Executive Summary

I had a thought today that I would like to know the answer to. With so much publicized research being done on the properties of breast milk (antimicrobial, stem cell properties, brain development and so on), where is the research into real lactation problems? Where is the safe approved drug to increase milk supply (Metclopramide isn’t really ‘safe’ and Domperidone isn’t really ‘approved’), where are the actual diagnoses for supply problems? Maybe companies would rather head toward synthesizing the properties of breast milk rather than helping to fix bodies to produce it. After all it’s only several hundred thousand women a year, and formula does exist (my tongue is so far into my cheek it might poke through…)

I don’t know. I suspect there is not a satisfactory answer.

So I leave you with this. A short guide to various posts that are intended to be helpful.

I need help:

How to interview a Lactation Consultant

11 things a Lactation Consultant should know how to do (IMO).

Do I need help?

I find my tongue tie resources out of date, though you can see my experience here. For better information I would urge joining this Facebook group. They maintain lists of providers and are fairly knowledgeable about what is to be expected. If a provider is not on their list people can often recommend local alternatives (for instance I know of at least 4 laser tongue tie release places in New Zealand now, but none has made the general list. Do see the New Zealand Tongue Tie resources page instead.)

I need to combination feed-how do I do this?

The big fat Combo feeding FAQ

Walking the line

Benefits of

With low supply

SNS tutorial

Nipple confusion

Managing long term

Formula

Solids

Weaning

Body Image

What is causing this?

Able

Potential causes

Birth complications

Rare vs Undiagnosed

My most popular post

Making Milk beads

And the rest of my life.

I think I no longer feel bad, because it isn’t something I did wrong. It’s purely a medical issue.  A medical issue that some people would have me believe is my fault. A medical issue I cannot get satisfactory treatment for and that is largely undiagnosed. That makes me mad.

I lie. I still feel bad and somewhat inadequate, but I no longer feel guilt. I do wonder how much of my feeling bad is a normal level for someone suddenly faced with a non-life threatening failure of a body part. Somehow I can’t imagine people feel a mix of loss of gender identity and self loathing after losing a kidney or having a splenectomy. Or losing a finger or a limb. I’m sure there are other mixed feelings but I wonder how often self hatred/loathing/failure is a part of that.

Moving on from low supply.

Other than the frustration of feeding my second, things went well all things considered. I mean I had moments (many) I wanted to stop and it was more difficult in several ways. One because I had more support.

Back to that in a minute.

Another one was that I knew what my end goal was. With my first I was struggling on because I had been told I couldn’t, that I would fail. With Miss M I knew I could come out the other side and have a time of normalcy with a nurseling. And besides, she would love me no matter what.
Back to the more support thing. I lined up a supportive midwife and didn’t really have anyone around me telling me that I was terrible for using formula or anything. I had some stress in the hospital as midwives argued about how things would turn out, and brief moments of false hope that things would be normal, but it was not to be. My midwife I think thought I was crazy and wanted to give me permission to stop. I had a great online due date group (note: I highly recommend getting one of these. I joined a local parenting forum, mine was associated with a magazine, and when I became pregnant joined the month due date group. We formed a facebook group, there are about 30-35 of us, and it’s fantastic. Local is key, because you can swap tips about sales and local brands. And meet up! With my first I was a member of parenting community primarily UK and US based. So not really local at all. Also much larger and impersonal. I really think 30ish is the ideal number of people to be civil online.), and a weekly breastfeeding group attended by an IBCLC who was familiar with major breastfeeding issues. All around I felt like no one would judge me if I did stop. But I knew what I was aiming for so it was all personal drive, not some misplaced feeling of needing to prove I could do it. I knew I could. And if it turned out I couldn’t there would be people there to say well done you. If I had had that support with my first I would have stopped I think. But I didn’t and that’s how I have succeeded twice now. But wanting to stop is not a form of failure, nor should it be a source of guilt. It’s just a symptom of frustration. This time I knew my frustration was temporary.

I’ve come to think that so much mommy war crap is very first world problem-esque. Even low supply. Yes, it’s a big and valid problem, that is not as open, treated or acknowledged as it should be, but the guilt and regret is very much a western world bullshit thing to feel bad about. A bit of a tantrum which is negatively reinforced if you will. Our perceptions are skewed by the way we live. Yes, we have an inability to nourish our babies alone but in ‘the wild’ we would not be alone. Ok, not unless you were homesteading or repopulating the world. Much like we aren’t meant to be alone in the weeks and months after having a baby, and yet we often are. Yes it can feel raw and horrible and heartbreaking, and I’m not disputing that, but I posit that those feelings are a mixture of betrayal and being thwarted in our choices, combined with various breastfeeding movement backlash baggage. Betrayal as we’ve been told that we can do it-and then we can’t. Breastfeeding backlash baggage in that even though the issue is becoming more well known it still is not widely accepted so you have people disbelieving you, questioning your commitment and motivation. As if it’s a contest, or endurance event, rather than keeping a baby alive by any means necessary. Thwarted in that this was something you made the choice to do and that choice is taken away from you. I think the emotional repercussions from that is largely a construct of the other two. If you could not do some other choice would you feel so bent out of shape about it? Not likely…until people disbelieve you, question you, badger you and tell you the option you do have is wrong, repugnant and harmful. That leaves you as a sad little ball of raw despair.

All I can really say is that parenting is so much more than the first few years, yet these years are consumed with ideals to do things the right way and when the right way, like breastfeeding, does not work out, or goes poorly we become bitter; consumed with sadness, guilt and regret, because honestly we don’t have bigger problems. Our first years ideals mean well, but the jealousy, the warring, the guilt of if you are stimulating your baby appropriately, enough, right, the worry if you are doing things the ‘best’ and frankly, fashionable way…. it’s all so much bullshit. There are righter ways and wronger ways to do things but so much of the hype sold to us in packages, physical or conceptual, is entirely irrelevant. Babies need touching, feeding, cleaning. To be comfortable and comforted. To be responded to. Kids need a hell of a lot more than that. You haven’t failed as a parent until your kids don’t call you after they grow up. They won’t even remember the first years. The first years are a start but what shapes a child into a person is ongoing interaction.

With that I will leave my next post with a compilation of links on various topics. This blog is not so topical to me anymore and no one likes an irregularly updated blog. I have moved on from low supply. I hope others with this issue can as well.
Oh, it will be a fact of life with my future and last child, but that’s all.  It’s moved on from being an emotional problem to purely a medical problem. I’ve accepted it is not fixable. I will never have a diagnosis (well not unless I can find a breastfeeding clinician). And I guess it doesn’t matter. My kids don’t care that they had to be born via cesarean section, that they weren’t fed 100% breast milk. My main focus now is actual parenting and I don’t know that I will have time or motivation to navel gaze about that. I’ll be learning as I go, and my right ways, or even the ways that things go aren’t for me to judge or write a how-to manual for anyone else. It’s just going to be regular difficult from here on out, so I don’t think my musings are going to be particularly relevant.

Let’s talk formula

Because someone needs to.  So here it is from me- someone who wanted to breastfeed and supports breastfeeding where reasonable, yet used and uses formula for medical reasons. Maybe that makes me a mostly neutral party. Maybe not.

First off- everything I learned about formula is self-taught or I learned from a Lactation Consultant. A good LC, on seeing that you want or need to use formula should be able to give you some pointers. Theoretically all formulas should be pretty much the same, brand name or budget. The WHO is supposed to regulate the ingredients and basic proportions. However-sometimes things are not so straightforward.

What you want out of a formula is to have it be whey based. Not casein based. You want the from birth formula. The follow-ons  marketed from age 6 months + are not as well regulated and unnecessary (though they are often cheaper…). If your child requires supplementation beyond 1 year, full fat cow milk can be given (or mixed with formula if you are concerned about diet or intake).

Cow milk is recommended because growing brains need fat. If your child does not like cow milk to drink (mine didn’t), just be sure to supplement with other high fat foods alone or in cooking. Food such as- avocado, cheese, coconut oil or cream, peanut or seed butters, butter, cream, lamb, olive oils, and so on. For extra calcium try various vegetables like kale, alfalfa, etc and fish like sardines, salmon etc.

Back to formulas. Whey or milk solids should be the first ingredient. Maltodextrin is a common additive and should be around the 3rd-5th ingredient. It is sometimes seen as the first ingredient- this is not necessary and may make your baby eat more- its a carbohydrate that is digested quickly.

If you are combination feeding you do not need any special formula. Any birth to 12 month one that suits you is fine.

This sort of thing

4seURmZ

Image credit

Is straight up predatory marketing. I was always ambivalent about formula companies being big and bad and preying on the breastfeeding mother, but yeah. Not after seeing that. I’m pretty sure people are eating it up too. I’d hate to be more cynical but I’d imagine that if the one on the left cost more people would be paying for that too.

Let me reiterate: You do not need anything special to combination feed. No formula is better than any other. In fact less is often more.

Some reading on safe formula use can be found here http://info.babymilkaction.org/infant_feeding/formulafeeding

Deficient.

I do often wonder if there is something mentally wrong with me for doing this mixed feeding malarkey. In my cynical moments I see myself as a mother willing to risk starving her child out of stubbornness. At this point I know my breasts do not lactate appropriately. There is no tricking, hoping or stimulation that is going to make that not be the case. I don’t think formula is that bad or I’d maybe motivate myself to get some donor milk. Despite that I am now citrus, tomato, brassica, onion, garlic, pulse, and gluten free to keep my baby reasonably happy. Yeah if you’d told me ever that I would be on a restricted diet feeding a baby through a tube I would have thought you were crazy. But here I am. Anyhow. But at some level I can not let go of breast feeding and go completely over to the bottle and formula. Now that we are at the point where it isn’t complete hell to mix feed (seems to be 12 weeks is the magic hump) I seriously wonder what is wrong with me.

I see mothers blithely (so I imagine though I’m certain the reality included tears) say that they stopped breastfeeding due to low supply and I wonder why not me? Since this method is definitely not the standard way of dealing with low supply I do wonder of those that have low supply how many would like to be educated about management option and how many prefer to stop outright.

Last time I persevered because it was a giant fuck you, a because-I-can to everyone who told me I couldn’t. This time, in light of a tricky, overly sleepy baby who is not easy to feed and is orally particular, I wonder why I am so stubborn and dangerous.

I do know that once solids are established my feeding rig will be packed away and things will be…normal. Is that reason enough though? To deal with 6-7 months of difficulty for another year of unfettered breastfeeding before I have to encourage weaning and do it all again?

It’s certainly been harder with two. The mixed feeding takes more time than a healthy breastfeeding relationship so the older child misses out. We had planned three children when we were being logical (before kids) but the idea of doing this feeding regimen again is depressing at minimum. The only thing that makes me consider doing this mixed feeding thing again is that we can self wean. The perks of being the youngest.

Belief in research

I was discussing some things on a blog I used to read with some people a few weeks ago. Someone brought up the idea that formula fed, or I suppose bottle fed, babies over eat. Which, you know is possible, but not something an attentive parent necessarily does. I pointed out that babies suffering from reflux, whether they be breast or formula fed will frequently overeat to soothe their throat. And that tongue ties can exacerbate (as in make worse, as that is the meaning of that word right?) reflux. And that tongue tied babies often end up being bottle fed due to lack of correct diagnoses… But I got called to task for saying that tongue tie ’caused’ reflux. Which is not what I said, and then for not providing studies on that. I dutifully provided a few papers and proceedings that referenced reflux being a symptom of untreated tongue tie, but I suppose that wasn’t appropriate or strong enough evidence. Or something, as I’ve now not had any of my further comments on other topics published on the blog. Makes me wonder exactly what I’m being censored over there. Fair enough, perhaps they don’t like me (I suspect people often don’t), but it seems a bit ridiculous. To me it seems like an appropriate place for anecdotal evidence. To me it seems a bit like if you say people with colds often have runny noses. Yes, observed, often anecdotal, and of course since colds are much more studied than tongue tie we know that runny noses are caused by a variety of things and that a cold does not always have a runny nose, and that runny noses can, in fact, happen independently of colds as well. But I can’t think I’ve seen a study talking about the relation of runny noses to colds because it’s something most people have seen enough of to know, ok, yes this can go with that, often but not always, and so on. Also, because we see colds and runny noses from them so often it seems moronic to do such a study because we know that they can, and often do, go together.

At the time I pointed out that studies are difficult to do on tongue tie since even experts have a hard time agreeing on diagnoses. I’ve also heard that doctors can be reluctant to do much about reflux as well. So you kind of have a double whammy of suck there. Regardless, there’s certainly nothing I’ve seen taking a statistically significant number of babies with both reflux and tongue tie (what classification of tongue tie?) and cutting the frenulua (was it done deeply enough? Does that have significance in soothing the problem?) and measuring the severity of the reflux before and after (how do you do that? Count the number of vomiting instances in a 24 hour period? What if it’s silent reflux?). The idea that there are NOT such studies is apparently more satisfying to some people than observations from someone who works with such issues on a daily basis (not me, but one of the articles I provided as evidence). Sure it would be an interesting study to people who care about and deal with those issues, but who’s paying?

I think for some things it’s easy to be over-reliant on published evidence. It hardly seems appropriate to discount the existence of something because there are no popular studies on it. You have to balance that with realizing how studies are designed, funded and carried out. It’s easy to pick apart studies for not taking into account various correlating factors, having confirmation bias and similar, and there are some truly badly designed studies out there. From my molecular biology point of view human health studies are messy and flawed even when they are done well. I understand the reason for it; you can’t do some of the things to people that you’d need to do to have a decent scientific control.

Now, on the other hand I’m not a huge fan of anecdotes as evidence. Mainly as anecdotes often come from someone untrained in what they are extemporizing on and are frequently used to justify doing something that studies and statistical analysis thereof have told us is not necessarily typical. A sort of  ‘nyah nyah nyah take that statistics’. An anecdote by definition is an isolated example. It progresses to an observation or an interesting correlation when the examples are no longer isolated and made by someone who sees a lot of examples. It’s an untested hypothesis at that stage, but just because it is untested does not mean it doesn’t have grounding in strong observation. From there you’d obviously need sponsorship or funding to progress to an actual research article. Probably sloppy language is to blame here somewhere. People can have wild suppositions with no grounding, call them theories (when a theory is really a highly tested hypothesis) and thus lend faux credibility to their imaginings.

Further compounding this is when accurate correlations are noticed by those with otherwise inaccurate suppositions. In short it’s possible to be wrong and right. Just because someone believes the sky is pink, grass is green and rocks are hard does not make them wrong about the grass and the rocks, only the sky. If you are discriminating you can believe some things and not others. It doesn’t have to be all or nothing.

This really goes both ways. Illogic is an equal opportunity employer. And of course things always seem stronger when whatever you are espousing backs up what you want to believe. Sometimes enough to fudge things into to going your way.

One thing that’s annoyed me for years is the insistence that various things are untested. Often coupled with the addendum that the government (or some other entity), by releasing the untested item, is engaging in a conspiracy of some sort to test something on the unsuspecting public. They may indeed be releasing something on the unsuspecting public, but ‘finding out what happens’ is certainly not the goal. It’s often more along the lines, of ‘I hope nothing happens so I can keep my job and this money’. The thing about conspiracies is that generally what looks like a conspiracy is actually a series of incompetent mishaps, and if it is actually some kind of conspiracy (more likely to be a high flow of money from private interests/lobbyists with low public coverage) it’s nearly always profit driven.

One thing regarding this I run into a lot is that something isn’t tested on pregnant women. Well, no. What do these people expect, that some pregnant women are going to be rounded up and subjected to whatever treatment for the benefit of those in the developed world? Of course not! Studies of things on pregnant and breastfeeding women are most often done on an observational and situational basis. Write ups by doctors or other professionals of a group whose care providers decided the treatment, for them, outweighed the risks of the unknown. Observational studies don’t always lend themselves to statistical analysis, because they are just published accounts of professional observations. Sure, statistics will be applied to it to make it more interesting, and conclusions drawn on what it all means, but as we all know since it was observational it wasn’t designed, so naturally there are confounding factors. Well, I guess the problem is that we don’t all know that. And we, as well as policy makers, take these written observations as ultimate truth, when all they are is simply case studies.

The biggest problem with this is that most people are not scientifically minded. They aren’t ok with maybe being wrong. They get all emotionally invested in their beliefs. All you can really do is realize that things are not one-size-fits-all and make educated guesses based on your personal situation.

Becoming a pariah: Breastfeeding’s underclass

I was a member, as previously mentioned, of a large parenting forum. I had a journal there which I started shortly after my baby was born. In that journal I documented our ups and downs with our breastfeeding issues. I’m considering how best to showcase those posts, often very raw and unhappy, on this blog. Anyhow, I titled my journal our journey with low supply as I thought that was our issue for 8-9 months. I keep digressing, but the main topic was about our struggle with low supply.

First off it made me hugely unpopular because the noisy breastfeeding advocates exclaimed that low supply was so rare and here someone was living with it, struggling with it, being public about those struggles and emotions, and apparently most aggravating, finding a way to keep breastfeeding despite it. Somehow being a successful combination feeder was a huge insult. I guess it’s easier if people fall into the breast feeder or formula feeder camps. It seems that once someone has fully gone over to not breastfeeding and they say that they did because of low supply it’s easier for those vocal people to tut and say that that wasn’t the issue. Far more difficult for them to do so to someone who has kept breastfeeding and has not managed to increase supply. Anyhow, as long as I didn’t argue the party line (all women can breastfeed; try harder!) too much I mostly got left alone; ignored even. But until I changed the title of my journal to something more general, at least three separate people came into my journal for the purpose of arguing with me about how I was wrong. I was told that if I’d been better educated, if I hadn’t doubted my abilities I would have seen that I was wrong about having low supply and I would have been a successful breast feeder. Now, at the time I tried to be nice and civil. After all they weren’t quite that blunt (ok, one person did tell me that if I’d believed I could breastfeed I would have been able to do it). People hardly talked to me in there as it was. I was trying to be sociable. But it got to me. I spent so much of that time plagued with extra doubt because of the things people were saying to me. By openly labeling myself a low supply mom, I publicly invited scorn from those breastfeeding advocates indoctrinated in the belief that 99% of women can breastfeed. One of the most hostile to me now has a blog herself (possibly one of the more hostile pro-breastfeeding blogs I’ve ever seen, not that I go looking) and is very much a ‘I did it why can’t you’ type.  I gave her latching advice and other support and she threw it in my face because after she ‘educated’ herself she decided my low supply wasn’t ‘real’.

I continued to offer advice and support to women who were also experiencing similar issues. During this time I noticed an upsetting trend. I am a member of other open breastfeeding support and information sites and networks and I saw it there as well. It was acceptable to treat women with breastfeeding issues as second class breast feeders. Talking about what problems looked like was ‘not ok’, ‘scaring women’ and the like. Those who had issues were dismissed as uneducated and failed by the system, those who succeeded were hailed with a ‘job well done’. This further glossed over what symptoms of breastfeeding issues look like. Who needs breastfeeding information and advice most? Those with issues, yet these areas are frequently dominated by passionate women with breastfeeding as their cause. Those who had issues, with pertinent advice to give, are most often relegated to the back seat while those who have overcome, or did it without too much fuss, become the first line of offense for those looking for help. The feelgood message is all very well and good, but it’s not appropriate for anyone with an issue beyond ignorance. So yes, know what a normal newborn feeding pattern is like, but also know when things are verging on abnormal and do not apply the protocols for ‘normal’ to that.

I know this is overflow from the dispelling breastfeeding myths movement. Dispelling myths is all well and good since our cultures need to relearn what normal breastfeeding looks like, but preventing knowledge of what problems look like to keep from ‘scaring’ someone hurts us all. No wonder when breastfeeding fails women feel so lost. They don’t know why or how things went wrong. There’s rarely any closure. On top of  not being able to access adequate help that is able to competently discuss the issues and come to a satisfactory resolution, you have these freaking mommy wars pushing that it was all about toughing it out. Advocates pushing that it’s all about the mother’s ability to stick with it and it becomes a spiral of what-if and if-only long after the fact.

I spent a long time feeling really bitter about how I couldn’t get any meaningful advice. Then I realized, those who had it to give had long since distanced themselves from those who only had platitudes because the self proclaimed bearers of breastfeeding wisdom feel continually justified and vindicated in what they are telling people (most of which is more or less true and nonetheless helpful and reassuring to those who are simply ignorant of what normal newborn behavior looks like), while those who have advice to give on problematic matters get shot down, belittled, accused of scaring or misleading women and other negative things. So they, though they may crave the providing of proper information and support, slowly withdraw because frankly it’s a demoralizing atmosphere. Like me. So now I’m part of the problem. At least I’m preserving my sanity.

Regret for information not had, and tears shed for the wrong reasons, are most bitter indeed.

Being better at baby friendly.

When I was pregnant I was pleased to learn that every hospital and maternity centre within reach was baby friendly. By that I mean BFHI accredited. I was pretty set on breastfeeding and I’d heard too many tales from acquaintances in the US and elsewhere who had had to fend off staff with bottles of formula, or who’d had bottles given to their babies as a matter of course. The way New Zealand implemented the BFHI has been of some interest. The number of BFHI hospitals here is much higher than in similar OECD countries. New Zealand has 72 as of 2010, or over 90% of it’s maternity hospitals, where the US has 119 , which is less than 5%, and the UK has around 52, or less than 20% of it’s hospitals.  Small country advantage, clearly.

Here’s what the BFHI is:

  1. Have a written breastfeeding policy that is routinely communicated to all health care staff.
  2. Train all health care staff in skills necessary to implement this policy.
  3. Inform all pregnant women about the benefits and management of breastfeeding.
  4. Help mothers initiate breastfeeding within one half-hour of birth.
  5. Show mothers how to breastfeed and maintain lactation, even if they should be separated from their infants.
  6. Give newborn infants no food or drink other than breast milk, not even sips of water, unless medically indicated. (this is for staff)
  7. Practice rooming in – that is, allow mothers and infants to remain together 24 hours a day.
  8. Encourage breastfeeding on demand.
  9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants. (this is for staff)
  10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

The program also restricts use by the hospital of free formula or other infant care aides provided by formula companies. (Definition shamelessly stolen from wikipedia)

That’s all really. Now, of those 10 steps I can say I personally experienced 6,7,8 and 9. I probably would have seen 4 as well if I hadn’t been groggily recovering from my (non general anaesthesia) emergency c-section. When I was aware I wasn’t in the operating theatre and able to ask for my baby she was handed to me and I was helped.  I was also summarily helped most (but not all) of the other times I asked for help during my stay. So halvsies on number 5 then because no one ever showed me how to pump. I was also given a cartload of flyers so I guess that’s the effort for number 10 there as well. So 4 fully out of 10, with an additional 2 tacked on the end and one which probably would have been done had circumstances permitted.  The other 3, 2 really aren’t about me, they are about staff, and the third wasn’t an issue as I was already intending to breastfeed.

Why I think the BFHI is a good thing:

Those first days are important to teaching the baby how to suck from the breast appropriately. Giving bottles or soother devices when not medically indicated can cause issues like flow preference and nipple confusion which can be a challenge to overcome. I think if women do want to breastfeed they shouldn’t have to worry about what the staff are getting up to in terms of accidental sabotage.

In addition, the first few hours are regarded as critical for longer term breastfeeding success.

It does increase breastfeeding longer term rates. No question, there are many countries with success stories. If you don’t want to breastfeed you are able to bring your own feeding materials, and if you change your mind you are often not in hospital for very long. Our usual stay here is 48 hours for normal vaginal deliveries and 96 for caesarean. Complications like excess blood loss or surgical vaginal deliveries merit additional time. If you don’t want to breastfeed or suspect potential complications I’d urge anyone to get a copy of the hospital’s written infant feeding policy. Actually, probably it should be required reading for anyone giving birth, but that’s probably above and beyond what most people are interested in doing in terms of informing themselves. After all if they are BFHI they have to have one that they give to staff.

Where I think the BFHI needs work:

  • The quota system: Part of the BFHI is that to maintain the BFHI designation (and often the extra funding that goes along with it) BFH institutions must have at least a 75% breastfeeding initiation (discharge?) rate. This effectively turns front line staff into sales people selling breastfeeding to mothers to keep their institution’s funding. Can sales and support really be the same thing? I’d kind of think if you implemented the rest of the guidelines sensibly that the increased breastfeeding rates would follow without any uncompromising push from staff. Many people do actually want to breast feed. Really. But if they don’t, it’s less energy all around to just leave it. Give more flexible limits (apply the ‘quotas’ to only healthy singleton term infants, or have different quotas for mothers and infants at risk of lactation failure) to hospitals dealing in more complex cases.
  • Points 1 and 2. The staff training, which is where the implementation of the BFHI can go awry, needs better minimums or at least better standards. What goes into that staff training exactly? Is the training the same kind of overzealous lactivism that is used on women to push breastfeeding or is it something more along these lines? I find some of these scripts useful and some of them pretty objectionable.  Right now the minimum staff training for BFHI accreditation for nurses and midwives is 18 hours (I’m not clear if this is yearly or once ever), and for non nursing staff, so obstetricians, pediatricians and similar, is 3 hours (this is per year). The article referred to above (here it is again) outlines a lot of the issues with getting and keeping everyone trained. No wonder then that the result of the training seems to often turn front line care providers into walking breast is best posters. Which, you know, I’ve never seen? I did see a lot of breastfeeding posters at my various stays, but they were about gauging infant hunger cues, appropriate bodily output for the breastfed infant, signs of dehydration, and latching technique. So, more helpful things instead of useless platitudes.

I think this is the most telling quote from the article:

…specific resources and training may need to be provided for birthing centres that deal with complex cases where exclusive breastfeeding may be less likely to be achieved.

  • Point 3.  Misinterpretation of the guidelines. This is such a recognized issue I found a PubMed article about it. Being baby friendly does not disallow use of formula or information about formula. There are two main goals, one of which is to stop the free and low cost formula from being marketed to hospitals. The other is to protect breastfeeding by following the 10 steps for accreditation.  Because of the tie to certain numbers of breast feeding rates that I outlined in my first objection the guidelines are often exploited by staff.
I guess what I’m asking is if the education of front line staff  is adequate to have women’s experiences be more positive. I don’t think it is.  More interestingly, what goes on in those 3-18 hours of staff training? Is is a seminar with dire warnings about breast being best or is it something more informative, like infant stomach size marbles and spotting potential issues?
I’d imagine the 15 hour training time difference for primary support staff does have some more practical help with latching and positioning. But what about informing mothers they are at risk of lactation issues? Those with high blood losses, C-sections and similar? Gosh, what about tongue tie or IGT screening while we’re wishing? I think they must have some leanings toward that here as I had a lactation log card I was given to be filled out for feeding times and durations. I saw the writing on mine and though I dutifully filled it out my milk status was written on there for various days without having consulted me at all (colostrum, filling and full when full didn’t ever really happen). So even in fully compliant institutions there is some data fudging to get people out the door.
So, what should front line staff be taught?

Oral confusion-how nipple confusion works

Let’s talk about nipple confusion. Wherever anecdotes are valued as useful you’ll find plenty of stories that illustrate either view on nipple confusion. Babies who were given bottles early on and the mothers who had huge struggles getting them back, if ever, to the breast, as well as those who routinely gave their babies bottles and never had any issues at all.  So what’s the deal with nipple confusion? Nipple confusion is a collective name for something that is a combination of factors. Side note: I found this article, which looks like it would be a fantastic resource. Unfortunately, like many of Dr. Neifert’s articles, I can’t get electronic access to it (even at work where I have access to all kinds of journals). I’m sure that would pretty much replace my little post here, but since I can’t read it, I’ll just write this instead.

Teat Confusion:

First off there is teat confusion. How something is sucked. Babies are crafty, tricky little beasts. It’s part of their biological programming to experiment and problem solve in order to figure out how to best get milk out of breasts.  So teat confusion can arise from bottle teats and pacifier teats. Bottle teats as the method of getting fluid out of a bottle teat is different than out of a breast (see Myth 15 and associated citations). With a breast the mouth needs to gape wider and the tongue move to extract the milk via a peristaltic action. So undulation of the tongue.

With a bottle, the mouth does not need to open as wide and the tongue does not need to move out to extract the milk, but instead stops the milk from running down the throat too fast.

With a pacifier the method of suck also can effect musculature changes and the pacifier is inherently a non-nutritive sucking action. So the baby will do it because they enjoy the action of sucking. Something they are also biologically conditioned to like. With pacifiers there is no reward for improved technique (as with breast and in some cases bottle feeding) and the sucking action does not train the tongue appropriately. In addition the baby may associate sucking with no reward and be less enthusiastic about trying their luck with sucking from the breast.  With normal breast feeding let down can take a short while to start, so a baby who is conditioned early to suck an artificial nutritive teat may lose patience with waiting for letdown to produce milk

Flow Preference:

Another factor in nipple confusion is flow preference. Bottles have different flows, slow to fast. Not all slow flows are created equal as well. Probably each bottle/teat type is slightly different. So if a bottle, which has a different sucking method required, produces a faster, more generous flow of milk, or conversely a slower and more manageable flow, then the infant may find that preferable.  There is evidence that bottle fed infants suck less frequently and in different patterns than breast fed infants. Flow from the breast changes over the duration of the feed and a bottle is constant.

Latch:

The main factor in nipple confusion, however, is how good the latch is. The better the latch, the less likely the infant will experience nipple confusion. So babies with tongue ties or other oral abnormalities, or who have mothers with difficult nipples, will exhibit higher rates of nipple confusion signs. In addition to these conditions often producing issues with appropriate latch and milk extraction, often resulting in early bottle use, extracting food from the bottle is often easier for those without a normal range of oral movement.

Time sensitive:

Another factor to consider is that nipple confusion may not be immediate. I found when I needed to start combination feeding that while things were fine at first with supplementing by bottle, starting at 5 days with expressed milk and moving to formula by 2 weeks, by 4-6 weeks we had had some strong instances of breast refusal. This goes back to babies being tricky beasts. They start learning that if they fuss or refuse the breast that they can get some other potentially easier food. The most common ages for breast refusal due to nipple confusion or flow preference are  under 1 week, 2-3 weeks, 6 weeks, and 4-5 months. These coincide fairly consistently with growth spurts.

This is why it is recommended to not introduce bottles or artificial soothers before 4-6 weeks. By that age it’s assumed that the infant will have figured out milk extraction from the breast and will be less inclined to prefer the bottle over the breast. In addition, the mother’s milk supply will have begun to stabilize and a missed feed here or there under normal circumstances will not unduly affect supply. This guideline obviously errs well on the side of caution.

Prevention:

When you need or want to supplement with breast milk or formula and you want to minimize nipple confusion there are a few ways you can do this

  • The bottle latch: You’ll need a wide base bottle that encourages a wide opening of the mouth. Choose the slowest flow teat you can find to start with. Here is a  guide on choosing a teat. Purely by chance we used the Avent newborn flow. We used these until 12 months of age.
  • Finger, syringe, cup, and spoon feeding. Of these finger feeding may be the least pain in the ass. I’ve done both syringe and cup, as well as suck training with my finger and finger was by far the easiest. I’d imagine spoon feeding is similar to cup feeding in mechanism. This article sums up alternative feeding methods well. It says that cup is often not worth the hassle unless repeated supplementation is required more than 3 times. You can also use an at breast supplementer taped to your finger.
  • At breast supplementation: If you have a latching baby under 6 weeks this is the way to go. After 6 weeks if you have not yet experienced any latching issues or breast refusal you can try bottles. If you have been using bottles up until now and your child is not  yet at that grabby phase you can give this a go. Some babies are ok with it, some hate it. It’s just something to try.

The Big Fat Combofeeding FAQ

I see a lot of people combination feeding (combining both formula and breast milk in various ways) either out of necessity or desire. Many professionals either disregard the impact this practice can have on one’s supply of breast milk, or believe that combination feeding is unworkable. Many people who start combination feeding without proper knowledge may find themselves stopping breastfeeding prematurely. I had a lot of questions when I started so here are the questions I see asked most often and some answers.

Why combination feed?

  • Work

Perhaps you have a job where pumping is not an option, either due to social considerations, the nature of the work, or simply that you are unable to pump  enough to feed your baby while you are apart.

  • Supply

If you suffer from a low supply or milk transfer issues you may wish to breastfeed but be unable to do so exclusively.

  • Preference

You may prefer to have a family member do one or more feeds per day via a bottle.

Is combination feeding hard?

Yes it can be. Depending on when and how you start, as well as your personal biology and situation, it can also be a good alternative to stopping breastfeeding completely.

How do I do it?

  • Frequency

How often does my baby need formula? This is something that will depend on your circumstances and why you are combination feeding. If you are doing it for work or other separation from baby then you should feed your baby as normal when you are together and have a caretaker feed them as much as they would like during the day. If you are combination feeding due to low supply then you need to figure out how much milk your baby can get from you and offer the balance. There are calculations for this, but I did it by breastfeeding first and allowing my daughter to take as much as she wanted via at breast supplementer.

  • Amount
Breastfed babies often take smaller volumes than fully formula fed babies. The average breastfed stomach volume is 2.5oz to 6oz. Don’t worry if your combination fed baby is not taking a full 5-9oz. This is normal. The entire time my daughter was combination fed her usual volume intake per session was 3.5oz, or around 100ml.
  • Supply

How do I keep my supply? The best way I’ve found to do this is to have rules about combination feeding. You need rules because you are beating back biology. Producing breast milk is a resource heavy process. This is why it burns 20+ calories per ounce/30ml. So your body would naturally prefer to not burn those calories and store them for later. You need to challenge your supply to some extent. A one off break in routine (you are ill and need sleep so you do not breastfeed the baby at the normal time) will not ruin your method, but a consistent pattern of breaking your rules will erode your supply (I’m too busy/tired etc to maintain my rules). This is especially important early on (before 3-6 weeks) before your supply stabilizes. My maxim for this is formula feed on a schedule and breastfeed on demand.

  • Method

How you combination feed will depend on a few factors. Why you are combination feeding, the age of the child when you start, and your schedule.

If you are combination feeding for low supply or milk transfer issues and your child is not very old I highly recommend trying an at breast supplementer.

If your child is older (6 weeks +) and you have supply issues and the latch is fine then you may have better success with a bottle. Of the people I know who have combination fed long term using bottles they started after 6 weeks. If using a bottle I recommend using teat that most replicates your personal let down. Many people find a slow flow teat to do the trick, but if you have a fast let down (not usual in low supply), you may find a slightly faster teat works better for you. I don’t know if any of the specialty teats marketed as breastflow or otherwise will help with nipple confusion. We used a newborn flow (single hole) Avent teat for home and daycare until 12 months.

If you are combination feeding due to work or other separation from baby or preference you may find bottles or cups more appropriate for your situation.

  • What’s the best formula for combination feeding?

Short answer-there isn’t one.

Long answer-The WHO (World Health Organization) mandates that all commercially available baby formulas have similar ingredient lists. Not to say they are all the same. There are variations. The best way to see which is right for you is to give your child 2 weeks on it. If after 2 weeks (or you are experiencing some other major issue) it is not working, feel free to try another brand. I know that’s not very helpful. Sorry. Some formulas have more protein, some have more iron. What you do want, especially if your baby is under 6 months old,  is a whey based formula. The casein based formulas are not suitable for younger babies. Things like hungry baby milk have a higher proportion of casein than whey as it’s more difficult to digest. Here are some articles on that: Gut floraChoosing a formula #1, Choosing a formula #2

  • Is there some kind of magical breast milk formula balance?
No there isn’t. Any amount you can give will be beneficial. Formula doesn’t do any ‘cancelling out’ of the benefits of continuing to receive breastmilk. You may be interested in reading about the benefits of combination feeding.

Personal considerations Your biology

A sensitivity of a woman’s supply is highly variable. Some women can miss a pumping session or feed and find their supply tanking almost immediately. Others stop breastfeeding completely and still leak milk weeks down the line. You’ll need to determine through observation where on that continuum you lie. Generally though, you will not see significant changes in under 3 days. That means, that after your supply is established it will take 3 days of dropping a feed for your body to get the hint and slow down production. This also means that it can take 3 days to see an increase. This is not necessarily applicable during the early stages. Before 3-6 weeks milk supplies are much more variable. Small things like pumping in addition to feeding can cause your supply to increase, and skipping feeds early on can cause your supply to dry up very quickly. Engorgement will also slow down your milk production. The fuller your breasts are the slower you produce milk. A consistent pattern of engorgement will decrease your supply during that time frame. You will need to tailor your combination feeding plan to work with your body.

Poop- what is normal?

Considering one of the main ways we communicate with our babies is observing poop this is a pretty important consideration.

There seem to be fair number of resources on what normal breastfed poop is like and what normal formula fed poop is like, but what about a baby receiving both?

  • Appearance:

This is very dependent on what your formula looks like (as poop) and how much your baby has.

For example, my baby was on three different formulas. Formula #1, which my baby was on from 2 weeks to 2-3 months was a probiotic formula. This formula started off coming out as yellow, but eventually progressed to coming out green. The consistency started off as loose and semi-solid and progressed to being more like modeling clay. The second formula was used in various emergency situations and not regularly. The color was yellow, the consistency semi firm, similar to paste. The Third formula was used from 2-3 months until no longer needed. The color was yellow and the consistency was like mashed potatoes.

  • Frequency:

A breastfed baby, after several weeks of age, may poop as infrequently as once every 10+ days. A formula fed baby may need treatment for constipation if poop is less frequent than every three days. A combination fed baby may fall somewhere in the middle. I found mine would go daily, or more, at first but by several months of age had progressed to every 3-5 days. No one could answer my questions about how frequently my baby should be pooping so we were treating her for constipation with diluted fruit juices and sugar water. After pushing a bit more some of my health care professionals decided that since she was not in pain during the bowel movements, the consistency was not hard or pellet like that the 3-5+ days was fine.

So I’ll pass that on. As long as the consistency is not hard or pelletlike, the child is not in pain from pooping and is not unduly uncomfortable from not pooping then it is not a major concern. This is also dependent, in my opinion, on how much formula your child is receiving on a daily basis. The less formula, the longer you may wait between bowel movements, more then less. My child was receiving 300-400ml (12-14oz) of formula daily, so about 1/2 her expected intake.

Update: In response to a some search engine hits I get I’ll expand on this to cover the other end of the spectrum. Breastfed babies, instead of not pooing, can also poo upwards of 10 times a day. And this is normal as well. If your combination fed baby is pooing frequently there is unlikely to be any cause for concern. Normal breastfed baby poo is fairly liquidy, seedy and yellowish.  What is not normal even for the combination fed infant is dark poo (after the meconium has all passed), ongoing greenish poo that may be frothy, excessive mucus (again, this may be expected around teething), and of course blood. Green poo is  ok for a few days as it can be a sign of illness, and is also normal after vaccinations and if you are giving a probiotic formula. The other ones may merit a doctor visit.

Important things to consider

  • The importance of establishing your supply.

The first 2-3 weeks are important for your development of prolactin receptors. It’s very important to feed on demand during these times so that you will have an adequate supply later on. After 2-4 months your supply stabilizes, your breasts soften and milk production becomes less hormonally controlled and instead based on what is removed. The amount of prolactin receptors you created early on can help you maintain your supply long term.

  • Breast milk is use it or lose it

As mentioned earlier breast milk is a system with high production costs. If your baby isn’t using it (emptying the breast) your body will make less. Your body is lazy and wants to do as little work as possible.

  • Your baby is a person too and may not cooperate with best laid plans!

Your baby may decide they don’t care for the at breast supplementer, or like the bottle, or don’t like the bottle or any number of other things. Or you know, maybe they just aren’t that into breastfeeding as they get older. Early on when we were using bottles and breast my child went through some breast refusal which is what prompted me to swap to an at breast supplementer. Then when she went to daycare at 4 month she had to be retrained to take bottles. Now at 14+ months she will not take a bottle from me.

  • How your baby can help

Consider this if you find yourself losing your supply: if your baby increased your supply once they can do it again. Sure it means clusterfeeding, but it can come back up.

Managing being away from baby

  • Pump or no pump?

To pump or not to pump will depend on several factors. How touchy your supply is should be one of them. However, you may be combination feeding because you cannot or do not want to pump during the time you are away. While dealing with low supply I pumped at least n or n-1, where n is the number of feeds my baby would have had, times during the day when I was apart from my baby. I managed between 30-50ml per session from both breasts combined. I was away from my baby from 8am until 5pm+. From 4-6 months I pumped 3x per day (10am, 12pm, 2pm), from 6-8 months I pumped 2x per day(10am, 2pm) and from 9-11 months I pumped 1x per day (12pm). At 11 months I stopped pumping during the day and fed from the breast when at home. During this period my first day home was full of frequent feedings as my daughter increased my supply again.

If you are unable to pump you may find some benefit in hand expressing during bathroom breaks. This will continue to stimulate your milk production and help prevent blocked ducts and mastitis.

  • The 5 day work week

I had a part time job so I only had a 3 day work week. For those with a 5 day work week (or longer) you will find that by midweek your supplies are decreasing. If you are pumping add an extra session later in the week. You will also want to encourage you baby to eat from the breast as much as possible at the weekend, or on other not work days to maintain your supply. It may go without saying, but I’ll say it anyhow, but the longer you can give your baby time to establish breastfeeding the easier it will be to maintain when back at work, whether pumping or not.

Nipple confusion and flow preference

Nipple confusion is thought to be most prevalent the younger the baby is.  From reading I’ve done it has a few other factors as well including how good the latch is (if bottle milk is vastly easier than breast milk for the infant to obtain then bottle milk will be preferred) as well as the milk flow from the teat. I’ve mentioned it previously, but many people find a slower flow teat helps preserve the breastfeeding relationship. I find that whatever is closest to your let down (slow or fast) will keep the confusion to a minimum. The times when you are most likely to see issues with swapping between breast and bottle are any of the growth spurts (10 days, 3 weeks, 6 weeks, 12 weeks, 4 months, etc), although the 6 week one is the worst. The other one where people doing breast and bottle are likely to hit issues is around 4-5 months. This is an incredibly fussy time with teething, sleep regression and similar and if breastfeeding is not well established as both a comfort and food activity then babies may not be willing to expend the effort to continue. This outlines some details on nipple confusion and how to prevent it.

  • Momma vs not-the-momma

Babies will form different rules for different people. They may expect only breastfeeding from their mothers, and refuse a bottle, but happily take a bottle from another family member or caretaker. I found that preserving our breastfeeding relationship depended early on on how my baby knew to get food from me. Because I had to start so early I had to be very strict with what rules we followed so that we could continue breastfeeding. After we started using the at breast supplementer I did not give my baby bottles. She had bottles from dad and bottles at daycare but mom=boob. If you do want them to take bottles from the breastfeeder I recommend waiting until after 6-8 weeks to introduce them, and certainly by 8-9 months.

What’s the deal with growth spurts? 

This is a new subsection in response again to search engine hits. So what do you do with a combination fed baby having a growth spurt? Be aware that typical growth spurt ages are 7-10 days, 3 weeks, 6 weeks, 3 months, 4 months, 6 months, 9 months and 12 months. This is on average. You may miss or not notice one, or have an extra one (we had an additional one at 9-10 weeks).  During this time babies are unsettled and may want to eat frequently either for comfort or out of hunger. I found during these times that it wasn’t strictly necessary to increase the amount of formula, but it was necessary to give smaller more frequent feedings. As our typical supplementation pattern was 7am, 12pm, 4pm, 7pm, (with breastfeeding sessions at those times and also at 10am, 2pm and several times overnight), during growth spurts breastfeeding became more constant between 9am and 11 am, and also between 1pm and 3pm. At times I split the 12 pm supplementation into two sessions, with smaller amounts at 11am and 1pm.  Do be aware that this is temporary and your baby will be fussy.  Try to stick to your schedule and plan and get through it. Growth spurts and teething are times when your combination fed baby will be more likely to refuse the breast.

Other tips:

If you can, avoid mixing expressed breast and formula milks. Why? Because if your baby doesn’t drink all the breast milk you can re-refrigerate it and reuse it at the next feed and you can’t do the same with mixed or straight formula milk.