Sunday, 30 August 2015

Breastfeeding, Confidence and the Top-Up Culture

We have a top-up culture within a lot of breastfeeding "support" in Northern Ireland.  Too often I hear top-ups of formula suggested for virtually any issue that a mother cares to mention in the early days of breastfeeding, and unfortunately many times the suggestion comes from a health care provider (HCP).

Baby feeding frequently - try a top-up after breastfeeds
Slow weight gain -  give a top-up after feeds 
High weight gain but baby seems colicky - maybe he's hungry and needs a top-up
Baby unsettled in the evenings - maybe he needs a top-up
Baby doesn't settle in his cot at night - give him a wee top-up after the bed time feed to help him sleep
Etc etc etc.

As you can see, the situations where top-ups are suggested are varied and often contradict each other, so I wanted to look at little at what is actually going on when top ups are suggested.

There are certainly situations when the supplementation of a baby is indicated.  If a baby is not latching well and not drinking well then supplementation is needed.  If a baby is early and isn't able to create good vacuum, or if a baby of any age has a dysfunctional suck supplementation may be needed.  If a newborn is very sleepy and not demanding frequent feeds, supplementation may be needed, and if a baby at any age is not gaining weight appropriately supplementation may be needed.  Supplementation does not mean formula, however.  Ideally supplementation means using mum's expressed Breastmilk.  Supplementation is an intervention, and as with any intervention it should be defined, planned, monitored and finally removed when no longer needed.  There should be a careplan which is created between the professional and the mother, balancing the mothers wishes and the needs of the baby.  It should include expressing to boost mum's supply so that the supplement can be phased out as soon as possible.

Frequently, however what actually happens is that when a mum has any kind of difficulty in the early days, a top-up of formula is suggested by her care providers.  Risks to mum and baby (reduction of supply, health implications to mother and baby, early weaning etc) are rarely discussed, and it is often almost a throw-away suggestion, when there is no clinical reason to suggest formula  I have heard top ups suggested because a new mother is tired, for nipple pain, for when there are siblings to take care of, to "help" a baby sleep, for normal frequent feeding, for reflux and for colicky behaviour.  Each of these things are difficult, and I'm not suggesting for a minute that they are not.  The early days with a baby are exhausting.  Adjusting to the new family dynamics and trying to meet the needs of older siblings is not easy.  Difficulties with latching or weight gain or an unsettled baby are painful, both physically and emotionally.  These things are overwhelming, and mothers do naturally feel overwhelmed.  What a mother needs in these situations is help.  If she wants to breastfeed, then she deserves help with breastfeeding.  If breastfeeding is going better then it becomes easier to manage siblings.  If breastfeeding is going better, it is easier to get some much needed sleep.   If breastfeeding is going better the baby will be more settled.  It isn't helpful to suggest top ups with formula to a mother who wants to breastfeed.  Of course, some mothers want to use formula, and that is their choice.  This blog is not about those mums.  This blog is about the mother who wants to breastfeed exclusively, yet has top-ups suggested when there is no clinical need.  For reference, the list of reasons that the World Health Organisation give for acceptable use of formula include:
  • low birth weight (<1500g)
  • very preterm e.g.32 weeks gestation
  • metabolic disorders e.g. galactosaemia, PKU, maple syrup urine disease
  • risk of hypoglycaemia (e.g. preterm, small for gestational age, intrapartum stress, maternal diabetes) - if blood glucose fails to respond to optimal breastfeeding in spite of frequent effective suckling
  • HIV positive mother (if formula can be made safely)
  • cytotoxic chemotherapy
  • certain medications e.g iodine and psychoactive drugs
  • active herpes on breast

The full WHO document on can be found in the further reading section at the bottom of the blog.
Clearly in Northern Ireland formula top-ups are suggested for a variety of reasons not included in the WHO list.

So why does it happen?
There may be many reasons why it happens, but I want to suggest that a big factor is our Cultural  lack of Confidence in breastfeeding and that it creates a vicious cycle within breastfeeding support.  Let's look at our breastfeeding statistics.  The Infant Feeding Survey tells us that in 2010 64% of mothers in NI began breastfeeding.  By 6 weeks this had dropped to 13%.  We know from studies that most women who stop breastfeeding stop before they wanted to, and that leaves many women with a sense of failure.  When you get most of the population not succeeding (in their eyes) at breastfeeding it feeds into an idea that breastmilk is not enough, or that they were not enough.  This idea ripples out through those in contact with that woman.  
The statistics in 2010 are actually high for Northern Ireland.  In 1990 (one birthing generation ago) the number of women who started breastfeeding was 36%.   The generation who gave birth in the 1970s virtually all formula fed.  Those that did breastfeed were extremely lucky if they managed to create a full milk supply since babies were removed to a nursery and feeds were timed.  This means that for most of us, we do not have a chain of breastfeeding behind us through our female line.  The line of breastfeeding mothers was broken and most of us have at least 1 generation where the children were formula fed.  For many there may be 2 or 3 generations who formula fed.  This leads to a lack of understanding of breastfeeding and of biologically normal baby behaviour.  Frequent feeding is normal behaviour.  Wanting to be held constantly is normal behaviour.  Feeding 3-4 hrly (common with formula fed babies ) is not normal behaviour.  A baby sleeping alone is not normal behaviour.  The lack of understanding in turn creates a cultural belief that breast milk is not enough.  That  babies need more in order to settle.
Our healthcare providers are part of those statistics.  Statistically it is likely that many of our HVs and midwives did not breastfeed.  Of those that did, statistically most fed for a very short time.   They likely have a broken chain of breastfeeding behind them also, and it is likely that they also experienced problems and stopped before they wanted too.  

Confidence in breastfeeding is experiential.  I'm not saying that HCPs don't have breastfeeding knowledge, but for some of them I am wondering about their own sense of confidence in that knowledge.  Obviously we have many fantastic HCPs who are very skilled in breastfeeding support, but not all are.  Perhaps, how could they be?  If you grew up in a country like Norway where 99% begin breastfeeding and 80% of babies are still breastfeeding at 6 months, your expectations about breastfeeding would be very different than here, and that applies to all our viewpoints - mothers, family members and health care staff.  HCPs are in the difficult position of having responsibility for the welfare of their patients.  They are responsibile for assessing growth and development and ensuring that medical issues are flagged.  Consider now that you are in that position, having come from a background in N.I. and are responsible for a mother with a 2 week old who hasn't regained birth weight.  You know that the baby needs more calories.  Do you feel confident enough to work on a breastfeeding plan?  Formula may seem like an easy alternative.  It has known quantities, known calories and is easy to "administer".  You may not even appreciate the risks.

The suggestion of top-ups undermines mothers.  It quietly instills in the mother an almost hypnotic suggestion that she cannot meet the needs of her baby.  The mother who is already tired, worried about her baby's weight or unsettled behaviour and seeking reassurance and help.  Once the top-up has been given, the mother's supply starts dropping and now she really feels she needs the topup and often a cycle of ever decreasing breastfeeding ensues.  The woman grieves her lost breastfeeding experience.  

Let me clarify a few very important things.  Breastmilk is perfectly designed for your baby.  Your milk is exactly what your baby needs.  There is no need for a modified cows milk product in order to add "something" to help our babies develop or settle.  If your baby isn't settling, or wants to feed frequently consider whether what you are experiencing is actually normal.  If you are worrying about having enough milk remember that it is biologically normal to produce enough milk for our babies.  It is not normal to have insufficient milk or for our milk to not meet the needs of our baby.   When you hear your parents/grandparents talk about how they didn't have enough milk, remember that they were never given a real chance to breastfeed.  They had their babies when they perhaps a "feed" was considered a few minutes (maybe even 3-4 minutes in the first few days).   The basics of demand and supply were never considered.  Remember that these were the days that women were advised to "toughen up" their nipples prior to birth, and the basics of latching were poorly understood.

Women's bodies are designed to grow, birth and feed their babies.  We grow entire human beings from one cell, and then birth that baby human.  Contemplate the creative processes involved in that, and what exactly happens in our bodies.  It doesn't make any sense that our body would be able to do that, but not be able to feed that child.  Pregnancy, birth and breastfeeding are all one event evolutionarily speaking.  They are about producing an offspring.  Most of us probably played mothering with our dolls as young children, just as we watch our children do now.  I suspect that many of us just expected that one day we would grow up and have a baby.  When you played, how did you feed that baby?  Did you use your chest or a bottle?  It is a cultural issue that we doubt that we will be able to feed that baby, not a biological one.  The human race wouldn't have got this far if women could create the baby, birth him but not be able to feed and grow him.  

If you are having top-ups suggested and you want to breastfeed - ask your HCP if there is an breastfeedkng alternative solution.  If you aren't happy with the answer search out a lactation consultant (IBCLC) or breastfeeding counsellor who believes in breasfeeding.  One who is confident in breastfeeding, in breastmilk and knows that you can feed your baby.  Break the cycle and find someone who will help you meet your breastfeeding goals.  Resolving the issue through a breastfeeding solution increases your own confidence in yourself and your mothering, and not only that, confidence is contagious.  As more HCPs see breastfeeding resolutions, their confidence grows as well, and little by little our culture changes.  
Top ups aren't the answer to normal early day breastfeeding difficulties.  Breastfeeding Problems have Breastfeeding Solutions.  You and your baby deserve a breastfeeding solution.

Further Reading 

WHO document - "Acceptable Medical Reasons for use of Breast-milk Substitutes". 

Developed Countries Breastfeeding Scorecard page 45

Thursday, 13 August 2015

Conflict, Compassion and Breastfeeding

I've been thinking a lot about compassion over the last few days.  World Breastfeeding Week has just ended, and the cyber world has been full of content about how to make Breastfeeding Work.  There have been beautiful brelfies and inspirational stories.  At the same time there was so much hurt expressed.  Articles from outspoken critics of breastfeeding, personal stories from mums where breastfeeding didn't work as they hoped, blogs about pain and lack of support.  I read facebook threads where mums expressed their great joy at feeding their baby and others where mums talked of their baby being supplemented against their wishes; comments where women had reached their goal and were ready to wean; and others where the mother felt forced to wean before she was ready.  Such a mix of joy and grief, and it left me wondering what articles were most appropriate to post on my own Facebook page.

Grief - it isn't often talked about in relation to breastfeeding, but grief is often a huge part of our exprience as mothers.  It can come as part of the package of pregnancy and birth.  Every year in Northern Ireland approximately 5500 couples attend a GP for fertility issues.  When you consider that there are around 25000 births annually in NI, over 5000 with sub fertility is a large number.  1 in 3 (or 1 in 4 depending on what you read) pregnancies end in loss.  I have had 2 pregnancy losses and I know that the way that a mother is treated around the loss of her baby can massively compound or ease the grief.  Some women suffer traumatic birth and have subsequent PTSD as a result.  Kathleen Kendall-Tackett, a LLL Leader and researcher writes extensively on post partum grief and depression and comments that the percentage of women suffering full PTSD following birth in the U.S. is greater than the percentage of people of lower Manhatten who suffered PTSD after 911.  That is a huge statistic.  I was unable to find a percentage of women suffering PTSD from birth trauma in N.I. but since the NHS now has clinics dealing specifically with this we can assume  it isn't negliable.  Research shows that 1 in 4 women have or are suffering domestic violence, and 30% of domestic violence starts during pregnancy.  Yet more may suffer psychological trauma from a premature birth or necessary or unnecessary separation from their baby after birth.

What does this have to do with breastfeeding?  It has everything to do with breastfeeding, because our experiences shape who we are and the decisions we can make.  Reproduction and breastfeeding (which I see as part of the reproductive process) is a high stakes business.  A woman who has been traumatised in birth or abused simply may not be able to contemplate breastfeeding.  It may just be too much to bear and she may need to set some limits around her physical boundaries.  Women who have had infertility or losses may have a loss of confidence in her body which may negatively affect her experience of breastfeeding.  

Even without overt trauma, women often have a confused and conflicted relationship with their breasts.  Our society has lost its relationship with breasts as a functioning gland and instead uses them to sell products, advertising which often has little regard for the rest of the body those breasts are attached to.  
Example of an ad using isolated breasts to sell
with no concept of being attached to a woman.

After birth whether we choose to breastfeed or not, milk is produced and our Breasts change and  we need to reconcile the conflict between what we thought our breasts were, and what they are now.  That is not easy, and for some it may be too much.
For others, breastfeeding is what heals trauma.  It can be what brings them into a new safe and healthy relationship with their body; the discovery of the purpose of breasts as biological can resolve confusion.  The association between them and a new kind of biological mothering relationship can be healing.  Nourishing and growing a child from her breasts can give a new mother confidence which she may have lost due to her pregnancy or birth experiences.  Keeping a baby close can also help to undo the damage done by necessary or unncessary separation in hospital.

Between the 2 borders of exclusive breastfeeding and total formula feeding there is a huge range of choice and experience.  There are women who want to combi feed by design of course, but so so many others who feel pressured to supplement due to low weight gain or jaundice or because their baby is feeding frequently.  There are those who feel they have no choice but to supplement or move to formula due to nipple pain, blocked ducts, mastits, thrush, reflux, dietary issues.  There are those who have ended their breastfeeding because their baby's tongue tie was not recognised or adequately treated.  Others continue while in pain.  Everyone feels pressure.  Pressure to breastfeed, pressure to formula feed.  Pressure from health care professionals, pressure from family and friends. Often it isn't seen as pressure.  Often it is well meaning, but each little comment: "is he feeding again?"; "how do you know how much he's getting?" is pressure.

Yes I know some will read this and say, "I chose to formula feed.  It had nothing to do with grief, loss or any other experiences".  That's fine.  You have your experiences and your choices, and others have theirs.  I am not for one minute saying that everyone who chooses to feed their baby formula is doing so out of grief, but I am saying that some do, and for many others the move to formula before they wanted to brings a sense of loss and grief and we should be mindful of that.  When one mother  thinks, "I don't understand why she didn't even try to breastfeed", I say that perhaps there is no way you can.  If you had lived the life of that woman then maybe you would have made the same choices.  Likewise for those who think that breastfeeding mothers are making some kind of selfless sacrifice then please realise that if you were in her shoes you may have made the same choices and actually be taking great joy from breastfeeding.

The birth world is waking up to the reality of needing to explore grief around birth processes.  Where some now recognise that a healthy baby is not all that matters, i believe the same is true for breastfeeding.  Ignoring the grief and loss helps no one.  When we ignore the pain we tell the woman that her feelings do not matter.  Women are told, "your baby got colostrum and that's what matters", or "there's no value in it after 3 months anyway" or the old, "well it never did mine any harm".
Colostrum is not all that matters.  Putting aside any normal need for breast milk, the fact that the woman wanted to breastfeed matters!  Women know that it has value past 3 months.  Quite apart from the messages telling her that her baby needs breast milk for at least 6 months, the act of breastfeeding has value to her.  Hearing that breastfeeding just doesn't work for everyone just creates more confusion and conflict.  Why wouldn't it work  out for everyone? What is wrong with me when it works for others?  Often years after their nursling are grown, women talk about how they weren't able to breastfeed. "Oh I tried but I didn't have enough milk".  "I couldn't breastfeed because .. ".  Or they remember with horror the awful mastitis that caused them to stop.  It is often associated with a deep sense of failure.  I wasn't able to.  This sense of failure is exactly the same as the sense of failure that often is linked to birth interventions or birth trauma.

Our lives are very rich, complex woven tapestries.  Some of those threads are rich hues of laughter and joy and others are dark threads of longing and regret.  Through it all we need compassion. The woman who felt she couldn't start to breastfeed although she wanted to needs compassion.  The woman who breastfed as long as she wanted but struggled though reflux / allergies / pain or a tongue tie that no one would treat deserves compassion.  The woman who things didn't work out for, who is bitter and verbally vitriolic about breastfeeding deserves compassion.

Breastfeeding support needs a compassionate approach.  Support isn't telling a woman that is is ok to feed formula if she wants to feed exclusively.  Support isn't telling a woman that she should continue breastfeeding if she feels she needs to stop.  Nor is it saying that your painful experience is wrong and wouldn't have happened to you if xyz.

 Support is saying, " I see you.  Tell me your story.  What do you want to do and how can I help you?  I am here."

Maybe later you can talk about how to overcome those issues, or what could happen in the future, but doing this without first connecting, really connecting, is pointless.  If we could listen to each other, connect and accept each other's experiences as valid then the mummy wars would have no fuel.  

Yes, I believe that all babies deserve to be breastfed and that if babies had the choice they would always choose to breastfeed.  I recognise, however, that not all mothers are in a place where they can do that right now.  With good support maybe they will choose to breastfeed a subsequent child.  Maybe they won't but that's not for me to judge either.  
Support is compassionate.  Support is non judgemental.  Support which listens while a woman relives her exprience with you can help her to process that experience.  It can weave a new thread through the tapestry which gives the entire picture a new hue, or sometimes it won't - but at the very least it can leave the woman feeling heard, her experience recognised and her feelings accepted.  Isn't that act healing in itself?

We could all do with approaching each other with more compassion.  I was reminded about this yesterday as I got on a plane for a family holiday.  As we sat on the tarmac and the clock ticked past our take off time the pilot announced that we would be delayed due to some passengers who would not be travelling.  Their luggage needed to be found and taken off the plane.  We grumbled about the delay assuming that since they had cleared security and luggage had been stowed, that the passengers must have been drinking or rude to staff.  I later discovered that it was a family, and the reason they didn't travel was because their son was too afraid to get on the plane.  A family has lost their holiday,and  a small child  was terrified and they need to deal with the aftermath of that.


Further Reading

NI Birth rates in 2013
NI Fertility figures
AIMS page on PTSD
Kathleen Kendell Tacketts page on breastfeeding and grief -