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Posted on October 10th, 2012 by Jessica M. Lang | Uncategorized

During the last two decades, the healthcare community developed a consensus that breastfeeding is important, and should be encouraged.   Public health messages are not known for subtlety and nuance, or sensitivity to individual circumstances, so sadly the “encouragement” sometimes happens in ways that can feel dreadfully discouraging.   I understand where Michelle Gerdes is coming from when she writes  “Of all the decisions a new mom makes perhaps none is more personal than whether or not to breastfeed.  So why is it that everyone from nurses to doctors to mothers-in-law feel free to press their agenda on the matter?”

Her blog post describes an unfortunately common scenario – she intended to breastfeed, but a combination of factors got in the way early on.  Eventually, she decided enough was enough, stopped nursing, and wanted others to respect her decision and butt out.  Reasonable enough.  All parents make judgement calls, all parents compromise.  Kibitzing and Monday-morning quarterbacking are uncalled for.

But her blog post raises some other questions.  At two days postpartum, Gerdes was exhausted, overwhelmed with her struggles to breastfeed, and desperate for a break.

I asked the nurse to take my daughter to the nursery and give her some formula.  The way the nurse reacted, I might as well have asked her to take my daughter to the dungeon and feed her eye of newt.

The nurse ran through her list of tsk-tsks: breast is best, nipple confusion, milk supply, bonding, the end of human civilization as we know it. 

OK, wait a minute.  A healthcare provider, faced with a mother at the end of her rope, responded by lecturing her.  Now, I’m the first to say that mothers should have plenty of info about the baby’s need for breastmilk before making a choice to feed formula.  Informed consent requires it.  But at a moment like that, how does spouting warnings help?   Gerdes makes a striking comment: “And nobody seemed concerned with the well-being of me.”  She felt she was regarded as just a pair of breasts, a vehicle for her child’s nutrition.

No woman should be treated that way.  That is as wrong as it gets.

But suppose the nurse had responded by comforting her, praising her persistence, and assuring her it would get easier?  Suppose she had offered suggestions for other ways she could get a much needed rest without artificial feeding?   If this nurse had the time and skills to do that, Gerdes might have had much better care, regardless of how her breastfeeding turned out.

Another part of the blog jumps out at me: “ . . . studies haven’t shown definitively that breast-feeding results in health improvements.”  From a medical standpoint, that statement makes no sense.  The burden of proof is not on the biological system, but on the artificial replacement.  Try inventing an artificial knee joint and telling the FDA that studies haven’t clearly proven that the knees we are born with are any better.

From a scientific standpoint, it’s also bogus.  Epidemiology is really hard to do.  Humans can’t be randomized and controlled for studies of breastfeeding.  So for each study, each outcome, each population, there is controversy.  But the overall picture is this: the evidence is overwhelming that no formula supports infant health and development as effectively as breastmilk.  Check with the World Health Organization, the American Academy of Pediatrics, and the HHS.  The scientific and medical consensus on this is just as clear as the consensus that smoking is bad for you, and exercise is good for you.

Fundamentally, though, that’s the wrong conversation.  A mother struggling with breastfeeding needs to weigh both medical and non-medical factors.  She needs to make a decision for her particular situation, not for a study population.    This is why reasonable people sometimes make different choices.

An important point is that parents are entitled to make an informed choice. Mothers can’t always count on getting unbiased education about infant feeding, because unlike other countries, the U.S. allows hospitals and healthcare providers to benefit from and participate in formula marketing.   It often happens in subtle ways, like sponsorships, gift bags, and formula logo stickers on the plastics bassinets in the hospital.

Sometimes it’s blatant. Once, I spoke with a pediatrician about the baby care brochure in his waiting room.  It was printed by a formula company, marked with their logo, and full of “breast is best” platitudes but stripped of any references to negative effects of formula.  Among other outdated tidbits, it suggested that mothers could get more sleep by giving formula “such as Brand X” at night, contrary to research showing that parents actually get less sleep when they formula feed.  The doctor responded, “These things are expensive to print.  If we can get someone to pay for it, we’re not going to say no.”

The hospitals are supporting breastfeeding with one hand, while undermining it with the other.  Nobody offers them corporate money to hire enough nurses and lactation consultants, or train their staff in breastfeeding counseling.  The CDC says that less than 4% of US hospitals offer effective breastfeeding support.  Gerdes is right to complain about the tsk-tsking nurse, but let’s remember that the poor counseling skills of an overworked untrained nurse are no match for the formula advertising juggernaut.

When a vulnerable and exhausted new mother is targeted by pervasive and manipulative marketing, and advised by hospitals who accept the freebies and the influence of formula companies, is this really a free choice?

The Surgeon General’s Call to Action to Support Breastfeeding is focused on identifying “Barriers to Breastfeeding” and the actions needed to eliminate them.  Inadequate breastfeeding support in the hospital is a major one, and Gerdes’ experience shows that just flooding mothers with warnings does not make for effective support.  The Surgeon General is starting the right conversation – one about removing barriers to breastfeeding so that women who want to breastfeed get the best chance to do so.  This is part of a larger conversation our society needs to have.

The question is not “Is breast best?”   It’s “How do we stop scolding mothers and remove the barriers that make modern mothering unnecessarily tough?”

 

 

This post is excerpted from a guest post by the author originally published on The Other Baby Blog

Posted on August 24th, 2012 by Jessica M. Lang | General
One couple had been rubbing butter on the cat’s back so he would spend a while licking it off . . .  Parents come up with some weird stuff when we’re exhausted and out of ideas.

My kids introduced me to a TV show – “My Cat from Hell” – about a guy with a weird beard and Rock&Roll tattoos who helps out people whose cats are ruining their lives. They call him because their cat attacks them constantly, bites and scratches, trashes the furniture, terrorizes other pets, harasses the neighbors, and makes them too afraid to bring a baby into the family.

In the first episode I watched, I was fascinated by a couple describing how they fought daily about their cat: the woman would give the cat treats, trying to induce better behavior. The guy relied on negative reinforcement, shouting and throwing sofa cushions at the cat when it stalked and attacked him. Neither strategy was working, but that didn’t stop both people from criticizing the other’s approach.

Sound familiar, parents?

Jackson Galaxy is described as a cat behaviorist. But he’s constantly solving relationship problems between the humans. And he’s not – in psych lingo terms – using a mainly behaviorist approach. Nearly every household he deals with has been trying some form of carrot & stick – classic behaviorist strategy. When parenting books urge you to use it for kids, it’s usually termed “consequences.” Or “reinforcement.” Anyway, Jackson mostly makes them stop. Both the rewards – usually food treats; and the punishments – often spraying with water, yelling ‘bad kitty’, or shooting with a soft projectile. One couple had been rubbing butter on the cat’s back so he would spend a while licking it off, and Jackson wasn’t sure whether that was intended as positive or negative reinforcement. They said mainly it “just buys us some time.” Parents come up with some weird stuff when we’re exhausted and out of ideas.

So what does he have them do instead? Usually, he watches the cat a lot, and then talks with them about the cat’s nature and needs. Seriously. The cat may need to hunt, to climb, to mark territory, to feel included in the family, to have a safe place to eat and a clean place to poop, to be picked up in a way that feels secure. When these natural instincts are frustrated, the cat misbehaves. A hunting cat with no normal outlet sees everything that breathes as potential prey.

Jackson teaches them to meet the cat’s needs in constructive ways. Play with the cat every day using a toy that is basically some feathers on the end of a fishing rod, to simulate hunting a bird. Put the litter box away from the eating area and clean it more often. Put up shelves she can climb. Get scratching posts.

They have to put effort in on a consistent basis, but it works. The cats get happier and stop drawing blood from the family members. And the couples stop fighting about it.

So when you read that consequences, whether positive or negative, are the only way to deal with your child’s misbehavior, consider an alternative. Try observing your child and thinking about her nature and instincts. Does he need more running around? Being held close? Challenging games or activites? Exploring and dismantling stuff to see what’s in it?

OK, it won’t be as easy as Jackson makes it look. It won’t solve all your problems in one 30 minute episode. But it’s a different way of thinking, and might give you some different ideas. It might help you have a less frustrating conversation with your spouse. And it might keep you from becoming a subject of a reality TV show called “I buttered my toddler.”

Posted on August 24th, 2012 by Jessica M. Lang | General

First published March 21 2011 on The Other Baby Blog

In pre-industrial societies, women typically did not leave their babies to go to work, but neither did they leave their work to be with their babies.  . . . . For me, neither choice felt natural.

In second grade, I brought in a newspaper story about my mother’s appointment to a government post that started with, “She’s a feminist – yet very feminine.”(!) I remember my mother and grandmother pinning an ERA banner on me when I was small, and explaining what it meant. I understood by then that my mother was a pioneer – the first female lawyer at her large law firm, and one of the first few women to make partner at any law firm in our city. On the radio, I heard debates on the “controversy” of mothers working. It seemed odd to me – though most moms in the neighborhood did not work, mine did, and it was simply a fact of life. What else would she do? But I understood that she was unusual, and courageous, and I was proud of her. So the feminism of the ambitious professional woman entering a male-dominated milieu was mine at an early age.

This feminism served me well as a student and later as a scientist. I sought out female teachers and mentors, and built my own confidence and savvy with their help. I watched how they handled the pressures of career and mothering, expecting that I would follow their lead. My mom had been a leader of my girl scout troop and attended all my brother’s sports events while starting and building her own law firm. I fully intended to do likewise, and assumed that feminism required it.

When I first got pregnant at 28, I was a postdoctoral scientist working in genetic toxicology at MIT. I researched daycare centers and breastpumps, and assured my mentor I’d be back in 12 weeks. Then I had a baby.

Initially, I breastfed my son and wore him in a sling because it was the biologically correct thing to do. Soon it felt like the only thing to do. At three months, I had no interest in going back to work. I’d been assured by other women that I’d be bored on maternity leave, but that was far from true. Exhausted, yes, but never bored. My neighborhood was a good one for walking outside, and my son was happiest moving around, so we were always out and about. Also, I quickly learned to read or use the computer while nursing, so mental stimulation and conversation (of the online sort) were readily available. My husband was a fulltime student at the time, so quitting my job was not practical. But aside from practical concerns, it was unthinkable. I would be letting down the women who had trained and supported me directly, and the earlier generations who had worked so hard to eliminate barriers for women.

I started to realize that the question in my mind ran much deeper than the logistics of daycare, breastpumps, household chores, and time-management. In pre-industrial societies, women typically did not leave their babies to go to work, but neither did they leave their work to be with their babies. Whatever skilled work a woman was doing before childbearing she continued to do afterwards, with her baby on her hip or back. She usually was in the company of other women who could assist her with her baby and her work. Modern society mostly pushes women to chooses between two options – either be physically separated from their babies for most of the day, or forgo not only income but the sense of accomplishment and connection to the larger world that comes from skilled work. For me, neither choice felt natural.

Meanwhile, I was finding myself increasingly passionate about breastfeeding. I loved looking at my ever-growing son. I loved being able to make him so peaceful. I started volunteering with La Leche League. Becoming part of this chain of shared women’s wisdom, stretching back though all human history, connected me to a source of strength that transcended the societal and political struggles of the moment. I liked to open meetings by saying, “We are not designed to mother in isolation. For thousands of years, women have learned to mother and breastfeed from their own mothers and sisters, and the women of their community. What we want to offer is the support of experienced mothers, just as women have always offered each other.” This was my own thread of feminism. Gradually, I came to trust my own instincts, and to realize that I was drawn to a different kind of work. Work that would involve mothers and babies, and that would complement my own mothering, not compete with it. And that is when I found my true calling.

Posted on August 24th, 2012 by Jessica M. Lang | General
Some women are eager to maximize their milk production, others don’t want to make a project out of it. I’ll always remind her that she isn’t a milk dispenser, she’s a mother.

“My baby isn’t gaining enough weight.”

Many of my consults start this way. But even with the same starting point, these visits can go in so many different directions, because so many factors are involved. Physical issues can come from the mother’s side or the baby’s, and there are always personal and family dynamics to consider. It’s never just about milk.

Always, much of my time is in conversation with the parents. First, is the weight gain really too low, or is this a healthy baby who happens to be on the slow end of normal? Are the right growth charts being used? Many pediatricians’ offices are still using older growth charts, which were not based on breastfed babies. And any charts are just averages. Outside of Lake Wobegone, we can’t all be above average.

I need to know also whether the baby is at the breast often enough and long enough. If you aren’t in the restaurant, you don’t get a meal. Rigid schedules from books are one problem, but aren’t the only concern – one mother described to me how she tried every possible comforting technique when her baby cried, and only if she was still crying did she feed her. Of course sometimes the baby would run out of energy before this point, so she would give up and go to sleep, missing a feeding she needed. The mom was very health conscious, and conscientious, and had no idea she was underfeeding her baby. She came from a family where overeating, and associated health problems, were common. As a child, she felt she had been encouraged to eat for comfort, and eat past the point of satisfaction, and wanted to make sure she didn’t feed her daughter unless she was truly hungry. She was reassured when we discussed how feeding on cue would actually help her daughter learn to feel full and regulate her own eating. “When in doubt, whip it out!” was my advice. It was well received, but wouldn’t have found it’s mark if we hadn’t had the whole conversation.

Sometimes there’s a medical issue that needs attention, and it can be with either mother or baby, or both. Often the mother who calls me is already assuming the problem is on her end, saying “My milk supply is low.” Which it may well be, but lactation works by supply and demand. So a baby who doesn’t drain the breast leads to a mom producing less milk. If nobody’s ordering, the chef stops cooking.

I check inside the baby’s mouth, feel his sucking pattern, and watch the way he moves his head. A tongue tie – when the tongue can’t move normally because of the way it’s attached to the floor of the mouth – may be preventing the baby from nursing efficiently. Sometimes a difficult birth or awkward position in utero has left the baby with tension in the neck and jaw that makes breastfeeding difficult. Some babies, often those born a little early, have a weak or uncoordinated suck. I may wind up referring a baby to a specialist, and teaching the parents some suck-training exercises, and feeding techniques to help compensate.

Occasionally the mother’s medical history or breast exam gives me a clue that something is off in the “kitchen.” In these cases, I’m especially glad she is pursuing help. Low milk production can be a sign of a medical condition, like low thyroid; if she just stopped breastfeeding and left it at that, a chronic problem might go undetected for years, putting her at a greater risk for long term health issues. In those cases, I’ll be referring to a physician to treat the medical issue, while working with the mother on rebuilding her milk supply, and a feeding plan to help the baby get enough nutrition meanwhile. There are a lot of ways to approach supplementing, and it’s more important that the plan be sustainable than that it be perfect.

With a few mothers, I’ll have to bring up a tough subject: insufficient glandular tissue (IGT). This is when the mammary tissue did not develop fully, and can’t make enough milk as a result. This is hard news to give. The mother is likely to feel terribly disappointed, but she may also be relieved to have an answer. What I want to focus on with her is that she still has options. She might decide to give supplemental feedings at the breast. She might be interested in using donated human milk for supplemental feedings. Her milk supply may never be full, but there are ways to increase it if she wants to try. Some women are eager to maximize their milk production, others don’t want to make a project out of it. I’ll always remind her that she isn’t a milk dispenser, she’s a mother, and mention the saying “Love is not measured in ounces.” Her breastfeeding experience will be different from what she expected, but it can be rewarding, and it will be all hers.

Breast-feeding with SNS

Mothers who can’t produce milk do have options for breastfeeding

Not long ago, mothers with slow-gaining babies would probably have switched to formula feeding immediately, end of story. Now, more often they want to figure this out. I’m glad of that, and not only for the sake of mother and baby’s health. I hear the sadness in the stories older women tell me at parties all the time: “I really wanted to breastfeed, but my milk wasn’t enough.” They were never offered the chance to get a real evaluation, which could have solved the problem, or at least offered an explanation for why breastfeeding didn’t work. However the lactation turns out, I want my client to eventually look back on her breastfeeding experience with pride in herself – not because she did or did not lactate, but because she faced a difficult situation early in mothering, took charge, persisted, adapted, and ultimately fed her baby in whatever way she decided was best.

I love my work, because it’s not just about milk.

© Jessica Lang Kosa Ph.D, IBCLC 2012