Can an IBCLC be a source of objective information about formula feeding?

In recent discussions about whether formula companies are a good source of advice on breastfeeding, my emphatic answer was NO! A few people chimed in and asked who could provide objective, evidence-based, judgment free advice on infant feeding. Could it come from a lactation consultant or are they too biased toward breastfeeding? I put the question to local International Board Certified Lactation Consultant (IBCLC) Fleur Bickford who blogs at NurturedChild. Please read what she had to say.

A dad feeds a baby a formula supplement

If you're a breastfeeding mother and you need help with feeding your baby, a lactation consultant is an obvious choice for information and support. What if you're a mother who needs, or chooses to use formula? Who do you turn to for accurate information and support? Where are you going to get the information you need to make an informed decision about feeding your child?

Your doctor or nurse might seem like the obvious choice if you have questions about feeding formula, but unfortunately, doctors and nurses receive very little training about infant nutrition. For many doctors, their knowledge of infant formula is limited to the information that they are given by the formula reps who come to visit with their free samples and glossy brochures about why their formula is the closest ever to breastmilk. Hardly an unbiased or complete source of information.

Annie asked me to write a guest post about how I work with moms who need to use formula for whatever reason, or those who choose to combo feed (give some breastmilk, some formula), while also upholding the requirements of my designation as an International Board Certified Lactation Consultant (IBCLC). She wanted to know where moms who need or want to use formula can go to get objective, judgement-free support on feeding their infant, and whether or not an IBCLC is a good place to turn.

How does an International Board Certified Lactation Consultant Work With Moms Who Use Formula?

Many people think that lactation consultants can't or won't provide information about formula feeding. They often mistakenly believe that the World Health Organization Code of Marketing Breastmilk Substitutes (WHO code) prevents anyone who upholds it from talking about formula or bottle feeding. This is not the way the WHO Code works. The Code deals only with marketing. As an IBCLC, I can uphold my commitment to the WHO Code and still talk to moms about how to prepare formula, and how to bottle feed, as long as I am not using my practice to market formula or bottle feeding.

As an IBCLC, I am required to work within a framework that is defined by several documents from the International Board of Lactation Consultant Examiners (IBLCE) and the International Lactation Consultant Association (ILCA). In all of these documents, the focus is very much on helping mothers to meet their breastfeeding goals. This means that if a mother's goal is to feed some breastmilk and some formula, then it is my job to help her do that successfully, while at the same time making sure that her decision is an informed one. There is no getting around the fact that there are risks to feeding your baby something other than breastmilk. The possible consequences of not breastfeeding are well documented by research. Having said that, I do not think formula is evil. I disapprove of the marketing tactics used by formula companies, but if a mother's own milk or donor milk are not an option for whatever reason, infant formula is an acceptable alternative.

Am I biased towards breastfeeding? Yes, of course I am! I am aware of that bias however, and being a lactation consultant does not mean that I can't or won't provide information for parents who need or choose to use formula. Although the vast majority of women want to breastfeed (as evidenced by high breastfeeding initiation rates) we do not yet live in a society that is truly supportive of breastfeeding (in fact I'd argue that our society isn't supportive of mothers in general, but that's another post). There are many factors that may play into a mother's decisions about infant feeding, and I strongly believe that all babies deserve to be fed in a safe and biologically appropriate manner. In order for this to happen, parents need information and support. Unfortunately, with all of the emphasis on "breast is best" it seems that often, care providers are afraid to talk about formula feeding.

As a lactation consultant, I see moms who are having trouble with breastfeeding, and often they are already supplementing with formula by the time I see them. My job is to support a mother to reach her breastfeeding goals, not mine. If a mother wants to supplement or combo feed, who am I to say that is not the right approach for her. I do provide info about supply and demand, how introducing bottles or formula might impact breastfeeding etc., however I also do a lot of teaching about safe formula preparation and how to bottle feed in a manner that respects a baby's natural biological rhythms, and protects baby's airway. Often, parents have been told to supplement and have been handed a can of formula, but they haven't been given any instructions on how to feed it. Whether that is because it's assumed that everyone knows to bottle feed, or due to a reluctance to talk about formula feeding for fear of seeming unsupportive of breastfeeding, I'm not sure. In many cases it may simply be due to the fact that the doctor/nurse doesn't know anything about formula/bottle feeding themselves.

When I'm working with breastfeeding families, my concern is more about the experience than the outcome. If a mother chooses to combo feed, or exclusively pump and bottle feed, it may not be what I would have chosen for her, but if she is happy with her decision and happy with her experience with me, then I feel that I have done my job. If a mother comes to me looking for information and leaves feeling like she's a bad mother for using formula, then I've lost that mother for good. If she leaves feeling supported by me and empowered as a mother, no matter what her choices for infant feeding were, then she is far more likely to come back to me down the road for her next baby, and perhaps next time she may be ready to try exclusive breastfeeding.

So to answer part of Annie's question, yes, an IBCLC can be a good source of evidence based information about bottle and/or formula feeding. Our clinical competencies require that we are familiar with how to prepare formula safely as outlined by the World Health Organization. We are also required to be able to provide information about the safe and appropriate use of devices that breastfeeding mothers may use, including bottles.

Can an IBCLC Provide Objective, Judgment-Free Support?

The second part of Annie's question - where can mothers who need or want to use formula go to get objective, judgement-free support on feeding their infant, and is an IBCLC the right choice? - is much harder to answer. All health care professionals are human, and all come with their own individual levels of knowledge, training and continuing education, and also, their own beliefs, perceptions and personals biases. All IBCLCs should be able to provide information about safe formula preparation and bottle feeding. Whether or not that information is provided along with non-judgemental support depends on the individual IBCLC. It can also depend on a mother's perceptions. It can be very difficult to ensure that a mother has all of the information she needs to make an informed decision about feeding her baby (including information about the risks of formula) without the mother feeling like she is being judged. This is one reason why we should be working to ensure that women have this information before their decisions about infant feeding are made.

So what is a mother to do? As I wrote this post I realized that the available information and support surrounding infant feeding for all mothers, whether breastfeeding, formula feeding, or some combination of the two, leaves a lot to be desired. If you are not finding the information and support you need, keep looking until you find it. It is out there, but sometimes it is necessary to shop around. At the same time, we need to continue to put pressure on health care providers and governments to ensure that our society becomes one that supports all mothers.

Fleur Bickford is the mother of two breastfed children, and an RN and IBCLC working in private practice. She is very active in the Ottawa breastfeeding community, having volunteered as a Le Leche League Leader and Ottawa Breastfeeding Buddy, and she is currently president of Ottawa Valley Lactation Consultants. Fleur blogs as NurturedChild and is on Twitter and Facebook. She also writes for the Best for Babes blog.

Image credit: petitshoo on flickr

Comments

[Amber McCann]

Excellent article, Fleur (and Annie). I also work with moms every day who are using formula and need guidance on how to do that correctly. And I can recognize my own biases enough to know that, while it might make me wish things were different, I am first and foremost committed to the mother.

Another resource for mother's who have chosen to feed formula and not breastfeeding (and for whom calling an IBCLC might seem counterintuitive) is to contact a nutritionist who specializes in infant feeding.

[Karen L]

Great post and very informative! Another avenue I might suggest if, say, one of my friends were struggling with any kind of feeding, is to take the public health nurses up on their offers of support. In our city (Toronto), _every_ mother gets a phone call within a couple of days of hospital discharge from a public health nurse with some questions about the transition home and an offer of a house-call (the offer may be strenuous based on the questionnaire answers.) I'm guessing that the nurses who are calling are dedicated to post-natal care. I've heard that if a new mother so much as breaths anything resembling "trouble feeding," the public health nurse will drop everything and RUN to her house. I think that some at-risk mothers are visited prenatally by the city public health maternity unit too. Of course, if my friend had a midwife, I'd point her that way, too.

It may be very city-specific, of course, but does anyone have a reason/experience why contacting midwives or the city public health nurse maternity unit might be ill-advised?

Also, the doula/childbirth educator who ran our hospital's prenatal and baby bath and massage classes also gave us her contact info for post-natal visits, though I can see how it might be harder to track down someone like that in a hurry, if hurrying is warranted.

[Liz Brooks JD IBCLC FILCA]

Hear, hear. You have described our profession, and our obligations to mothers, well.

[Lara]

My unfortunate experience with a consultant began and ended with "Since you've given up...". My resounding answer upon reading the title question was "NO!" It is comforting to know I just ran into a judgemental person.

The problem is that I didn't give up. I fought hard and lost due to an injury that prevented me from doing anything but lie flat on my back and horrible medications that were not safe for breastfeeding. Because the nurses in the hospital were supportive of me maintaining my supply, I turned to the nurses at our local health unit.

I also turned to various websites on bottle-feeding the breast-fed baby. I think that this points out that an IBCLC can help with proper formula feeding. As I said, a judgemental person turned me bias against getting help from a consultant. She damaged not only my self-esteem, but the profession she attempted to represent.

Thank you for this article above.

[Teri]

Your perspective seems well-balanced. However, I would like to stress that many, many parents have not run into good IBCLCs like you. It seems to me that many of your colleagues are vastly misrepresenting your profession, if you say that IBCLCs are supposed to be able to provide proper bottle support. Perhaps they're supposed to, but far too many seem to choose not to, and I see no quality control procedures in the profession to ensure this. This is why my overall opinion of the profession is very low, and I believe a massive amount of reform is necessary before the vast majority of IBCLCs can be truly trusted to give proper, INDIVIDUALIZED infant feeding support that is about mother and baby's health, not being a slave to a cause.

You say to keep looking until you find someone willing to support your breastfeeding goals, but I have to ask, till when? How many times can a mother face truly heinous advice that harms her and her child, vicious rejection from the people supposed to help her, and people who care so much about the cause of breastfeeding that they fail to recognize that breastfeeding has its risks for many women? Risks such as starvation for the baby because all women are assumed to be capable of adequate supply, even by IBCLCs, and conditions like IGT or PCOS are frequently missed by IBCLCs. Risks like exacerbating PPD/PPA/PPPTSD. Risks like passing medications onto the baby that have never been tested to see if they do lasting harm; this boggles my mind. Lactivists who claim to be so evidence-based and against the formula companies are so willing to trust the very same formula companies (which make pharmaceuticals!) and have no longitudinal evidence that those drugs are safe. Risks like exacerbating auto-immune disease (some of which women have struggled for decades to have recognized as not "all in our heads" and yet these conditions are sniffed at by many breastfeeding zealots as just that). Even just risks of developing mastitis that requires hospitalization, which could mean major hardship especially in this economy...I could go on, but given that you seem to understand that women don't have to breastfeed to be good mothers, hopefully you know what I'm talking about.

You mentioned women needing to know their breastfeeding goals--what if the only goal option a woman's given is "breastfeed or you're a terrible mother who never should have had children in the first place?" That's the message the IBCLCs who taught my 3 prenatal classes essentially delivered. Oh I was informed prior to birth, all right. I knew every breastfeeding hold and every latching problem they taught me; I read books, read websites, everything. Even the class that was supposed to be about all aspects of infant care was mostly about infant feeding, the "risks" of formula, and how selfish mothers are if they want to get more than 2 hours of sleep at a crack.

Breastfeeding education prior to birth preys upon the most basic instincts of new moms--the aversion to being a "bad mother." Breastfeeding promotion in the States is insidious, but in some places abroad it's downright dishonest, not to mention disempowering. Move over, Nestle! Breastfeeding promotion is often not about facts, it's about naked persuasion in which info about alternatives is deliberately withheld, so how can a new mom have any perception of what her breastfeeding goals SHOULD be? You have people online and in person telling mothers that they want to call child services on them for using formula, kicking them out of playgroups and parenting forums if they don't BF, telling them that they are so selfish that formula should be prescription-only to force them into making the "right choice." Breastfeeding has been perverted from a medical decision to a moral one. If a goal is coerced, is it really a goal? Because the societal pressure to breastfeed has in some circles gone from pressure to just that--coercion.

I saw 3 IBCLCs and talked to a one on the phone. They couldn't really help me with bottles, they were there to help with breastfeeding, I was told. Even though it was absolutely apparent that breastfeeding was exacerbating underlying conditions for me, and that I couldn't care for myself much less a child by the time I stopped. The one I saw 3 days after giving birth gave me some half-hearted advice on pumping but couldn't even figure out that I needed larger flanges, I stumbled upon that on my own. The last LC who finally figured out what was going on (why did it take that many LCs, by the way, to figure it out? Because people are so afraid of "booby trapping" women that they will practice bad medicine!) basically said buy some bottles and a tin of formula and go for it. And she was the good LC! When I asked questions about water and sterilizing bottles she referred me back to our pediatrician, even when I said he'd kill me for going to formula. That pediatrician was such a militant lactivist that he refused to return my phone calls once I called asking for formula advice. Prior to that he blasted me (interestingly, not my husband, even though he was in the same room at the time) for supplementing my daughter a little in the hospital because of her jaundice. Imagine telling a 3-day postpartum woman who has slept maybe 10 of the past 72 hours that she has ruined her baby's immune system *for life* because of a few ounces of formula. Pediatrician #2's colleagues were such militant lactivists that they advised going with unpasteurized goat milk "to avoid the corporatist agenda." I'm not kidding. Needless to say, we're on pediatrician #3, who hosts LLL meetings in her office but said it was no big deal when I explained why we were formula feeding.

There is a vast gulf of differences between the experience you're describing in your own practice and the practices of the IBCLCs I met--both the teachers of my prenatal classes and the IBCLCs I consulted with after having my baby. All nice people, but terrible in the bottle support department. The current climate for new moms and moms-to-be is toxic; new mothers are nothing but fresh meat for bullies, scare-mongered into breastfeeding, never informed about the risks of breastfeeding or the situations that might preclude it (on the assumption that we aren't intellectually capable of handling that info without reaching for the formula tin), and never informed about bottles unless we voluntarily submit to a sound whipping with the "breast is best" mantra as "punishment" for going against the grain (even on the formula tins!)--you present a great ideal, but in reality, this is nearly impossible for a sizable chunk of your client base.

I appreciate your willingness to write an article like this and thoughtfully approach the valid questions of "where do I go when this breastfeeding thing doesn't work out? And can I trust the people I'm directed to?" I have no doubt that you do a great job for the women you help. But I have serious doubts about the vast majority of your colleagues. The only way that women are going to come to people like you with the ability to make an informed choice is if that choice is truly informed--not scare-mongered, not coerced, not brow-beaten, not with information about risks of BFing deliberately withheld, not with the risks of formula feeding deliberately overblown, and not group-thinked to death--which is how breastfeeding is promoted now. Perhaps if there were more quality control measures for IBCLCs, more standards like what you wrote published so women knew what they *should* expect when seeing a LC, then we'd be getting somewhere. Thank you for writing this.

[Rebecca (Public Health Doula)]

I thought this was an excellent piece and loved the linked post on safe formula preparation and safe bottle feeding...I am bookmarking it to pass along in the future! I think Fleur makes an excellent point that when we try to make sure a mother is informed, she can hear judgment even when we are trying to be as neutral as possible. It's a difficult line to walk.

I have to say I didn't love the photo, though! It's making me nervous looking at that baby, lying on his back having liquid dripped into his mouth - it makes me worried he's going to choke. I like that it shows that there are other ways besides bottles to give formula, but I would much rather see a photo of a baby being supplemented at the breast, or cup fed!

[Carina]

When I went to an IBCLC for help with nursing my first child she gently explained that the number one rule was "Feed the Baby." No matter what, it was most important that the baby was getting fed, no matter what baby was getting fed with. She helped me set up a supplementation and pumping schedule that eventually got us back to nursing exclusively. I'll be forever grateful to her for saving our nursing relationship and helping us to use formula as a tool.

[Josette at Halushki]

This is a great article. I wish all lactation consultants would read it.

I have three kids, breastfed until they could break chicken bones between their teeth. I also supplemented at different times for different reasons and lengths of time, sometimes in the very beginning, sometimes in the middle.

Unfortunately, I didn't meet up with any non-judgmental lactation consultants. It was all "all or nothing" and "if it's not working, it's your fault for not trying hard enough." The crusher was by my third child, when I had some simple questions, I was condescended to as if I had just discovered I had boobs that very morning, let alone already breastfed too children.

Am I bitter? Only around my salty edges.

[Josette at Halushki]

two, of course, not too

[Karyn-grace Clarke]

Another well-written article! Thank you Fleur & Annie.

As an IBCLC in private practice, most of the clients I work with are already using formula to some degree, which is why they find me or are referred to me - their goal is to either get their baby off formula or to maximize their milk production while also using formula. In some rare cases, because the goal when dealing with newborns is FEED THE BABY, infant formula is started after I begin working with a family, but only as a stop gap until we can figure out what the breastfeeding problems are.

With all of those types of cases, it goes without saying that a mother needs to know HOW MUCH formula to provide and HOW OFTEN. I can help with that, because both over feeding and under feeding is a big problem with little babies, and I have a good understanding of what infants need.

Also, when introducing formula to a breastfed baby or to a baby who's mother is trying to establish breastfeeding, is HOW TO ADMINISTER that food. Sometimes we use syringes, sometimes finger tubes, sometimes a supplemental nursing system, sometimes cups, and sometimes bottles. I can help these families choose a correct feeding method for them, based on mothers milk production levels, over all health and state of well-being, any oral/physiological challenges that baby may have, as well as what works best for mother's lifestyle.

But! What I CANNOT do, and what I won't do, is recommend to a family WHAT TYPE of infant formula to use. That is completely beyond the scope of my experience, and, I believe, puts me in jeapordy of violating my professional ethics. In my professional opinion, only a qualified health care professional (Registered Dietitian would be the standard, but a Public Health Nurse or Medical Doctor with special training in this field would also suffice) should recommend a specific brand or 'formula', based on an infant's current health and their genetic and lifestyle considerations.

So, to sum up, as an IBCLC I do *not* recommend infant formula to any family. However, I do sometimes have to inform a family that baby needs additional calories than what mom is able to provide at the time. After considering the options, if that family decides to use infant formula to ensure that baby is well-nourished, I first suggest that they speak with their doctor or health nurse to help them choose a product that is right for their child, then I help them figure out when and how to feed it to baby while continuing to establish or build their milk supply.

Thank you for bringing up this issue.

~kg

[Karyn-grace Clarke]

Exactly, Amber! I just started a dialog on Facebook about this very thing: How parents are left in the dark when trying to decide what food to feed their babies (when they can't or won't breastfeed), and how they receive their information about what formula to use from the very companies who MAKE it. Manufactures can hardly be seen as giving an unbiased opinion of their product and they certainly cannot be seen as knowing what is best for any infant they have not met nor assessed.

Feel free to chime in: http://on.fb.me/qhD4JZ

[Kathy Morelli]

Nice balanced article. I used a lactation consultant once, to assist with positioning. She was non-judgmental and wonderful. She tried to helped me with my PPD issues, which were long-term, and goodness, it was once visit! But breastfeeding actually was one of my experiences that helped me get through a very debilitating and long bout with PPD. ,even a good therapist I saw for a while didn't really help me. I refused to take medication, as this was 17 years ago, now we have so much more info abt psychotrophic meds, that I realize now it would've been safe for me to help myself with this modern convenience.

[bhn]

Yes! Feed the baby, and love the baby. That is what matters.

I too am forever grateful to my IBCLC for saving my nursing relationship with my son. It was rocky at 5 weeks and at 2 years it was still delicious.

[Becky]

As someone who was told I had to give formula, the attitude by my consultant was not helpful. When I asked what type I should give I was told *it doesn't matter*.
It's just an additional heartbreak to A) not be able to breastfeed like envisioned then B) be told that the substitute you are being told you need to fill that gap is so unimportant that the differences don't even bear discussing. What you want at that point as a heartbroken mother is some kind of support, some kind of information. It doesn't have to be a recommendation of a brand, but when a mother finds herself needing to use formula against her original plans a little sensitivity goes a long way. I know the WHO does mandate the ingredient list to some degree, but to outright dismiss them 'as all the same; it doesn't matter' is very unhelpful. I had one LC who I saw after I was already supplementing. I just went to make sure the SNS was the best thing I could be doing and see if I could get any additional help (I couldn't). She was very open to discussing formula types with me, yet did that without recommending any brand. She simply said things like, this one has more protein, this one has less iron and so on. These are things that you can get off the tins or from the manufacturers, but she'd read them, memorized some key point about each one so that when someone asked, but which do I use, she had an answer that didn't promote anything. It empowered me, made me feel like I could make a choice when I'd already had the choice to exclusively breastfeed taken away from me. That's probably all mothers want. Just some guidance, support and the return of feeling like they have some control over what is happening. Just recognition that they do want to do their best.

[Nicole Davis]

Thankyou for writing this beautifully worded critique of the LC profession. This should be posted on every Breastfeeding Association website in the western world so that other women know they are not alone in their breastfeeding difficulties. I encountered the same dogma in my prenatal classes and my baby was denied any formula in the hospital even though after 5 days my milk still hadn't come in. She lost so much weight the paediatrician had to step in and demand the midwives feed her formula. We are lucky in Australia that our obstetricians and paediatricians believe largely that it does not matter what you feed your baby as long as they are fed. I suffered postnatal depression brought on solely from the attitude of lactation consultants and child health nurses toward bottle feeding. I would not be bullied with my second child and ended up being able to breastfeed well albeit on a strict routine which didn't go down well with the nipple nazis! Thankyou for this response.

[Fearless Formula Feeder]

Interesting article. And I'm a big fan of Fleur - I think she takes a very nuanced approach, in general, and I appreciate her honesty about her bias.

I have thought about this question a lot, because I actually do get quite a lot of requests for advice about formula feeding. It puts me in an uncomfortable position, for a few reasons: 1) My area of research is the breast vs bottle discourse, not necessarily the mechanics of formula feeding itself - in fact, I would posit that I know more about the logistics of breastfeeding at this point than I do formula feeding. Ironic, huh? 2) In the case of a woman who has yet to give birth (and these are typically the people emailing me in this regard) I always feel the need to "encourage" her to keep an open mind about breastfeeding, unless she has told me specifically that she has a strong opposition to doing so.

#2 is the reason why I do not believe an LC is a good person to be giving formula feeding advice, or even combo feeding advice. Because I'm the freaking "Fearless Formula Feeder" and even I probably end up unintentionally guilt tripping moms who've made a decision to bottle feed, even though I wholeheartedly think it's okay for them to do so. I think I just still believe that breastfeeding is so inherently awesome (up until the point that it becomes NOT awesome, something I think happens to quite a lot of women, which is where I part ways with most LCs, I imagine) that I want every woman to succeed, and hope that by hearing from me that it can work out and be sunshine and roses, she'll be inspired and not have to suffer the fate of self-doubt, defensiveness and guilt that so many formula feeders do. We all have our bias, especially those of us who are so entrenched in infant feeding.

On the other hand, if I had the medical expertise to do so, I think I COULD offer advice on formula feeding because in the end, I have a stronger bias towards getting the baby fed in a way that makes the mom happy. The problem is, people like me do not pursue the IBCLC credential. I've thought about it, to be honest. I even made some calls. But I couldn't fathom sitting there with my teeth clenched through class after class of advice that I don't agree with, on principle. I've read enough lactation training textbooks to know what I'd be asked to take as gospel, and I don't have the stomach.

I think it is unfair, punitive, and dangerous that we do not have Feeding Consultants - people who have simply been trained in the mechanics of all feeding methods, without the philosophical stuff behind it. As Teri stated above, this should be treated as a medical decision, and not something with moral indictments attached. The best LC I saw was one who told me that she believed in breastfeeding but felt that "god made formula too", and without blinking an eye, showed me how to supplement as part of our meeting - thus saving my son from inevitable starvation, considering he never quite got that latching thing, which was causing a huge delay on lactogenesis 2... but that's another story.

[Lynn]

What a great discussion. It's very hard to strike a balance, and to have any assurance that what an LC says is actually what a mom hears. For example, we know that there really isn't that much difference between major brands of formula and the generics, and I could see how a mom would hear that as "It doesn't matter," and really take that personally.

When I meet with a mom who is supplementing or needs to, I always tell them that Rule #1 is Feed the Baby, but RULE NUMBER ONE is that Mom is the expert in her own baby and her own family. I'm there to come alongside and provide information and support, but this is her family and her decision and I respect whatever she chooses and want to make sure she knows that she can change her mind or alter course at any time and I will keep walking with her as long as she wants me to.

I let moms know that formulas all follow the same basic nutritional guidelines, but sometimes it takes a couple tries to find one that agrees with her baby, and that sort of thing should be discussed with her pedi. I help with mechanics of delivery, and I always provide mom and doc with a copy of the who guidelines on safe preparation.

[Susan E Burger]

Dear Nicole:
Again, I'm sorry you did not initially receive sufficient postpartum care from the LCs in your area. As an IBCLC with a PhD in Nutritional Sciences I would respectfully disagree with the somewhat patronizing dichotomy of "breastfeeding is best, but it doesn't matter if you use formula" that you were given by your health care practitioners. It DOES matter what you feed your baby and part of assessing risks is, as others have said, starting with priorty #1, that you must feed your baby. With my PhD in Nutritional Sciences I have come to recognize that many health care practitioners only receive marketing information that is thinly disguised as a lecture and sometimes even makes it into peer-reviewed literature. I would have taken the time to talk to you about a WIDE array of substitutes for your own milk and the risks involved in each, including donor milk, and the vast area of different TYPES of artificial substitutes. I would NOT have talked to you about BRANDS. I would have told you why the ready to feed liquid formula was a safer option than the powder in terms of reducing the risks of bacteria and let YOU make the choice once you had the information about ALL the various options.

One nice way I have found to think about breastfeeding problems is the diabetes analogy. If you don't have diabetes, you would never need to use insulin and it wouldn't make sense to use it, or be given promotional samples of it. If you had type II diabetes, you my have to use insulin and your health care practitioners would help you figure out how to improve your diet and incorporate exercise that might enable you to get off the insulin. They would not tell you its just as healthy to have diabetes, but they would praise you for doing the steps that were possible. If you had type I diabetes, you would have to use the insulin and they would still help you figure out how to maintain a healthy lifestyle. At the same time, researchers would continue to work for a cure so that sometime in the future you might not need the insulin.

Post-partum despression is not brought on by other people, but other people can become a focal point for blame. When breastfeeding does not work well, you are deprived of oxytocin. Lack of oxytocin can definitely change the serotonin levels to the point that it can tip the balance. When people seem to be working against you it can exacerbate the feelings that are brought on by that imbalance. And feeding is so crucial to our role as mothers, that it can feel like feeding is the cause because it is the one thing that we do so frequently in the early postpartum period. I work with many many mothers and have seen the many ways in which women are not given appropriate help with infant feeding -- and it runs the gamut from terrible shaming for trying to breastfeed to terrible shaming when breastfeeding is not going well. No one can make you feel guilty - that is an internal emotion -- BUT people can SHAME you for not doing what they think is right. I would say that is an equal amount of SHAMING on both sides of the issue, at least here in Manhattan.

Finally, as one who has worked with mothers whose relatives survived the Holocaust, I am going to ask you to refrain from using the term Nazi. Using the term Nazi lightly can be for some people as horrible as using the term Nigger lightly. Nazis committed genocide. Dogmatic advice about infant feeding whether it is the family members who tell women that it is "disgusting to breastfeed" or "you're poisoning your child with formula" is not in the same category as genocide. Both, in their own way are trying to offer advice to help you, even if they are really NOT being helpful (to put it mildly). You have a perfect right to complain about your lack of care, but please for the sake of those who did survive the Holocaust, do not equate it with the Nazis.

[Susan E Burger]

Nicole:
Congratulations for toughing it out with your second baby and figuring out a way of feeding all on your own. I feel bad that you were NOT given the actively engaged support with your first baby. Anger is a perfectly fine emotional response to such a situation --- and is one part of mourning the loss of that perfect image of lovely feeding that all women have in their heads before their baby is born and not all women get. I've been taking Martial Arts to keep fit and I'm wondering about bringing in hand mitts to my groups for moms to punch --- to let them release the anger about all the stupid things they have been told that make them feel bad. Perhaps this might help the release the anger and get to a point where they can laugh about the stupidity of generic advice.

[Nicole Davis]

Dear Susan
Thanks for responding so kindly to my comment. I apologise if nazi references offended, we here in Oz tend to colloquialize and use expressions with ironic intent - a cultural difference I should be more aware of.
I would quickly like to address the post partum depression issue. Whilst I accept that it can brought on by physiological issues, one must never overlook environmental causes in any disease. Both are contributory factors. Take the diabetes analogy (esp Type II): you may develop diabetes because your body cannot adequately use insulin or produce enough, but if you intoduce environmental factors such as obesity and a sedentary lifestyle, you have an increased risk of developing this disease. This is a simplistic analogy but I am certainly of the belief that you cannot have a physical condition without an environmental catalyst. Food for thought I guess.
Thanks also for the comments about being able to breastfeed my second child. Whilst it was more difficult than bottle feeding, I am happy to say I enjoyed it for the 5 months I breastfed and with the benefit of hindsight can happily say without a trace of guilt that I believe that both my children have received equal nutrition.

[Vicki]

What a great piece.
I had a breast reduction when I was 22, and now at age 30, I'm facing the consequences of that choice (which I do not regret at all; it was much needed). I have a 9 month old son, and I breast and bottle feed him.

I saw a lactation consultant through the birth center where I went for prenatal care, and she encouraged me to supplement around 1 month, when my son was gaining weight slowly. Our pediatrician said he was ok and encouraged me to keep exclusively breastfeeding while taking him for weekly weight checks. When he was two months old and had only gained 2 pounds (from his lowest weight after birth), we decided to supplement him. With evil formula. I cried.

He's a chubby, happy boy. I still nurse him to sleep and through the night, but he gets a small bottle when he wakes from his naps, and before bed. I hate giving him the formula, but I love that he is healthy and happy. That is more important.

[Laura Gruber, IBCLC San Antoni]

Congratulations on a well-written post! As an IBCLC, I appreciate any and all conversations which help explain our role in supporting moms. IBCLCs are not "Breastfeeding Nazis" and we're not anti-formula. Every willing mother, regardless of feeding-choice should be embraced, empowered and respected for her concerns, her questions and her good intentions. Whether a mom plans to breastfeed for a feeding, a day or a year...or...decides that breastfeeding isn't for her and her baby...she has my love and support in responsibly implementing her feeding plan. Thank you, Fleur!

[Judi Hall]

thank you for this article which I have just read. I was one of those mothers who needed to supplement her babies. With my first, I received bad advice repeatedly because no one would say to give formula. My 8 lb. 2 oz baby boy who was nursing 20 out of 24 hours a day was 6 lb. 12 oz at 2.5 weeks of age. My second child was born in 1985 and I saw a lactation consultant when she was 3 days old. For those of you in the profession, my LC was Joanne Scott! I can still hear her saying, "Formula is not the enemy." The belief that anyone can make enough milk was just being questioned. Our profession needs to take a serious look at being the kind of LC described in this article. I also hear Linda Smith saying, "Rule # 1, feed the baby." In our Lactation department, one of our first assessment questions is to ask mothers what their goals are. We then give information that may or may not help her consider a bigger goal, always telling her we are there to support her goal. We must support mothers in mothering, not just breastfeeding.