Sometimes, Breast Isn’t Best (Really)

Peri-Natal Psychiatry
Photo attribution: Photo by NIKOLAY OSMACHKO from Pexels

A modified version of this article was originally posted on wellrounded: I’m a doctor and I think breast isn’t always best: why we are putting too much pressure on new moms to breastfeed.


 

Establishing nursing with my oldest two children was never a struggle – it was comforting, enjoyable and felt like our special, protected time. My third, a preemie, latched and ate readily but rarely kept milk down, at times even vomiting blood. She struggled to gain weight and was clearly in pain. ‘Push on, continue to breastfeed’ advised my friend, a well-meaning lactation consultant and midwife. ‘Breast milk can’t be the problem.’ But, then we heard ‘Start a prescription formula, stop breastfeeding,’ from our trusted gastroenterologist after running tests, prescribing medications and finally admitting we had run out of options. My baby had taken to breastfeeding so well that day in the NICU, 24 hours after her early arrival, and it had given me hope. Now, I felt broken, scared and sad, but this was about her health, not about me. I stopped nursing and never looked back. I had failed in my plan to breastfeed my third and last baby for nearly a year, as with my older kids. But, we remained as bonded as ever, staring into each other’s eyes over a bottle rather than a breast, and my baby started to grow and thrive. In our case, breast wasn’t best. Are we really such an exception to the rule?


Breast milk is undoubtedly the ideal nourishment for an infant and baby. Many women plan to breastfeed their babies, and for the lucky, breastfeeding is a rewarding and easy experience that facilitates bonding and nurturance. However, for some moms, the act of breastfeeding can range from difficult, to taxing and painful, to absolutely impossible, and the inability to attain this goal can supercede the joys in having a newborn. Our culture often focuses on breastfeeding at the expense of a new mother’s mental health and wellness, too often forgetting that filling baby’s belly is ultimately all that matters.

 

Breast And Formula Feeding – A Quick Historical Perspective

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Breast milk was considered the optimal baby nutrition in the 18th and 19th centuries. Mortality rates were incredibly high for bottle-fed babies due to factors such as poor bottle sanitation procedures, unpasteurized animal milks, and malnutrition. The early 20th century saw a profound reduction in infant mortality owing largely to the introduction of glass bottles and the subsequent release of Liebig’s formula, the first artificial formula considered a reasonable alternative to breast milk. By the 1940s, the general consensus among pediatricians and the overarching opinion of the American Medical Association (AMA) was that formula was a safe alternative to breast milk.

Rates of breastfeeding declined steadily until the late 1960s into the 1970s. People viewed breastfeeding as an uncultured practice maintained by the uneducated and those unable to afford formula. Many viewed the practice as ‘disgusting.’

Since that time, public support for breastfeeding has swung back into the pro camp, increasing so much over the past 20 years that in some circles there is currently almost a blind enchantment with the practice. Formula advocacy is not about supplanting breast milk at all times for all people but instead reasserting the idea that health of mom and baby is ultimately what is most important; the drumbeat of breastfeeding advocacy sometimes obliterates this message. Let me explain.

 

Bottle As Self Preservation

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On a frequent basis, overwhelmed, despondent women who feel they are failing at breastfeeding and thus at motherhood turn up at my practice after first consulting friends, social media, and lactation consultants. Instead of concern and helpful guidance, these mothers are greeted with criticism and a myopic focus on the breast is best narrative.

The messaging is not subtle or flexible. One of my patients who attempted to calm her fussy infant with a pacifier during a breastfeeding information session was called out as a ‘bad example,’ told she was being lazy, and ultimately ejected from the event. Nipple confusion is typically cited as the reason why pacifiers should be avoided, yet multiple studies have failed to find causality between pacifier use and reduced rates of breastfeeding. Pacifiers may actually confer safety benefits as they have been linked with a decreased risk of sudden infant death syndrome (SIDS).

Knowing that she was at particularly high risk for postpartum psychosis and that sleep deprivation was, in her words, “the kiss of death,” a pregnant, bipolar patient of mine painstakingly mapped out a plan to fulfill her dual goals of breastfeeding while remaining emotionally well: she would breastfeed by day and have baby receive a bottle at night while she optimized sleep.

Unfortunately, her plan was not honored after baby arrived via a complicated C-section. Shamed for her nighttime formula request, this new mom was woken every two hours by nurses for breastfeeding. A nursery was out of the question; “rooming in” was non-negotiable. After barely sleeping for three days, she was discharged feeling broken and scared and subsequently developed the very postpartum psychosis she had hoped to avoid.

Beyond anecdotes such as these, an extremely common scenario is the woman who initially has no problems breastfeeding but who struggles as time progresses. One such patient of mine became exhausted after exclusively breastfeeding for several weeks. She felt like a shell of her former self, focused as she was on the all-consuming cycle of either planning breastfeeding or engaging in it. Feeding her baby had become a chore rather than an anticipated bonding time. She did not routinely leave the house and could not recall when she last ate a proper meal or showered. She felt disconnected, sad, resentful towards her partner and developed severe anxiety and depression.

 

Formula As A Lifeline

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Crystal Sanchez: 1 Day Old

Breast milk is the optimal source of nutrition for an infant, yet there are a wide variety of modern formula options that are very similar to breastmilk in terms of nutrients and sometimes opting out of breastfeeding can actually be protective.

A 2018 study out of UCSF found that supplementing with formula in the first few days of life does not harm baby – instead for babies who had lost significant weight after birth, providing formula reduced rates of hospital readmission (such as for hyperbilirubinemia) compared with babies exclusively breastfed. In rare cases, a bottle of formula can literally be lifesaving. Furthermore, formula in addition to breastfeeding does not lead to premature weaning, as is often suggested by breast is best adherents, and does not change baby’s gut flora.

Study after study shows that mom’s mental health is intimately bound to baby’s short- and long-term health and welfare. Consistent data indicates that maternal depression is associated with impaired child cognitive and neuro-development, behavior problems in preschool and beyond, and depression in the teen years.

If breastfeeding is for whatever reason detrimental to mom’s mental health, then bottle feeding is a reasonable alternative. Medical evidence and common sense favor this approach, so it’s a mystery as to why our culture continues to shame moms who opt out of breastfeeding.

 

Happy And Fed Baby, Happy Mommy

While breast milk is undeniably the optimal form of nutrition for baby, this is not possible or recommended in all situations, as we’ve covered in this article.

The crux of it is that there is no right or wrong answer – the best way to feed your baby is to do what works: breastfeed, bottle feed, do it all – just don’t beat yourself up or feel like a failure.

Whether the breast glands work or not has absolutely nothing to do with whether someone is a loving, kind and engaged mother. The ability to breastfeed has become a litmus test by which one’s worth and value as a new mom is measured, and this is ridiculous. It’s time to move beyond the politics of breastfeeding and respect each parent’s decision for how they feed their baby. Babies need to be fed, the mode is not as important as the love provided while doing so. Being a mom is a long journey with countless opportunities to nourish and support your child – this is only the first.

 

 

22 Comments

Dr. Nadia

Great article on the history of breastfeeding. I agree that though breastmilk is amazing and breastfeeding is a wonderful experience, it may not be best fit for mom/baby in all cases. Definitely taking a case by case basis is important.

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Carey MH Chavez

As a Maternal Fetal Medicine physician, I could not agree more with you. Breast is best, but unfortunately and for many reasons, sometimes that doesn’t happen. Guilting a new mother is not helpful. In the end, a fed baby and a mentally healthy mom is best.

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Jacqueline Winkelmann, MD

I am a hospital-based pediatrician, and I talk to moms every day about breastfeeding. I encourage them to do what worlks for them. Yes, there are medical reasons why a mother might not be able to breastfeed (my own son had severe milk protein allergy and was on a special formula for 6 months). With my daughter, I just needed a break at night and she had a bottle so I could sleep 6 hours a night-and that is OK! So many moms feel it has to be one or the other, and the combination of breast and bottle feeding can work too! You can just need a break! No guilt! Love this article so much! Thanks for writing it!

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Dr Kennard

Brava!! I am an obgyn with interest in lactation medicine. Failure of desired breastfeeding is the biggest risk factor I see for PMAD (and lived it myself)

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Priya

What a wonderfully written article! Could not agree more with the points made above. Yes breast is best but it is not always right for every mom and baby. So important not to judge and to provide support to all the moms out there.

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J Sant

As a practicing surgeon who rises quite early and a sole income earner for the household, I actually exclusively pump and my kids are extremely healthy and bright! This article is spot on!! I keep my job and my house and my kids get breast milk!

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Lauren

I did not breastfeed either of my two children. I tried my best, even exclusively pumped for a brief time with my oldest, but it was not right for me for various reasons. I am probably in the minority of women who chose to transition to bottle feeding without batting an eye. It seemed ridiculous to beat myself up about not breastfeeding when I did give it my best effort. My baby was eating (formula) so that’s all the mattered to me. I wanted to enjoy being a new mom & loving my newborn. I really don’t understand why some women are so hard on themselves when breastfeeding doesn’t happen naturally or doesn’t work out as planned. It is hard & I wish someone has forewarned me about that! Be kind to yourself & give your baby a bottle. I truly believe that a happy mom = happy baby. Thank you for reiterating that bottle feeding is a fine alternative. After all, I myself was bottle fed & made it through med school!

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Kristen Stuppy

Thank you for writing this! As a pediatrician, I’ve seen too many mothers struggle when they hear the baby should have nothing artificial. I find that pacifiers help more than hinder breastfeeding. A little formula, when used appropriately, can also help mothers and babies successfully breastfeed. Mothers should never be made to feel bad in any way for not breastfeeding, partially breastfeeding, or any other form of feeding – as long as they’re giving either breast milk or a formula that is made for infants that includes all the recommended nutrients. (I’m trying to word this carefully because there are many online recipes for milk substitutes that are not safe.) In general, we need to support moms so that they can help their babies feed and grow in a healthy way!

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Marcia Walker

Great article. I had a lot of milk, but my son could not tolerate it and continue to have diarrhea with it. I donated the my milk for a long time in the hopes that could outgrow his intolerance to my milk. He never did.

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Dr. Zinn

Another outstanding, thoughtful article by Dr. Snyder. Supportive of all mothers and their very personal choices in their quest to deliver the healthiest and best for their newborns.

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Nancy

Spot on. Thanks for this great article. I hope this reaches many moms out there. Opting for formula after struggling with pumping for those precious first few months was the best decision I made for myself and our daughter. I just wish I had given myself some grace and switched to formula sooner. I will always regret wasting those early months obsessing over the few ounces of breast milk I was eeking out rather than enjoying my newborn.

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Dr. April yuki

Great reminder to look at the big picture and remember the bottom line is to provide nutrients to the baby in whatever method works best for you and your baby

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R. Tolar

Great article. I couldn’t agree more!!! I’m a mom of 4. I breast fed 3/4, 2 of which were preemies and one with a facial deformity. We need articles like this!

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Dianna

Great article! I’m a pediatrician and my milk never came in! My baby was admitted for jaundice and 16% weight loss at day 5. I pumped for 5 months (8 times a day) and never got more than 1/2 an ounce per pumping session. Breast milk is excellent, but nursing isn’t possibly for everyone nor is it good for every baby (milk protein intolerance etc). Thanks for your thoughtful article!

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Helen

Mostly good article. Towards the end you speak against shaming mothers who use formula, yet at least three times you start sections with the statement that breastmilk is the optimal milk for babies, hammering home the idea that breast is best and the implication that choosing formula is choosing second-best. How can you speak against mother’s being guilted into choosing breast over formula when you are doing it yourself?

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Carly Snyder, M.D.

Thanks for your comment, however I have to disagree because I am absolutely not shaming any woman who formula feeds – medically, it is well established that breast milk is the optimal nutrition for the vast majority of infants (obviously my youngest daughter and other babies like her being the exception). But, as I reiterated several times throughout the article, moms should not feel pressured to breast feed or to pump because her mental and physical health must be considered in the equation and formula is a great alternative. In a perfect world, all women would be able to breastfeed if they wanted to and all women who didn’t want to would feel comfortable opting to bottle feed – but sadly, our world isn’t this way and thus my message is that ultimately fed is best and that a happy, healthy mom leads to a happy, healthy baby.

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BG

I have to agree with Helen. The simple language “breast is best” is a HUGE part of the shaming culture, and this article repeatedly uses that phrase. Yet the whole point of that article is that it’s frequently NOT best, so why do you keep using it? Why keep saying “breast milk is the optimum source of nutrition”? As if to drive home the point that anything else is second best? Studies show there isn’t a difference between breast and formula feed babies (the exception being extreme preemies, from what I understand) so WHY are you using language to make mothers feel guilty??

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Carly Snyder, M.D.

my hope is no one feels any guilt regarding their choice for feeding their child.

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