"Lactastrophes" -- what's up with your doc when breastfeeding goes wrong

A lot of what you read online about breastfeeding is divisive or superficial, unscientific at best, dangerously misguided other times.  One writer whose work I always admire, though, is Alison Stuebe, MD, MSc, who writes for the Academy of Breastfeeding Medicine.  Her latest post, about "lactastrophes" -- when breastfeeding doesn't work -- is terrific.  

All too often my students and clients say that they feel that, while "everyone" is pressuring them to breastfeed, "no one" (they mean, none of their doctors) are actually there at the right time and place to help them make it happen, or seem to care.  This is, in part, because physicians do not learn about lactation management in med school.

Dr. Stuebe notes that although obstetricians routinely screen for breast cancer, which is not strictly within their realm, they can be "reluctant to take responsibility for the functioning breast," and, consequently, kind of ignore breastfeeding. (In fact, when she tried to submit the essay to an obstetrics journal, it was rejected, with the reviewer saying it belonged in a pediatric journal, even though it is about lactation, which is, obviously, an adult's issue.) 

Meanwhile, pediatricians don't routinely consider lactation to be within their purview, either. Though some give breastfeeding advice, I rarely hear of pediatricians who observe and assess an entire feeding, and have never known a pediatrician to assess the mother's breasts, let alone take a thorough maternal history to try to understand how the mother's physiology is at play in a nursing relationship. Without looking at half of the dyad, how can they assess what's going on or why something isn't working?

Appropriate care of a breastfeeding pair involves looking at the baby, the mom and the way the two work together, over time. It involves understanding what happened in the pregnancy and birth as well as what's going on right now, and the mom's plans for the future. You have to consider the mother's learning style and access to resources. It's is more than a side issue to fit in during your 8 minute OB checkup or your 10 minute pediatric visit; it takes time.  

To thrive, it's imperative that new moms have access to competent, trained specialists in human lactation -- IBCLCs are the gold standard in clinical support of human lactation. But unfortunately, most new moms I meet, even ones who know about lactation support, haven't the faintest idea that there is even a difference between a L&D nurse offering breastfeeding advice, versus an IBCLC, a CLC, an LLLL, a CLE . . . there is a whole alphabet soup of lactation support personnel, each of whom is competent to handle different situations. Some docs think any lactation professionals are "woo woo," and ignore them (as though breastfeeding problems will resolve themselves when no one helps the new mom); some lactation professionals spend more time defending the legitimacy of their credential instead of being candid with moms about their scope of practice, and experience.  And way too many people all over the profession ignore the relationship between nursing and a mother's mental health, or fail to follow the mom over time to see how their "advice" has played out.  Mothers aren't generic; followup is essential for good care; success is not merely "baby gains weight." 

With this backdrop, and with posters everywhere saying "Breast is best!" and people suggesting, routinely, that it always works if only the mom tries hard enough, moms end up confused, and, if breastfeeding doesn't work out, resentful. What is "trying harder," anyway?  I remember the first time I encountered a situation Dr. Stuebe also describes in her piece: a new mom with classic, obvious signs of insufficient glandular tissue. Her breasts presented so clearly --  more than four fingers' breadth between the breasts, each breast long and tube-shaped with bulbous areolae, one about twice as long as the other, unchanged during the pregnancy -- she could have been the text book photo of IGT. Her baby had lost a lot of weight; she had been told by her caregiver -- who had seen her breasts many times and knew her menstrual history -- only to "make sure the baby nurses twenty minutes a side."  She contacted me because the baby was very sleepy and wouldn't stay at the breast for that long and she felt guilty that she couldn't get the baby to keep trying. Try harder, she had been told.  Try harder at what!?  Trying to keep a starving, exhausted baby active for an arbitrary number of minutes was not going to fix anything.  Recommendations that don't begin by asking: why is this happening in the first place? can result in moms who exhaust themselves without actually making progress. 

Breastfeeding does not always work. It works best when the mom has access to excellent prenatal, intrapartum and postnatal care and education, ideally with continuity of care so that the same people who get to know her prenatally can be of service after the baby is born. Excellent care reduces the number of problems that come up and increases moms' satisfaction.  

But, as Dr. Stuebe says, we must stop asserting that "all women can breastfeed." Grandiose claims 

about the infallibility of lactation are not cited about any other physiologic processes. A health care professional would never tell a diabetic woman that ‘every pancreas can make insulin’ or insist to a devastated infertility patient that ‘every woman can get pregnant.’ The fact is that lactation, like all physiologic functions, sometimes fails because of various medical causes.  

OBs, midwives and pediatricians need to work as a team with IBCLCs and other specialists to investigate what is going on when breastfeeding goes off the rails, and be candid that sometimes the honest answer is, "we don't know why this has happened." The network of clinicians around new moms can, together, ponder how best to either restore physiologic function or to support the breastfeeding dyad through weaning if that's not possible.  

If we work together, we can develop solutions to some of the physiologic problems, and we can insist on training for everyone who works with new mothers in how best to support those who cannot meet their goals.  We should be honest with mothers that the reason that this is not already standard is that it's costly and time consuming to appropriately train everyone, and we haven't made that the standard of care. Currently, it's mothers who pay the price in exhaustion and disappointment.  It's not the mothers that need to try harder, it's everyone else who works with them.

The lactating breast should not be ignored by the health care providers moms see most, her OB/midwife and the pediatrician.  "Too many clinicians treat the lactating breast as a hot potato," Stuebe writes, "leaving moms and babies lodged in the gap between pediatric, obstetric and lactation specialists. In an era where public health campaigns urge all mothers to breastfeed, we need to urge all health professionals treat breastfeeding management as an integral part of health care."  Let's do better for moms and their babies.

What you can do:

• take a good prenatal breastfeeding class taught by an IBCLC.
• have contact information for local breastfeeding resources.  Kellymom.com is a good place to start, and, if you're in New York, check out nylca.org.
• ask your caregivers, prenatally, what their resources are for breastfeeding mothers.  If they have none, is this the right caregiver for you?
• have resources for a good facilitated moms' group for after the baby comes, where you can get the support you need.  

What Not To Say To A New Mother: Eleven Ways To Get It Right

Recently, I wrote about undermining things I’d heard hospital staff say to new mothers, and I have been overwhelmed by the feedback. I have read over a thousand responses and comments, too many of which confirm the themes of my original post:  that moms can feel seriously undermined by even small thoughtless remarks by their caregivers, mixed messages, or misinformation, and they hold on to the pain of that for years to come.  This comment struck me particularly:

when my daughter was placed in my arms, I had an overwhelming feeling of confidence that I could take care of this child, no problem; this was slowly eroded over 4 days in hospital, getting contradictory advice and information — so confusing!

Ugh!  

Seasoned moms know that once the adrenaline of childbirth wears off – be it 24 hours or four months - taking care of a child is rarely a “no problem” thing.  We all doubt ourselves sometimes; no one has perfect confidence.  But in those first few days, moms need encouragement.  They need to be taught what to do when they feel doubt, and confusion; they don’t need more doubt and confusion heaped upon them.  

But!  Several people wrote in positive comments about their time in the hospital, too, and those stories are so moving – not just as a reminder that there are great, great hospital staff members out there, but as a reminder for all who encounter new moms: small positive comments and acts are surprisingly helpful, just as the small negative comments were surprisingly destructive. Years later, moms still remembered: 

• how good it felt when a nurse congratulated her on how much she’d pumped, and 

• when a L&D nurse brought a newborn who needed immediate pediatric care to mom’s belly for a kiss and hug before being rushed away, and 

• the doctor who said “I can see you’re going to be great,” at a moment when the mom could not see it herself, and 

• Nurses who knocked before entering, asked, “is this a good time?” or “do you need to pee before we do this?”

And there were several comments about caregivers who slowed down, sat on the edge of the bed and simply smiled.    

I don’t mean you should tell a new mom everything is spectacular if it isn’t. But if you’re a friend or loved one visiting a new mother, or if your work requires you to care for new parents – small things make a huge difference and are remembered for years to come. 

Helpers, loved ones, and all who interact with new moms can be memorable for the good they do with these eleven basics:

• Put yourself on a five-second delay.  Helpers often “hit the ball back” with a response as soon as they hear a new mom’s question.  Whether you are a caregiver or a friend, take a pause before answering mom’s question, and think about what you’re about to say, and check the phrasing. 

• Make sure you are qualified to answer.  (If not, there’s no shame!  You can say, “let me think about that” or “let me ask so and so”).  Then, get help for her.

• Think about your tone.  If you sound bossy or defensive, New Mom may hear that, more than she hears your words.

• You are responsible for your body language – If your shoulders are relaxed and you’re smiling, it’s easier for the new mom to hear the substance of what you’re saying, and to learn.  If she sees your eyebrows scrunched together and a frowny face and your shoulders up by your ears, it can drown out whatever you’re trying to tell her!  Even if you’re worried, don’t distract with your body. The most effective way to get the baby and mom cared for is not to scare them, but to use your brain and words to get them what they need.

• SMILE.  It makes everything you say more absorbent.  Try not to behave as though there is an emergency unless there is an emergency.  

• Stay away from hypotheticals (“if, by tomorrow, we don’t see a change in X, we will have to do Y” or, for friends: “if your baby starts doing A now, you’re going to be in for it when she’s B months old”) unless there is a clinical need to discuss them right now.  People do this to show off their knowledge and to spread their own anxiety around, but it’s not fair to the new mom.  Unless it’s clear you need to act, try to keep the mom to the present, and stick with her so you can jump in if need be.

• Ask whether you need to say anything at all.  Sometimes a grin is truly enough interaction. 

• Use open ended questions to get the mom talking.  ”Tell me how breastfeeding is going” or “How are you feeling today?” or “So, what do you think of your baby?” will get you more information than, “how many minutes did he latch?” or “has he pooped yet?” or “has he been crying a lot?” 

• Observe the mom.  Find something she is doing well.  There will be something – the way she smiles at the baby, the way she holds him more confidently each time, the way she asks good questions or shows appropriate instincts.  Tell her, specifically, that you notice these good things.

• Observe the baby!  Find something totally adorable, and tell them mom you notice.  I remember one client I had whose baby was in the NICU.  I saw them on day 2 and pointed out how adorable it was that the baby was gripping Dad’s finger.  The mom burst into tears, saying, “That’s the first compliment she’s gotten since she was born!  Everyone is only talking about all the things she’s not doing.”  

• Friends and loved ones:  Help the new family develop a “home team” (and be part of it), to get their needs met and their questions answered once they’re home.

What about you?  Do you remember what helped in those early days and weeks?

What Kind Of Help Would Help?

My friend Jessica Lang Kosa, PhD, IBCLC, a lactation consultant in the Boston area, and general new-mom-bad-ass, recently linked to this great post from Bay Area Breastfeeding, LLC, which tells new moms when to seek help for a breastfeeding problem.  It’s a good check list, and reminded me that I’ve been meaning to blog about how new moms sometimes need help sorting out what kind of help would help.

I find that new parents’ needs tend to fall into three categories, in ascending order of prevalence:  clinical help, information, and general support.  Let’s talk about how you can get all those needs met.

1. CLINICAL HELP:  This is the thing you’ll need least frequently, but requires the most expertise.  Clinical problems are problems that require an expert and need to be solved or else something bad will happen.

If you have a concern about the baby’s health, the person to go to is his physician.  If you have a concern about your own physical health after the birth, you should consult with your own health care provider.  If you have a toothache, you see a dentist.  If you are clinically depressed, counseling and/or medication is what will help.  Etc.  This much is obvious, I think.  

If you have a clinical concern about breastfeeding, you should consult with an Internationally Board Certified Lactation Consultant (IBCLC).

Somehow that one is less obvious to people.  So let’s explore it a little.  If you had strep throat, you wouldn’t rely on your mother, or your co-worker, or your neighbor, to deal with it, right?  Because it’s a clinical problem.  Your mother (or co-worker/neighbor) has no training in dealing with your medical problems!  She is not qualified.  She might provide you with comfort by giving you tea with honey, and she might be very compassionate and do a load of laundry for you because you’re sick and can’t deal.  She might help you not feel so down in the dumps about it.  And all these things are super-helpful.  But if you have strep throat, you also need clinical help for your throat, and your mom can’t fix that.  So you go to the relevant expert — your doctor.  

Likewise, if you have a clinical concern about breastfeeding, the person to go to is an IBCLC.  Because your mother (or co-worker, or friend) has no training in assessing and addressing a clinical breastfeeding concern, and is not qualified to help.  

If you had just given birth and you had strep throat, would you look to your Labor Nurse for a solution?  No.  The nurse is trained as a labor nurse.  She does not have the training and qualifications to deal with strep throat.  You’d see a doctor.

That labor nurse also doesn’t have training dealing with clinical breastfeeding issues, unless she is also an IBCLC.  

(Why do so many of us assume that just because she was looking at your vagina for ten hours, the labor nurse knows about human lactation??  Yet many people mistakenly look to their labor nurse for clinical guidance about breastfeeding, and, unfortunately, many non-IBCLCs spontaneously offer clinical advice about breastfeeding, instead of saying, “let me send an IBCLC to see you right away since you have a question about breastfeeding.” It’s up to you to remember to ask whether the person advising you is an IBCLC.)

By the way, speaking of who is and isn’t qualified to provide clinical breastfeeding assistance:  Let’s say your husband had a toothache and you happened to be at your kid’s pediatrician for a well-visit, would you ask the pediatrician what to do about his tooth? No.  The pediatrician is not the expert you go to for that.  

Guess what, your kid’s pediatrician also doesn’t have the training to deal with clinical breastfeeding problems.  

Can you imagine if you sat at your pediatrician’s office and described what was going on with your husband’s tooth and she said, “it sounds fine to me” without even seeing him?  

She might be right about his tooth.  But it would not be right to take that as appropriate guidance.  Your dude needs a dentist. 

Even weirder, can you imagine if the pediatrician said to you “it sounds like his tooth is a problem” and then she told you what to do about it, without seeing him?  

No! 

And what if she told you your husband should only be brushing his teeth once every three days and never flossing, because his teeth might not learn how to fight the germs off themselves if you let them rely on dental floss.  Wouldn’t you be like, “Wait — aren’t you a pediatrician?  With all due respect, have you ever had any training about dental health?” 

Right?

Your kid’s pediatrician isn’t an IBCLC, either, and hasn’t had training in human lactation.

The person to see for clinical breastfeeding problems is an IBCLC.  

Hopefully you’ll encounter many people who are gifted and knowledgeable about breastfeeding in general.  A postpartum doula or a childbirth educator or an experienced nursing mother — or even your kid’s pediatrician — might turn out to be a great, helpful resource for general breastfeeding support.  That is all that most people ever need.  Just like most of the questions you have about your baby (how do I give a bath?) don’t require an expert fix by your pediatrician.  But if there’s a clinical problem, you go to the expert.  And if you’re not sure whether there’s a clinical problem, ask an IBCLC.

(I should mention here:  I am an IBCLC.  But most of what I do isn’t clinical practice, but, rather, the guidance and education and counsel that are more commonly sought by new moms.  I got the IBCLC so that if I’ve developed a relationship with a client around our work on the logistics of going back to work, the challenges of sleep deprivation, the weirdness of developing a parenting style, or the marital strain that becoming a mother has entailed, I don’t have to refer her out just because she also has a bleb.)  

2. New parents also sometimes need INFORMATION.  (How much weight gain can I expect of my baby in the first three months?  How do I give a newborn a bath?  Why is my hair falling out?  Where can I find a great new-mom’s group in my area?) Some of this kind of information can be answered online (you can find growth curves here) and sometimes you’ll consult a book, or your childbirth educator, or doula, and sometimes your friends and family will have answers. Try to distinguish questions that have One Correct Answer from questions that come down to personal style.  If it’s a question that has a Correct Answer, you want to make sure you’re asking someone qualified to answer correctly — a lactation consultant, or a childbirth educator or a parenting educator, or a physician or midwife, or a tax attorney, depending on the question.  

Other topics, such as how often to bathe your baby and how to do it, come down to personal style and don’t have one “right” answer.  For that stuff, your mom or friends or even an email from your co-worker’s wife’s friend’s babysitter’s mother might be the best help.  

But if you don’t like their “advice,” do it your own way!  That’s the difference between “right answer” information and “personal style” information.

3.  SUPPORT.  More than any of the other issues, new parents need support and companionship.  Most moms I work with never need clinical help.  Their pediatric visits are well-visits, and their six-week followup with their own OB or midwife is a routine checkup.  They mostly never need the clinical services of an IBCLC either.  But they still need support, counseling and gentle guidance. 

Good support is a blend of guidance and friendship.  A great support person listens to you, helps you get the little stuff off your hands so that you don’t have to waste your energy on it, and gives you enough guidance that you have the tools to do the big stuff for yourself.  She helps you sort out the advice you’ve gotten into “right answers” vs. “personal style.”  She helps you figure out whether you’ve got a clinical problem, and if you do, she helps you get clinical help.  

Mostly, she lets you talk about what’s bothering you and sort it out.  You trust her judgment so it’s reassuring when she tells you you’re doing well, and if she tells you she’s concerned about you, it inspires you to make changes.  She is looking out for you.  

Every single new mother needs multiple support people, and they’re mostly going to be people you already know. Some of your support people will play a mentor or coaching or counselling role, and some will be more like helpers, and some will just be friends who make you laugh or make a good cup of tea.  You should have lots of people in your life — this is what it means to have a village!

It’s right to need support, and it’s right to look for it.   Too often the new moms I meet are embarrassed to admit how much help and guidance they need.  But that’s kind of backwards.  I think if we can remember that it’s so human to look to other people for support and guidance and companionship, and stop pretending that Good Mothers Have Everything Under Control All The Time, the whole world will be a happier and more gentle place.   

So open up to the people in your life and ask them to come hang out with you.  You’re not asking them to be experts and you’re not required to follow all their advice.  You’re looking for a human touch. That’s not being weak or dependent, it’s being a human being — we humans take comfort from friendship.  And when your need for support and information is more than your own family and friends is ready to provide, look beyond the nest — try going to new moms’ groups or working one on one to get the help you need so that you can find your way. 

"Breast Is Normal"

Here’s a really interesting recent piece by Ceridwen Morris on the “Breast Is Best” slogan.  We’ve all heard “Breast is Best” for years, but, come to think of it, doesn’t it sound a little too “goody goody” to you?  Do you really need to be “best” at everything?  Some breastfeeding folks point out that calling breastfeeding “best” makes it seem like an extra special A+ you might not feel you need to go for, instead of what it is:  the normal way our species feed our young.  You give birth and your breasts get milk.  Whether you use them or not, we are mammals.  

But once we describe breastfeeding as plain old “normal,” what does that make formula?  When we call breastfeeding “beneficial,” formula feeding sounds “normal”.  If breast is normal, formula is:  worse.  Inferior.  Not as good.

I know this is a touchy subject, but before you click “unfollow,” let me finish.

Here's another article I saw today, noting that 96% of US hospitals fail to support, or undermine breastfeeding. 96%!!  No, hospitals don't say “Don't Breastfeed!”; they undermine it with inconsistent and misinformed practices, and by not implementing WHO's 10 step plan to become “Baby Friendly.”

It matters. Moms trust hospital caregivers and assume the hospital staff gives appropriate, state-of-the-art feeding advice.  But when moms are discharged without establishing breastfeeding, or having been given inconsistent or misinformation, many go on to wean, saying they “couldn’t” breastfeed / didn’t make enough milk /  etc.  Often they don’t realize the whole endeavor was sabotaged in the first days after the birth, by misguidance, inconsistent advice and inappropriate practices in the hospital.    

Then, moms who’ve weaned feel criticized by pro-breastfeeding advocacy that describes breastfeeding as “normal” or formula as “inferior.”  And we all dance around, trying not to hurt anyone’s feelings.  

Here’s the thing.  We shouldn’t hurt Moms’ feelings.  There is no use making any new mom feel like crap about herself, or suggesting that breastfeeding is the be-all-end-all, or that there is no place in the world for formula, or that it’s evil.  There’s a place for formula.

We need to support mothers’ choices, and respect their individual situations.  We don’t support them when we get sidetracked on a “did she or didn’t she” discussion of infant feeding, or act like mothers who formula feed are weak of character or inadequate.  But we also don’t support them when we pretend breastfeeding isn’t the normal way human young are meant to be fed, species-wide. 

Instead of Mom On Mom Criticism, here is where to focus our energies instead:  We MUST change what happens in the hospital. Hospitals’ newborn protocols are a crucial element of breastfeeding outcomes and all but 4% are failing.  Why are almost no hospitals “Baby Friendly”?  The answer has to do with money and time.  To be “Baby Friendly,” a hospital cannot accept free formula samples.  It must develop a comprehensive breastfeeding policy.  It must provide staff training.  It costs.  And if formula is “normal” and breastfeeding  ”extra-specially beneficial” then, that cost seems too much to bear.  Especially since  most exhausted and overwhelmed mothers will blame themselves if breastfeeding doesn’t work, and most won’t turn back to the hospital, saying, “How could you have failed me in those early days when my baby and I were fragile and needed your help, support and information?”

Why are any of us giving our business to hospitals that fail us in *any* area of care?   Write to your hospital and request that they become “Baby Friendly.”  If you are pregnant, take a prenatal breastfeeding class with your partner.  If you’re in NY use this website to look at breastfeeding outcomes in your hospital (scroll down to find the percentage of babies who are “fed exclusively breastmilk” as the AAP recommends).  If the breastfeeding rates are low, bring contact info for an IBCLCwith you to the hospital when you go into labor.  You may well not need her, but if few babies leave your hospital exclusively breastfeeding, why would you trust what the maternity nurses tell you about breastfeeding?  Consult with an expert when you have questions.

Breastfeeding is not simply a matter of what fate has in store for you.  You, your partner, and your support people are factors in the outcome.  Get educated; ask for help; reach out when necessary.  Reach out to the right folks.

P.S. For those in NYC:  Only two hospitals are “Baby Friendly”:  Harlem Hospital Center and NYU-Langone Medical Center.