feeding babies by bottle was just how it’s done.   Asking her to consider breastfeeding would have felt to her like asking her to perform surgery or argue a legal case in court.  She knew some people did those things but definitely not her. 

Anne has a special interest in how a mother’s confidence in breastfeeding builds and often asks new mothers when they really began to feel like a breastfeeding mother.  According to Anne, some mothers raised in breastfeeding families see themselves as breastfeeding mothers even before becoming pregnant and giving birth.  In Kelly’s case, it took about a week.  For others it takes a few weeks or even months of breastfeeding.  Anne has noticed that once “breastfeeding mother” becomes part of a woman’s self-image, she is unlikely to let breastfeeding problems get her way.  Some term this phenomenon “breastfeeding self-efficacy,”1 which is really just how much confidence a mother has that breastfeeding will work for her.   Not surprisingly, greater breastfeeding self-efficacy has been associated with longer duration of breastfeeding, even in cultures where fewer women breastfeed.2

What can we do to enhance mothers’ confidence in breastfeeding?  Physician Christina Smillie describes one way as “oozing confidence in the process.”  Most breastfeeding advocates do this naturally.  Showing mothers tricks that make breastfeeding easier is another. Contact with other breastfeeding mothers--either one-on-one or in support groups--is a big one.  Spending time with mothers who enjoy breastfeeding has a major impact, as does their encouragement.

The wonderful women I met in West Bromwich, England do this every day in their role as peer counselors.  It felt good to thank them personally for the important work they do.

References

1Dennis, C.-L. Theoretical underpinnings of breastfeeding confidence: A self-efficacy framework.  J Hum Lact 1999; 15(3):195-201.

2McCarter-Spaulding, D. and Gore, R.  Breastfeeding self-efficacy in women of African descent.  JOGNN 2009; 38(2):230-43.

Unintended Consequences

What’s a breastfeeding mother to do?  Is it riskier to bedshare with her baby during the night or is it riskier not to?  That’s what a survey of 4789 U.S. mothers with babies under one year clarified.1

In the U.S. parents are admonished never to sleep with their babies.2 The Milwaukee, Wisconsin health department, for example, uses the image of an adult headboard transformed into a tombstone as a warning about the dangers of bedsharing. (Click here for a video on this campaign.) 

Bedsharing appears even more dangerous when—as often happens in the U.S.—infant deaths are blamed on it even when other more hazardous practices are present, such as adult alcohol intoxication and drug use and when the “bed” is actually a recliner, chair or sofa.  One Scottish study, for example, found that the risk of an infant dying was nearly 67 times higher on a sofa compared to an adult bed.3

According to the U.S. mothers surveyed, despite their awareness of these public campaigns, nearly 60% of their babies shared their beds for at least part of the night.  Among the mothers who attempted to follow the recommendations against bedsharing, 55% fed their babies at night in chairs, recliners, or sofas and 44% of these (25% of the total) reported falling asleep some of the time in these much more dangerous places.  In other words, their attempts to “follow the rules” often led to the unintended consequence of much riskier behaviors.

The authors of this survey concluded that safe-sleep campaigns should include information on safe bedsharing, because when this information is absent, parents will continue to bedshare in unsafe ways.  The Japanese experience confirms this.  As bedsharing as has become more common in Japan (it is now the cultural norm), rates of SIDS have decreased. 4What’s different there is that Japanese families bedshare safely.  Families sleep together on futons on the floor away from walls, so babies cannot fall far or get trapped.  Fluffy pillows and bedclothes are not used. 

To save more lives, U.S. safe-sleep campaigns should consider taking a page from the Japanese playbook.  By emphasizing how to create a safe sleeping environment—rather than trying to browbeat parents into avoiding bedsharing—more babies’ lives would be spared.  And as an extra plus, more families would also get a better night’s sleep.

For a brochure for parents on safe sleep, click here.

References

1Kendall-Tackett, K., Cong, Z., and Hale, T.W.  Mother-infant sleep locations and nighttime feeding behavior.  Clin Lact 2010; 1(1):27-30.

2American Academy of Pediatrics, Task Force on SIDS.  The changing concept of sudden infant death syndrome: Diagnostic coding shifts, controversies regarding the sleeping environment, and new variables to consider in reducing risk.  Pediatrics 2005; 116:1245-55.

3Tappin, D. et al.  Bedsharing, roomsharing, and sudden infant death syndrome in Scotland: A case-control study.  J Pediatr 2005; 147:32-37.

4McKenna, J., Ball, H., and Gettler, L.T.  Mother-infant cosleeping, breastfeeding and sudden infant death syndrome: What biological anthropology has discovered about normal infant sleep and pediatric sleep medicine.  Amer J Phys Anthropol, Suppl 2007; 45:133-61.

Doing It Right

Today my guest blogger is one of my favorite people in breastfeeding, Diane Wiessinger, coauthor of the new The Womanly Art of Breastfeedingand author of the seminal article “Watch Your Language,” which forever changed how we think about the “benefits” of breastfeeding. 

I took my young son to a Chinese restaurant for lunch years ago.  I asked our waiter to show us the right way to use chopsticks.  “Well,” he said, scanning a nearby table of Chinese waiters, all busy eating lunch, all with chopsticks, “None of them are doing it right.”

Whether we’re eating, walking, or putting on socks, we don’t have to do it “right”; we just have to do it so it works for us.  So why are there so many rules about breastfeeding?  And why don’t they work very well? 

More than 30 years ago, when my first child was born, there were no rules at all about how to make a baby take the breast (there was no such thing as The Latch).  All anyone knew was that if a baby’s cheek is touched when he’s hungry, he responds by turning his head with a wide, searching mouth.  It was the height of the natural childbirth movement, and many of us who were interested in breastfeeding also had medication-free births, which meant our babies were competent from the start.  Skin-to-skin was unheard of, our babies were kept in central nurseries, often they had a bottle before their first nursing… but most of them latched with little or no difficulty.  It didn’t occur to us that they might not.

Trouble is, we were sore, often for weeks.  So the field of Lactation Consultants began – not to help babies latch, but to figure out what caused the pain.  We LCs looked carefully at each tiny piece and realized that the pain was usually from holding the baby as if for bottle-feeding.  But we broke everything into tiny steps, created rules about how to do each step “right”… and the whole thing worked even less well.  Now we began seeing non-latching babies!  So we added more rules, and more, and mothers’ confidence eroded.

When a baby learns to walk, he’s pretty awkward.  He falls a lot, he wobbles, but no one says, “Oh dear, if you don’t take that baby to a specialist, he’ll never walk right.”  Everyone knows he has the basics built in, and just needs time.  Making him follow a detailed set of rules would probably drive him back to crawling! 

That’s what happened with breastfeeding.  We laid down rules for something that had never had any, and we left mothers feeling incompetent and babies feeling totally confused. 

So try this:   lean back comfortably, your baby’s whole front on you, and let gravity take care of the holding.  Your baby lies there with his cheek against your breast.  If he’s hungry, he turns toward his cheek, and there’s that wonderful nipple right nearby.  You’ve done nothing in particular (in fact, any fumbling that you do probably helps), and he chooses the moment that suits him best.  What a concept! 

Are you doing it right?  Well… if both of you are comfortable and the milk is flowing, what else could possibly matter?  Let the Lactation Consultants save their problem-solving for if you have a problem. 

London Memories

Life can include some incredible moments.  I experienced one in London on the 26^th of October, when I was privileged to speak at the Womb to World conference along with sleep researcher Helen Ball, author Me and Kathy Kendall-Tackett in LondonDeborah Jackson (Three in a Bed), and my coauthor and all-around marvel Kathleen Kendall-Tackett.  This was the first conference where the second edition of Kathy’s and my book for parents, Breastfeeding Made Simple: Seven Natural Laws for Nursing Mothers, was on hand. 

Being in London was fabulous.  Speaking with my coauthor at the same conference was also a rare treat.  But to have our book debut in such an exciting place with the two of us together made the event even more special.

The question I was asked most often that day was, “What’s new in the second edition?”  I was happy to report that lots had changed even in the five short years since the first edition was released.  It felt fitting to talk about these changes at this particular conference, as Suzanne Colson was the conference chair and it was sponsored by her organization The Nurturing Project.  It was Suzanne’s 2008 journal article that triggered a sea change in our understanding of breastfeeding dynamics, which is reflected in this second edition.  You can read more about these new perspectives by clicking on my blog history section “Laid-Back Breastfeeding.” 

In addition to her amazing insights into how mother’s body position can make early breastfeeding easier or more difficult, Suzanne’s research also inspired us to tweak our Natural Law #1.  Rather than reading “Babies Are Hardwired to Breastfeed,” as it did in the first edition, it now reads, “Babies and Mothers Are Hardwired to Breastfeed.” 

Over the last decade, we in lactation came to accept that human babies, like all other mammals, are born with reflexes that help them get them to their feeding source and feed.  Now—thanks to Suzanne’s research—we must seriously consider the possibility that mothers may also have breastfeeding Me. Deborah Jackson, Suzanne Colson, and Kathy Kendall-Tackett at the Womb to World Conferenceinstincts.  However, one drawback to being human—at least as far as breastfeeding is concerned—is that we have large brains, which makes it possible to overthink it.  Some of my most respected colleagues are beginning to suggest that despite our sincere desire to help, some breastfeeding interventions and instructions—including positioning and latch-on—may actually cause breastfeeding problems.  When mothers are convinced to let others guide them, this may short-circuit their instinctive breastfeeding behaviors and cause difficulties.   Stay tuned for more on this…

Today, I’m basking in the glow of my London memories and excited that my second new book of 2010 is finally out.  Kathy and I are very happy with our new-and-improved Breastfeeding Made Simple.  We hope you like it, too.

Process, Product, and Personal Growth

I write these words on my oldest child’s 30th birthday, a milestone that also marks the 30th anniversary of the day I became a mother.  In those 30 years, I have learned many life-changing lessons about breastfeeding and parenting.  To mark this occasion, I’d like to share a few.

Child-rearing is an incredible opportunity for personal growth.  When I was pregnant with my son, I imagined all sorts of things I could do to give him a better life.  What I couldn’t imagine was how my child would affect me.  In hindsight, I don’t think I really grew up until after I gave birth to him.  Round-the-clock breastfeeding was a part of that.  When it became clear that my baby knew what he needed and when he needed it, it also reinforced my understanding that my child’s needs were valid and deserving of respect, another step toward my own maturity.  From my child’s perspective, having his needs met demonstrated beyond words that they mattered, which helped him stay in tune with his own inner voice—a dynamic that increased his resistance to peer pressure during his teen years. 

What about parenting “experts” who encourage mothers to remain in control by scheduling their babies’ routines by the clock?  As I wrote in my post “Fear and Surrender,” my decision to surrender to my baby’s individual feeding rhythm not only gave me abundant milk but was also instrumental in achieving a life-changing intimacy with him.  Had I tried to control the process, I have no doubt our relationship would have been different.  One of my early lessons came after several days of heeding the voices around me and letting him cry at night.  I was dismayed to find that I began to care less when he cried during the day.  Because this was not the kind of parent I wanted to be, I decided to go my own way and never looked back, convinced that these cry-it-out methods could distance me from my baby.  Unfortunately, many new parents embrace rigid methods that feed into their fear of change and the unknown, and their chance to experience this growth may be stunted.

Process trumps products and people trump things.  BC (before children) I was a Type A, check-it-off-my-list kind of person.  When my son was born, it was a big adjustment for me to put my list away and focus on him.  In the evening, we both looked the same as we did in the morning, which at first was hard to accept.  It slowly dawned on me, though, that rather than having a finished product to show for all my hard work each day, what I had instead was a thriving, happy baby.  I began to realize that my new job as a mother was more about the process rather than the product, and that was okay. 

This product-versus-process struggle can also spill over to breastfeeding.  Some mothers become overfocused on the milk, which is of course important.  But perhaps even more important is the process of breastfeeding.  As the months and years passed, breastfeeding became much more than a way to feed my son.  It morphed into an all-purpose mothering tool and a significant source of comfort for us both.  I found myself calmed by breastfeeding at family funerals and saw my toddler son’s tantrums short-circuited by the breast.  I began to see the milk as a nice “value add,” while the bond we shared at the breast as the real deal.

On this special day, I say: Happy birthday, Carl!  Thank you for everything you have taught me and have given me.

Some Ins and Outs of Laid-Back Breastfeeding

In an earlier post I explained why it’s time to change the way we teach breastfeeding.  I described research findings indicating that early breastfeeding is easier when mothers lean back with their babies’ weight resting on their body.1  (See my new Blog History category “Laid-Back Breastfeeding” in the right column for a link to all my posts on this subject.)  These laid-back positions not only make breastfeeding less work for mothers, they also make it easier for babies to take the breast deeply, especially during the early weeks.  That’s because in these positions gravity helps rather than hinders babies’ inborn feeding reflexes, which can make a huge difference when babies are at their most uncoordinated. 

After decades of teaching mothers to breastfeed sitting upright or lying on their sides, many have difficulty visualizing this new approach.  One common question I am often asked is whether these positions are practical after a cesarean birth.  The answer is most definitely yes.

A number of adjustments can be made to help a mother customize laid-back breastfeeding (also known as “Biological Nurturing”) to her body type and situation.  As you can see from these line drawings, one adjustment is changing the direction of the baby’s “lie” on her body.  In all laid-back positions, baby lies tummy down on mother, but this can be accomplished in many ways.  The baby can lie vertically below mother’s breast (as on this website’s banner), diagonally below the breasts, across her breasts, at her side, even over her shoulder.  As Suzanne Colson explains in her DVD, “Biological Nurturing: Laid-Back Breastfeeding,” the breast is a circle, and the baby can approach it from any of its 360 degrees, except for positions in which the baby’s body covers mother’s face.  So after a cesarean birth a mother can use many laid-back positions without baby resting on her incision.

Another possible adjustment is the mother’s angle of recline, or how far the mother leans back. In laid-back positions, the mother leans back far enough so that her baby rests comfortably on her body without needing to support her baby with her arms but is upright enough so she and her baby can easily maintain eye contact.   Because most hospital beds are adjustable, finding their best angle of recline is especially easy during the hospital stay.  At home, I suggest mothers imagine the positions they use to watch their favorite television show.  Most of us lean back on a sofa, chair, or bed, using cushions or pillows so we can relax our shoulders, head, and arms.  Colson says the best laid-back breastfeeding positions are those that mothers can easily and comfortably maintain for up to an hour.

When using laid-back breastfeeding, ideally each mother finds her own best variations by trial and error.  In light of these insights, I think the time has come for us to stop naming and teaching specific breastfeeding “holds.”  (After all, no one teaches bottle-feeding mothers how to hold their babies during feedings!)  That way, mothers will no longer waste their time trying to duplicate feeding positions taught in classes or pictured in books that may not be right for them or--even worse--may even make early breastfeeding more difficult. Instead, each mother’s focus will stay exactly where it belongs: on her and her baby.

Reference

1 Colson, S. D., Meek, J. H., & Hawdon, J. M. Optimal positions for the release of primitive neonatal reflexes stimulating breastfeeding. Early Human Development 2008; 84(7):441-449.

Fear and Surrender

Many cultures consider the first 40 days after birth a distinct time in a woman’s life.  Referred to as “la cuarentena” in many Hispanic cultures, and the “lying-in” period during America’s past, nursing couples are kept together and cared for in isolation, with others doing their household chores and taking care of older children. 

Somehow in modern America, this concept and practice—once key to establishing healthy milk production—have been lost.  Rather than planning to spend the early weeks recovering from childbirth and focusing on feeding the newborn, many parents in the U.S. today feel social pressure to “get back to normal” as quickly as possible. 

This relatively new attitude has wreaked havoc on lactation and no doubt contributes significantly to the steep drop in early nursing rates.  Once well-understood, most parents now give birth with no inkling that nursing involves intense, sometimes constant feeding.  As part of the natural order of things, newborns use these feeding frenzies to boost their nursing parent’s milk production from 1 ounce (30 mL) on Day 1 to 25-35 ounces (750-1050 mL) per day by about Day 40, when most reach full milk production.  

If new parents don’t understand or expect this intense early nursing, they may assume there’s something terribly wrong.  They may be fearful they aren’t making enough milk or decide that nursing is just too much work.  They may wean or start supplementing with no idea of what they stand to gain by simply responding to the baby’s feeding cues and surrendering to the experience.   

By about Day 40, surrendering to the reality of early nursing usually results in full milk production.  But there is more.  The baby who once fed for 30 minutes may now be done in 15.  The baby who fed 12 times each day may now feed only 8.  Over time, nursing usually becomes much less time-consuming than the alternative.  Intense early nursing is an investment that pays back many times over. 

But parents who surrender to early nursing enjoy another, often unexpected reward: the amazing emotional experience of getting in sync with their newborn.  Many describe this as the greatest intimacy they’ve ever known, an experience that can influence parenting for a lifetime.  Research has found, for example, that when older babies start solid foods, mealtime battles are less common in nursing families because these parents learned to trust their babies to know what they need and when they need it.1 The trust and sensitivity that nursing fosters enhances early attachment, which is the oil that greases the wheels of parenting for decades to come. 

Why are many parents afraid of surrendering to the intensity of early nursing?  Ignorance and social pressure are two reasons.  Popular but misguided authors warn that letting baby “use them like a pacifier” (see my post on that HERE) will produce children lacking in discipline or at risk for drug addiction.  Health professionals unaware of nursing norms may recommend formula as a remedy for frequent nursing.  But when—out of fear and ignorance—parents sacrifice or attempt to take control of nursing, they may lose much more.  

One mother I spoke with yesterday shared with me her unhappy odyssey through early breastfeeding, which included frequent milk expression so her partner could feed the baby.  The extra work of pumping convinced her that breastfeeding was just too hard and she began regularly feeding formula.  Now at 4 months, her baby was mostly formula fed and she spent much of her time alone with her baby while her partner traveled for work.  She felt regret at this state of things and wondered if she could somehow reclaim breastfeeding.  I talked to her about normal feeding patterns in the beginning and afterward and she began to realize that many of her choices made her life more complicated.  Because she began our conversation by describing her need as a mostly single parent to simplify her routine, I suggested rather than continuing with regular pumping—which she was still doing even with her partner gone—to just breastfeed more often.  As we discussed the resiliency of breastfeeding, I assured her that it was not too late.  She told me, “You’ve made me realize I need to rethink some things.”  

These moments of insight are not only satisfying, they’re key to becoming a breastfeeding-friendly culture.  It’s a good day when we can serve as an antidote to the fear, ignorance, and social pressure that plague new parents.  By dispelling the myths and conveying the realities of nursing, we can make it easier for parents to surrender to the experience and enjoy the profound rewards that they and their babies can enjoy. 

References

1Farrow, C., & Blissett, J. Breast-feeding, maternal feeding practices and mealtime negativity at one year. Appetite 2006; 46(1):49-56.

Changing How We Teach Breastfeeding

We are experiencing a sea change in breastfeeding.  But how quickly can we change our approach?  At a breastfeeding conference last weekend, I summarized breastfeeding teaching strategies since 1980, how our understanding has evolved, and how this affects the way we help mothers. 

In 1980, I was told to breastfeed my first baby by holding him in my arms with his tummy facing the ceiling, which I realize now was a bottle-feeding position.  Over time, these instructions changed.  Instead, we recommended mothers hold their babies “tummy to tummy.” To make latching easier, we suggested breast support using the “C” hold and “U hold.”  We incorporated a variety of techniques for helping babies achieve an asymmetrical—or off-center—latch.  

However, in 2008, U.K. researcher and midwife Suzanne Colson published an article indicating that some of our fundamental assumptions had been wrong.  Not surprisingly, our “latching” or “attachment” instructions had been influenced by what we grew up seeing.  Generations of bottle-feeding had convinced us that mothers needed to sit upright or lie on their sides to breastfeed their babies.  

What changed?  In her research, Colson identified 20 inborn reflexes that help babies breastfeed.  And surprise!  Like baby piglets and other newborn mammals, Colson found that these reflexes work best when our babies feed on their tummies.  It turns out that all those years of teaching upright and side-lying breastfeeding positions may have been wrong-headed.  Although our tried-and-true methods make sense in some situations, rather than using them sparingly, we taught all new mothers to breastfeed this way.  As a result, gravity pulled babies away from their mothers’ bodies and made breastfeeding more challenging.  Colson noted that as “positioning and attachment” techniques became more widely taught in the U.K., more new mothers gave up on breastfeeding early. 

Colson’s research demonstrated that when mothers simply lean back and rest their babies tummy down on their semi-reclined bodies, most of our complicated latching instructions are no longer needed.  In “laid-back” positions, gravity keeps mothers and babies touching and helps rather than hinders breastfeeding. 

Last week I spoke to a mother with a 5-day-old baby who at first had decided to formula feed because her baby wouldn’t take one breast and breastfeeding was just too hard.  But then she felt her milk increase and decided to give it another try.  Her goal was to do some breastfeeding and some formula-feeding.  I told her about laid-back breastfeeding positions and steered her to http://www.biologicalnurturing.com/ to watch Suzanne Colson’s video clips.  When we spoke again yesterday, her 10-day-old baby was now exclusively breastfeeding and she told me how much easier laid-back breastfeeding had been for her. 

After my conference talk, many of my listeners—most of whom work with breastfeeding mothers every day—struggled to accept this new approach.  Clearly much thought and reflection was needed before many could translate this knowledge into practice.  Major paradigm shifts are never easy.  But for the sake of mothers and babies, here’s hoping this one doesn’t take too long! 

For more on laid-back breastfeeding, see my earlier post: /blog/2010/7/18/laid-back-breastfeeding.html

Reference

Colson, S. D., J. H. Meek, et al.  Optimal positions for the release of primitive neonatal reflexes stimulating breastfeeding. Early Hum Dev 2008; 84(7): 441-9.

Nipple Shield: Friend or Foe?

Last week, I spoke to a mother whose 1-month-old baby was born 4 weeks preterm.  She was breastfeeding with a nipple shield, which she was given in the hospital, and she was confused by conflicting advice.  Should she pump after feedings?  Was her baby getting enough milk?  How should she wean from the shield?  This was her sixth breastfeeding baby but her first preterm baby and first time using a shield.  She was emotional and unsure of herself.  My answers below were based on the research described in my book, Breastfeeding Answers Made Simple. 

Express milk after breastfeeding?  As long as her baby was gaining weight normally (which she was), there was no reason to pump after feedings.  A study of 54 mothers and babies compared babies breastfeeding with a nipple shield to those breastfeeding without it and found no difference in weight gain during the first 2 months of life. 1 Although one 1980 study found babies took 22% less milk at the breast with a shield, 2 these mothers used thicker, rubber shields.  As long as the baby is suckling effective, today’s thin, silicone shields do not appear to decrease milk intake during breastfeeding.

How to gauge baby’s milk intake.  Weight gain is the best way to know a breastfeeding baby is getting enough milk.  This baby was gaining well, so adequate milk intake was guaranteed. After feedings, other signs of milk intake include reduced feelings of breast fullness and milk seen in the tip of the shield.

Weaning off the shield.  A hospital nurse told this mother to wean her baby from the shield by gradually cutting it away.  This strategy made sense with rubber shields, but cutting silicone shields produces sharp edges that could irritate the baby’s mouth.  A better strategy is to start the baby feeding with the shield and when the mother hears swallowing to quickly slip off the shield and slip in the breast. But I told this mother to be patient.  Her preterm baby may not be ready to wean from the shield.  One study found nipple shields increased milk intake in preterm babies having trouble suckling actively and staying on the breast.3  While not all preterm babies need to use a shield, I told this mother that for now her preterm baby may breastfeed better with it.  The baby’s readiness to wean from the shield is as important as the mother’s readiness.

In general, should nipple shields be considered “friend” or “foe”?  It depends.  As 88% of the mothers in one study reported,4 when used appropriately, nipple shields can help preserve breastfeeding.  Or—like any breastfeeding tool—they can be misused and undermine it.  In some cases, weaning off the shield may be the right thing to do.  In others, a mother should be patient and wean from the shield later rather than decrease her baby’s breastfeeding effectiveness or turn the breast into a battleground.

References

1Chertok, I. Reexamination of ultra-thin nipple shield use, infant growth and maternal satisfaction. J Clin Nurs 2009;18(21):2949-2955.

2Woolridge, M. et al. Effect of a traditional and of a new nipple shield on sucking patterns and milk flow.  Early Hum Dev 1980; 4(4):357-364.

3 Powers, D., & Tapia, V. B. Women's experiences using a nipple shield. J Hum Lact 2004; 20(3):327-334.

4 Meier, P. et al. Nipple shields for preterm infants: effect on milk transfer and duration of breastfeeding. J Hum Lact 2000; 16(2):106-114.

Too Late to Transition to Direct Nursing?

In my last post I wrote about a mother I spoke with who had been pumping and bottle-feeding for 3 weeks.  She was convinced that breastfeeding was no longer possible for her and her baby.

Many parents think there’s no turning back once they stop nursing.  But because babies are hardwired to breastfeed, it’s always possible to nurse later.  In Australia, for example, babies cannot be adopted until they are 6 to 12 months old, but even so, many adoptive parents report successfully transitioning their babies to nursing, even after a year or more of bottle-feeding.  This makes sense if you think of nursing as a survival skill nature builds into babies. (Click HERE to read one mother’s story of transitioning her 20-month-old adopted son to nursing when he joined their family.)

I remember one mother I worked with during my 10 years in private practice whose 5-month-old experienced neurological damage during what should have been routine surgery.  This mother was pumping her milk in the months since the surgery and produced ample milk.  She scheduled a home visit with me to help her bring her baby back to direct nursing.  She decided that in addition to the therapy her baby was receiving, he needed the comfort and physical stimulation only nursing could provide.  I pulled out my bag of tricks and—to her joy—before long her baby was fully nursing again.

What tricks did I use?  Latch attempts while he was in light sleep (eyes moving under eyelids) provided the first breakthrough.  When a baby accepts the breast during sleep, this can be repeated at every nap and night feeding to lower resistance to nursing during waking hours.  Whether awake or asleep, lying the baby tummy down on his semi-reclined parent’s chest releases the feeding reflexes that spur babies to nurse. (Click HERE for examples of these positions.)  These simple approaches can work wonders, as long as the parent’s chest remains a happy place and baby does not feel pressured to feed there.

If you’re a parent wondering if it is “too late” for nursing or if you work with new parents in this situation, don’t despair.  No matter how difficult nursing once was and no matter how long it has been since the baby latched and fed, it is almost always possible to make nursing work.  A healthy milk production helps but is not absolutely necessary.  I often remind parents that babies eagerly accept pacifiers (aka dummies), which provide no milk at all.  The parent’s body provides a place to suckle and so much more!

Anxiety and Breastfeeding

As part of my day job, I talk to mothers by phone about breastfeeding.  At its essence, the main reason most mothers call the pump company where I work boils down to anxiety. 

When breastfeeding matters to a mother, it’s natural for her to worry.  But the more anxious a mother feels about breastfeeding, the more likely it is that her anxiety will undermine it.  If her worry centers around her baby’s milk intake, she may try to relieve her anxiety by feeding some formula, which may temporarily make her feel better.  However, if her baby seems more satisfied for longer periods—which is common with formula—it may confirm her worries and increase her anxiety about breastfeeding, leading to more formula use and less milk produced.   

Or she might decide to express her milk and feed it to her baby in a bottle.  Seeing how much her baby consumes may temporarily reduce her anxiety, but trying to keep up with a grueling pumping schedule may increase it again.  A routine of pumping, feeding, and cleaning can take two to three times the effort of direct breastfeeding.  One study found, not surprisingly, that among mothers of preterm babies, 72% of those whose babies made the transition to the breast were still going strong at 4 months, whereas only 10% of those 4-month-olds whose mother pumped and bottle-fed were still receiving mother’s milk.1 It’s difficult to make pumping and bottle-feeding work long term.

Today I spoke to a mother who described her intense emotional upheavals during the first week of breastfeeding.  Her baby was struggling at the breast and the visiting nurse told her that her baby seemed to feed better from the bottle, which convinced this mother to stop breastfeeding.  By the time we spoke, she had been pumping and bottle-feeding for 3 weeks and was convinced that breastfeeding was impossible for her baby.  I explained to her that babies are hardwired to breastfeed and that even babies adopted between 6 to 12 months of age successfully transition to the breast.  I told her that there’s a world of difference between a 1-week-old and a 4-week-old and that although breastfeeding had been traumatic before, it didn’t have to be traumatic now.  I described laid-back breastfeeding positions and encouraged her to help her baby to the breast while in light sleep.  And I described how direct breastfeeding could make her life easier.

Many have rightfully referred to breastfeeding as a “confidence game.”  Encouraging a mother one-on-one can help boost her confidence and decrease anxiety.  Another great confidence booster is experiencing the oxytocin-rich zone of a breastfeeding support group.  Being with other breastfeeding mothers, hearing their stories, and seeing first hand thriving breastfeeding babies have helped many mothers take a deep breath and just keep breastfeeding.

Reference

1 Smith, M. M., Durkin, M., Hinton, V. J., Bellinger, D., & Kuhn, L.  Initiation of breastfeeding among mothers of very low birth weight infants. Pediatrics 2003;111(6 Pt 1), 1337-1342.

Ouch! What If Pumping Hurts?

Some families assume pumping should be painful.  Not so!  “No pain, no gain” does not apply here.  Painful pumping means something needs to be adjusted. 

Pump Suction Set Too High.  The highest suction setting does not always pump the most milk. In fact, too-high suction can actually slow your milk flow.  Set your pump at the highest suction that feels comfortable during and after pumping…and no higher. (If you’re gritting your teeth, it’s too high!)

Pumping milk is not like sucking a drink through a straw. With a straw, the stronger you suck, the more liquid you get. When pumping, most milk comes only when a let-down, or milk release, happens. Without a milk release, most milk stays in the breast.

What is a milk release?  Hormones cause muscles in the breast to squeeze and milk ducts to widen, pushing the milk out. When this happens, some mothers feel tingling. Others feel nothing.  A milk release can happen with a touch at the breast, hearing a baby cry, or even by thinking about your baby. Feelings of anger or upset can block milk release.

While breastfeeding, most mothers have three or four milk releases, often without knowing it. To get more milk with your pump, you need more milk releases, not stronger suction.  For a free, downloadable handout on pumping that includes tips for triggering more milk releases, click HERE.

Fit Issues.  Many nursing parents pump comfortably with the standard diameter nipple tunnel that comes with their pump. But if pumping hurts even on low suction, you most likely need another size. (You may even need different sizes for each nipple.) If the standard nipple tunnel size is too small or too large, a better-fitting one will feel more comfortable and may also pump more milk. To check your nipple-tunnel fit, click HERE. 

Breast or Nipple Issues can also cause pain during pumping.  If your pain is not due to too-high suction or too-small or too-large nipple tunnels, it is time to consider these questions.  Do you have nipple trauma?  If you had nipple trauma in the past, could you have a bacterial infection of the nipple?  Do you have an overgrowth of yeast (also known as thrush or candida)?  Is mastitis a possibility?  Does your nipple turn white, red, or blue after pumping?  If so, see your lactation consultant or other health-care provider to rule out Raynaud’s Phenomenon and other causes related to breast and nipple health.   Thankfully, in nearly all cases, pain during pumping is a solvable problem. and scroll down

Guest Post: The Importance of Support

My guest blogger today is Laura, whose comments on my post "Milk Paranoia" seemed so fitting, I wanted to highlight them.  They reinforce the importance of Step 10 of the Baby-Friendly Hospital Initiative. which involves referring mothers to breastfeeding support groups after hospital discharge. Without ongoing support, long-term breastfeeding is an elusive goal for many. --Nancy

I suspect most women don`t even realize what qualifies as having an oversupply to begin with. I didn`t realize I was in that category until just recently. Although I am quite blessed to have more milk than I need for my monster-sized 29 inch, 22 pound, 6-month-old baby, I often worry whether pumping and working will affect my supply at some point and I won`t be able to keep up. Never mind that I successfully nursed my oldest for 3.5 years without issues.

It`s hard not to find breastfeeding horror stories out there. All one has to do is read a breastfeeding forum to hear the tales of lost milk supply and madly switching to formula, which baby promptly refuses. For myself I wouldn`t dream of posting on these forums about my oversupply and ability to produce milk at the drop of a hat.

I guess the point is that whether I trust my body or not it`s quite easy to fall into the trap of worrying about supply. It`s not like I can just run to Walmart and pick up some breastmilk if I run out. Not only is breastfeeding about trusting one`s body, it`s also about having the right information and surrounding oneself with people that are confident in their breastfeeding ability. This can be difficult to do. The breastfeeding horror stories are everywhere and so is the misinformation.

Milk Paranoia

Not long ago, most of the mothers attending my monthly breastfeeding group had overabundant milk production.  Our meetings were full of their struggles.  At the breast, their babies choked, coughed, and pulled off crying.  Bouts of mastitis were common.  Their babies gained twice the average weight and displayed their “thunder thighs” as living proof.  Some regularly donated the 100-ounce (3 L) minimum required by one area milk bank.  Yet despite the obvious downsides of producing so much milk, not one of these mothers wanted to reduce her production to a level closer to her baby’s need.

One mother beamed as she described her overabundant production, clearly relishing this badge of honor.  She regaled the newcomers with tales of her overflowing freezer, her ability to squirt milk across the room, and the amazing volumes she could express at a sitting.  I toyed with the idea of buying her the tee shirt: “I make milk.  What’s your superpower?”   Others with obvious overproduction lacked her confidence.  They contacted me regularly with worries their milk would disappear.  After developing mastitis and seeing a decrease in her milk, one mother went into a panic, even though she still expressed more milk at work than her baby needed.  These mothers all made it clear they “felt better” making too much milk.  The very thought of reducing their milk production filled them with anxiety.

What was the root of this “milk paranoia?”  I chalked it up to the naysayers around them who make breastfeeding sound like an accident waiting to happen.  They share stories of mothers who wake one morning to discover their milk is gone.  They cast doubt on whether they have enough milk.  They criticize feeding patterns that differ from formula-feeding norms.  Is it any wonder so many mothers suffer from milk paranoia?  Or is even more remarkable that more don’t? 

The 'Magic Number' and Long-Term Milk Production (Parts I and II)

In my last blog post, I told a military mother who had returned to work at six weeks postpartum that she was making as much milk as her thriving baby would ever need.  To meet her breastfeeding goal of one year, I told her, “all she had to do was maintain her milk production.”  But maintaining milk production is not always easy for employed mothers, especially when they don’t know the basic dynamics affecting how much milk they make.  I shared some of these dynamics with this mother, and my explanation set her mind at ease.

Breast storage capacity.  This is the amount of milk in a woman’s breasts when they are at their fullest each day and this amount can vary greatly among mothers.  Breast storage capacity affects how many times every 24 hours a woman’s breasts need to be drained well of milk—either by breastfeeding or expression—to maintain her milk production.  When her breasts become full, this sends her body the signal to make milk slower.  In other words, “drained breasts make milk faster” and “full breasts make milk slower.”  The amount of milk needed to slow milk production will be much greater in a woman with a large breast storage capacity, so she can remove her milk fewer times a day without her milk production decreasing

The “magic number.”  This refers to the number of times each day a mother’s breasts need to be well drained of milk to keep her milk production stable.  Due to differences in breast storage capacity, some mothers’ “magic number” may be as few as 4-5 or as many as 9-10.  But when a mother’s total number of breast drainings (breastfeedings plus milk expressions) dips below her “magic number,” her milk production slows.

Daily totals.  Many of the employed breastfeeding mothers I help by phone are diligent about maintaining their number of milk expressions at work, but often, as the months pass, they breastfeed less and less at home.  With this change in routine, they may drop below their “magic number,” which causes a dip in milk production. 

Recently, as I asked one employed mother with decreasing milk production about her daily routine, she told me that her baby was sleeping in a swing all night.  She discovered that in the swing he did not wake at night to feed, so she was sleeping on the couch in her living room next to the swing and waking every hour to check on him.  I told her that eliminating those nighttime breastfeedings was the likely cause of her decreased milk production and I asked if she thought returning to breastfeeding at night might mean more sleep for her as well as more milk for her baby.

More breastfeeding when together means less expressed milk needed.  The amount of milk per day babies need between 1 and 6 months stays remarkably stable, on average between 25 and 35 oz. (750-1050 mL) per day.  By thinking of the 24-hour-day as a whole, it becomes obvious that the more times each day the baby breastfeeds directly, the less expressed milk will be needed while mother and baby are apart.  But many mothers don’t realize that dropping breastfeedings at home and encouraging baby to sleep more at night adds to the amount of expressed milk their baby needs during the day.  Understanding these basic dynamics can go a long way in helping mothers meet their long-term breastfeeding goals.

More on the 'Magic Number' (Part II)

In response to the previous post, "The 'Magic Number' and Long-Term Milk Production," a reader of this blog wrote: “I have a 6-week-old and just returned to work. I pump once every 3 hours and am pumping more than enough milk for my baby. But I am fearful of pumping less. Given my son’s eating routine is still getting established and will likely change still, how do I determine my ‘magic number?’”

I suggest you begin by thinking back to your maternity leave, assuming you were breastfeeding exclusively and your baby was thriving.  On average, how many times every 24 hours did your baby breastfeed?  As a starting point, consider this your “magic number.”  For example, if the answer is 8 (which seems to be average), assume that to keep your milk production steady long-term you will need to continue to drain your breasts well at least 8 times each day.  If you’re pumping 3 times each workday, this means you’ll need to breastfeed 5 times when you and your baby are together.  (This will be much easier if 2 of these breastfeedings include one just before leaving your baby for work and another as soon as you and your baby are reunited again.)

Another factor that can affect milk production is the longest stretch between breast drainings (breastfeedings or pumpings).  Ideally, to keep milk production stable, do not regularly allow your breasts to become uncomfortably full, as that gives your body the signal to slow milk production.  If your baby sleeps for long stretches at night, I usually suggest going no longer than about 8 hours between breast drainings.  Despite the social pressure for your baby to sleep through the night as young as possible, for most mothers it is easier to keep long-term milk production stable if they continue to breastfeed at night. 

So don’t just focus on your pumpings at work.  Also keep your eye on the number of breastfeedings outside your work hours.  As I mentioned in a previous post, many of the employed breastfeeding mothers I talk to pump often enough at work, but as the months pass, the number of breastfeedings outside of work gradually decreases.  It’s not just how many times you pump at work that determines your milk production.  More important is the number of breast drainings every 24 hours and how this total compares to your “magic number.” 

Facts Every Employed Nursing Parent Needs to Know

Today I spoke by phone with an employed breastfeeding mother in the military who had recently returned to work.  She told me she was worried she would not be able to keep up her milk production over the long term.  I shared with her some facts that could smooth the way for any employed breastfeeding mother but are not widely known.

From 1 to 6 months of age the breastfed baby’s daily milk intake stays relatively stable.  This mother assumed—like most—that as her baby grew bigger and heavier, he would need more milk.  In fact, that’s not what the research shows. Because babies’ rate of growth slows between 1 and 6 months, daily milk intake remains remarkably consistent during this time.1 I told this mother that since her baby had been thriving on exclusive breastfeeding for his first six weeks that she was golden.  She was already producing as much milk as her baby would ever need.  All she needed to do was maintain it.  (Note: This is not the case for the formula-fed baby, as explained in my blog post “Breast Versus Bottle: How Much Milk Should Baby Take?” which leads to many mistaken assumptions.) 

After solid foods are started, the breastfed baby needs less milk.  This mother also expressed concern about meeting her one-year breastfeeding goal because her husband was scheduled to deploy in January, when her baby would be 7 months old.  She was worried that as an employed mother alone with a 7-month-old baby and a 2-year-old toddler, she would not be able to keep up with her baby’s need for milk.  I told her that once her baby started on solids, which is recommended at six months, the baby would actually need less and less milk, as he ate more and more solids.2,3

She told me that this information was a huge morale booster and that it made meeting her breastfeeding goals seem much more feasible.  This is information every employed breastfeeding mother needs to know.

References

1Kent, J. C., et al. (2006). Volume and frequency of breastfeedings and fat content of breast milk throughout the day. Pediatrics, 117(3), e387-395.

2Islam, M. M., et al. (2006). Effects of varied energy density of complementary foods on breast-milk intakes and total energy consumption by healthy, breastfed Bangladeshi children. American Journal of Clinical Nutrition, 83(4), 851-858.

3Cohen, R. J., et al. (1994). Effects of age of introduction of complementary foods on infant breast milk intake, total energy intake, and growth: a randomised intervention study in Honduras. Lancet, 344(8918), 288-293.

Seeing the Glass as Half Full

The years seemed to fly by in an instant.  I became a La Leche League leader in 1982.  During the first decade I led meetings and helped mothers, about 50% to 60% breastfed after birth.  Breastfeeding to ayear was unusual.  La Leche League and other mother-support meetings were the only place you could count on seeing other nursing mothers and getting breastfeeding help and support.

Make no mistake, we still have a long way to go, but in the last 28 years the changes have been amazing.  Now about 75% of U.S. mothers start breastfeeding after birth and 22% are breastfeeding at one year.  The U.S. has more than 90 Baby Friendly hospitals.  In the Chicago suburb where I lead my LLL meetings, new mothers attend hospital mother-support groups, Attachment Parenting groups, baby-wearing groups, Baby Cafes, and many more.  When I started my new LLL group four years ago, one mom told me that she went to all of these groups’ meetings (at least one per week) for her first few months postpartum because she needed the emotional support as she made the transition from working woman to at-home mom.  

When I was a new mother, I described my LLL meetings as a parallel universe where breastfeeding was the norm.  Experiencing that for one evening each month was the antidote I needed to combat the social pressures of the time.  It gave me confidence to continue breastfeeding despite the naysayers.  Now breastfeeding mothers can find support in many places, and thank goodness for that.  I’m thrilled to be “one of many” for the moms and dads who attend my monthly meetings.  Breastfeeding is much easier when mothers have many people to turn to and they can connect with them more often.

I’ve always been a “glass-half-full” kind of person.  So as I lead my LLL group meeting tomorrow night, I encourage you to celebrate with me the strides we’ve made.  There is still much to do, but let’s spend a few minutes this week to appreciate what we’ve accomplished.  Happy World Breastfeeding Week!

Photo:  This 1989 image was taken of me and my two younger sons by a newspaper photographer to show an LLL leader at work and later appeared on the cover of Leaven (an LLLI publication for leaders).  As one LLL leader wrote to me later: "How typical, a leader talking calmly to a mother on the phone with her happy toddler on one hip and her older child contentedly drawing...in a CLEAN kitchen"   LOL!

When Is a Book Like a Baby?

Authors often say that writing a book is like giving birth.  This act of creation can produce powerful brain contractions that feel as intense as labor and delivery.

During the two years I spent writing my latest book, I experienced all the usual moaning, groaning, and self-doubts, but in one sense it was even more like the real thing.  On July 21, when I held Breastfeeding Answers Made Simple (BAMS)in my hands for the first time, I discovered that at 6.3 pounds, it was as heavy as a full-term newborn.

It happened during the festive first evening of the International Lactation Consultant Association (ILCA) conference in San Antonio, Texas where we celebrated ILCA’s 25th anniversary and the silver anniversary of ourprofession.  As the exhibit hall opened, I rushed to the ILCA bookstore.  Would it arrive on time?  How would it look?  When I got my first glimpse, it seemed impossible that I had given birth to this.  It was enormous!  How would I manage?  Could I even fit it into my suitcase?

As I sat down to take a closer look at its nearly 1,000 pages, many friends and colleagues stopped by to say hello, congratulate me, and admire my gigantic tome.  Many despaired with me about getting it home without going over luggage weight limits.  Yet somehow it all worked out.  Thankfully, baby and I made it home safely.  And all of us are doing just fine.

Photos:  Upper left, Catherine Watson Genna, Nancy, and Kat Shealy from the CDC; Lower left: Rene Fisher and Nancy; Right: Tom Hale (BAMS publisher), Nancy, and Kathleen Kendall-Tackett (BAMS editor)

Guest Post: Formula Companies Say WIC and US Government Shouldn't Discriminate

My guest blogger today is Elita, a woman with a definite point of view whose work never ceases to impress me.  It is reprinted from her blog "Blacktating: Breastfeeding News and Views from a Mom of Color." --Nancy 

I came across a really interesting article in the Washington Post titled, “Lobbying fight over infant formula highlights budget gridlock.” You may or may not be aware that in the United States, the biggest purchaser of infant formula is the US government via its WIC (Women, Infants & Children) nutrition program. Basically, the formula companies offer state governments rebates (sometimes as high as 98%) of the wholesale cost of the formula in exchange for an exclusive contract. They’re not being benevolent; they know that WIC doesn’t give a mom who’s formula feeding full-time enough formula to get her through the month and they’re betting when she does have to come out of her own pocket to buy formula, she’s going to stick to the brand she gets for free from WIC. To put in perspective how much WIC spends on formula, the WIC budget for fiscal year 2009 was about $7.3 billion and about $850 million went to the formula companies.

So you’ve noticed lately that the formula companies have all kinds of extra special ingredients they’ve added to the formula. These additives are things that are naturally found in breastmilk, like DHA, ARA and probiotics. Of course these additives are not the same as what is found in breastmilk, because that’s impossible. So the formula companies have to get them somewhere else, like from algae. There’s no proof that these additives confer any benefit to the baby, save for a few formula-sponsored studies. But of course these new formulas are more expensive, and as they add in more functional ingredients, the original, regular iron-fortified versions disappear from store shelves.

What does this have to do with lobbying? According to the Washington Post article,

“When WIC was reauthorized in 2004, Congress tucked in language telling states that when soliciting bids for infant formula, they could not require manufacturers to include or omit specific ingredients. You can guess what happened next: Formula makers began submitting bids only for the costlier products. A February 2010 Agriculture Department study pegged the added cost at $91 million annually, more than a tenth of the infant formula budget. Now new formulas with even more ingredients -- and even higher prices -- are being offered through WIC. With WIC up for reauthorization, the Senate Agriculture Committee has approved a measure to require the Agriculture Department to assess the additives. A House committee this week is poised to consider a similar provision that directs USDA to get the best scientific advice before deciding whether to provide costlier foods with extra ingredients.

Not surprisingly, formula makers -- Abbott, Nestle and Mead Johnson -- are lobbying hard against the provision. So is the manufacturer of the additives, Martek Biosciences Corp., which has brought in well-connected Democratic lobbyist Lanny Davis. “

There are a lot of issues here we could tackle. First, is the too cozy relationship the formula companies have with WIC. The fact that the infant formula companies are spending big bucks to lobby in Washington proves just how lucrative this business really is, and what a shame that such an inferior product is being fed to the majority of babies, some from day one. We could also focus our rage on how although the FDA has approved these functional ingredients as “safe,” no one can prove there’s any actual benefit for babies, and if there were, what does that say about the infant formula business? Essentially they’re making it all up as they go along, constantly tweaking the recipe. It’s one big experiment, so for the babies who got 2001’s version, uh…sorry about your eyesight and IQ points.

While all of these aspects of this saga make me stabby, I have to admit I wasn’t expecting the formula companies to pull the race card. But lo and behold they did! According to the International Formula Council, which is made up of representatives from Nestle, Enfamil & Similac, to not force WIC to buy the formula with the functional ingredients would create a “two-tiered system, in which nutritionally at-risk WIC participants, many of whom are minorities, are denied access to products widely available to the general public.”

Are you as disgusted as I am? And do you, for one single, solitary second believe that the formula companies are worried about the health and fate of black and brown babies? And while I do appreciate their “concern,” wouldn’t a better way for them to prove how much they care about poor babies of color be to stop aggressively marketing their product to their mothers? Or perhaps they could back off, and let the decision be based on science, not their own bottom line? Maybe they could think about how, if formula eats up even more of the WIC food budget, that means less fruits and vegetables for WIC eligible families. Heck, since they care so much about the poor, maybe they should think about all the families who will no longer be able to receive WIC because there won't be enough money to go around once we cover their worthless functional ingredients?

I think we all agree that if the ingredients were really going to make a difference, and protect and nourish formula-fed babies in a manner more like breastmilk, that the increased cost would be justifiable and we'd be all for it. So if the formula companies are so sure that their new products are superior, why not let scientists--ones NOT on their payroll--determine it?