After I had my daughter via cesarean section, I diligently tried to breastfeed. I kept my baby latched as directed, and maintained skin-to-skin contact. But milk was not coming in, and my baby was not happy about it. If she was awake, she was screaming. My husband and I were worried, but the hospital-issued lactation consultants assured us that she was fine. I recalled something from the breastfeeding class we had taken at the hospital while I was pregnant. The lactation consultants told us that even a drop of nutrient-dense colostrum (the substance present in breasts from pregnancy until mature milk comes in) can satisfy a newborn. Not my newborn! Eventually, a pediatrician took notice of our baby’s abnormal weight loss and procured a bottle of formula, against the lactation consultants’ orders.
I was so relieved as our baby sucked down that tiny bottle and finally seemed satisfied! Then I felt crushing guilt that I had allowed her to starve. In my post-op drugged state, I didn’t really feel that I had been offered a choice. The lactation consultants’ orders did not seem to be optional. She lost more than 11 percent of her body weight before that doctor stepped in. Lactation consultants didn’t want us to supplement with formula—even a few ounces—because of “nipple confusion” (when a baby won’t breastfeed because they think of the bottle nipple as normal, or they prefer it due to its faster flow of milk) and interference with breast milk production, resulting in a low supply. But those things never happened. Eventually my milk came in, and from that point, we didn’t need to supplement any more. My daughter was exclusively breastfed with no issues whatsoever despite this brief flirtation with formula.
Eventually I discovered that many new moms had similar stories; lactation consultants pressuring them into avoiding temporary formula use, despite weight loss, dehydration, or jaundice—which infants are at higher risk for if they’re dehydrated or not getting enough calories. Lactation consultants are specialists in breastfeeding. They help new mothers learn to breastfeed and help troubleshoot when problems arise. But I began hearing tales of overbearing decision-making rather than gentle guidance from consultants. So who is really in charge of a baby’s early nutrition, and what’s best? What are the guidelines? How much weight loss is actually worrisome?
I delivered at a Los Angeles area hospital in 2013, when it was working toward becoming a “baby-friendly” hospital (It received that designation in 2016). The Baby-Friendly Hospital Initiative (BFHI) was launched by the World Health Organization and UNICEF in 1991 as a global effort to implement practices that protect, promote, and support breastfeeding. BFHI was designed with babies’ health in mind. “The existing evidence indicates advantages for breastfed infants in terms of neurodevelopment, growth and immune-related outcomes,” says Sarah A. Keim, the principal investigator at the Center for Biobehavioral Health at The Research Institute at Nationwide Children’s Hospital. Hospitals seeking that Baby-Friendly designation must adhere to certain guidelines promoting breastfeeding such as treating breastfeeding as the norm and providing breastfeeding assistance, and staff must follow step six in the “Guidelines and Evaluation Criteria for Facilities Seeking Baby-Friendly Designation”: “Give infants no food or drink other than breast milk, unless medically indicated.” In fact, according to the guidelines, hospitals must track their rate of formula supplementation in breastfed infants, and are told that information will be analyzed. Furthermore, they need to see that rate decrease over time.
Hospitals seek Baby-Friendly designation because (as mentioned in the guidelines) it carries credibility and prestige, it’s marketable to the community, and it increases demand at that particular hospital. “Many hospitals are aspiring to meet these requirements, at least partly because it’s a good marketing tool to encourage women who want to breastfeed to deliver at those hospitals,” notes Keim. “It’s changing hospital policies around pacifiers and when to offer formula.”
But the best-intentioned lactation consultants and Baby-Friendly guidelines may be contributing to a crushing pressure to breastfeed at all costs. And it’s not just the hospitals. “First-time mothers are generally poorly prepared for breast feeding, yet the societal pressure to breastfeed these days is enormous,” says Keim.
Devin Garcia, a new mom from San Bernardino, California, had a more extreme situation than I did. When her son Nolan was born, despite help from lactation consultants, Garcia’s milk wasn’t coming in. “I kept asking the hospital for formula and they refused to give me any; they kept assuring me he was getting enough,” she recalls. The family went home from the hospital and Nolan began cluster feeding—breastfeeding in sessions close together—to no avail. “I was told by the professionals that this is normal and it's okay,” Garcia says. Nolan was born on a Thursday; by Sunday morning, he had lost 23 percent of his body weight, as Garcia and her husband discovered when they brought him back to the hospital.
“My poor baby was deemed dehydrated, low–blood sugar, high-jaundice, and we were admitted to [neonatal intensive care] to stabilize,” she says. “Nolan stayed in the NICU for four days, getting IVs, his blood drawn every two hours to check blood sugar levels, and was on the light treatment for the jaundice. It was the hardest thing in the world to see.” Once her mature milk came in, Garcia had issues with low supply, but Nolan is now two months old and doing fine on formula. “Breastfeeding isn't for everyone and my body sure as heck let us know that,” Garcia says.
Lactation consultants understandably want to encourage new mothers to breastfeed; it’s their job, and they believe passionately in it. And there’s science to support the idea that breastmilk is healthy for babies. But while formula mimics many of the same nutrients found in breast milk, it’s not a perfect match. “For instance, there are substances in breast milk produced by the maternal immune system that babies use for their own immune protection, and those are not mirrored in formula,” explains Keim. “Also, emerging science indicates that breast milk contains beneficial bacteria that helps the infant gut.”
However, there is some evidence that while breast milk is healthier for infants, it may not be vastly better. Keim describes a study led by Michael Kramer at McGill University. It was a randomized controlled trial that compared children who were born in baby-friendly hospitals to children born in hospitals that had not joined the baby-friendly program. “Children in the intervention group had fewer respiratory infections as infants, and there might have been some limited benefit to neurodevelopment, but in general the benefits were limited,” Keim says. “For instance, the children in the intervention group were not less likely to be obese and not less likely to have allergies.” So if mature milk simply isn’t coming in, how far should hospital staff and lactation consultants go to prevent formula supplementation?
In the classes I took at the hospital while pregnant, we were assured that breastfeeding would be easy and convenient if we simply learned the right ways to hold the baby, and they had the physical ability to latch on at the breast. It wasn’t even supposed to hurt if we were doing it right (this turned out to be very false for me), and nothing was mentioned about the fraught time when milk has yet to come in, except that the colostrum would be enough to sustain the baby. Perhaps the optimism is to keep from scaring pregnant women, and I know lactation consultants want to give breastfeeding a positive spin so that more moms will want to breastfeed. But if they had been more forthcoming about common challenges (delayed milk, pain, and a host of other issues), I would’ve felt more prepared. Instead, I felt a bit deceived.
With her first newborn, digital media coordinator Jessica Dickieson’s milk didn’t come in for three weeks and she was eventually “allowed” to supplement. So when supply issues happened with her second child, and nurses wouldn’t give her formula for her newborn son, the Los Angeles mother of two saw the signs. “The baby was starving, I knew it. I'd been through it before,” she says, recalling that her son’s weight was down 12 percent at his pediatrician visit four or five days after birth. “Formula has saved my kids from starving. I wish I could fully breastfeed them but also wish it wasn't looked down as such a terrible thing and to make moms feel guilty for needing it.”
Janet Guida-Davis, a mom from Grants Pass, Oregon says her doctor warned her about lactation consultants. “She said they mean well but they have their own agenda. Take what you want and leave the rest! Follow your instincts.” After a C-section birth, Guida-Davis’s newborn got jaundice and started losing weight, so the new mom asked for formula. He started gaining weight and Guida-Davis’s milk eventually came in and all was well. Her son could even switch from bottle to breast with no issues. “It would have been nice if somebody at the hospital would have suggested that sooner,” she says of supplementing. “I don't understand why nobody suggested that option.”
Despite a great latch, Melissa Foresta’s newborn wasn’t getting any milk. The screaming baby had lost 14 percent of her body weight before Foresta, a mom from San Clemente, California, demanded formula, threatening to get it herself. “She sucked that first bottle down so fast,” Foresta says. “I felt terrible that she was so hungry and that I had let myself be manipulated and guilted into not supplementing.”
Tanya Altmann, a pediatrician and author of What to Feed Your Baby, says a good way to ensure your baby stays healthy in the early days of breastfeeding is to find a pediatrician who checks them frequently. “A few days after leaving the hospital and every few days until baby has regained birthweight and is growing well,” she recommends. Altmann doesn’t feel that the threat of “nipple confusion,” for instance, warrants avoiding supplementing if it’s needed. “Most babies can go back and forth well, especially once breastfeeding is well-established.”
Altmann says there are no actual medical guidelines to offering formula when milk doesn’t come in, but she wouldn’t let her infant patients lose more than 10 percent of their body weight. “It all depends on baby and how baby is growing and developing, if baby is losing too much weight or getting jaundice,” she says. “It isn’t a number of days, but the overall picture of mom/baby health.”
Altmann also recommends finding a lactation consultant. Despite the bad experiences some mothers have, lactation consultants can be invaluable in guiding new mothers in feeding their babies. Hurdles like tongue-tie (a condition that restricts the tongue’s range of motion), thrush (a fungal infection of the mouth), or latch issues can be resolved with a good lactation consultant. “Babies aren’t born experts and neither are moms,” Altmann says. “With a little help, time, and patience, everything usually begins flowing fine and breastmilk is really the best nutrition for baby.”
“I had an amazing lactation consultant who saved my breastfeeding,” says Melissa Miller, a mom in Los Angeles. “I had all the issues. My baby was tongue-tied and tongue-thrusting and my milk came in late ... I got mastitis and had clogged ducts. This woman got me through all of it with my nipples and sanity intact.” Miller says that the pain caused by her early breastfeeding issues caused her to have panic attacks and postpartum anxiety. “When the lactation consultant gradually helped me fix my breastfeeding issues, that went a long way in reducing my anxiety to manageable levels.”
Amanda Sitko, a writer who lives in Los Angeles, eventually found a wonderful lactation consultant after the birth of her baby. “She was the first LC I came in contact with who didn't make me feel stupid/ashamed and broke it down in a mathematical way that made sense to me when I had to supplement,” Sitko explains. “The other LCs I came across were pretty gruff and just grabbed my breasts without asking.”
Julie Matheney is a preemie feeding specialist and certified lactation educator, counselor and consultant. She says that cesarean births delay the natural switch from colostrum to mature milk, which is what happened in my case.
I asked Matheney how long it is safe for a mother to wait for mature milk to come in before supplementing with formula. “This is a loaded question because every story is different,” she says, noting that in hospitals that call is usually based on bilirubin numbers—an indicator for jaundice, a liver condition commonly associated with infants. “In my practice, if a baby has not had the recommended number of wet diapers by day three we're supplementing at the breast using an SNS at the very least.” (An SNS is a supplemental feeding tube designed to simulate breastfeeding.) She says there are no set rules as to when formula should be offered. “Unfortunately there are no guidelines and every practitioner comes from their own experience and setting.”
“Ten percent is normal weight loss for all infants,” she explains. “Birth weight needs to be regained by two weeks.” Red flags that should prompt supplementing also include lethargy, sleeping more than four hours in a row, or not producing enough soiled diapers by 48-72 hours.”
When it comes to looking for a lactation consultant, Matheney says the “gold standard” are consultants certified by the International Board of Lactation Consultant Examiners.
The earlier you get help, statistics show, the longer mothers will breastfeed. “If breastfeeding is your goal, get help in the first 72–96 hours,” says Matheney. “Enlisting help gives mothers the confidence in knowing subtle changes in positioning and latch that can make a world of difference. An LC can also identify if there is something wrong, like a tongue tie, inverted nipple, swelling of the breast from fluids at birth, etc., that is impacting feeding.”
Matheney disagrees with the “Fed is Best” campaign (as opposed to “breast is best”), which posits that mothers should be supported in however they (safely) feed their babes (after all, she’s in the breastfeeding business) but admits that sometimes formula can’t be avoided. “There are obviously cases when supplementation is absolutely necessary and mothers should never be ashamed of needing to supplement,” she says. “They should also be encouraged to get professional help as soon as possible to facilitate breastfeeding from the beginning. So many issues can be prevented before they're a problem.”
“I think everyone seems to assume LC support is helpful and positive, but it’s not always,” says Keim, who found that 30 percent of the women she studied as part of upcoming research reported negative experiences with their lactation consultants. “Part of this could be women’s expectations—maybe because women are not well-prepared for the reality of breastfeeding they may have a rosy picture of how it should be and then disappointment hits hard. Part of it could be that not all LCs are well-trained in or really skilled with the counseling part of offering this support.” Part of these negative experiences with lactation consultants could also be that hospital pressure to obtain or maintain Baby-Friendly designation. But the more information expectant and new mothers have about early breastfeeding, the more confidence they’ll have in feeding their babies, and the more prepared they’ll be, should things go wrong.