Since growing numbers of health experts began championing the benefits of breastfeeding — such as strengthened immune system for babies and better recovery and even reduced risk of certain cancers for moms — the numbers of new mothers who nurse their babies after delivery have risen steadily. The American Academy of Pediatrics (AAP) and the American Congress of Obstetricians and Gynecologists (ACOG) both recommend exclusively breastfeeding an infant for the first six months of his life, and then gradually adding solid foods while continuing to breastfeed until the baby is at least a year old. After that, the doctors’ groups recommend, a mom should continue to nurse for as long as both she and her baby want to keep going.
Today, as many as 4 out of 5 moms start to breastfeed their newborn, according to the Centers for Disease Control and Prevention (CDC)’s 2016 Breastfeeding Report Card. But the rates decrease significantly as the months go by: A little more than half (51.8 percent) of moms are breastfeeding at 6 months of age, and less than a third (30.7 percent) are nursing at 12 months of age.
Battle Over the Breast
Doctors say it’s not exactly clear why this drop happens but some theories point the finger at inadequate support — from employers, family members, and in some cases, even health care providers. Breastfeeding advocates and initiatives like Baby-Friendly USA, which works with hospitals to implement policies and practices geared toward encouraging mothers to begin and to continue breastfeeding, are continuing to work to improve breastfeeding rates.
But some critics have questioned the safety of one of the Baby-Friendly “10 Steps to Successful Breastfeeding,” which states, “Give infants no food or drink other than breast-milk, unless medically indicated.” While hospitals encourage breastfeeding by instilling practices like letting newborns stay in their mother’s room and encouraging more skin-to-skin contact between mom and baby, critics say the potential pitfall lies in overzealous or undereducated nurses, lactation experts and other health care professionals who emphasize breastfeeding over making sure that a baby is fed adequately.
Organizations like Fed is Best, a nonprofit group of parents and health professionals whose mission is to support mothers who wish to breastfeed but to also educate the public about “the safest, most brain-protective methods for breastfeeding, mixed-feeding, formula-feeding, pumped-milk-feeding and tube-feeding” to ensure that infants get adequate nutrition, are working to get their message out: that we must make sure all newborns get enough nutrition to stay healthy and safe, even if that means supplementing breastfeeding with formula or expressed milk.
Caught in the Crossfire
As various baby and breastfeeding advocates, parents, and health care professionals debate the issue of how best to feed a baby, two things are clear: One, health care professionals who are trained and qualified in breastfeeding medicine know how to find solutions to most feeding problems, and are there to support moms and babies. And two, moms and their babies can get caught in the middle when well-meaning advocates engage in a debate over breastfeeding.
For the most part, experts agree that efforts to encourage moms to breastfeed are important — research does show that breastfed babies are, on the whole, somewhat healthier than formula-fed babies (though it’s worth noting that most studies have not conclusively determined that breastfeeding actually causes better health). “Baby-friendly hospitals do increase breastfeeding and moms are more likely to be successful,” says Julie Ware, MD, a pediatrician at the Center for Breastfeeding Medicine at Cincinnati Children's Hospital Medical Center, in Cincinnati, Ohio.
But while all of that is good news, the needs of the baby and mother must never be shunted aside for a narrow and inflexible idea of what good baby feeding is. What is it like for moms who run into breastfeeding problems and nurse with difficulty or pain or are forced to stop for their baby’s health? Or moms who, despite their best efforts, cannot keep their milk supply as strong because they’re not able to pump much at work? For moms who’d imagined themselves breastfeeding their babies blissfully just like the moms in those gauzy and beautiful images of nursing moms on the posters at the doctor’s office and on the cover of breastfeeding books and pamphlets, and who’d always expected that they’d be doing so for many months or even years, the unexpected challenges can be difficult, and even devastating.
Not What I Had Pictured
The moms who weren’t able to nurse their baby in the way that they’d envisioned experience a gamut of emotions, chief among them guilt and sadness. “Latching was always excruciatingly painful,” recalls Meredith Kaufman Younger, 42, a Brooklyn, NY mom of two boys, ages 3 and almost 5. With her first son, Kaufman Younger sought help from a certified and experienced lactation consultant. The consultant advised Kaufman Younger to use a shield to help her baby latch onto her nipples, which weren’t pronounced enough, and she also pumped her milk after feedings. The consultant massaged her baby’s jaw and showed her how to do stretching exercises to strengthen her baby’s neck. Kaufman Younger soldiered on, attending lactation support moms’ group meetings. Finally, after four months of struggle, she gave up.
She had a similar experience with her second son, though with him, she wanted to avoid any possible problems and worked with a lactation consultant at the hospital. Then, as before, she enlisted yet another lactation consultant and attended breastfeeding moms’ group meetings. Despite all that, she was once again forced to give up after about four months.
“It was horrible,” says Kaufman Younger. “I’d wanted to go a year.” Then there was the guilt, not so much from an external source but from within. “I felt angry because my experience didn’t align with my expectations,” says Kaufman Younger. Even though she knew that she had done everything she could, she recalls thinking, “There must have been something I could have done and should have done.” She is thankful that the experts she consulted were all supportive, and tried everything they could to help her breastfeed her babies. “The lactation consultants said, ‘First, feed the baby; everything else we can work with,’” recalls Kaufman Younger.
Signs That Something Might Be Wrong
If you see any of these indications that your baby may not be getting enough breast milk or that there might be another problem, call your pediatrician right away:
- You see your baby do what’s called flutter sucking. This is when a baby is not swallowing but is simply sucking on the breast. “You should see a wide-open mouth with her lips like a fish and your breast deep in her mouth,” says Dr. Ware. (Videos from Global Health Media, such as this one about how to get a good latch, are extremely helpful, says Ware.) Not having a good latch can lead to cracked and bleeding nipples. “It’s not something to soldier through,” says Dr. Ware.
- Your baby is too sleepy to eat. All babies sleep a lot — that’s what they mainly do besides eat, pee, and poop, especially in these early days. But if you have to wake your baby for most feedings and she only suckles for a few minutes and then falls asleep, there may be a problem.
- Your baby is feeding longer than 45 minutes to an hour. If your baby still wants to nurse after almost an hour at the breast, it could be a sign that he’s not getting enough milk out or that there is a problem with your milk supply.
- Your baby still seems hungry after a feeding. Does your baby seem content after a feeding or is she still rooting, unsettled, or crying? Watch your baby’s body language — she should be happy and relaxed, not frantic with clenched fists, which can be a sign that she's not feeding well, says Joan Meek, MD, chair of the American Academy of Pediatrics (AAP) Section on Breastfeeding and associate dean for graduate medical education and professor of clinical sciences at Florida State University College of Medicine in Tallahassee, Florida.
- He cannot maintain his latch. His mouth may be too small or there may be tightness in his jaw or neck.
- Your baby hasn’t gained weight. By her second week checkup, your baby should be at least back to her birth weight if not heavier, says Dr. Ware.
- Jaundice is increasing. It’s normal for some babies to be jaundiced (characterized by yellowish color in the skin and whites of the eyes) in the first 1 to 5 days after birth. But if your baby’s jaundice is increasing, it may be a sign that she’s not getting enough breast milk.
- Your breast doesn’t soften after a feeding but remains engorged. “Anytime we leave milk in the breast, it lowers the milk supply,” says Ware. Pumping can help to protect your milk supply.
- You see signs of dehydration in babies. Some common signs of dehydration in newborns include dry mouth, dark- or red-colored urine, or fewer than six wet diapers in 24 hours.
- The poop isn’t progressing as it should. Here is what you should see in your baby’s diaper in the first few days after birth: meconium (the dark, tarry poop first produced by newborns), dark green looser stools, then yellow and seedy stools. There should also be an increase in the number of poopy diapers. “If you see no change in the stools and they’re still dark and tarry after five days, see your doctor right away,” says Dr. Ware.
- Your baby is never consoled. “All babies cry, but not being able to be consoled is not normal,” says Dr. Meek.
What Moms Should Know About Breastfeeding
First and foremost, remember that “every mom has to make the decision that’s right for her,” says Dr. Meek. The pressure to breastfeed can be overwhelming at times, but you are not a failure if you can't or choose not to breastfeed for any reason.
Here are a few more tips to keep in mind:
- The most important thing is that your baby is well-fed. No matter what your breastfeeding goal, making sure that your baby is being fed properly is one that is cited first by health care practitioners and doctors trained in breastfeeding. Many moms are surprised by how often a baby eats (generally, eight to 12 times every 24 hours) and how much time it can take, Dr. Ware says.
- Don't be afraid to ask for help. It’s very common for moms, especially first-time mothers, to need a bit of assistance getting the baby to latch on or to look for signs that things are going well or that there might be a problem. However, research has shown problems often occur between 3 and 7 days postpartum, according to Dr. Ware. Talk to a nurse or lactation consultant while you’re still in the hospital (this is especially important if you had trouble breastfeeding with a previous baby), and if possible, schedule some sessions (either private or group) with a lactation consultant after you get home to prevent problems.
- Get support for breastfeeding and baby care from peers, too. If your hospital provides support groups for new moms to address breastfeeding and other aspects of newborn care under a trained professional, take advantage of it, Dr. Meek suggests.
- Trust your instinct. If you think you may be seeing signs that your baby isn’t getting the nourishment she needs, listen to your own voice. Angela Bowers, 38, whose daughter was born prematurely at 34 weeks, diligently pumped her milk “right from go.” After she was discharged from the hospital and continuing to have her breast milk, Bowers, a head of video talent for a media company who lives in Maplewood, New Jersey, noticed that her baby seemed uncomfortable. “Everyone said babies are gassy or that it’s just reflux,” says Bowers. “But something kept telling me that something wasn’t right.” When Bowers saw blood in her daughter’s diaper, she knew it was something else and sought help, which eventually led to her baby being diagnosed with a milk protein intolerance. She was put on a special formula and the difference in 12 hours was remarkable, says Bowers. “She was able to sleep, lay on her back, and wasn’t in pain.”
And perhaps the most important one: Don't feel like you have to sacrifice the happy time you could spend bonding with your baby for the sake of your breastfeeding goal. While you’re working to try to solve any breastfeeding problems you may be having, try to focus on just being together and relaxing with your little one.
Angelly Shahani, 39, an operations manager for a major investment bank who lives in Brooklyn, New York, breastfed her daughter for 7 months. She looks back on that time with a newfound understanding and a tinge of regret. Shahani worked with nurses at the hospital and lactation consultants after coming home, and joined a breastfeeding moms support group, but she still couldn’t make breastfeeding work. Her daughter cried and “screamed” at the boob, and ultimately, Shahani had to supplement. “I shouldn’t have been so focused [on making nursing work],” says Shahani. “You don’t always think so clearly after having a baby. I saw all those posters and how serene the babies are, and I pushed myself.” She wishes now that she’d spent less time and energy feeling guilty and worrying about breastfeeding and had taken more time to enjoy her bay.
That sentiment is echoed by another mom whose son was born 3 weeks early and was later diagnosed with a serious allergy to milk protein. Danielle LaSelva, 38, an analyst who ironically works in digestive disease, breastfed her baby without issues until he was about 3 weeks old, when signs of serious reflux began to appear. She put herself on a strict diet, but when she accidentally ate something that made her son violently ill, she had a wake-up call. “It was so terrifying to see a seven-pound baby Exorcist-vomiting,” says LaSelva. “I suddenly thought, ‘Why am I doing this?’” Recalling the pressure she says she put on herself to breastfeed, she says, “Instead of just enjoying time together with my baby, I spent half that time panicking about what he was eating,” says LaSelva. He was given a hypoallergenic formula and has had no issues since. “He’s healthy and free of that harrowing sickness,” says LaSelva. “He’s blissfully average.”
How Can We Better Support Nursing Moms?
There are many ways we can raise breastfeeding rates by supporting moms, such as through measures like paid parental leave or better support for moms who pump at work. And of course, hospitals that encourage breastfeeding are a key part of success. Today, more and more moms are giving birth in settings where doctors, nurses, and lactation consultants will work with them to facilitate breastfeeding. In 2007, less than 3 percent of births in the U.S. happened in approximately 60 Baby-Friendly designated facilities. Those numbers skyrocketed in just 10 years: In 2017 more than 22 percent of births occurred in more than 450 Baby-Friendly designated facilities, according to Baby-Friendly USA.
But while the growing numbers of hospitals enacting policies encouraging moms to breastfeed is certainly a positive trend, how that goal is put into practice isn’t always smooth, and can vary widely depending on the facility, and in some cases, depending on which health care staff member you see within a facility. Earlier this year, the AAP acknowledged that pediatricians can and should do more to help nursing moms and rolled out a new policy to implement best practices such as working with ob-gyns to offer breastfeeding guidance before a woman gives birth and hiring an International Board Certified Lactation Consultant (IBCLC) that new moms can work with.
Why Support Can Be Hard to Find
Even at Baby-Friendly hospitals, this variation in quality of support is evidenced by the experiences of moms who’ve recently given birth, and their stories show that there’s definitely room for improvement.
Kaufman remembers feeling “very under-informed” after the birth of her first son, and says that no one told her that her baby should eat often, every 2 hours or so. It wasn’t until her baby’s first well-baby checkup that her pediatrician told her to wake her baby up and feed him. When she had her second baby, she knew how much a baby should eat, and knew to be more aggressive about getting private time with the hospital’s lactation consultant.
Shahani also remembers not having enough support, and remembers having to wait, not only for a lactation consultant to stop by but even for a Tylenol for her neck pain, which was interfering with her nursing. She also felt isolated, and wishes a breastfeeding moms’ group had been available at her hospital. Then there was the lack of consensus among the staff. “One nurse chastised me in the middle of the night for waiting too long to feed my baby,” says Shahani. “Another nurse weighed my baby and said I have to pump and can supplement as well, but a senior nurse told me I shouldn’t overreact. But my daughter didn’t latch well and the madder she got, the harder it was,” says Shahani.
For Bowers, whose son was in the NICU, there was a great deal of support. “A lactation consultant came daily and scheduled me to practice with my baby in the NICU, and I was even booked into a seminar one morning with other new moms,” says Bowers. They went over different nursing positions, and someone came daily to check on their progress. Bowers produced so much that she was able to bring frozen milk to the NICU nurses four times a day.
LaSelva’s hospital offered a couple of options for nursing mothers: drop-in sessions where you could do weigh ins and purchase supplies and more structured groups that required registration. She was given clear feeding guidelines — she was told not to let her baby go longer than 3 hours between feedings until he was back to his birthweight — and both the daytime nurse and lactation consultant were excellent at supporting breastfeeding, says LaSelva. “She helped me physically position my baby and waited while I attempted to breastfeed initially, and when it was clear he was having trouble latching — he almost tore my nipple — she had no qualms about bringing me a nipple shield and things went quite well after that,” says La Selva. “A few hours later a lactation consultant came in, and basically said keep doing what you're doing and encouraged me to alternate breastfeeding positions to avoid clogged ducts.”
But even here, she encountered an unpleasant experience. “The first pediatrician who came in later that evening was frankly, awful,” says LaSelva. “I was twenty-two hours post-delivery, and she asked ‘How do you think things are going?’ and I responded ‘We think they’re going great.’” She responded by saying, “No, they're not” and proceeded to lecture LaSelva that using a nipple shield was a "crutch."
“My husband and I were both shocked,” recalls LaSelva. Then, the second pediatrician who came in the following day contradicted the first pediatrician and told them to ignore what the first doctor had said. “At this point, I was about forty hours postpartum and my head was spinning,” says LaSelva.
When it comes to breastfeeding success and the best way to support new moms, the bottom line is that no matter what kind of hospital or other birth setting you choose to have your baby in, the doctors, nurses, and lactation consultants must work together to support moms who want to breastfeed. In the meantime, while hospitals and health care professionals work toward that goal, moms can make sure they have the confidence to ask for help, to trust their instincts, and to know that no matter what, the end goal is a healthy baby, whether that means supplementing with formula, pumping breast milk, choosing not to breastfeed, or doing any combination of the above.