Breastfeeding Articles of Interest

If breastfeeding is so wonderful,
why aren't more women doing it?

by Alicia Dermer, M.D., I.B.C.L.C.

Breastfeeding is generally accepted as the ideal form of infant nutrition, and major medical associations and governmental agencies have taken strong positions promoting it. Despite this, breastfeeding rates are barely higher today than they were 15 years ago. As a follow-up to the review of breastfeeding benefits written by Anne Montgomery, M.D. and myself (see The Medical Reporter, Feb 1997), this article will focus on the reasons why few women in the United States of America are choosing to breastfeed and even fewer continue for more than a few weeks (many of the same issues apply worldwide, although some factors play a greater or lesser role in other countries, depending on cultural, political and public health policy issues).

Another goal of this article is to provide readers with some practical ideas for overcoming some of the very real obstacles to choosing, and continuing, to breastfeed optimally.

The history of the infant feeding decision
At the turn of the century, more than 90% of American mothers breastfed their children, but breastfeeding rates declined to a low of 25% in the late ‘60s. With a new understanding of the health benefits came a resurgence of breastfeeding, peaking at 60% in the early ‘80s. Rates gradually declined to just above 50% in the early ‘90s, bouncing back slightly to 62% in 1997.

Unfortunately, this 62% represents only the mothers who are breastfeeding at hospital discharge, both exclusively (no added formula) and partially (with added formula). In 1997, a larger proportion of breastfeeding mothers were already mixing breast and bottle at hospital discharge. This has serious health implications. First of all, early formula use is associated with shorter breastfeeding duration. Secondly, some of the health benefits such as decreased risk of ear infections, asthma and diabetes depend on exclusive breastfeeding for at least 4 to 6 months, and many of the maternal benefits such as decreased risk of breast cancer and osteoporosis also depend on at least several months of breastfeeding.

Despite the American Academy of Pediatrics (AAP) recommendations that breastmilk should be the sole source of infant nutrition for about the first 6 months, only a third of mothers who initiate breastfeeding continue to do so for 6 months, and even fewer breastfeed that long exclusively. Currently, about 80% of American babies are fully formula-fed at 6 months, and about half of 6-month-old breastfed babies also receive formula -- only about 10% of American babies are exclusively breastfed at 6 months according to the AAP recommendations. Of course, there are ethnic, socioeconomic and regional differences in breastfeeding rates. More white mothers breastfeed than their minority counterparts, and younger less educated women are more likely to bottle feed. It is possible that the increased asthma and diabetes among African-Americans is to some extent due to the low rates of breastfeeding, especially among inner city dwellers.

Why are so few women breastfeeding?
Let’s look at some of the reasons for the low breastfeeding rates. There are many factors which can influence a mother's infant feeding decision to varying degrees. Some of these factors affect the decision whether or not to breastfeed, while others have a greater effect on actual breastfeeding duration.

One important factor in both breastfeeding initiation and duration is the inescapable fact that the United States is a bottle feeding society, where until very recently bottle feeding has dominated the general consciousness about infant feeding. Arguably, in some ways it still does.

One needs only to look at the plethora of dolls with feeding bottles and the omnipresence of bottles in pictures of children in the media. Even in the ‘90s, despite general acceptance of breastfeeding as the healthier infant feeding method, the average person is more likely to be exposed to bottle-feeding than to breastfeeding. Clearly, people who grow up with bottle-feeding as the norm are apt to be more comfortable with that method, and to feel a degree of unease about breastfeeding. In some populations, breasts are seen largely as sexual, which adds to some mothers’ discomfort. Even some breastfeeding mothers who do not wish to use formula are so embarrassed or intimidated about the thought of nursing in public that they bottle-feed their babies in public, using their own previously-expressed milk. 

Although breastfeeding is natural, learning to do it requires observation of other nursing mothers. The majority of today’s mothers were either not breastfed or were breastfed for only a few weeks. Their siblings and friends bottle-feed or breastfeed for only a few weeks. Unless a woman is lucky enough to have grown up in a household where breastfeeding was practiced optimally, her chances of observing normal breastfeeding are extremely limited. Some mothers also get little support (sometimes outright hostility) from the very people whom they would rely on, including their significant other, mother, mother-in-law or even their friends. The only source of exposure and support for most mothers is a volunteer mother-to-mother breastfeeding support group such as La Leche League International (LLLI). For women in lower socioeconomic areas without access to this kind of support, LLLI and the Women’s, Infants and Children’s (WIC) program can provide peer counsellors (PC). PC’s are breastfeeding mothers within a community who have had special training to help mothers in that community. As helpful as these programs are, the need far exceeds the supply.

Another factor in the low breastfeeding rates is a lack of information about just how important breastfeeding is, as well as a lack of accurate and standardized consistent information about how to successfully breastfeed. Few doctors discuss the infant feeding decision with expectant parents, whereas doctors’ offices are often sources of formula-company-sponsored "educational" materials about breastfeeding. Although doctors in general are becoming more supportive of breastfeeding, few have the training or the skills to help breastfeeding mothers. As a result, it is still common for a doctor to suggest weaning to a bottle if any breastfeeding difficulties arise. Despite increasing numbers of lactation consultants, the level of training and experience varies and therefore so does the quality of the information they provide. The international standard is the International Board of Lactation Consultant Examiners, which certifies lactation consultants with rigorous eligibility requirements and a standardized examination. Those who successfully complete these requirements have the initials IBCLC. However, there are various other courses available which provide participants with "certificates." The result is numerous people without standardized training who call themselves lactation consultants. I must point out, however, that many LCs without the IBCLC are highly knowledgeable and experienced, while the IBCLC initials are by no means a guarantee of excellent lactation help.

Among other resources available to mothers, there is a profusion of books with a wide range of accuracy relating to breastfeeding. In fact, some of the most popular pregnancy and childbirth preparation books are filled with outdated and incorrect breastfeeding information. Parenting magazines are equally inconsistent in their treatment of breastfeeding. For accurate and practical books on the subject, see breastfeeding books (below). The quality and depth of the information provided to mothers in childbirth education classes vary to a large extent with the personal experiences and biases of the instructor.

Mothers’ personal contacts include family and friends, many of whom have not breastfed or may have had negative experiences. Even relatives or friends who successfully breastfed are not necessarily knowledgeable beyond their own personal experience and may have little to offer if the mother develops a problem they didn’t have to deal with.

Then there are the media. Although there are scattered reports about newly discovered benefits of breastfeeding, it’s more common to see misinformation and sometimes extremely distorted sensationalistic reports about breastfeeding problems.

Another important factor is the large number of mothers in the work force. Although mothers who will return to paid employment choose to breastfeed equally as often as stay-at-home mothers, they tend to stop breastfeeding sooner, with the exception of mothers who work part-time. Some mothers who anticipate having to wean on returning to work never even breastfeed at all, depriving their babies of the early benefits of colostrum and themselves of the breastfeeding experience. Ironically, mothers who choose bottle-feeding or wean completely on return to work are setting themselves up for more frequent absences from work due to a baby who is more likely to get sick. With increasing awareness of this among corporations, there is now an encouraging trend towards providing on-site day care, breast pumps and pumping facilities, and/or flex-time to promote continued breastfeeding.

Other factors which come into play in decisions of mothers about breastfeeding and their success in continuing to breastfeed, include cultural beliefs, mismanagement by hospital staff and other health care providers, and the marketing practices of formula companies, some of which I will explore further.

In view of all the obstacles to breastfeeding in this society, it’s not surprising that 40% of American mothers never even try breastfeeding. Although we have no real measure of how many of those 40% even considered breastfeeding their babies, it’s probably fair to say that some of them never even gave breastfeeding a second thought. But, equally likely, some of those 40% may actually have thought about breastfeeding but decided against it because the perceived negatives outweighed the positives.

What can you do to prepare for breastfeeding?

First of all, obtain reliable information. Avoid formula-sponsored materials, which may have some accurate information but may omit important information or imply that supplementation with formula or eventual weaning to formula are desirable or inevitable. For example, we have yet to find a formula-sponsored breastfeeding pamphlet which states unequivocally that the American Academy of Pediatrics recommends breastfeeding for the full first year of life, exclusively for the first 6 months. Instead, there are words such as "breastfeed for as long as possible..." More importantly, although cow’s milk protein and soy protein are the two most common allergy-causing substances in babies, there is no mention of the importance to families with histories of asthma, eczema or allergies to breastfeed exclusively, avoiding formula supplements to prevent sensitization of the baby to these proteins.

Although some formula literature now recommends waiting to introduce a bottle until at least 3 to 4 weeks, the implication is that the bottle will inevitably be introduced. In fact, bottle-feeding (even with mother’s milk) is not always desirable or necessary. Mothers who breastfeed according to the AAP recommendations may never need to introduce a bottle at all, as they can start the baby on cup feeds at six months and continue nursing. Even before six months, if the baby needs to be fed while mom is away, there are alternative feeding methods (e.g. spoons, medicine cups, medicine droppers or syringes, supplemental feeding tube devices) that can be used instead of bottles. Nipple preference (also known as nipple confusion) is most likely to occur while a baby is first learning to nurse, but breast refusal can occur at any age in a child who has been getting a lot of bottles.

So should you never use a bottle? Well, never say never. There are certainly situations in which bottles are fine. However, a baby’s refusal to take a bottle is a remediable problem, whereas a baby unable to breastfeed because bottles were introduced too early may spell the end of the breastfeeding relationship. For a list of non-commercial breastfeeding literature sources with more accurate information, see Resources for breastfeeding information (below).

Another good way to become informed and better prepared is to attend breastfeeding classes preferably given by a lactation consultant who is IBCLC. Be somewhat skeptical of a class where the handouts provided are sponsored by a formula or bottle manufacturer. Alternatively, attend a La Leche League meeting. Why bother with a class or a meeting? These sessions provide valuable hands-on and interactive learning and/or sharing of experiences by mothers who have overcome problems. They are especially helpful to mothers who have not breastfed successfully in the past and have no good breastfeeding role models.

Secondly, check out how truly supportive of breastfeeding your doctor and hospital are. It’s not enough to hear that they support breastfeeding (after all, it’s like motherhood and apple pie -- who wouldn’t support it, right?). Your doctor (be it your family doctor who is doing your prenatal care, delivery and caring for parents, baby and other family members; or your obstetrician and your pediatrician), should demonstrate strong support of your decision to breastfeed and be knowledgeable about the basics of breastfeeding management.

Unfortunately, as evidenced by a recent national survey, physicians’ knowledge about breastfeeding is sadly deficient due to a lack of teaching of lactation in the medical schools and residency programs. Therefore, if your doctor demonstrates ignorance in this area (evidenced by a total discrepancy by what he/she tells you and the current literature you have read), it does not reflect on his/her general abilities as a physician. At the very least, your doctor should refer you to a good lactation consultant (LC) or La Leche League leader (LLLL) as needed. Your obstetrical care provider (be it an obstetrician, family doctor or midwife) should be aware of the potential detrimental effects of labor medications on breastfeeding success and be open to helping you achieve as natural a birth experience as possible. Your doctors should be aware of the fact that, although most medications get into your milk to a small degree, there are very few that you should not take if you are breastfeeding. They should be able to provide you with accurate information on specific medications, referring to reliable resources (not the Physician’s Desk Reference [PDR], which was written by the pharmaceutical companies largely for medico-legal purposes and tends to recommend against the use of most medications, even medications which are given at full dosage [much larger amounts than in your milk] directly to babies). Remember that the risk, if any, of a small amount of a medication in your milk, has to be weighed against the well-known risks of formula; even a brief interruption of breastfeeding, especially in the early weeks, can lead to ultimate breastfeeding failure. For more reliable references on medications, please see References for medications during breastfeeding (below).

Your health care provider should also know that the only medical contraindications to breastfeeding are as follows:

• Maternal - HIV infection

• active untreated tuberculosis (Okay to breastfeed once on anti-TB medications for 1-2 weeks)

• chickenpox contracted within 2 days before to 5 days after birth (Okay to breastfeed once the lesions have scabbed over and it’s ok to be with the baby)

• illegal drug use (methadone maintenance may be Okay)

• contraindicated medication (anti-cancer chemotherapy drugs; bromocriptine; lithium)

• Baby - galactosemia

• phenylketonuria (PKU) (Okay to breastfeed along with special phenylalanine-free formula -- in fact, recent research shows higher IQ’s in PKU babies who were breastfed)

• herpes on the mouth (Okay to receive mother’s milk, resume breastfeeding once healed)

So if your doctor’s first response to any breastfeeding problem you have is "switch to formula," or if he/she insists that you wean your baby for medical conditions other than those listed above, consider a second opinion. If you have concerns about your doctor’s commitment to helping you breastfeed, contact your LC, who may have scientific references for you to show your physician, or may know of a physician more knowledgeable about and supportive of breastfeeding.

As for your birthing facility, it is critical that you assess the degree of breastfeeding support. It has been shown that nursing early and often is crucial to ultimate breastfeeding success. Since the majority of American mothers give birth in hospitals, that will be our main focus. Some outdated routines such as mother-infant separation, scheduled or timed feeds, and routine supplemental bottles, which have all been proven to decrease breastfeeding success, persist to varying degrees in most US hospitals. Your best bet is a hospital which has applied for a Certificate of Intent from the US Committee for UNICEF for the Baby-Friendly Hospital Initiative (BFHI). BFHI is a research-based world standard with guidelines for maternity facilities to provide optimal breastfeeding support. Their "Ten Steps to Successful Breastfeeding" are as follows (comments on the rationale for some of these guidelines are in square brackets):

Currently, over 300 hospitals in the USA have applied for a certificate of intent and are in the process of implementing the above guidelines. 15 hospitals and birthing facilities have now been certified "Baby-Friendly". If you are lucky enough to deliver at one of these centers, you have a good chance of avoiding some of the early hospital practices which can interfere with your breastfeeding success.

If your hospital neither has a certificate of intent nor is certified, it may help you to take a few steps. First of all, discuss your concerns with your obstetrical care provider and your baby’s doctor, and request that he/she be your advocate by writing explicit orders in line with the "Ten Steps." Then, let hospital administration know of your wishes. Make up a written birth plan and make sure that it is known by the staff. Most importantly, enlist your own support people (e.g. baby’s father, grandparents, designated labor coach) to advocate for you if you should be unable to insist on having your wishes followed. You may be too weak, drugged or otherwise unable to insist that your baby be brought back to you from the nursery, but father may well be able to do this. Even if you’ve had a Caesarean birth, as long as you and the baby are medically stable you should be able to nurse early and often. This would be another situation where your support people can intervene.

Of all the "Ten Steps," the one which is most likely to help you and your baby get off to a good start is #7. If you room-in with your baby, you will get to know his/her early hunger cues such as rapid eye movements, sucking on hands, rooting movements of the mouth, and promptly put the baby to the breast. A mother whose baby is in the nursery must rely on the nurse to bring the baby, which usually occurs after the baby is long past these early hunger signs, screaming for several minutes, and too upset from hunger and frustration to "practice" breastfeeding. Also, despite all well-meaning reassurances that the baby will be brought out in the middle of the night every time he/she is hungry, there are still nurses who give the baby bottles of formula either inadvertently or on purpose. Then the baby is brought to mom, stomach full of formula which sits there longer because it is so poorly digested, and is not interested in nursing. Mother’s breasts are not being drained to signal more milk to be made, and mother feels rejected and loses self-confidence. Rooming in effectively prevents this. Don’t be fooled into believing that leaving the baby in the nursery will ensure a good night’s sleep. Mothers whose babies were kept in the nursery were found in one study not to sleep any better than those who roomed-in.

Another option available to some mothers is a free-standing midwife birthing center, which may be preferable if the pregnancy is not high risk and there is obstetrician back-up with a hospital nearby. These centers tend to provide natural birthing experiences and may be more conducive to breastfeeding success.

How to succeed at breastfeeding without really trying
First of all, get prepared as noted in the above section. Remember, most breastfeeding problems can be avoided or easily treated by nursing more frequently, and by proper positioning and latching technique.

Second, and most important, plan on 4-6 weeks of "practicing breastfeeding" and don’t bother with all the other things you thought you were going to accomplish immediately after birth. Get help with the housework, and if at all possible, get someone to be a doula for you. A doula is a person whose sole job it is to "mother the mother," so that the mother can take care of just herself and her baby. Plan to keep your baby skin-to-skin with you and nursing most of the time. Even if you will need to introduce bottles for returning to work or school, or for an occasional night out, wait until you and your baby are expert nursers (you’ll know this when you don’t have to check how well the baby is latched on or support your breast or find a special area to sit and nurse). Breastfeeding is truly "low-tech." If you are well prepared with knowledge and commitment, then you’ll find you don’t need all the gadgets and gizmos. Another thing you won’t need is the gift pack with a sample of formula often given out at the hospital. You may wish to return it and let the hospital know how you feel about them marketing formula to you.

Instead, set aside some money in case you need a lactation consultant’s help. It’s an excellent investment when you compare the alternative, a year’s worth of formula (currently runs families between $1,000-$2,000, not counting added medical expenses). Keep the lactation consultant’s phone number (and your local La Leche League Leader’s number) handy in case of urgent breastfeeding problems or concerns. This will be much more helpful to you in the long run than opening up a sample of formula. Of course, if you never need the LC, then you have the money to treat yourself.

What if you run into problems?
So your very carefully drafted plan didn’t work out after all because of unexpected complications or lack of support. So your baby got a few bottles of formula despite your wishes to the contrary. So now he/she is not latching that well and you don’t feel that you have enough milk. Maybe you followed all the above recommendations, and despite all that the baby clearly is not getting enough milk (by numbers of wet and soiled diapers, or lack of weight gain). Maybe the initially slightly sore nipples have become extremely sore despite proper positioning and latching and avoidance of bottles and pacifiers. All is lost, right? Wrong. Although difficulties sometimes arise, a mother who is determined to breastfeed can overcome them, with a little help from the right people. If the baby is not latching or sucking effectively, or if you are having pain beyond the initial latch-on or are getting painfully engorged, get help promptly.

The kind of help you get is important. Although the credentials are, of course, helpful, anyone who is very supportive of breastfeeding and knows the basics should be able to help. Obviously, there are not enough IBCLC lactation consultants to help every breastfeeding mother, nor should there have to be. Here are some things which your breastfeeding consultant, be it an LC, nurse, midwife, or other health care professional, should help you to do.

In a situation where the baby is not latching well, it’s very important to keep up your milk supply by frequent removal of milk. This can be done by expressing with your hands (the breastfeeding consultant can show you how) or with a pump. Hand expression is excellent, especially in temporary situations. If the problem will last longer than a few days, pumping with a quality electric pump is probably best (if still in hospital, this should be readily available; if home, this can be rented -- refer to the resource list). Pumping or expressing should be done often (at least as often as the baby would nurse).

The other essential step is working towards getting the baby latching and sucking effectively. This may be very simple, essentially proper positioning and latch-on technique, or it may be more complex, including teaching the baby to suck properly if he/she has an ineffective suck. If the baby needs supplements, your milk (donor milk or formula if there isn’t enough) should be given by alternative feeding method, preferably by supplemental nursing system at the breast. This method is ideal, because the baby sucks on your breast while getting the extra nutrition. However, this works only for babies who suck well in the first place. If the baby isn’t sucking well, other feeding methods may be needed, such as cup, spoon, syringe with finger feeding. Bottles can be used, but may make things worse for some babies. The breastfeeding consultant should be flexible about feeding method and help you use what works best in your particular situation.

If the baby has "nipple confusion," a condition which some babies develop after getting bottles, you may need to use frequent skin-to-skin contact, supplementation without bottles, and possibly a silicone nipple shield may be temporarily needed to get the baby to latch on (the firmness of the shield "fools" the baby into thinking it’s like a bottle, but allows nursing from the breast; then the baby can be weaned from the shield and soon can feed directly from the breast). This is an example of a use for nipple shields, which generally are not recommended without a breastfeeding consultant’s help.

What if you’ve tried everything and breastfeeding just isn’t working?
In very rare instances, a mother doesn’t have enough functioning breast tissue to produce the amount of milk needed for her infant’s growth. This applies to only about one in 2,000 mothers. In addition, some (but by no means all) mothers who have had breast reduction surgery may have had functioning breast tissue removed, or the nerves and ducts cut in such a way that they cannot release the milk to their babies. Most mothers who "don’t have enough milk" really don’t have a true anatomical  problem such as these, but rather didn’t get adequate help and support or gave too many supplements, causing their milk supply to dry up. If you are one of the rare mothers with true insufficient milk, or if your milk supply dried up because you had to wean unnecessarily or were not given appropriate help, this need not mean that you can’t breastfeed the baby.

Even adoptive mothers who never had the hormonal stimulation of pregnancy can nurse their babies with the help of supplements. Remember that breastfeeding is much more than just food. It’s a relationship which provides skin-to-skin contact, a unique closeness, and hormonal changes. Even a little bit of milk contains antibodies that may help protect the baby from disease, and the special sucking at the breast provides optimal jaw and tooth development. If, despite everything, breastfeeding doesn’t work out for you, pat yourself on the back for your efforts. You have done your best to give your baby the best. Your love of your baby can shine through in the way you bottle feed him/her. We recommend "bottle feeding like a breastfeeding mother." If possible, obtain donor human milk (contact the Human Milk Bank of North America). This is especially important if your baby is at high risk of asthma, eczema, diabetes, or other conditions which are more common in formula-fed babies.

If you feed your baby formula, the baby may never get the same health benefits as a fully breastfed baby, but whether it’s donor human milk or formula in the bottle, you can provide the close skin-to-skin contact and give the baby your full attention throughout the feeding by holding him/her close. Change the baby from side to side as you would if you breastfed. This helps develop better hand-eye coordination. Wear your baby in a sling for increased contact, and consider keeping the baby in your room or bed at night. If anyone makes negative comments about your bottle feeding, ignore them and know that you have done the very best you can under your circumstances. This is easier said than done, since the sense of loss and lowered expectations can be devastating. Guilt, anger and frustration are common and natural in such circumstances. They are common emotions for any parent. If these emotions are overwhelming for you, get help from a supportive person or from a support group such as Mothers Overcoming Breastfeeding Issues.

Conclusion
This article was written to provide an overview of the many barriers to breastfeeding in our society, and hopefully to help women and their families deal with some of the common obstacles encountered by breastfeeding mothers. Please refer to the list of resources and references for further reading. Good luck with the great adventure of new parenthood.

Resources for breastfeeding information
The Academy of Breastfeeding Medicine. P.O. Box 15945-284, Lenexa, KS 66285-5945. (913)541-9077; Fax (913)541-0156. e-mail: [email protected]

Human Milk Banking Association of North America, Inc (HMBANA). 8 Jan Sebastian Way #13, Sandwich, MA 02563. (508)888-4041 or (508)888-232-8809. Fax (508)888-8050. e-mail: [email protected]

International Lactation Consultant Association, 200 N Michigan Ave, Ste 300, Chicago, IL 60601. (312)541-1271. e-mail: [email protected]

La Leche League International, 1400 North Meacham Road, P.O. Box 4079, Schaumburg IL 60168-4079. (847)519-7730; Fax (847)519-0035. http//www.prairienet.org/llli/

Mothers Overcoming Breastfeeding Issues, http://www.internetbabies.com/mobi/default.asp, e-mail: [email protected]

Breastfeeding books
La Leche League International. The Womanly Art of Breastfeeding. 36^th ed. Schaumburg, Ill La Leche League International, 1997. Pryor, G. Nursing Mother, Working Mother. Boston The Harvard Common Press; 1997.

Renfrew, M., Fisher, C and Arms, S. Bestfeeding Getting Breastfeeding Right for You. Berkeley, Calif. Celestial Arts; 1990.

Stuart-Macadam P, Dettwyler KA, Eds. Breastfeeding biocultural perspectives. Hawthorne, NY Walter de Gruyter, Inc, 1995.

References for medications during breastfeeding
Briggs, G., Sumner and Yaffe. Drugs in pregnancy and lactation. 4^th Edition, 1994. Williams & Wilkins.

Committee on Drugs The transfer of drugs and other chemicals into human milk. Pediatrics 1994;93137-50.

Hale TW. Medications and Mothers’ Milk. 7^th Edition, 1998. Pharmasoft Medical Publishing, 21 Tascocita Circle, Amarillo, TX 79124-7301. (806)358-8138. Lactfax service (806)356-9480. (subscription service providing faxes on specific medications).

Editor's note: Alicia Dermer, M.D., I.B.C.L.C. is Clinical Associate Professor in the Department of Family Medicine at the University of Medicine and Dentistry of New Jersey -- Robert Wood Johnson Medical School. She is board certified in Family Practice.

As part of her interest in wellness and health promotion, Dr. Dermer has developed a special interest in the area of breastfeeding education and promotion. She is active in educating health care professionals, especially fellow physicians, in lactation. She is collaborating on the development of a curriculum for her medical school. In 1995, she successfully passed the certifying examination of the International Board of Lactation Consultant Examiners. She has published medical journal articles on lactation, and lectures extensively on the subject. She may be contacted at: Alicia Dermer, M.D., IBCLC, 69 County Road 516, Old Bridge, New Jersey 08857 USA, Telephone: (908) 254-1515; FAX: (908)651-0774, e-mail: [email protected]

WORKING LIFE
By Diane Brady

Commentary: Give Nursing Moms a Break at the Office

The Japanese screen in my glass-enclosed office gives the place a sort of geisha-girl feel. But that beats the Old World-peasant vibe it had when I donned a shawl and crouched over a breast pump--or the harem look when I simply taped the shawl to the window. With no privacy in the ladies' room, I use my office to pump milk for my eight-month-old son, Elliott. Then I bag the bottle and store it in the staff refrigerator.

Aside from the one time a cleaning woman burst in on me, pumping milk at work has been easy because I just close the door. But that's not all you need. Kati Haney of Chapel Hill, N.C., had her own office but had to endure her male boss calling out "moooo" when she shut the door. Others recount stories of crouching in toilet stalls, suffering razzing, or even being fired for pumping on the job.

NEW LAW. In many cases, there's little women can do. The U.S. is one of the few developed countries with no mandatory breaks for nursing workers, according to the International Labor Organization. Bucking the trend is Illinois, which became one of the few states to require such breaks with a new law signed on July 12. Other states are only just getting around to protecting a woman's right to nurse in public. Just mention the word "breast-feeding" in the average U.S. office, and colleagues may run for cover.

Companies shouldn't be so squeamish. The U.S. Surgeon General and the American Academy of Pediatrics have identified low breast-feeding rates as a serious public health concern. One-third of women never start, and most stop after returning to work--as more than half of women with infants do. Only one in ten working mothers nurses for the recommended year. This despite mounting evidence of breast milk's superiority over formula for reducing allergies, obesity, childhood cancer, and other diseases--not to mention lower rates of some cancers for the mother.

A big part of the problem is that employers often make it tough for working women to nurse. Roughly 7% of U.S. companies now provide designated rooms to pump. If you don't pump regularly, you stop producing milk, and nursing is no longer an option. Corporate America makes big noises about the importance of retaining women. But one reason
female workers flee large corporations is their inability to balance work and family once they give birth.

Accommodating nursing is a small step toward making that juggling act a bit easier. The payoff is fewer sick days, increased satisfaction, and lower turnover among mothers on staff. CIGNA Corp. (CI ) says its four-year-old national lactation program, with about 500 participants a year, or a third of its returning mothers, saves more than $300,000 a
year in health costs and has led to a 77% drop in lost work time compared with other new moms.

So why do so many large companies ignore the issue? For one thing, most are run by men who may find the topic embarrassing. Ronald K. Beam, vice-president of engineering consultancy RETTEW Associates Inc. in Lancaster, Pa., admits he was unnerved when a worker said she wanted to
pump. Brushing aside worries that others might be uncomfortable, he bought a fridge for about $800, plus installed an electrical outlet in the ladies' room.

Ideally, such support should amount to more than a new plug. It should also include consultants, manager training, and classes, along with private places to pump. Eastman Kodak Co. (EK ) takes the extra step of providing pumps to each nursing mom on staff. Mattel Inc. (MAT ) has covered the cost for traveling employees to courier their breast milk home. Even formula maker Nestle USA Inc. (NSRGY ) has a lactation program, which is becoming more popular despite free formula coupons. An added benefit: Pumping at work helps me feel close to my son while we're apart during the day. For a short, sweet period of motherhood, what's best for baby can also be a boost for the bottom line.

Associate Editor Brady plans to lend her screen to other returning moms.

Copyright 2000-2001, by The McGraw-Hill Companies Inc. All rights
reserved.

WHY BREASTFEED?

"Human milk is the preferred feeding for all infants, including premature and sick newborns...It is recommended that breastfeeding continue for at least the first 12 months, and thereafter for as long as mutually desired"
- excerpt from the American Academy of Pediatrics (AAP) breastfeeding guidelines

Breastfeeding is one of the most important things you can do to give your child the very best start in life. Breast milk provides the optimum nutrition for your baby. Despite their efforts, formula companies simply CANNOT duplicate the amazing benefits of breast milk. The World Health Organization recommends breastfeeding for AT LEAST two years.

Health Benefits for Babies
Health Benefits for Mothers
Emotional Benefits
Environmental Benefits
Formula Just Doesn't Measure Up!

Health Benefits for Baby
Breast milk is more easily digested than ANY formula, resulting in less colic, gas, and spitting up

Breastfeeding reduces or even eliminates food allergies & eczema. Babies who are breastfed for less than six months have seven times the incidence of allergies as those who are breastfed longer than six months.

Breastfeeding is associated with a much lower incidence of wheezing, prolonged colds, diarrhea, and vomiting (Merrett, T.G., "Infant Feeding & Allergy: 12 Month Prospective Study of 500 Babies Born into Allergic Families". American Allergies, 1988.)

Eczema is less common and milder in babies who are breastfed. In one study, (Chandra R.K., "Influence of Maternal Diet During Lactation and the Use of Formula Feed and Development of Atopic Eczema in the High Risk Infants". Br Med J. 1989) it was found that of infants fed soy based formulas, 63% developed eczema. In those fed cows milk based formulas 70% developed eczema."

Formula fed children have a drastic increase in childhood cancers. "The risk of artificially fed children was 1-8 times that of long-term breastfed children, and the risk for short term feeders was 1-9 times that of long term breast feeders." Davis, M.K. Infant Feeding and Childhood Cancer. "Lancet 1988

Breastfed babies get protection from bronchitis, bronchiolitis, pneumonia, diabetes and asthma.

Formula fed babies suffer higher instances of cardiopulmonary disturbances. (Particularly Preterm infants)

Breastfed babies have fewer diaper rashes .

Breastfed babies have 5-10 times fewer stomach infections than formula fed babies

Babies who are breastfed are 10 times less likely to be admitted to the hospital during the first year.

Breast milk contains endorphins, chemicals that suppress pain.

Breast milk contains at least 100 (some sources say up to 400) ingredients not found in formula including at least 4 unique proteins. There are unique and powerful immune building properties in breast milk, and it can enhance brain development

There is growing evidence that breastfeeding can raise your child's I.Q. and there are numerous studies pointing to higher developmental test scores in breastfed children.

Breast fed babies have up to 50% fewer ear infections than bottle fed babies

A recent study by the National Institute of Child Health and Human Development indicated that breastfeeding was protective against SIDS. (Hoffman, H.J., "Risk Factors for SIDS: Results of the SIDS Cooperative Epidemiologic Study". Ann NY ACAD Sci, 1988.)

Another source states that "Breastfed babies are one-third less likely to die of SIDS."

Breastfeeding enhances the baby's development of oral muscles and facial bones.

Benefits for Mothers

Breastfeeding mothers have lower rates of certain cancers (breast, ovarian, uterine, and endometrial) as well as a reduced risk of osteoporosis. Also, "Women who were breastfed as infants, even if only for a short time, showed an approximate 25% lower risk of developing premenopausal or postmenopausal breast cancer, compared to women who were bottle-fed as an infant." (Freudenheim, J. "Exposure to breast milk in infancy and the risk of breast cancer." Epidemiology 1994 5:324-331)

Breastfeeding "confirms a woman's power to control her own body, and challenges the male-dominated medical model and business interests that promote bottle feeding." from Breastfeeding-A Feminist Issue by Penny Van Esterik

Breastfeeding encourages uterine contractions after childbirth, returning the uterus to it's pre-pregnancy size much faster. It has been shown that the uteruses of formula feeding mothers sometimes never return to the pre-pregnancy state.

Breastfeeding also: Boosts prolactin (a hormone that enhances feelings of nurturing and contentment) levels, speeds up post-partum weight loss and helps child spacing.

Current research confirms that as long as a woman is fully or nearly fully breastfeeding, and has not resumed menstruation, she has a less than 2% risk of becoming pregnant. Family planners know this method as Lactational Amenorrhea Method (LAM). In areas of world where artificial contraception is unaffordable, unavailable or unacceptable, breastfeeding provides a woman with an effective means of family planning. Source: WABA World Breastfeeding Week Action folder 1995 "Breastfeeding: Empowering Women"

Breastfeeding boosts women's self-reliance and self esteem: by meeting the needs of their infants, they increase their confidence in their ability parent and nurture.

Breastfeeding reduces women's dependence on medical professionals and validates the tried and trusted knowledge that mothers and midwives have about infant care and feeding. Source: WABA World Breastfeeding Week Action folder 1995 "Breastfeeding: Empowering Women"

Breastfeeding is easier and less time consuming. There is no preparation involved, and you don't have to prepare, warm, or transport bottles.

Emotional Benefits

Breastfeeding stimulates a mothers body to produce prolactin and oxytocin, the "mothering hormones" (Prolactin helps you feel relaxed, loving, and calm. Prolactin levels can increase 10-20 fold within 30 minutes of beginning a nursing session)

Breastfeeding provides extra closeness that helps your baby bond and develop trust.

The skin-to-skin contact offered by breastfeeding reduces the stress babies experience when they enter the world from the warmth and safety of the womb.

Breastfeeding provides comfort during illness or pain.

Even the Environmental Benefits

Breastmilk is actually the most ecological food available to humans.

There is less consumption of natural resources and landfill space. The production and packaging of formula uses paper, glass, plastic, and metals, all of which need to be produced and disposed of.

"If every child in America were bottle-fed, almost 86,000 tons of tin would be needed to produce 550 million cans for one year's worth of formula. If every mother in the Great Britain breastfed, 3000 tons of paper (used for formula labels) would be saved in a year. But the formula is not the only problem. Bottles and nipples require plastic, glass, rubber, and silicon; production of these materials can be resource-intensive and often leads to end-products that are not-recyclable. All these products use natural resources, cause pollution in their manufacture and distribution, and create trash in their packaging, promotion, and disposal. "
-From Mother Nature Loves Breastmilk&ammp;quoot;, by Dia Michaels
These materials are rarely recycled and the two most common disposal methods, landfill and incineration, both contribute greatly to pollution. Plastic feeding bottles and nipples will take 200 to 450 years to break down and it is impossible to determine the amount of time it takes for glass feeding bottles to break down. Landfill sites are hard to come by in many countries and they can pollute groundwater. Incineration releases pollutants into the air. The fumes from burned plastic can contain dioxin and other toxic substances.

If all U.S. babies were artificially fed, the 550 million formula cans sold each year, stacked end to end would circle the earth one and a half times. In 1987, 4.5 million feeding bottles were sold in Pakistan alone. These feeding bottles stacked end to end would reach the top of Mount Everest. Source: WABA Breastfeeding...WBW 1997- Nature's Way

The industrial processes used to create artificial feeding products for babies use vast quantities of energy and natural resources (fuels) and create air pollution (acid rain and greenhouse gases)

If you consider the global or even national scope, even the water and energy used in homes to prepare formula and the bottles and nipples themselves (washing, boiling, etc) have a tremendous impact.

Most artificial baby milks are made with cows milk, the production of which wastes land and resources and contributes to the pollution of the environment in numerous ways:

Cows excretion and flatulence produce 100 million tons of methane every year, which equals 20% of the earths total emissions. (Methane is the second most problematic gaseous contribution to the greenhouse effect and global warming.)
The fertilizers used to grow feed for dairy cows pollute rivers and groundwater.
The ammonia from cow pastures and slurry tanks cause acid rain.
The clearing of land for pasture means deforestation, an increase in greenhouse gases, the destruction of animal and plant species and erosion of the soil. For example, each kilogram of baby milk produced in Mexico "costs" 12.5 square meters of rainforest.
Even the production of soy based formulas are detrimental to the environment:
Soy formulas require just as much natural resources and energy to produce and package.
In Brazil, forests are cleared and burned to create soy plantations. The Soya beans are then used to feed cattle and as the base for soy based formulas.
The growing of soy beans requires a high input of fertilizers and irrigation.
Source: Breastmilk: A World Resource
Formula Just Doesn't Measure Up

Breast milk composition changes over time, as well as from feeding to feeding. From premature infants to young children, breast milk always has the right proportions of fat, carbohydrates, enzymes and protein as well as numerous other components.

Colostrum is the perfect first food for babies. It is produced during pregnancy and changes into mature milk a few days after baby's birth. Colostrum provides baby with an unequaled immunity against viruses and bacteria.

Breastmilk is a living substance. Each woman's milk is individually tailored for her own baby. What's more, her milk changes constantly - both during a feed and day by day - to meet her baby's evolving needs. When a mother is exposed to pathogens in the environment, she produces antibodies to combat them. The mother's antibodies are then passed on to her baby via her breastmilk. Source: WABA Breastfeeding...WBW 1997- Nature's Way

Breast milk is created by the human body to feed human babies. It is perfectly formulated for the nutritional needs of human babies.

Cow's milk is created by cows to feed calves. It is perfectly formulated for the nutritional needs of calves.

Formula is an industrially manufactured food. It contains chemicals, flavoring, vitamins, and proteins that attempt to replicate breast milk. The multiple processing's, ingredients and alterations required to convert cows milk or soy beans to the finished product opens up numerous opportunities for contamination by harmful bacteria, chemicals, insects, and foreign bodies.

The following is a PARTIAL list of known contaminations of infant formulas:

1997 - UK : Milumil withdrawn from sale after being linked with salmonella infection.
1997 - USA: FDA recalled Nestlé's Carnation follow-up formula because of adulteration and production under unsanitary conditions. Linked with mild gastrointestinal illness. 11,317 cases of 6 32 oz. cans to a case recalled.
1996 - USA: Carnation Alsoy Concentrate liquid in 32 oz. cans withdrawn because instructions on the top of the can state: Do not add water. Mislabeling could have led to infants consuming undiluted, concentrated formula. The side label indicated the addition of water.
1996 - USA: Heinz apple and prune juice for infants in 4 oz. bottles recalled because they contained quantities of lead in excess of 80 ppb.
1994 - Sri Lanka: Customs officers sent back a large consignment of Nestlé's milk powder imported from Poland because it was contaminated with radioactive particles.
1993 - USA: Nutramigen formula recalled after it is found to contain broken glass.
1993 - USA: Soyalac formula withdrawn following discovery of salmonella contamination.
1992 - India: Live black insects and crawling worms found in a packet of Lactogen infant formula.
Source: WABA World Breastfeeding Week Action folder 1997 "Breastfeeding: Nature's Way"

In fact: There were twenty-two different recalls of infant formula in the United States because of health and safety problems between 1982 and 1994, . Seven of these recalls were classified as "Class I" (potentially life threatening) by the FDA. In random testing, a number of lab-tested infant formulas have been found to contain bacterial and elemental contaminants.

Breast milk is always safe, fresh, perfectly clean, just the right temperature, instantly available and it is the most nutritious feeding system for the lowest cost.

Questioning the Convenience of Bottle-feeding (NursingBaby.com)

True, anyone *can* feed your baby. The question is, who do you want to feed your baby? Probably not just anyone. Probably, you'll only want the people you want caring for your baby to feed him or her. That will probably be yourself, your husband, and perhaps your mother or trusted friend.

Now, once we've narrowed the list down, it doesn't sound like such a convenience. And when you come up against the reality that most bottle-feeding mothers face, that they feed their baby themselves almost every single feeding, it ends up being a convenience only seen once every week or two.

And for husbands who do insist on feeding the baby before solids are introduced, breastfeeding mothers can let them share on occasion with minimal effects on milk supply.

I can leave my baby.

Actually, you can leave your baby whether you breastfeed or bottle-feed. This can be a true advantage if you plan on absences longer than 4-6 hours. Your breasts will never engorge at long absence, nor do you need to take time to pump. However, most mothers don't want to leave their babies for long in the early months, except for working mothers who must. Certainly don't plan a feeding method based on what you think you may want before your baby is born - it's bound to change as the realities of motherhood sink in.

I can bottle-feed anywhere.

You can bottle-feed anywhere. You can also breastfeed anywhere as well. Some moms are initially embarrassed at nursing in public, it's a skill that requires a bit of practice. And even if you choose not to nurse in public, you can still give bottles (of breastmilk or formula), so don't choose bottle-feeding just for this reason! And remember, if you are nursing, you don't need to bring premixed formula or worry about how to heat your bottle. Most nursing moms only need a tiny diaper bag to carry two diapers, wipes, and a toy.

I can go back to work.

Actually, breastfeeding rates are similar between working and stay at home mothers. Nursing mothers can go back to work and choose to bottle or cup feed their baby breastmilk or formula while they are gone. Should they choose formula, it may take a few weeks for the engorgement they experience during the workday to go away, but their milk supplies are generally still adequate for when they are home.

I can drink or smoke.

Evidence strongly exists that a smoking mother should still breastfeed, despite the contaminants in the milk, because of the protection breastfeeding gives against respiratory infections and allergies. Also, although drinking large amounts isn't recommended, alcohol is considered compatible with breastfeeding by the American Academy of Pediatrics.

It's true that a bottle-feeding mother's fertility and libido will likely return faster than a breastfeeding mother's. This is one of the reasons that mothers who nurse for a total of 24 months over their lifetime have a 25% reduced chance of breast cancer. Mothers should be aware that breastfeeding can have a libido reducing effect, but they should also be aware that parenting a young child has a strong libido reducing effect as well. A couple's sex life is often different after children, mainly because the demands of parenthood are so high.

Common Misconceptions of the Breastfed Infant (NursingBaby.com)

Let's Put an End to Breastfeeding Ignorance!

1. Formula is just as good as Breastmilk. There is simply no comparison. Not only is breastmilk superior nutritionally, but it contains all the immunological properties (live cells) from the mother that formula can never contain. This is why an estimated 8000 babies die every year in the US from receiving formula instead of breastmilk.
2. Formula is Easier. Although in the early weeks it may be easier to pop a bottle in your baby's mouth than to get the hang of breastfeeding, learning this fine art certainly pays off. Breastfeeding moms don't have to get up in the middle of the night to prepare a bottle. Breastfeeding moms don't have to lug refrigerated bottles with them and baby when they leave the house. Breastmilk is always available, warm and perfectly suited to your infant. And with a little practice, you can breastfeed so discreetly no one will ever notice. Another argument that keeps some moms using formula is that breastfeeding takes more time. This is generally true in the initial weeks. But what are these moms doing with this extra time? Cleaning their house? Gardening? Or ( hopefully), nurturing their infant - which they could have done right at their own breast.
3. Breastfeeding Moms Can't Diet. This is just not true. Studies have shown that except in widespread famines, women are able to make milk for their babies. When that fails, many of their other organs have begun to shut down as well. And those babies still receiving breastmilk in famines are much more likely to survive than their bottle-fed cousins. We advise sensible weight loss, for any mom. Mothering is a difficult job all by itself. Drink plenty of fluids.
4. Breastfed Babies Need Vitamins. Not true for healthy babies, although the case might be different for a preemie, whose iron stores never built up. The baby vitamin industry was developed entirely for formula fed babies, after it was discovered that cow's milk (from which formula is derived), does not contain all the nutritional components of breastmilk. Vitamin D was at one time believed not to exist except in minute quantities in breastmilk. 20 years ago, it was discovered that breastmilk had plenty of vitamin D, and that the original study contained a flaw in the breastmilk separation process.
5. What Mom Eats is What Baby Eats. This is both true and untrue. Some proteins from what the mother eats does pass into her milk, but studies have rarely found any connection with baby fussiness dependent on the mother's diet. However, many moms report subsequent gassiness in their baby from foods mom eats such as broccoli or cabbage. And moms of colicky babies should be aware that in about 5% of colic cases, elimination of dairy products from the mother's diet may reduce the colic. Also, be aware that the more mature the baby's digestive tract is, the better able to withstand anything you eat is.
6. A Nursing Mother May Not Take Medications. Most medications do pass into mother's milk, but at rates much lower than what was passed during pregnancy. An excellent book on the subject is Tom Hales's "Medications and Mother's Milk". Beware of your doctor's opinion on the subject. If they go by their physician's desk reference, most drugs are classed as untested on infants and therefore unsafe for nursing mothers. The AAP also has a list of safe medications. Ask your physician if the drug is AAP compatible. Most either are, or have an alternative. Some drugs which are usually contraindicated include lithium and drugs used to treat thyroid problems, though, once again, there are alternatives.
7. Nursing Toddlers Cling More. This perception has no basis in fact. While some mothers do continue to nurse toddlers who seem to need more reassurance than others, nursing (or otherwise comforting and meeting your baby's needs) tends to mature the baby at their own pace. Studies have indicated that these babies have more self confidence than their prematurely weaned peers.
8. At One Year, Breastmilk Loses Valuable Nutrients. Although breastmilk composition *does* change, it changes to meet the needs of your growing toddler. Introduction of cow's milk is not necessary and in fact may lead to weaning. Part of this perception of the one year limit came from the AAP, who had recommended that mother's nurse for 6-12 months. Look at the latest guidelines for current recommendations.
9. Nursing Mother's Can't Work. Nursing mothers have always worked, sometimes in and sometimes out of the home. There are many ways to combine nursing and working. A mother may have caregivers offer formula and nurse when together. A mother may also pump and provide expressed breastmilk for the caregiver to give. Or a mother may combine the two. It does sometimes happen that introductions of the bottle may spell the end of a breastfeeding relationship. You might investigate using cups instead.
10. Nursing Mother's Have Functional Breasts, Not Sexy Ones. Although a certain proportion of men find breast play uncomfortable during lactation, it is certainly not true of all. Just as a pregnant woman is in the full flower of her reproductive feminity, a nursing woman may exult in her life- giving and life-nurturing capabilities. And hopefully, her partner will enjoy her new confidence in herself as well.
11. A Little Cereal Helps Baby sleep Through the Night. Studies have shown no difference in babies given cereal or not as regards to how long a stretch they sleep. You can give this old wive's tale a big thumb's down, especially since early introduction of solids is associated with possible anemia and allergies.