Busting breastfeeding m’larky

Did you know that women should apply essential oils to their nipples so that their nurslings can better digest breast milk? Of course you didn’t, because breastmilk is the most easily digested food available; it’s why breastfed babies nurse often.

During one of my prenatal yoga sessions, a very well-intentioned mother and instructor advertised the benefits of essential oils applied to nursing mothers’ nipples to aid in babies’ digestion. I watched first time moms absorb her instruction, wondering how many of them would immediately seek out her suggested concoction after class.

_MG_6225 croppedI got to wondering about breastfeeding myths and how they inhibit mothers from successfully and uncomplicatedly nursing their babies.

Why do myths arise? What causes them to persist? What are some of the most common breastfeeding myths? How can we debunk myths to better serve moms and babies?

I turned to the visionary Linda Smith, MPH, FACCE, IBCLC, FILCA, founder of Bright Future Lactation Resource Centre Ltd, for answers.

Why do breastfeeding myths arise?

It’s a combination of things: Many health professionals hardly know how breasts and lactation work, Smith says.

Breasts are one of the least studied parts in the human body.

Because humans are heuristic creatures, we seek answers to the unknown even if we must speculate.

Formula companies also have a lot to do with myth creation and while their marketing campaigns might be clever, they are predatory and wrong.

“There is an influence of the formula companies telling mothers that they don’t know how to make enough milk,” Smith explains.

Likewise, formula companies influence health care professionals. In “Free” Booklets Aren’t Free!, Smith asks health care workers to purchase educational material from sources without conflict of interest.

When formula marketing became widespread by the mid 1900s, breastfeeding rates dropped to an all time low. Formula feeding and mother baby separation became the norm.

The knowledge we had about babies back in the 1940s and 1950s was severely inaccurate, Smith tells me. She recalls a LLL colleague of hers who told her that many health care professionals didn’t even think babies could see until several weeks after birth.

“A lot of what we know now about newborns’ neurophysiology has been learned in last ten to 15 years,” Smith says. “We are trying to undo 50 plus years of misinformation.”

What perpetuates breastfeeding myths?

Many of the same ideas that create myths, perpetuate them; namely lack of knowledge and the financial interest of formula companies.

Smith adds that we have developed a society that has weird perceptions about breasts. We use breasts to sell a car but women aren’t permitted to feed their babies, for example.

And although we have laws in place to protect the breastfeeding mother, unlike when Smith nursed her children,  mothers are still harassed for feeding their babies.

Simple language can perpetuate myths.

In her article Watch Your Language, Diane Wiessinger, MS, IBCLC advises lactation professionals to consider the impact of language on the normalization of breastfeeding.

She writes: “All of us within the profession want breastfeeding to be our biological reference point. We want it to be the cultural norm; we want human milk to be made available to all human babies, regardless of other circumstances. A vital first step toward achieving those goals is within immediate reach of every one of us. All we have to do is…watch our language.”

In Smith’s attempt to debunk breastfeeding myths, she also reminds us of the power of language.

She cites a common myth, “Milk is made faster during letdown” and offers this clarification, “Empty breasts try to refill. Milk flows faster during letdown.”

Further she reminds us that the phrase “milk supply” implies an unchanging quantity.

“Milk is production,” she clarifies. “Yet we talk about supply as if it’s static like the number of eyes or arms you have. It’s like saying I don’t have enough tears.”

Maternal food quality and/ or quantity, fluid intake and general emotional state (unless it affects her willingness to bring baby to breast) do not influence milk production.

So what does matter? Frequent and thorough milk removal from breast. In other words,

The milk in your breast

Wasn’t put there to stay

More milk isn’t made

Till you give some away,

Smith quotes her daughter Hannah.

What are some common breastfeeding myths?

I’m willing to bet you’ve heard the myth, “Some babies are just lazy.” This is perhaps the most disheartening myth circulating, because it blames the child instead of acknowledging what adults are doing to make feeding difficult.

Smith puts it perfectly. “Lazy implies wilful opposition. Babies don’t willing starve.”

So what might be going on in the baby who seems lazy?

  • Baby has been injured during a traumatic birth experience. Perhaps he or she has a headache from instruments used during birth.

  • Baby is premature and has not fully developed the capability to feed at the breast.

  • Baby is ill.

  • Baby is drugged from labor procedures.

Similarly in our go, go, go world we often expect babies to finish a feeding in ten minutes flat.

In Eating is Not a Race, Smith writes, “Adults who guzzle their food this fast are considered to have an eating disorder.”

She says that if you ask a group of adults how long it takes them to consume food when they aren’t being rushed, they report anywhere between ten to 30 minutes. This eating window is virtually equal for a healthy adult and healthy baby.

In order to put an infant’s experience into perspective, let us remember that they are humans too!

The same advice goes for the bedsharing controversy. Adults do not typically sleep alone, so why should babies?

Smith explains that babies are trying to double their weight in just a few months, so an infant under six months typically eats between one and three times throughout the night (countless if you’re my daughter). When the dyad is separated, mothers miss out on important feeding signals and that causes concern like improper weight gain and stunted development.

So what’s the beef with bedsharing? Smith cites three common concerns:

  1. Mother might squish baby. This is true if she’s drunk, on a couch or other factors are present. The Mother-Baby Behavioral Sleep Laboratory at the University of Notre Dame provides an abundant list of articles on the evolutionary perspectives of bedsharing and safety guidelines.

  2. Couples will never have sex again. Fortunately, most couples figure out how to be romantic outside of the bedroom, Linda says. Fancy that.

  3. If you let baby sleep with you now, he or she will never sleep alone. Linda compares this argument to, “If you don’t get them to walk at two weeks, they never will.”

On top of nine months gestation in the womb, human babies require about another nine months “external gestation” to reach the same level of maturity as other primates. At birth, the human neonate’s brain is only at about 25 percent of its adult capacity, Smith explains. Plenty of skin to skin contact and breastmilk allows for optimum brain growth and bedsharing can offer an opportunity to practice both of these. (Smith’s Best Start Conference presentation The Co-Sleeping Contoversy offers more information.)

“You’ve got under a year to get it right,” Smith says of baby’s fundamental development. “You can’t go back and do it when the child is five.”

The most ridiculous breastfeeding myth of all time is scheduled feedings, Smith argues.

Where did the four hour feeding schedule come from? Smith says it was created in response to a typical eight hour hospital shift.

“It makes no sense in normal physiology,” she says.

Why debunk breastfeeding myths?

“Because according to the CDC at least 60 percent of moms who intend to breastfeed are not meeting their own goals. Mothers who want to are not able to succeed,” Smith offers a simple answer.

How can we challenge breastfeeding myths?

Smith has created an image that illustrates three core concepts of debunking breastfeeding myths. It encompasses practices that health professionals use and very appropriately resembles the breast.

At the center core, evidence based practice.

“The health care provider should be using evidence based practice when it exists,” Smith explains.

The middle ring encompasses common use and theory driven practice. These practices have some physiological basis and seem to generally make sense. Practices in the middle ring may move into the center core when and if research affirms its validity. Likewise, they might also be exiled to the outer ring.

Smith uses the example of episiotomy. Common practice once dictated the use of heat lamps to heal wounds. Fortunately this is no longer accepted as research has proven that heat decreases the likelihood of healing. Instead, cold assists the healing process. These findings can also be applied to the injured breast.

Lastly, new ideas, experimental and anecdotal evidence, trial and error, observation and case reports make up the outer ring. Sometimes health care professionals must resort to practices in the outer ring simply because there are no evidence based or physiological commonsensical answers.

“The message to all of us is when there is good research, use it,” Smith says. “When not, then use common sense.”

Teach the rule, not the exception.

Let’s look at the myth, “Just one bottle of formula won’t hurt” for instance.

In a Debunking Myths presentation, Smith shares some (of many) issues related to introducing just one bottle of formula:

  • Every brand of formula has triggered anaphylaxis

  • Formula permanently changes gut flora and pH

  • It adds iron which feeds pathogens

  • It introduces pathogens via fluid and feeding device

“Occasionally there is a need for [formula],” Smith agrees. Alison Stuebe shares an example of a mother more concerned about her milk production than tending to her crying baby in OB/GYN sheds lights on creating breastfeeding culture.

But Smith says, “There are exceptions to everything. It doesn’t mean we teach it as a rule.”

Many myths are deeply rooted in culture, so how can the health care professionals go about debunking breastfeeding myths in a culturally sensitive fashion?

Smith says, give people the facts.

“Biology doesn’t change their culture,” she adds.

Our formula feeding culture and culture of isolating mothers and babies aren’t backed by biology, for example.

In this light, Smith advises lactation professionals to question everything.

“And listen to mothers,” she adds. Mothers are always right, even the 14 year-old mother she says.

“I’ve been doing this work for 38 years and mothers have always been right.”

Smith is thankful for the researchers and authors who are putting evidence based knowledge into everyone’s hands.

“We’re on a wave of success that is just terrific right now,” Smith says. “There are a lot of good things happening.”

Lamb, reindeer and human milk: Making human breastmilk visible

LauriefamWhen Healthy Children faculty Laurie Tollens, RN, CLC, ANLC, IBCLC traveled overseas a few weeks ago to present donor milk research at a conference in England, she never expected to end up doing lactation consults on livestock. That’s right when Laurie hopped over to Scotland to visit old friends, they requested she examine a calf’s mucosal cleft and assist an ewe with mastitis.

“The hardest part was separating him from his mother and then catching him to have a look,” Laurie says of the calf. “It must have been quite a sight, me straddling a calf and getting him to open his mouth enough for me to check it out.”

instantlamlacLaurie also had the opportunity to feed Ewe Milk Replacer to orphaned lambs, which comes in giant, 25-pound bags.

“Even mixes in cold water,” the bag reads.

Lambs feed from plastic water bottles with funny, red teats, Laurie explains.

“They eat furiously and are so friendly once you’ve spent time with them,” she says.

Although there is no equivalent to species specific milk, there are certainly medical indications for the use of formula for both lambs and humans.

However, Laurie tells me about an interesting method farmers use for orphaned sheep: One lamb is orphaned by a mother who dies during childbirth. Another ewe survives, but her lamb does not. Farmers skin the deceased lamb, place it over the lamb who survived and present the “costumed’ lamb to the surviving ewe as an adoption method that will allow for a nursing relationship.

This practice so clearly doesn’t translate for human use, but we have another option when biological breastmilk isn’t available: donor human milk (DHM). Women’s breastmilk is a miracle commodity that saves lives every day. Unfortunately, it remains underappreciated and invisible.

Laurie recently completed research about the use of DHM in full term babies at Wake Med Raleigh Campus where she practices as a lactation professional.

Her work and research shed light on the realities of supplying human milk for all babies.

The importance of breastmilk for very low birth weight babies is well documented, but Laurie’s research serves to answer questions like:

  • “What is the experience of mothers of term babies who had been supplemented with banked donor milk for medical reasons during the hospital stay immediately after birth?

  • Are they more likely to exclusively breastfeed for six months or longer?

  • Are they more likely to donate their milk to a milk bank so other families can benefit the way they did?

  • Did they feel using banked milk shortened the hospital stay?”

Because of a shortage of banked DHM, the American Academy of Pediatrics created a hierarchy for donor milk recipients with the highest need being for infants in Level III nurseries. The Human Milk Banking Association of North America (HMBANA) estimates processing about two million ounces of human donor milk last year, but needed close to four million ounces. Still, Wake Med has access to small amounts of donor milk for term infants.

Wake Med’s milk bank is located directly below the mother-baby floor.

“We have access to milk right here and right now,” Laurie says.

Unfortunately, her research shows that this resource is virtually invisible to families and health workers alike perpetuating the idea that sharing banked donor milk is a taboo practice.

In fact, Laurie tells me that many partners demand a tour of the bank before allowing the use of donor milk for their infants because they simply can’t imagine that something like this exists.

It’s like they think there is a room full of women hooked up to breast pumps sitting in rocking chairs, Laurie laughs.

Interestingly, preliminary findings from Laurie’s research show that all mothers who received DHM for their term babies thought of the milk as a lifeline and deemed it valuable.

However, “the milk bank is under-appreciated by the administration,” Laurie says. “Someone needed to do something to show that this is around.” (Wake Med’s milk bank has been up and running for close to 25 years.)

Laurie shares an exchange she had with a Wake Med administrator:

“I want to know about the milk bank,” Laurie requested during a meeting with hospital administrators and staff members.

The hospital’s vice president cringed.

“Well apparently it’s a problem for you,” she replied.

“It just has such a stigma,” he said in defense.

Laurie suggested a billboard marketing the facility’s milk bank. Something along the lines of “Got milk?” or “We need milk” or “Donors needed.” She offers a simple design.

Laurie's proposed billboard design. Her darling grandson Bishop pictured.
Laurie’s proposed billboard design. Her darling grandson Bishop pictured.

“Donor milk sounds like roadkill,” she adds. “We need another name.”

Solicitation of milk banks will help to change perceptions about DHM and make breastmilk visible.

After all, we openly accept sperm, eggs, blood and plasma donations, but the miracle of human milk has somehow become tainted.

Laurie remembers seeing an advertisement in London decorated with the photo of a beautiful baby. “Need sperm?” it reads, promoting an infertility clinic.

Breastfeeding advocates have been successful in teaching the public the importance of breastmilk; as a society we are very slowly accepting breastfeeding as the normal infant feeding method. But the idea of milk sharing is something to work on.

“With this study, I got some really funny remarks from women,” Laurie says about the almost disgusted way mothers responded to the option of donor milk versus artificial baby milk when supplementation was indicated.

Still, Laurie finds that making such a significant decision about infant feeding, sometimes so unexpectedly, promotes special bonding between couples.

“Where I get my giggles is watching couples become families,” she says.

Offering a living substance to nourish infants brings a sense of life and loving into hospital-care, something Laurie says we have been missing.

“Babies have become the football in the room,” she says of the treatment of babies like objects. “It makes it easy for moms not to feel connected.”

DHM offers a unique way for care providers to make connections with families and offer babies nourishment in an almost ceremonious fashion when biological breastfeeding isn’t an option.

And because DHM offers a healthy alternative to biological mother’s breastmilk, hospital stays are generally shortened. That means higher turnover rates for hospitals and generation of revenue.

Further, The Joint Commission and Maternity Practices in Infant Nutrition and Care Survey (mPINC) track the success of exclusive breastmilk feeding rates.

When mothers’ desire to breastfeed is close to 100 percent but only about half of moms leave hospitals breastfeeding, that generally sends the message that providers are failing at breastfeeding support. DHM can serve as a bridge for both mothers and health care providers.

Evaluating birth practices can decrease a hospital’s risk of perpetuating the need for supplementation.

For instance, medically unnecessary, scheduled c-sections may pose difficulties to breastfeeding.

Laurie also reminds us to question what’s going on during labor. What kind of practices affect a mother’s milk from coming in on time? Which practices cause exaggerated weight loss in baby?

One culprit is the widespread use of pitocin. The drug’s risks are documented.

One of the side effects includes excess artificial oxytocin in mother’s body that suppresses the production of her own oxytocin. Her body may be producing milk, but the hormone to release it is stifled.

Further, severe water retention as a result of excess fluids from epidurals may cause a mother’s breasts to become so firm that her baby has difficulty latching on.

While the direct effects of common hospital practices on breastfeeding are evident, it’s important to remember that the practices affect the stores of rationed DHM.

Fortunately, Laurie’s research shows that women who have received DHM for their babies, report that they would donate their own milk if they had enough.

Promoting HMBANA milk banks has the potential to decrease informal milk sharing, a potentially risky practice.

In some instances, hospital staff encounter informal milk sharing.

This practice is a hot topic. Some trust the unscreened milk from another woman over artificial milk from a formula factory.

Authors of Milk sharing and formula feeding: Infant feeding risks in comparative perspective? suggest that “instead of proscribing peer-to-peer milk sharing, health authorities should provide parents with guidance on how to manage and minimize the risks of sharing human milk.”

While the risks of formula feeding are well documented, families should also be aware of the dangers informal milk sharing.

The Missouri WIC Association shares a slideshow describing the risks including infection and medication risks and motivational concerns.

Hospitals should consider adopting health policies for dealing with informal milk sharing. Laurie says Wake Med has yet to do so.

Laurie comments on the dangers of informal milk sharing as she remembers an article about two pediatricians who put an ad out for human breast milk donations for their baby. They tested the milk received and some of it was contaminated with hepatitis and HIV, she recalls.

“It was available, but unusable,” Laurie says.

So how do we turn usable milk into available milk?

“I wish everybody would be educated so that if they have extra milk, they would know that there are babies out there who need it,” Laurie says.

She explains that right around Thanksgiving and the winter holidays, mothers who don’t have room for food in their freezers because of excess frozen milk, look for a place to donate.

Perhaps this could turn into a clever marketing campaign for milk banks?

Laurie’s hopes for the future of milk banks don’t end here. She says many hispanic mothers aren’t able to communicate with milk screening staff. If there were a more inclusive process, perhaps we could reach a larger population of mothers with milk to donate.

If receiving DHM from a facility with an established milk bank is difficult, imagine the issues families face once they are discharged.

“Once I left the hospital, trying to get donor milk was like searching for reindeer milk,” Laurie quotes one of the mother’s responses from her research.

Cost can be one concern for families. While donor milk cost is generally consumed by the hospital (Laurie explains that food is included in the hospital stay; you don’t pay for formula), once a family leaves, the cost of milk usually falls on the individual.

According to this Massachusetts Breastfeeding Coalition article, HMBANA milk banks charge a processing fee to help defray some of the costs of donor screening and milk processing. Currently, fees average $3.50 to $4 per ounce. Shipping may or may not be included in this fee, depending on the milk bank.

And depending on the circumstance, insurance plans may or may not cover the expenses.

In Nikki Lee’s, RN, MSN, IBCLC, ANLC, CIMI, CCE, CKC article The dollar value of human milk., she describes the bizarre paradigm of the value of human milk.

“…Human milk is priceless, one meaning of which is without economic value,” she writes.

At the same time, scarcity generates economic value.

Human milk matters. It’s time to celebrate the value of the banks that collect, screen, process and distribute it so that more families can benefit from this remarkable, invisible commodity right under our noses.

Ramadan Mubarak: Breastfeeding in Islam

“Allah u Akbar,” the adhan resonated from the immaculate minarets of the mosques in Morocco. It’s one of the most profound, sensorial memories I have from my studies abroad; the deep, ethereal song dancing through the bustling streets of the medina inviting believers to prayer.morocs

Islam’s holy month of Ramadan, a time for introspection, purification of the body and strengthening of spiritual bonds marked by the sighting of the new moon, is now well underway.

During the celebration of Ramadan, from sunup to sundown, Muslims worldwide take part in:

  • daily readings of the Quran,

  • charitable efforts,

  • avoidance of smoking and sexual intercourse and

  • fasting with no food or water.

Fasting requires a great deal of self-control and offers Muslims an opportunity “to diminish…dependence on material goods, purify their hearts and establish solidarity with the poor to encourage charitable works during the year.” [Retrieved from: http://www.time.com/time/world/article/0,8599,1919257,00.html#ixzz2YlNq3Hlt]

But as much as fasting during Ramadan is about self-discipline, it also presents communities with a unique chance to come together in support of one another.

“A community that fasts together supports each other,” as Rabbi Robert W. Haas puts it in the film American Ramadan.

Perhaps it is this sense of community, where Muslims fast and partake in iftar together, that grants participants the strength for this religious undertaking.

While there are several interpretations of fasting for pregnant and lactating women amongst Muslim communities, Union Institute and University Maternal Infant Health student and Babies Express founder Alice Byrd RN, IBCLC, ANLC, CBE tells me that the choice to fast during Ramadan is typically up to the mother’s discretion.

Mothers sometimes express concern about fasting while lactating: does fasting during Ramadan affect the quality and quantity of breastmilk?

Bener’s research, Fasting during the holy month of Ramadan does not change the composition of breast milk, concludes that breast milk quality and composition in nursing mothers is unaffected by Ramadan fasting.

Kelly Bonyata, IBCLC of KellyMom also offers research that supports these findings in Religious Fasting and Breastfeeding. She provides information about maternal diet and breastfeeding in How does a mother’s diet affect her milk?

Although studies show that breastfeeding mothers need not worry about milk composition during Ramadan fasting, Byrd recommends lactating mothers reevaluate their choice to fast day by day.

“[Mothers] definitely have to get up to eat in the morning so that their energy level is up, especially early on when the baby is eating about every two hours,” she says.

When and if a breastfeeding mother finds that she is unable to participate in fasting due to the risk of her or her child’s health being harmed, she has other options to take part in the holy celebration.

She may make up the fast at any other point in the year.

She may offer food to the less fortunate, feeding one person for each missed day of fasting.

“For those who cannot do this except with hardship is a ransom: the feeding of one that is indigent…. Allah intends every ease for you; He does not want to put you to difficulties….” (Quran 2:184-1)

Interestingly, according to Lactation in Islam., “…the moral importance of breastfeeding is stressed. The mother receives the reward of a good deed for every single drop she gives her child.”

Byrd cautions that when fasting during Ramadan becomes too trying for a mother, she may resort to bottle feeding, spurring a potentially vicious downfall of her breastfeeding relationship.

However, stressing the religious importance for a Muslim woman to breastfeed her child may preserve and promote breastfeeding, as suggested by Lactation in Islam. Ensuring that she is aware of her religious rights as well as ensuring proper breastfeeding education and support offers mother the confidence to feed her baby and fully participate in her religion.

For example, the Quaranic verse 2:233 recommends breastfeeding for two years which is (potentially) significantly longer than the American Academy of Pediatrics’ breastfeeding recommendations.

Even more, “according to Islam a nursing mother is entitled to receive compensation from the father for nursing the child.” This idea stresses the value of breastmilk and may even serve as a source of empowerment.

Milk kinship, where non-biological mother breastfeeds a non-biological baby also implies the importance of breastmilk in Islam. Historically, milk kinship was practiced to forge loyalty amongst community members, but the custom persists in modern time.

Byrd tells me she has a friend who nursed her twin sister’s child after her friend’s sister passed away. (Click here and here to learn about the risks associated with informal milk sharing.)

Natural term breastfeeding isn’t always easy to achieve especially when a mother must return to work, Byrd reminds us.

“Becoming educated about pumping [in the workplace] and their right to breastfeed is hard for some women,” she explains.

Muslim families might also face the challenges associated with English as a second language. This is a particularly important barrier to recognize during prenatal care and labor and delivery as it is documented that birth experience affects breastfeeding outcomes.

Because there are an estimated 50 different dialects of Arabic, language can pose a special challenge when it comes to communicating with Muslim families.

Byrd says she often finds that families don’t quite understand the translated phone lines that she uses with non-native English speaking clients.

If language doesn’t present a barrier to breastfeeding, sometimes cultural misunderstandings do.

Byrd mentions traditional male and female roles within Islam for instance.

She also says that lactation professionals might misinterpret Muslim signs of respect for discourteous behavior.

“If a female [professional] is speaking to a male, he might be turned away from her or he might lower his gaze,” she explains.

Further, it is the mother’s postnatal right to be at a state of rest for 40 days after childbirth.

Byrd explains that family, friends and neighbors cook meals, clean the home and sometimes even feed the mother during this postpartum period. She says that medical professionals often deem Muslim mothers “princesses” or “needy women” instead of accepting this as a part of their upbringing.

How upsetting that we don’t better embrace this practice in America!

The notion of modesty within the Muslim religion may present cultural barriers when not fully understood as well. Female modesty is associated with endless interpretations.

For example, Muslim women may choose to wear no traditional covering, a full body covering called the burqa or any variation in between. (Explore more Middle Eastern veil styles here: http://www.huffingtonpost.com/anne-peterson/know-your-veils_b_812944.html#slide=228734)

No matter her image, all women’s humility must be respected. A woman in a low cut tank top may never nurse her baby in public whereas a woman dressed in hijab may.  Medical and lactation professionals should exercise special cultural sensitivity around nursing Muslim women and remember that things like region and adherence to traditional Islamic beliefs will influence her comfortability to expose any part of her body.

Byrd explains that there are special clothing for nursing Muslim mothers who wish to remain completely covered. I found this website which offers breastfeeding abaya: http://www.modestclothes.com/islamic/dept/muslim-nursing-clothing.html.

The Boston University School of Medicine has compiled a list of general guidelines to respectful interaction with Muslim patients that may be helpful for the lactation professional. This resource can be found here: http://www.bu.edu/bhlp/Resources/Islam/health/guidelines.html.

Lactation professionals working with Muslim families should also consider that culture and medical practice often muddle.

As I explored the Quran’s statements on breastfeeding, I found this narration from Imām as-Sādiq (as): “Oh Mother of Ishāq, don’t feed the child from just one breast, but feed from both, as one is the substitute for food, and the other is a substitute for water.”[359]

The Quran also directs women to eat only pure food because all she ingests affects her nursing child.

With these examples in mind, we’re presented with the dangers of culture dictating improper breastfeeding practice.

It is imperative that lactation professionals practice cultural sensitivity and receptiveness to better influence the success of Muslim families’ breastfeeding relationships.

Especially during the intense celebration of Ramadan, breastfeeding advocates and professionals can preserve a nursing dyad’s breastfeeding relationship through careful consideration of cultural and medical practice.

Advice from mama to physician

It’s obvious that pediatricians have the potential to influence the health and well-being of our children in a huge way. In order to effectively monitor the health of our little ones, it is essential for parents and physicians to establish trusting, respectful relationships with one another.

And because we know that breastfeeding offers unprecedented nutritional value, protection, and bonding and sensory opportunities, it is perhaps most important that pediatricians and parents develop dialogue about infant feeding methods.

Without the creation of open conversation and mutual respect, we risk developing antagonistic relationships between two important caregivers which may put our children in undesirable and unfair positions.

Let me illustrate.

When my daughter Willow was about two months old, I started to notice small amounts of blood and mucus in her stool. I was horrified. Conveniently, I was in the midst of my Certified Lactation Counselor training where I learned about proctocolitis otherwise known as a milk protein allergy. When Willow and I returned home from the CLC training, I took her into urgent care and offered my diagnosis to the pediatrician on call.

“What exactly do you do?” she asked, presumably impressed with my new vocabulary.

“I’m a stay-at-home mom,” I replied. She didn’t respond.

After a fairly thorough physical examination of Willow, the ped handed me several sheets about rotavirus and intussusception along with instructions on how to collect stool samples for further testing.

Aside from the trace amounts of blood in her stool, Willow did not present any other intussusception symptoms. She exhibited not one symptom of rotavirus. Although annoyed and concerned by the pediatrician’s uneducated verdict, I followed her instructions.

The following week, we visited Willow’s regular pediatrician and she was just as baffled by the on call ped’s prognosis as I was. To my relief, Willow was properly diagnosed with a milk protein allergy as I had predicted. Instead of worrying about the risk of severe dehydration or putting my tiny baby through surgery, I was simply instructed to eliminate casein and whey from my diet.

Unfortunately, this is not the only frightful story I have to share about the pediatricians my daughter and I have encountered. Reflecting on these unfortunate events, I have compiled advice for parents and pediatricians alike on how to work as a team to better serve our children.

Whyte,BryonI also spoke with Dr. Byron Whyte, MD a pediatrician currently working at Pediatricare of Northern Virginia. His insight enables a more balanced discussion and has allowed me to appreciate physicians as human beings rather than the all-knowing deities that I wish they were.

The following are recommendations for making health decisions for your child:

  • Interview, interview, interview.

“You should know from the beginning who it is that you are dealing with,” Whyte says of selecting a pediatrician.

What kind of practitioner are you interested in? Does the doctor welcome questions? Does the doctor seem invested in children? Is there something about the doctor that you wish was different?

Whyte reminds us that choosing your obstetrician or midwife is just as important a factor in caring for your baby after birth as choosing a pediatrician.

“I wish we could do more on the OB end,” he says of offering breastfeeding education and support.

That’s because we know that the birth team plays an essential role in helping mothers breastfeed successfully.

“It would be great if there were a study about how much we talk about breastfeeding prenatally and how much that changes breastfeeding outcomes,” Whyte says.

What we do know is that birth experience affects breastfeeding outcome, so starting a conversation about breastfeeding prenatally is invaluable and can have lasting effects on your child’s health.

Whyte says the Baby-Friendly Hospital Initiative is very exciting because its policy to “not stick a bottle in every baby’s mouth” will help to shift breastfeeding back to the infant feeding “default”. BFHI’s model sets moms up for breastfeeding success.

Because we lack continuity of care within our healthcare system, it is often the work of the lactation professional to bridge the gap between parents and other medical professionals. It is in parents’ and children’s best interest to look for practitioners who have established good relationships with lactation professionals.

However, Whyte sheds light on the reality of relationships between pediatricians and lactation professionals within the community.

“When you’re out in the community, it’s harder to communicate,” he explains.

That’s because medical professionals working in the community don’t share the convenience of physicality like lactation specialists and physicians do within a hospital setting.

Whyte explains because they don’t always have the opportunity to talk about their patients together, he sometimes has a hard time trusting the care that patients receive from the lactation specialists.

For example, he says that if he refers ten patients to a specialist and eight of them come back using nipple shields, he doesn’t feel like they have done their job. It’s such a relief to know that there are pediatricians out there like Whyte who aren’t comfortable with overuse of instrumentation!

  • Keep yourself informed.

When Willow was seven months old, I needed my wisdom teeth extracted. I was concerned about the effect of the anesthesia on my breastmilk and milk production, so I asked our pediatrician for advice. She told me that I shouldn’t worry about it “because so many women are anesthetized during birth and they breastfeed just fine.” RED FLAG.

Dr. Thomas W. Hale, RPh, PhD runs the InfantRisk Center an evidence-based medicine and research call center. I consulted the center’s InfantRisk Helpline (806-352-2519) where I learned that two of the three drugs to be used during my procedure were hazardous while breastfeeding.

IMG_0581Luckily, my oral surgeon gladly used the alternative anesthesia recommended by the center and my breastfeeding relationship with Willow continues unharmed.

The Drugs and Lactation Database (LactMed), a peer-reviewed and fully referenced database of drugs to which breastfeeding mothers may be exposed to, including information on maternal and infant levels of drugs, possible effects on breastfed infants and on lactation, and alternate drugs to consider, offers mothers and healthcare professionals a similar resource. [Retrieved from: http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT]

While the internet can be a scary place to receive medical advice, it offers parents supplemental information when they have concerns about the information provided by practitioners.

  • Trust your instincts. Trust your child.

 While I do not doubt that pediatricians are highly trained medical professionals, I firmly believe that parental instinct often outshines what practitioners sometimes pull from outdated medical textbooks.

For example, Willow recently had a urinary tract infection misdiagnosed as a yeast infection. Even after explaining how certain I was that she had a UTI judging by her symptoms, the infection went undetected for three days because our pediatrician failed to consider my intense instinct.

Looking back, I wish I would have insisted she reconsider the diagnosis.

Parents: don’t be afraid to stick up for yourself and your keen intuition! Physicians: Do not undermine the power of parental instinct.

  • Find respectful ways to convey your concerns.

I find that I have a difficult time being proactive about the issues I have encountered with physicians. I accept their advice with a quiet nod then return home to vehemently vent to my husband instead of trying to make change.

Don’t do as I do; alternatively, share the resources you find relevant with your child’s practitioner. Maybe it’s a book or a published study you’ve come across.

For instance, our pediatrician had never heard of the alternative vaccine schedule nor had she heard of Baby-Led Weaning until we reported that we would be practicing this infant weaning method. She was uninterested and unsupportive in our desire to do something “different.” Perhaps she would have been more receptive to learn about this alternative method from a professional; Gill Rapley’s books are a great resource for the uninformed.

When you find it difficult to express your feelings, it might also be helpful to bring a support person with you to appointments. Perhaps your partner is more comfortable questioning the physician and together you can better facilitate conversation.

  • Be receptive.

The other day, a girlfriend of mine told me that when she told her four-week-old son’s pediatrician that she and her son bedshare, he recited a laundry list of bedsharing safety concerns and told her that only poor, uneducated people do that. I can barely imagine how I might have reacted to a statement like that. Wrong on so many levels.

While Whyte doesn’t find that bedsharing speaks to a socioeconomic status, he does have his doubts about the safety of bedsharing when not accompanied by a manufactured co-sleeper. He cites increased SIDS risk as one concern.

My research shows that bedsharing can be done safely when mother exclusively breastfeeds. (See Dr. James J. McKenna’s Mother-Baby Behavioral Sleep Laboratory) Actually, bedsharing promotes breastfeeding and might even reduce SIDS.

When your thoughts about parenting practices differ from those of the pediatrician, it’s difficult to be receptive of their counsel. However, we must remember that physicians generally have our children’s best interest in mind and it’s always important to receive and reflect on the information they provide with open ears.

Likewise, physicians must remember that parents generally have their children’s best interest in mind.

  • Remember that physicians are humans too.

Whyte tells me that his experience as a father has influenced his work in a good way.

“It gives you the other side of it,” he says.

“For the most part, I’m speaking as a physician but the dad stuff comes in as well because I’ve been there,” Whyte says of the experiential things like being up all night with an upset baby.

He adds that as a physician and parent, he is better able to advocate for his patients.

“Listen, I know this isn’t my own child but if it were…” he role plays. Parenthood allows him to separate himself from the “sterile point of medicine.”

I am fascinated to hear about Whyte’s experience as a male breastfeeding advocate.

“There is no positive point to it,” he says.

He explains that he often watches people recoil when he talks about breasts, even in a medical context.

“These organs are completely different outside of the bedroom,” he references the intended function of breasts.

As a male breastfeeding supporter, Whyte encounters other challenges.

“[Mothers] are less inclined to nurse with me in the room,” he says. “The worst is if a mom will stop a feed.”

Whyte recalls working in the NICU. When he entered the nursery, nurses closed curtains around breastfeeding mothers to shield them from his presence.

“That really doesn’t send the right message,” he rightfully explains.

Whyte finds himself judged in additional ways too.

“I find that often times there is this sort of assumed barrier between [physicians] and [lactation professionals],” he says. “We end up in this weird tug-of-war where we are fighting for control of the baby. That’s not cool; we are all working together.”

He suggests lactation professionals not make generalized assumptions that pediatricians are automatically anti-breastfeeding.

Unless a physician “says something crazy,” Whyte encourages lactation professionals to assume that we all want the patient to breastfeed.

  • Know that you have options.

Keeping in mind that physicians are humans too, if you’ve encountered down right foolishness (like when I met a pediatrician who likened the female urethra to the vaginal canal) and can’t take it anymore, know that you have every right to change practitioners. If you do choose to leave, be honest about why. It might help the practitioner reconsider his or her practices.

Dr. Whyte starts work at George Washington University’s student health center this month where a Breastfeeding Friendly University Project has been established.

He says he’s most excited about helping people transition from childhood to adulthood.

“As a kid, mom and dad are in charge and they are kind of guiding you,” he says of adolescent health care. “The only way to get good care is to be forthright.”

Excellent advice indeed.  

kmcMom2Mom KMC shared this great resource they created to empower parents in the medical setting:

Breastfeeding empowering language in medical settings 

Goal: Productive dialogue ending in a plan that is best for baby/child

Questions:

What exactly is your recommendation/concern?  (“Maybe you should supplement with formula.”)

Why are you recommending this course of action?  (“Your baby is slipping on the growth curve.  He’s not gaining weight as fast as he should.”  Follow-up questions: “What exactly is your concern?  Is he missing milestones?  Is he losing weight?  How fast ‘should’ he gain weight, and how far behind is he slipping?”  “Are you using the WHO growth charts based on breastfed babies, or the CDC charts based on formula-fed babies?” etc)

What is the desired outcome of this course of action?  (“Formula will make the baby put on weight faster.”)  Follow up: How will that benefit the baby?

What are possible undesired outcomes of this course of action?  (Here’s where you need to be informed.  Dr. might say “none.”  This is your opportunity to state your case for why you are opposed to what is proposed, i.e. “Won’t introducing nutrition other than breastmilk increase my baby’s gassiness/fussiness?  Formula feeding causes me to miss breastfeeding sessions, which will decrease my milk supply and undermine the breastfeeding process.  What if my baby is allergic to formula ingredients?  I really need to be exclusively breastfeeding right now to help my body regulate my hormones.”  etc.)

Are there alternatives to this course of action?  (“Can I supplement with pumped milk instead?  Can I increase nutrients in my diet or take vitamin supplements to pass them on through my breastmilk?  Do I need to try feeding longer or more frequently?  Can I meet with a lactation counselor or consultant to make sure my latch is correct and the baby is getting all of my milk?”)

What if we wait on taking this course of action?  (“Let me try some of these other things first, and let’s see how the baby is doing at his next two checkups.”)

Helpful phrases:

We’re on the same team here.  We both want what’s best for my child.  I just need to understand exactly what you think is best so I can be comfortable with the decision we make together. (Lead into above questions)

I’m not sure I understand.  Can you provide clarification?

Could I please see the policy?

I’m willing to assume that risk, and I’ll sign a waiver of liability if you provide one.

Could I please speak with someone who is more familiar/comfortable with the breastfeeding process?

I’m a parent trying to do what’s best for my {sick, hurting} child.  Please have patience with me as I try to figure this out.

Please check the baby’s notes for the PCM’s orders on breastfeeding.  If there are questions, you’ll have to contact the PCM.*

*Ask your baby’s PCM to write a note ordering that the child will be breastfed through needle sticks, blood draws, IV’s, catheterizations, or any other unpleasant procedures.  No one can override a doctor’s order.

Have you seen the latest research on this?  (Direct to Academy of Breastfeeding Medicine at http://www.bfmed.org, or have research summary printed out in advance.)

I need some time to research this information.  What is the best way to contact you if I have more questions?

Read more about Mom2Mom KMC here. Visit them on Facebook.

[Please note change made 7/15: Dr. Whyte currently works at Pediatricare of Northern Virginia, not Olde Towne Pediatrics.]

OB/GYN sheds light on creating breastfeeding culture

alison_stuebe_abogMaternal-fetal medicine physician, breastfeeding researcher, and assistant professor of Obstetrics and Gynecology at the University of North Carolina School of Medicine Alison Stuebe, MD, MSc recently wrote Breastfeeding and depression: It’s Complicated,  a fascinating post on the Academy of Breastfeeding Medicine’s blog. Her work is of such value because she recognizes that overstating the “benefits” of breastfeeding sometimes negates the reality of the experience for mother infant dyads.

Particularly intriguing is the story Stuebe tells of a mother who admits experiencing more concern about her milk production and her relationship with the pump than mothering her crying infant.

“When we emphasize breastmilk, we have completely misunderstood the biology of infant feeding,” Dr. Jack Newman replies in the post’s comment thread.

Stuebe fills me in on a theory that explains this woman’s (and other’s) obsession with milk production. Dr. Barbara L. Frederickson, Kenan Distinguished Professor of Psychology and Principal Investigator of the Positive Emotions and Psychophysiology Lab at the University of North Carolina, argues that obsessive passion comes from negative reinforcement.

“When we talk too much about the evil agents in formula, we risk creating obsessive passion,” Stuebe explains.

She describes obsessive passion this way: A fervid runner injures her ankle. Although continuing to run on that injury will decrease her chances of healing, she continues to do so. Her passion triumphs in an obsessive fashion and she ultimately risks destroying her ability to run all together.

On the contrary, a runner who exhibits harmonious passion will nurture her injury so not to risk the chance of never being able to run again.

Stuebe relates this analogy to the breastfeeding mother. If the risks of formula feeding are so ingrained in her mind, she may be motivated to neglect her child’s needs just as long as she never allows that baby to consume “rat poison”, or formula as Stuebe half-jokingly puts it.

Too often, breastfeeding advocates (including myself) become so hung up on the evils of formula that we leave mothers who do not successfully breastfeed in the dust with no other way to connect with their babies; hence the baby left to cry while mother squeezes out her last drop of milk.

Stuebe’s current research on breastfeeding and depression questions conventional thoughts about infant feeding and its relationship to the way mothers and infants connect.

If you look at a population of several hundred three-month-olds, you will find that more of the depressed mothers bottle feed, Stuebe explains.

However when longitudinal studies are considered, it’s hard to argue, “If she would just breastfeed, she wouldn’t be depressed,” Stuebe continues.

The study’s current results about oxytocin and depression are provoking.

“It could be that mothers who have lower oxytocin levels have trouble with breastfeeding and also feel more anxious and depressed,” Stuebe reflects in Breastfeeding and depression: It’s complicated. “Or it could be that, for mothers whose baseline oxytocin is lower, breastfeeding gives them a boost that’s essential for them to feel connected to their babies.”

She concludes, “The nuances of the biology suggest that doctors absolutely need to think about the effect of breastfeeding on a woman’s mood symptoms.”

Tackling a fragmented health care system

In fact, all health professionals caring for the mother infant dyad need to practice with this suggestion in mind.

Because of the nature of fragmented care in our nation, lactation professionals are often the only caregiver assessing the mother and baby as a couple.

“We’re that glue and we need to be watching really carefully,” Stuebe says.

She gives us simple advice and reminds us that the Edinburgh Postnatal Depression Scale or EPDS is a very easy test to administer to measure postpartum depression. It takes about five minutes and is translated into many languages.

Although there is sometimes a harmful disconnect between mother and baby providers, Stuebe says that there are breastfeeding medicine practices that serve to bridge the gap springing up around the country.

For instance, MilkWorks located in Lincoln, Neb. offers support from a variety of lacatation professionals including a medical doctor, lactation counselors and consultants, nurses, breastfeeding educators and dieticians.

In Chapel Hill, N.C., women have access to the Women’s Birth and Wellness Center which also offers lactation care within the community.

For the mother suffering from PPD, these centers offer an alternative to medication that might ultimately require her to stop breastfeeding.

While many communities are developing support centers for mother infant dyads, there is still a lot of scatter within our system. Stuebe says it would be ideal if these services were offered at YMCAs for instance, or if family physicians were able to provide a kind of “one-stop shopping” experience.

Stuebe says that pushing health care to be more woman-centered in general is a huge step in the right direction. To accomplish this, we need innovative ideas, new models, and new approaches.

Considering all of the science

“Those of us involved in breastfeeding advocacy need to be thoughtful about how we talk about the science,” Stuebe explains.

Getting people excited about breastfeeding research is a start, but it only goes so far. For the non-believers, the breastfeeding skeptics, getting a roomful of people fired up about breastfeeding makes them think, “This is a cult,” Stuebe half-heartedly chuckles.

(She makes clear that she is part of the cult, so she says that with love.)

It’s important for breastfeeding advocates to remain open about the research that doesn’t confirm what we already believe. Similarly, we should consider the studies that completely turn what we once believed upside down.

Stuebe explains that it’s too easy to dismiss new research on the grounds that someone involved in the process received money from a formula company. Instead, we should look at the findings critically.

Stuebe’s breastfeeding wisdom doesn’t end here.

Saving nipples two ears at a time

She suggests we remain receptive with clients as well.

“Communication starts with listening,” she says.

Lori B. Feldman-Winter, MD, MPH, Head of the Adolescent Medicine Division at Cooper University Hospital and National Faculty Chair of the Best Fed Beginnings project once offered Stuebe this analogy to consider: A doctor asks a pregnant woman if she plans to breastfeed. The woman replies that she’s apprehensive because she’s uncertain she wants to have her nipples pierced. The doctor explains that the holes for breastfeeding are already in place. “Well in that case, of course I’ll breastfeed,” the woman responds.

Feldman-Winter suggests always starting conversation with a parent by asking what he or she has heard about breastfeeding. Listening saves nipples!

Creating conversation in the workplace

Conversation is crucial among lactation professionals’ colleagues as well. Fittingly, Stuebe tells me about a book called Crucial Conversations: Tools for Talking When Stakes are High which discusses how to establish mutual purpose and mutual respect.

Establishing collaborative relationships within the workplace can be especially valuable in the hierarchical field of medicine.

Perhaps a misinformed doctor gives a patient incorrect breastfeeding advice. Stuebe suggests lactation professionals respectfully question the physician’s information privately. She advises resisting the urge to shout, “You stupid fool!”

“Feeling stupid in front of the patient doesn’t feel particularly good,” she explains.

When physicians are the least knowledgeable about breastfeeding, it can either motivate them to learn, or it can turn them off completely; they may decide that breastfeeding isn’t their problem, Stuebe tells me.

She adds that unfortunately there is no culture in place that dictates offering proper breastfeeding support is the physician’s responsibility.

Considering the breastfeeding OB/GYN

As a mother of three boys, Stuebe is able to speak not only to the physician’s experience but also to that of the breastfeeding OB/GYN.

The training process is generally unfriendly to nursing mothers, she tells me. Demanding schedules often don’t allow time for pumping. And when there is time, co-residents sometimes see a mother’s need to pump as an excuse to dump her work on someone else.

Sadly, when nursing OB/GYNS aren’t supported in their breastfeeding journeys, their guilt and anger can sublimates into their general perception of breastfeeding. The same might happen if an OB/GYN’s partner had a difficult time nursing.

Fortunately, Stuebe reports being blessed with a supply that withstood extended spans between pumping.

She started her internship the first day her son turned three months old and recalls “walking down Brookline Avenue to Brigham and Women’s Hospital with a Pump-in-Style slung on [her] back and a vague determination to breastfeed.” [Retrieved from: https://bfmed.wordpress.com/2012/11/16/building-a-breastfeeding-culture/]

Her decision to breastfeed was hardly influenced by medical school as breastfeeding was “not really in the mix at all.” Most of her initial breastfeeding education as a mother was self-sought; reading So That’s What They’re For and observing her sisters’ breastfeeding adventures. Stuebe says that breastfeeding eventually defined her as a mother.

“Breastfeeding became the one thing they couldn’t take from me,” she says of her time interning. “They could take my soul, sanity and sleep, but they would not keep me from nursing my baby.”

In Building a breastfeeding culture, Stuebe further explains what motivated her to nurse her children.

Sharing her stories

Perhaps it is Stuebe’s willingness to share her personal experience that makes her contributions to the field of lactation so extraordinary. She is so human, so humble yet so outstanding.

Take her Twitter description for example: High risk obstetrician, aspiring midwife, Breastfeeding researcher and advocate, mom of three. Aspiring midwife catches my eye.

“I love low risk birth,” she explains. “I believe in physiology, but I think that even in the sickest patients I’ve taken care of, I try to remember that this is still a life event for them.”

She recalls a mother with severe cardiac arrhythmia who birthed her baby in “low lights and lovely ambiance” with the cardiac intensive care unit outside the door. Her baby went skin to skin immediately after birth and latched within the first four minutes! Stuebe remembers the image of the baby’s small hand resting on its mother’s defibrillator pad.

Stuebe has worked closely with the Massachusetts Breastfeeding Coalition, helping with web design and a variety of educational initiatives. She’s currently involved with the Carolina Global Breastfeeding Institute at UNC where she serves as an institute-associated faculty member.

In her pre-medical life, Stuebe worked as a journalist which she says has significantly influenced her ability to communicate with the public and her patients.

To read more about Stuebe’s work, visit the Breastfeeding Medicine blog here and her compilation of articles at the National Center for Biotechnology Information (NCBI) at the U.S. National Library of Medicine (NLM) here.