The Right to Breastfeed
Many women who would like to breastfeed are not given the right to decide about breastfeeding their baby or continuing breastfeeding their baby. In fact, many mothers are being told that there is no difference between breastfeeding and artificial feeding and thus are not, in fact, being given the information to make an informed choice. What woman would choose formula feeding if she were told that there is considerable evidence that mothers who breastfeed have a lower incidence of breast cancer, ovarian cancer and possibly uterine cancer and that the longer she breastfed the lower the risk?
Am I kidding? Who is going to stop a mother from breastfeeding?
The truth of the matter is that mothers do not seem to have the right to breastfeed and are forced, by health professionals, judges and child protective agencies not to breastfeed from the earliest days after the birth of their baby as well as to stop breastfeeding if they have started.
Even when things are going well, mothers are frequently told they must add cow’s milk to the baby’s diet, presumably because “there is nothing in breastmilk after a year”. They are often told they must stop breastfeeding altogether for this very reason, or because their child will be “overdependent” or incredible as it may sound, because breastfeeding past a certain age is abuse. This is not commonly said, but one child psychiatrist in France did make this statement to a newspaper. “One does not share the breast: to extend breastfeeding past 7 months is without doubt sexual abuse”. The mind boggles.
Mothers who had wanted to breastfeed and had trusted the health care system to help them prevent problems with breastfeeding or overcome problems with breastfeeding, are frequently left feeling guilty for not breastfeeding, feeling that they “failed” or feeling that they “couldn’t” breastfeed for medical reasons. They do not know that the health system actually undermined their breastfeeding and so they blame themselves, not the practices around labour and birth and after the baby was born that destroyed their breastfeeding. A lot of formula feeding by mothers who had originally intended to breastfeed would never have been necessary had the mothers been given the correct information that their medical condition or use of medication had not required them to stop breastfeeding.
In addition, the mother’s fear of the baby starving or his health being compromised are used as scare tactics to get mothers to consent to formula feeding and to shake her resolve to breastfeed. If health providers actually knew how to know a baby is well latched on and how to know a baby is getting milk from the breast even in the first few days after birth, then the health provider would know if the breastfeeding is going well or not and would know how to help the mother and baby if the breastfeeding is not going well, before the baby gets into trouble. Because they do get milk in the first days, even with the first latch, as shown by the pause in the chin as the baby opens to the maximum, where the pauses are rather short but present. See video 2, below. See also the other two videos.
Video 1. This baby is drinking very well from the breast. The pause in his chin as he opens to the widest shows his mouth is filling with milk. The longer the pause, the more milk the baby is getting. This baby is 3 weeks old, the milk flows quickly. But in the next video, the baby is 10 hours old, but still getting milk.
Video 2. This baby is only 10 hours old. He is latched on well and the mother is using breast compressions to help him get milk. The pauses are short because mothers don’t have a lot of milk in the first few days. But they get enough, if latched on well, and sometimes breast compression helps the baby get more.
Video 3. This baby is only 24 hours old but drinking very well from the breast, receiving much more milk than the average baby at this age. How to know? The pause in the chin as the baby opens to the widest.
The medical professional’s knowledge of breastfeeding is, in general, so poor that if the slightest breastfeeding problem arises, the first thing many mothers will hear from a large majority of doctors is “give the baby formula” or even “stop breastfeeding altogether”. Mothers are often forced to supplement, or stop breastfeeding altogether, not infrequently in cases of slow weight gain, with a threat of the child protection services taking away the baby if they don’t comply with “doctor’s orders”. This is appalling because the doctors who would do this, without referring to someone expert in management of breastfeeding problems, often haven’t the slightest notion of what is going on and what can be done to improve the situation and depend only on the baby’s weight. And weights are unreliable as a way of evaluating the adequacy of breastfeeding.
It is clear from our experience with many thousands of mothers having come to our breastfeeding clinic during the past 33 years, that much can be done to help the mother and her baby who is not gaining weight satisfactorily. With a little good help, the mother could carry on breastfeeding exclusively. However, in only a small minority of cases do the mothers actually get the help they need because the mother and baby are not referred to someone who can help, and, unfortunately, that is not the pediatrician, who should know, but only rarely does know.
Sometimes the solution is easy. The way the baby is latching on can be adjusted so that the mother no longer has sore nipples and the baby gets more milk from the breast with this adjustment of the latch.
Another way of adjusting the latch is by releasing a baby’s tongue tie. Sometimes the effect of releasing the tongue tie is dramatic in increasing the baby’s intake of breastmilk. Quite often using breast compression will increase the baby’s intake of milk enough so that the baby does not need supplementation.
But, true, sometimes it’s not so easy. However, even if the baby needs to be supplemented, the baby can be supplemented at the breast with a lactation aid at the breast. This preserves the breastfeeding whereas supplementing with a bottle, the usual way recommended by health professionals, most often ends up with the baby refusing the breast.
Photo 1. Lactation aid at the breast, used to supplement a baby when the baby may not be getting enough from the breast and other approaches have not worked. Breastfeeding is not just about breastmilk, it is a relationship, a close intimate, physical as well as emotional relationship. One way to help mothers preserve breastfeeding even when the baby is not getting enough is to use a lactation aid (which is different from and works better than the SNS) at the breast to supplement.
But most mothers don’t get such help. Most of the time, mothers are left feeling frustrated and devastated because they desired to breastfeed and due to the lack of qualified help or incorrect medical advice they begin to see breastfeeding as “unreliable,” “painful” and “potentially dangerous” and ultimately, the importance of breastfeeding as “exaggerated”. When women are prevented from breastfeeding when they wanted to, they may become angry and traumatized, unable to see and experience the joy of breastfeeding and they resort to all sorts of coping mechanisms which resurface in discussions of infant feeding. One of the coping mechanisms is blaming breastfeeding, when it is not the fault of breastfeeding, but the fault of the system that let them down.
Below are just a few examples of how we don’t allow mothers the right to choose to breastfeed their babies. They are examples of how formula feeding is considered the standard way of feeding and breastfeeding is seen as a dispensable, nice, but not necessary.
Many obstetricians and family doctors will offer formula company “information” pamphlets and quite commonly will also give out formula samples to the pregnant woman, both “gifts” coming in a pretty, cute little bag, along with coupons to buy formula at a lower price. The “information pamphlets” quite often imply that formula is as good as, if not better than breastmilk and that breastfeeding is necessarily painful. Breastfeeding is not necessarily painful. If breastfeeding is painful, then something is wrong, but many health professionals believe that pain is a part of breastfeeding. These pamphlets imply also that formula is a normal part of infant feeding, even if the mother is breastfeeding, and the use of formula will allow the father to take part in the feeding of the baby and that, well, “sometimes, you just want to take a break”, implying of course, that breastfeeding is hard work. It shouldn’t be hard work. In fact, mothers for whom breastfeeding is working well, will usually say how relaxing and easy breastfeeding is. But when it’s hard, it’s because of how we help, or rather, don’t help, indeed undermine, mothers ability to breastfeed.
The above photos from a typical “information booklet” from a formula company tell the story. The “gifts” are meant to undermine breastfeeding. It is patently clear to the most casual of observers. When these “gifts” come from a person of authority like the family doctor or obstetrician, it means a lot. It’s an endorsement of a product by someone the pregnant woman trusts enough to care for her and her unborn baby. But do doctors, including obstetricians discuss breastfeeding with the mother to be? At most they might reply “good, breast is best” to the mother who responds that she plans to breastfeed. And if these “gifts” come from a family doctor or pediatrician after the baby is born, well, the mother trusts these people with the care of her now born baby.
Mothers of babies born prematurely are almost universally told (at least in North America) that they cannot put the baby to breast until the baby is 34 weeks gestation (still 6 weeks premature). This undermines breastfeeding partly because the baby could usually have started much earlier than 34 weeks gestation and partly because the doctors and nurses insist the “babies must to learn to bottle feed before they can breastfeed”. Really? Where does that magic age of 34 weeks come from? Not from any scientific studies. But we do know from work in Scandinavia that premature babies will often latch on to the breast at 28 weeks and sometimes even earlier than that. Not all, but at least some. And it is not rare that premature babies can be exclusively and completely breastfed (at the breast) by 32 to 33 weeks gestation, 1 to 2 weeks before we even allow the babies to try to breastfeed in North America. (It is necessary to add “at the breast” because so many in Western societies believe that giving breast milk in the bottle is breastfeeding – no, it’s not at all the same).
Mothers of premature or sick babies or babies who are not gaining well are told that they must supplement with a bottle because breastfeeding is more tiring than bottle feeding. This comes from the mistaken notion that babies have to work to get the milk out of the breast, that they suck milk out of the breast. But that is just not how breastfeeding works. It is the mother who transfers the milk to the baby. The baby, of course, does his part, by stimulating the breast to “release the milk”. It is complete nonsense to say that breastfeeding is tiring for a baby, but it is widely believed because most health professionals learn almost nothing about breastfeeding in their training and nothing after they finish their training.
Babies respond to milk flow (see video 4 below) and if the flow is slow, the baby tends to fall asleep at the breast, especially in the first few weeks of life. The baby falling asleep at the breast and then obviously still hungry after coming off the breast is taken as a sign that breastfeeding tires out the baby. And this situation occurs simply because most mothers are not taught the basics of breastfeeding, (including how to get a good latch, and how to know a baby is getting milk from the breast or not getting enough from the breast or something in between). Watch video 4 showing a premature baby responding to flow from the breast. Furthermore, the breast has to compete with the flow the baby was receiving from the bottle and the fact that the mother’s milk supply is dwindling because they were pumping instead of being skin to skin with their babies and breastfeeding.
Video 4. Babies do not tire at the breast. Babies respond to milk flow. It is a complete misunderstanding of breastfeeding to suggest that babies “pull milk out of the breast”
Mothers of babies born prematurely are almost universally told that their milk is not good enough for a premature baby and that the baby must receive “fortifiers”, called “human milk fortifiers” which gives the impression that they are made from human milk which is not the case (though “fortifiers” have been made from human milk). The “fortifiers” are actually made from cow’s milk. Yes, sometimes “fortifiers” are helpful to make the baby gain more weight and assure adequate intake of nutrients, but the way they are used suggests very strongly that the use of “fortifiers” is routine! Even babies only a few weeks premature will receive fortifiers in most North American and European hospitals. But most of the time they are unnecessary. Some neonatologists/pediatricians will tell the parents that the baby needs to have breastmilk “fortified” until the baby is 10 months old. That is completely absurd.
Mothers of babies born at risk for low blood sugar are often forced to give or allow the baby to be given formula (by bottle of course). But it is known that breast milk, especially the very early milk called colostrum, is better for preventing and treating low blood sugar than formula. Most often, if the mother gets good help with breastfeeding, the baby is protected by breastfeeding (at the breast, because skin to skin contact also helps prevent low blood sugar).
Mothers whose baby has jaundice in the first few days are often forced to supplement their babies with formula, or even take the baby off the breast altogether because the health professionals “helping her”, think that breast milk causes jaundice. It doesn’t. What causes higher than average levels of bilirubin in the majority of babies of that age is that the baby is not getting enough breast milk. And the answer is not usually formula, but rather helping the mother breastfeed better and get more milk to her baby. Watch video 5 (below), of a baby drinking very well at the breast at the breast even though he is somewhat jaundiced. Even though he is 10% below birth weight, this is irrelevant because he is drinking so well. In the first few days, it can be so easy to turn inadequate breastfeeding around and make it work well and even prevent problems in the first place. Unfortunately, too many mothers and babies are not getting that help. And the worst of it all is that because the baby’s jaundice decreases rapidly once the baby is being formula fed, this proves to the health providers that they were right, that the breastmilk caused the jaundice, when in fact, the reason the jaundice decreases is that the baby now gets more milk. Could this decrease have been accomplished by helping the mother breastfeed more effectively? Yes, but it happens only rarely that mothers get this help and the default treatment is formula feeding by bottle. It is just so much easier and takes so much less time to tell the mother to feed the baby formula.
Video 5. This baby is breastfeeding very well, shown by the very obvious pauses in the chin. But he is 10% below birth weight and the mother is under pressure to supplement, strictly on the basis of the weight. This is so wrong, especially since basing the adequacy of breastfeeding on the weight is unreliable, especially if the mother received intravenous fluids during labour and birth.
Mothers are told that if their babies have a cleft palate then they cannot breastfeed and should not even bother trying. True, many can’t latch on to the breast, but some can. But one thing is certain; if one doesn’t try, breastfeeding can’t happen. The baby in this video has a cleft of the soft palate and he is breastfeeding (at the breast).
Mothers are told that if their baby loses more than 10% of their birth weight the baby must have formula by bottle. But the notion of 10% weight loss is based on nothing scientific at all and results in many babies being unnecessarily supplemented and as a result, much too often ending up only bottle feeding. Again, the mother and baby getting good hands on help can change the situation dramatically for the better. People sometimes act as if getting the baby fed and the baby being breastfed were mutually exclusive. The goal of helping mothers should be to get the baby fed by improving breastfeeding. Health professionals need to start looking at the long term effects of their interventions, not just grabbing at the quick fix which formula feeding seemingly offers. More on why percent weight loss is not only meaningless, but damaging to breastfeeding.
Mothers are told that if they have had breast reduction surgery, they won’t be able to breastfeed. Maybe most won’t be able to breastfeed exclusively, but they can still breastfeed with additional properly screened donated breast milk or formula as supplements. And the baby can be at the breast, without bottles, the supplement given with a lactation aid at the breast. Supplementing while the baby is still on the breast is important because, aside from the baby continuing to get more milk from the breast even as the baby is being supplemented, but also, very importantly, breastfeeding is so much more than breast milk. It is a close, intimate relationship between two people who are usually very much in love with each other. The value of that relationship is not measured by how much breast milk the mother can produce and it is important that people start seeing breastfeeding in its different forms.
Too many mothers are told they must interrupt or stop breastfeeding for medications they are taking. This is not true except with a very few, usually infrequently used drugs, many of which could be substituted by other equally effective drugs. The vast majority of drugs don’t get into the milk in quantities that are harmful to the baby, the amounts being vanishingly small. There are some drugs that don’t get into the milk at all and yet mothers are told they will harm their babies if they continue breastfeeding. In any case, the real question is this: Which is safer for the baby, breastfeeding with tiny amounts of drug in the milk (and the amounts are almost always tiny) or formula? Given the risks of not breastfeeding, in the vast majority of cases, breastfeeding is safer. For more on maternal medications and breastfeeding.
Judges dealing with access and custody cases, do not include the needs of the breastfed baby or toddler in their decisions, even though the guiding principle in these cases is the best interests of the child. Both father and mother could be accommodated in terms of spending time with the baby if the judge realized that breastfed babies and toddlers are different from bottle fed babies. And breastfed toddlers are even more different than the baby. Whether one agrees or not about toddlers breastfeeding, the breastfed toddler derives security and comfort, and yes, love, from the breastfeeding. As mentioned previously breastfeeding is not just about nutrition, a notion that is obviously foreign to so many people, including judges. For the toddler, being forced from the breast can be extremely disturbing emotionally. And it won’t be easy for the mother, or the father for that matter.
In many areas, the child protective services are a huge problem. Instead of mothers getting help to continue breastfeeding, what the mothers usually get is “Stop breastfeeding, give formula, or we will apprehend your child”. These workers just do not understand, they refuse to understand, they do not realize that help is possible. The most recent case I saw was that of a 6 month old baby who definitely was not gaining weight well. I saw the mother and baby and saw that the best way to deal with the situation was to have the mother add solids and to feed the baby on both breasts at a feeding (she had been told by a lactation consultant to feed on one breast only at each feeding which is a bad idea). The baby started to gain weight well, but the child protection services were unhappy. She didn’t listen to them and the mother was supposed to give formula. So they apprehended the baby. They showed her, didn’t they?
These issues are just a few of dozens of situations when mothers are unnecessarily told to stop breastfeeding, must stop breastfeeding, or else. Most of the time, the problems could have been prevented in the first place or treated without using formula or stopping breastfeeding. But most of the time, the mothers do not get the help they need.
I am not saying that breastfeeding will always work, even with the best of help, but a lot more mothers and babies could be doing a lot better.
If I went through all the situations I hear about on a daily basis, situations where mothers do not have the right to breastfeed even though they made an informed decision to do so, I would be writing something rather longer than War and Peace. Even if I just went into details regarding the above mentioned problems, it would take a book – many answers can be found in our information sheets or in our blogs.
If you need help with breastfeeding, make an appointment at our clinic.
Copyright: Jack Newman, MD, FRCPC, 2017