We Are Breastfeeding

I had the privilege of meeting April Foster, the author of this post, when I spoke in Napa, California on January 20.  After my talk, “Transitioning to the Breast,” April approached me to tell me that many of the strategies I described had worked for her and her son, who she adopted at 20 months.  When she told me her story, I asked her to share this amazing saga of love and devotion.  April’s sons are incredibly lucky boys! --Nancy

I have a son that came to us through adoption at 20 months of age. We started our breastfeeding relationship about 4 weeks after placement in our home. Our journey is astonishing, especially for those new to adoptive breastfeeding.

Almost any woman can induce lactation through breast stimulation with a breast pump or by just putting a baby to the breast to suckle. The hormones cause the milk ducts to start making milk. Mothers often question how much they will produce.  But the amount of milk I made is not what was important to me. I April and Andrewknew I would adopt a baby older than 12 months, so this did not concern me as much as it would if my child had been an infant.  

I had heard about adoptive breastfeeding for years, but since I was adopting an older baby, I assumed it wasn’t possible. I had already grieved the loss of having children by birth and had come to terms with never having a breastfeeding relationship with my children. This was okay with me. Then one day in an adoption search I saw a story about a wonderful breastfeeding relationship between a mother and baby who was adopted at about 2 years of age. I thought, “You have to be kidding me! How is this possible? What about the ‘nipple confusion’ I had heard so much about? How do you teach them to do it? And what impact does that have on their mind and soul? How would my friends and family react?” This would certainly be a strange thing to do. It turned out my friends and family were happy and supportive.  And breastfeeding my adopted baby felt completely natural. Many mothers find this a wonderful way to bond with their adopted children.

I decided to try inducing lactation, and started by pumping 5 to 8 times a day for about 10 minutes. The first day I only produced a few golden yellow drops. The next day I saw white milk but did not make much. At the end of 3 months I was only pumping about 1 to 2 ounces (30 to 60 mL) a day. It may sound crazy that I was pumping so much and getting so little milk. I kept reminding myself that getting a lot of milk was not my goal. I was preparing my breasts for suckling and stimulating milk for my baby. I was excited that my breasts were making any milk at all and amazed this was possible!

Then one day we got the call and went to pick up our children: two brothers 20 months and 3 years old. They told us my 20-month-old was not taking a bottle, but I had already purchased some bottles in preparation, so I thought I would try re-introducing it to him. I was unsure if he would want to breastfeed, but we would try and if he decided not to, that would be okay.

He loved the bottles of milk! They were one of the few things that comforted him at first. His hands held the bottle tightly as if someone was going to take it away. During the first few days, my son would not let me touch him. He only wanted to be held by my husband, who he gave him the bottles. This was heartbreaking after all my preparation, but I was also prepared for this and didn’t take it as a rejection. I knew he would come around. The first two nights he was up almost all night. The bottle would put him to sleep, but taking the nipple out of his mouth woke him. Moving him woke him and he woke within an hour of sleeping. He was scared and in a strange house with strangers all around. How in the world was breastfeeding ever going to work? He wouldn’t even let me hold him.

After a few days, I decided to sleep with him on the kitchen floor so I could get the bottles fast and my husband could sleep. My son still woke screaming. The bottles helped, but they didn’t always work. Then we decided only I would give him food and all bottles would come while I held him in my arms. This meant no high chair at dinner, no snacks he could hold himself, and no bottles while walking around. When he took a bottle, he wouldn’t look at us. He wouldn’t let me touch the bottle. I think he was scared someone would take it away. He wanted to keep the nipple in his mouth even in his sleep. This was a good sign he would like breastfeeding once we got there.

I did everything I could to get close to him during the first few weeks, rocking, walking with him, holding, co-bathing, co-sleeping. Any kind of skin-to-skin contact did us good. At first my 20-month-old wouldn’t let me put my hand on him while sleeping. He would wake up immediately and push my hand away, because he was used to sleeping in a crib all by himself. Within the first week, he let me put my hand on him for short times. I tried to stay close to him all day while he played and put my hand on him whenever he would let me. We still had moments when he would scream and cry, run away, and want me to leave the room. He would cry for hours. But it was expected and normal for him to be upset and mad that his whole world had been turned upside down. These moments always ended with him finally taking a bottle with me and going to sleep. We were getting closer, and he was getting to know that he could trust me, but it was slow going. I was up almost all night long but loved every minute of it. I remember one day sending an e-mail to my mom and sister at 5:00 am telling them that I hadn’t slept but that I was crying because I was so delirious with happiness. It had been one of the good nights when we played and laughed and cuddled and rocked with bottles with only a few bad episodes. It was getting better every night! 

I also talked to both of my kids about mommies and babies nursing. We would have the baby ducks nurse from their mommies in the bathtub. We would read books that had animals nursing. Both of my kids loved to play with their animals and dolls and to nurse them. This was a good way for my 3-year-old to learn how a mommy is supposed to take good care of her children.

After about 2 weeks, my 20-month-old finally started waking up looking for me, happy to see me instead of screaming. I put my hand on him more and more while he slept to get him used to the feeling of a warm body near him. One time he woke up, saw I was there, and went back to sleep. When giving him bottles in my arms, he started to let me hold him while lying down. The bottle still faced slightly away from me, but he could look at me now. I starting taking off our shirts for more skin-to-skin contact, and also so his face was next to my breast and he could feel and smell it. He still held the bottle really tight and wouldn’t let me hold it, so it was difficult to take it from him after he fell asleep.  I started wrapping the bottle in a big piece of soft material to give him something soft to hold onto but not to look at while the milk flowed. This worked. When he fell asleep, his hands fell gently away from the material.

During the third week, I began put the tube of an at-breast supplementer next to the bottle nipple. I planned to put this tube next to my nipple while breastfeeding so he could get more milk at the breast.  He needed to get used to that idea, so I pulled the tube through the bottle nipple with a needle, and then filled the supplementer bag with milk. Now the bottom of the bottle was no longer needed and the material hid the fact it was missing. I thought the slower flow of the supplementer might create anxiety, but he didn’t seem to notice the difference.

He was now used to sitting down with me for milk and began pointing to the refrigerator when he wanted some. He also started playing with my face and hair and laughing while drinking. Occasionally he wanted to sit and drink milk if he was upset or hurt. 

At the end of the third week I put the bottle nipple closer to my breast and then right over my breast.  Then I could move him toward me into a breastfeeding position. We were almost breastfeeding even though he had not yet latched on. He got milk from me while being held in my arms. He felt my skin next to his belly. He felt my breast against his cheek. He looked into my eyes. He smiled back at me. He got to know my smell and trusted that I would comfort him and give him nourishment when he needed it. He played with my other breast with his hand and my hair, nose, eyes, and mouth.  He put his leg up so I would play with his foot and make him laugh. He fell asleep while rocking in my arms. This is what breastfeeding is all about! If we stayed like this forever, and never actually breastfed, I would still be in heaven!

During the fourth week he was really happy and content, so I decided to offer my breast with the supplementer tube next to it. It felt different.  He was confused and didn’t want it. But when he was asleep, I tried offering my breast and he took it, sucking for about 5 minutes. Hurray! And wow, what a strange feeling. This was certainly different than the pumping I had done for 4 months. We were breastfeeding, even if it was only in his sleep.

Then there were a couple of bad days. He woke screaming again in the middle of the night and didn’t want the bottle nipple with the tube. He pushed both my husband and me away and wanted to cry by himself. This gave me doubts.  Maybe all these changes happened too fast, so I didn’t offer my breast again for 3 or 4 days. After a few days of this, he was happy with the bottle nipple and tube again and awoke happy to see me. I decided this probably had more to do with his grieving process than with breastfeeding.

So, at the end of the fourth week, I tried offering my breast more often when he was already asleep and rooting for the bottle. These moments didn’t happen very often, so I decided to try when he was awake. He seemed confused and didn’t want to take my breast. This was really tough for a couple of days. I always had the bottle ready in case. He took the breast a couple of times, but not for very long, and seemed confused at its different feel. Every time we tried my breast, my heart would race. I was nervous and anxious, which I think affected him. After 3 or 4 days, we both settled down and he started to get used to it but still preferred the bottle nipple if he could see it. So, I tried one day of offering my breast without the bottle nipple in sight. Eventually he took my breast, and as long as there was milk flowing, he was happy.

From that moment on, we were breastfeeding. It took a little over 4 weeks to transition him from bottle to breast, but he loved to suck and to breastfeed. I continued to use the supplementer, since I had no idea how much milk I was producing. I tried a couple of times without it, but he wasn’t happy. Someone asked if I thought it was because of the tube, which I had gotten him used to or because of the milk that was flowing. I had no way of knowing except…I could put the tube on my breast but crimp it so there was no milk flow. When I did this, he sucked just the same as he did before. This meant one of two Aprils sonsthings. Either, I was producing enough milk to keep him satisfied. Or, he liked to suck to pacify himself and didn’t care if there was a fast flow of milk. Either way, he was happy and I was happy. But, then I worried that maybe after a while of not getting enough milk, he might stop being happy with it, so I went back to the supplementer as a safeguard.

After about 3 weeks, one day I lost one of the supplementer parts and he breastfed just as often and just as long. We never used it again. It was such a relief to breastfeed without having to fill the bags or go to the refrigerator. He could then breastfeed wherever and whenever he wanted.  He caught on fast and asked to nurse often. His suck soon became much stronger. This increased my milk supply more than when we used the supplementer.

Sometimes I still wondered if this was good for my baby or if I was pushing something on him that he didn’t need or want. That question was answered when he had a fever for 3 days and then fell and cut his lip. He pointed to his lip and cried. The only thing that made him feel better was nursing. He asked to nurse every half hour during the day. He woke up every hour at night, and breastfed. He This was the answer I needed.

About 2 months after placement and 1 month into breastfeeding he sometimes woke just to check if I was there, breastfeed for about 3 minutes and peacefully went back to sleep. He did this about every 45 minutes. It was a great way for us to bond and attach, and for me to let him know that I was here for him whenever he wanted me.

He breastfed about 4 or 5 times at night and for 45 minutes first thing in the morning, sucking a little every few minutes. During the day, he breastfed more than I ever expected and I was thrilled with how much he liked it! It felt like he was an infant breastfeeding. I was also glad that some of those sessions were comfort sessions, lasting only about 2 minutes. Almost no one does this with a bottle. By the time you get a bottle ready, the moment is over. We breastfed in the living room, in the bathtub, at a restaurant, and by the side of the road. Some said I could have fulfilled my son’s need for bonding with hugs and kisses and other types of physical gestures. I say that my baby has all those and breastfeeding. What a nice addition to all those other wonderful things to make your child feel secure and loved. It may not be necessary, but it is precious.

We are now 8 months into breastfeeding. We still breastfeed every night to go to sleep and as soon as he wakes up. He now only wakes once at night to breastfeed. Some people told me that if I let him wake in the night so many times, it would last forever. He now sleeps peacefully, knowing that I am right there beside him if he needs me. Instead of cringing when I put my hand on his back, he rolls over and snuggles right next to me. Sometimes he wakes up and just wants to see I am there, rolls closer to me, grabs my hand and puts it around him and falls back asleep. This is bliss! He breastfeeds 5 to 10 times during the day, depending on where we are and what we’re doing. We will continue breastfeeding wherever and whenever he wants and for however long he wants, until he decides he doesn’t like it or need it anymore.

Some have asked if I have neglected my 3-year-old because I spent all this time with my 20-month-old. I think this experience has been great for him as well. My 3-year-old seemed comforted seeing a mommy taking really good care of his brother. He told me stories of when other mommies left his brother in a crib crying while he was scared. He now walks around and pretends to breastfeed his babies or brings them to me and says they want milk. He puts them to sleep and is very gentle with them. This is one of the most adorable things I have ever seen.

In the end, even after all the hard work, I know I had it easy compared to what I was prepared to do. Some women have taken many months to go through these same transition steps. I cannot say how happy I am to have stumbled upon something this wonderful. Had I not planned to breastfeed, I probably would have been happy that he was not taking bottles anymore. Who wants to fill bottles all day and wake up at night to fill them? How would we have bonded? How would he ever feel safe in my arms? We bonded with each other through this wonderful experience. I know we would have bonded eventually, but I am sure this way it happened much sooner.



Baby Friendly Hospitals Will Improve Black Breastfeeding Rates

This guest post comes from a fellow blogger I never miss, Elita (www.Blacktating.com).  It describes how a hospital’s Baby Friendly status affects breastfeeding initiation rates among Black mothers.  Similarly, a 2006 Australian study found that when breastfeeding rates there reached “universality” (in this study 96%), mothers of all ethnicities, education levels, and socio-economic status breastfed at the same rates.  In other words, once our institutions truly support breastfeeding, all women breastfeed equally.  Not surprising.  After all, we are mammals. --Nancy

A new update on California's breastfeeding rates and hospital policies was released by the California WIC Association and the UC Davis Human Lactation Center. The report, titled "One Hospital at a Time: Overcoming Barriers to Breastfeeding" takes a look at how instituting baby-friendly practices at Photo credit: edenpictureshospitals through California has impacted the breastfeeding rates.

California is currently home to 34 of the 150 hospitals and birth centers that have been certified as Baby Friendly by UNICEF/WHO. The report paints a very clear picture of how beneficial the Baby Friendly initiative has been to California's breastfeeding rates. Not surprisingly, the hospitals with the lowest breastfeeding rates are those that serve low income women of color and throughout the state, disparities are evident. The report states that in the past, these disparities were chalked up to differences in cultural practices, but the data clearly shows that hospitals that have baby-friendly policies in place were able to greatly reduce those disparities.

The report shows that the breastfeeding initiation rate throughout California for African-American women was at about 78% while the exclusive breastfeeding rate was around 40%. When you look at the exclusive breastfeeding rate for African-American women at the Baby Friendly hospitals, that number jumps from 40% to 60%. And although those numbers are still too low, they are far and away better than the national initiation rate of 54%.

We can also see the benefit of the Baby Friendly Hospital Initiative to African-American women in another state, New York. In New York City, all public hospitals are managed by Health and Hospital Corp., or HHC. HHC has encouraged its hospitals to incorporate all of the Ten Steps to Successful Breastfeeding, but only one, Harlem Hospital, has been certified as Baby Friendly.

Harlem Hospital serves a large population of African-American and African immigrant women. Any hospital that thinks becoming certified would be too difficult or wouldn't work with their population, need only look at Harlem Hospital as proof that it can be done anywhere. In 2007, right before officially becoming Baby-Friendly, 81% of women were breastfeeding when they left Harlem Hospital.

In a recent article in Heart & Soul magazine, a black woman who gave birth at Harlem Hospital talked about her experience. Alicia Lewis-Howard was told by family and friends that breastfeeding would hurt and she didn't think she would nurse for more than a month, but ended up breastfeeding for 6. She credits the nurses at the hospital with showing her how to properly latch the baby on so breastfeeding was not painful and for educating her on the many benefits of breastfeeding both to herself and her baby.

The Baby Friendly Initiative has been proven to increase black breastfeeding initiation and exclusivity rates. It is imperative that healthcare facilities that serve a large population of African-American women begin implementing as many of the Ten Steps as possible. Although the process of becoming Baby Friendly is extremely rigorous, there is no reason that hospitals can't make the smaller changes, like ensuring that all women are breastfeeding within an hour of birth and rooming in with their babies. If we want to see black breastfeeding rates improve, we have to see hospital practices improve. If California and New York can do it, why can't everyone else?

Should Milk Sharing Among Mothers Be Encouraged?

My guest poster today is Karleen Gribble, PhD, Adjunct Research Fellow in the School of Nursing and Midwifery at the University of Western Sydney in Australia.  She also serves as one of Lactnet's listmoms and is well-known worldwide for her research and writing on adoptive and long-term breastfeeding, the risks of formula-feeding, and infant feeding in emergencies.  Thank you, Karleen, for weighing in on this hot topic.

The recent launch of the peer-to-peer breastmilk sharing group Eats on Feets has brought the issue of women sharing human milk to the attention of health authorities. Due to safety concerns, organisations such as Health Canada and the U.S. Food and Drug Administration have warned mothers not to use another woman’s breastmilk unless it comes from a milk bank. Individuals associated with milk banking have gone so far as to describe peer-to-peer milk sharing as “very unsafe” and “dangerous”

The discussion about peer-to-peer milk sharing has much in common with the discourse that surrounds bed sharing. We know many mothers bring their baby into bed with them at night.¹ Bed sharing makes breastfeeding easier² and breastfeeding mothers get more  sleep.³  It also allows mother-baby interaction to continue throughout the night and may protect the infant against the long periods of deep sleep thought to contribute to SIDS.^4,5

However, we also know that bed sharing is not always safe. We know that if a mother smokes, if she has consumed alcohol or other sedatives, if the baby is formula fed, if the sleep surface is a sofa or water bed, or if the bed is also shared with other children that a baby sleeping with his or her mother is at heightened risk of SIDS or accidental death. Infant deaths that occurred as a result of bed sharing under these circumstances have resulted in health authorities such as the American Academy of Pediatrics recommending that parents not sleep with their infants.⁶  It is ironic that not only does blanket condemnation of bed sharing potentially make parenting unnecessarily more difficult for some mothers, it also has the unintended outcome of increasing deaths in places other than beds, such as sofas. This has occurred because due to fears of falling asleep while feeding in bed, some mothers have gotten up to feed on a sofa, fallen asleep there, and infants have died as a result.^7,8 Thus, it seems that bed sharing should not be promoted nor condemned.  Rather, parents should be given information about how to bed share safely as well as its risks so they can examine their individual circumstances and decide for themselves where their baby sleeps.

It’s much the same with milk sharing. There is a growing awareness of the importance of breastmilk to the normal health, growth and development of children and of the unavoidable risks associated with the use of infant formula. There are also women who are unable to provide their child with all the breastmilk they require because they have had breast reduction surgery or a double mastectomy or because they have insufficient glandular tissue or are extremely ill. These women have the choice of either obtaining breastmilk from peers or using infant formula. Health authorities who have condemned peer-to-peer milk sharing have told these mothers to obtain human milk from milk banks.  But banked donor milk is an extremely rare commodity available to only a tiny number of (usually hospitalised) infants.

The only real alternative to obtaining human milk from a peer is using infant formula, and the evidence for short- and long-term negative impacts on infants from exposure to infant formula is overwhelming.⁹ It is interesting that the same health authorities who condemn peer-to-peer milk sharing have not condemned the use of infant formula.  One wonders why the risks of formula are somehow more acceptable than the risks of milk sharing.  Is it because formula feeding is so entrenched in our cultures, while breastfeeding remains marginalised? It is ironic that nearly all of the risks Health Canada identified as applying to breastmilk from a peer (http://www.hc-sc.gc.ca/ahc-asc/media/advisories-avis/_2010/2010_202-eng.php) also apply to infant formula.  But a similar health advisory on the use of infant formula does not exist.

Milk sharing allows mothers to avoid the risks associated with formula feeding.  For some this may be particularly important, for example, those with a family history of diseases associated with formula feeding (diabetes or asthma), the death of a formula-fed baby from necrotising enterocolitis or SIDS, or a baby with formula intolerance.  In most cases, milk sharing is not something a woman does lightly or without good reason. For one mother’s story, click here. 

When mothers use human milk, they avoid the risks associated with infant formula.  However, they potentially expose their child to a whole different set of risks. Fortunately, most of these risks are manageable and some very easily eliminated altogether.  (Although very few diseases can be transmitted via breastmilk, one of them is HIV.  Fortunately, however, a simple home pasteurisation process destroys HIV.¹⁰) The Eats on Feets website provides extensive information on managing and minimising risks associated with peer-to-peer milk sharing.

As with bed-sharing, peer-to-peer milk sharing should not receive either a blanket endorsement or condemnation, because the safety of the practice depends very much on the situation.  An alternative to endorsing or condemning it is to acknowledge the reasons women want to milk share (banked donor milk unavailable, infant formula deficient), provide information on how to  manage the risks (recognising that the risks are manageable) and affirm that it’s the parents’ decision.  Just as with bed-sharing, as James McKenna noted:  “It remains the right of parents to make informed decisions, which requires access to unbiased information exchanged within an appropriately relaxed and non-judgmental educational venue.”⁵

1Rigda, R.S., I.C. McMillen, & Bucley, P.  Bed sharing patterns in a cohort of Australian infants during the first six months after birth. J Paediatr Child Health 2000; 36(2):117-121.

2Blair, P.S., J. Heron, & Fleming, P.J.  Relationship between bed sharing and breastfeeding: Longitudinal, population-based analysis. Pediatrics 2010; peds.2010-1277.

3Quillin, S.I.M. & Glenn,L.L. Interaction Between Feeding Method and Co-Sleeping on Maternal-Newborn Sleep. JOGNN 2004; 33(5): 580-88.

4McKenna, J.J. & Mosko, S.S. Sleep and arousal, synchrony and independence, among mothers and infants sleeping apart and together (same bed): an experiment in evolutionary medicine. Acta Paediatr Suppl  1994; 397:94-102.

5McKenna, J.J. & McDade,T. Why babies should never sleep alone: a review of the co-sleeping controversy in relation to SIDS, bedsharing and breast feeding. Paediatr Resp Rev 2005; 6(2): p. 134-152.

6Task Force on Sudden Infant Death Syndrome, 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(5):1245-55.

7Blair, P.S., et al., Major epidemiological changes in sudden infant death syndrome: a 20-year population-based study in the UK.  Lancet 2006; 367(9507):314-319.

8UNICEF Baby Friendly, U.K., New research reveals a four fold increase in babies dying when co-sleeping on a sofa, in Baby Friendly News. 2006.

9Ip, S., et al., Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries, in Evidence Report/Technology Assessment No. 153. 2007, Agency for Healthcare Research and Quality: Rockville, MD.

10Jeffery, B.S., et al., Determination of the effectiveness of inactivation of human immunodeficiency virus by Pretoria pasteurization. J Trop Pediatr 2001; 47(6): p. 345-49.



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.

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 Breastfeeding and 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.