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June 21, 2006

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I love this phrase I've seen on a message board before which goes loosely: "Guilt is what happens when your actions contradict your values." In otherwords, it's an internal alarm notifying you of a disconnect, so that you can rectify it. And I think that is useful, don't you?

(as she hears the little signal in her head that say s TURN OFF THE COMPUTER and start to-do list)

You know, I have a lot of thoughts swirling around about this whole thing. I'm planning on breastfeeding, (gah! Gotta call LLL soon!), so it's on my mind right now.

First, I don't know if you saw that Julie on A Little Pregnant posted about the same study today, but she has a totally different take on it. http://www.alittlepregnant.com/alittlepregnant/2006/06/this_just_in.html
Very odd.


Second, all these women posting on blogs about feeling guilty OR posting their anecdotes about why they had to stop breastfeeding -- these are not the ones that the ads are aimed at, I don't think. So I am not sure who is making them feel guilty.

I like your point about increased health-care costs. I am of two minds with WIC (or whatever gov't agency it is) providing formula for mothers. On one hand, at least the baby is getting something other than water or skim milk, which is good (my coworker's daughter is a teenage mother and they even switched the baby off of formula as soon as gov't benefits ran out ["formula's just too expensive!"], so I have my suspicions about what would happen if formula wasn't paid for). BUT, shouldn't the government be pushing the milk that is FREE as well as BETTER for the baby? (the official answer, when I asked about nursing early on was that "she tried but it just didn't work". Somehow I doubt there was much trying going on).

Ok, I think I have used up the parenthesis allotment for both of us so I will stop now. :)

"Why are some of the same people who say there is NO SAFE LEVEL for alcohol consumption in pregnancy so cavalier about formula supplementation? Which one is really more likely to have long-lasting sequelae, a five-ounce glass of wine during pregnancy or a five-ounce bottle of formula in the nursery?"

um... this isn't one of those "Are you trying to make me feel guilty??" thinhgs, but I am curious about the "long-lasting sequelae." My son had more than one bottle of formula in the nursery as we waited to get him out of that place. Long story. But, did you mean like, cow's-milk-sensitive child develops intestinal troubles or bleeding or allergic reaction or something? Not that a single bottle of formula is particularly likely to cause some kind of hidden lurking damage? I'm really just curious, not offended. I'm sure the other 22 months minus 1 day of his life that have been spent breastfeeding (still going strong) and eating mostly nutritious table food have had a much bigger impact than that day of formula supplementation in 2004 :)

Great topic and post. I'm saving your last sentences in my quotes notebook.

For anybody who didn't see the post Mary mentioned, Julie at A Little Pregnant linked to a piece that says, in a nutshell, "We're statisticians and breastfeeding is overrated." In particular, they say the Chen and Rogan article is worthless because it found a correlation between accidental death and formula-feeding.

Chen and Rogan (full text here) acknowledge that the finding about accidental death is odd. They point out that it was also seen in a previous study, and speculate that the physical proximity breastfeeding requires could be part of the explanation. Will it be a robust finding? I have no idea. It looks like the accidental deaths accounted for just over 10% of the total deaths, so it's not as if removing those deaths would eradicate the differences in death rates between the two groups.

I have been kicking around possible explanations for the difference in accidental deaths, some of which have nothing to do with feeding choices and lots to do with poverty. The authors say they corrected for known confounders, though. I'll be interested to see what future research suggests.

Thomasina, no guilt intended! I was thinking less about effects on babies (though it could make a difference for some babies) and more about breastfeeding relationships. Absolutely, sometimes supplementation is necessary. I wish more hospitals helped mothers to hand-express colostrum (pumping colostrum leaves too much on the flanges, since the volume is low and the viscosity is high), and encouraged them to stay skin-to-skin with their babies to promote frequent feeds and more rapid lactogenesis II.

If a tiny baby gets five ounces of formula, he's not going to be hungry for a long while. If he gets it from a bottle, he may be impatient with the slower flow of his mother's nipple when he's at breast. If a nurse is giving a baby that age five ounces, it is quite unlikely that she's using a paced-feeding approach that can foster baby's return to the breast.

So often I have heard mothers say, "Well, I thought we were doing okay with nursing, but they gave him a bottle and he sucked down x ounces in no time flat." A baby who sucks down formula may not be a starving baby; he may just be a baby who's trying to keep that fast-flowing liquid out of his airway. For many mothers, though, the experience shakes their confidence in their ability to breastfeed. Can they make enough milk to nourish the baby? Can they read his hunger cues, when they had no idea he was starving? (Usually this is becaus he wasn't starving.) If he's reluctant to latch on, should they just stick with the bottle? He sucked it down before, after all.

Obviously, lots of families go on to breastfeed successfully after supplementation in the hospital. But some don't. The chances that five ounces of wine with your anniversary dinner will harm your fetus aren't zero, but they're not very far from it. In my non-epidemiologist estimation, the chances that five ounces of formula in a bottle will cause some hiccups in your breastfeeding relationship are significantly higher.

The breastfeeding ads seem to be focused exclusively on how breastfeeding is healthier, and so on. So, people "try to breastfeed". Why is there such a large dropout rate? Ad-makers should put out more ads which address the fears and problems of these "would-be breastfeeders".

For example, ads pushing for better maternity leaves, better daycare near work, and better at-work support for breastfeeding.

Ads which reassure mothers who may be frantic that their baby has had virtually nothing to drink in the first couple of days after birth.

Ads which advise mothers to feed newborns on demand, and to let them drink their fill. And which reassure them that their bodies WILL make more and more milk if they let their hungry babies drink as much as they want.

There is also the older generation (=grandmothers from the bottle-feeding generation), who mothers have to contend with. Mothers need to be educated enough in breastfeeding matters to be confident that breastfeeding IS sufficient nourishment, in order not to take on the worries expressed (oops, pun) by their mothers.

When I breastfed my first, I was absolutely determined to breastfeed. Much of it was laziness, as I was NOT going to get up in the middle of the night to fumble around with bottles and sterilizing equipment! My sister had breastfed, so I had a good model and knew I could do it. It took several days before my son was really taking in a nice amount of milk. I knew this was normal, though, and then everything went fine.

With my second, of course it was so much easier to get started. This second baby was very hungry all the time, and used to breastfeed every 2 hours if he was awake, and after 3 hours if he slept between feeds. With 30 minutes per feed, there were often only 1 1/2 hours free before the next feeding! Busy, busy... Even when the milk ran out, he used to want more and I would call to my husband to bring water or milk for me to drink, and then shortly after, more milk would come in (I know it wasn't the same liquid getting through instantly, but anyway it seemed to work). Baby was fat(tish) and happy, but still my mother-in-law used to say, "Maybe he isn't getting enough milk?", when she saw how hungry he was. My husband was even fatter as a baby, fed exclusively and proudly on "Cow and Gate" formula. At least I was experienced and knew enough to laugh off her worries...

With both children, I introduced a bottle for the afternoon feeding, sometime around 5-6 months. This was wonderful, as it enabled us to spend the whole afternoon on an outing to the park or wherever, without having to worry about "where to breastfeed". Or I could take the whole afternoon off and leave someone else in charge of baby!

My first son had been prepared for this by having about 1 bottle a week, starting a couple of weeks after birth. With our second child I didn't get around to trying him out on a bottle until about 4 months, just in time to bottle-feed him for 2-3 days straight when I became ill with food poisoning and could not nurse. The milk came back in fine and I continued nursing afterwards, and then started him on the afternoon bottle around 6 months.

Breastfeeding gets easier with each week and each child. It is sad to me that the majority of homes are now dual income families when many may not need to be. Breastfeeding becomes a burden when you attempt to put to many parameters around its occurence. Maybe if there were more social/government support of mothers raising their children for the first four years at home (a reasonable minimum) then breastfeeding might become a more standard choice. While I am regarded as a "dependent" on my husband's tax return, I wonder what provisions the government could make in my absence. Nothing that would be particularly equal or good even on my worst days.

Needless disclaimer: I know not everyone can be on a single income.

Oh yes, I honestly, temporarily forgot about the nursing difficulties the supplemental bottles can bring, even though they probably contributed to our engorgement/latch problem for a day or two following the cessation of formula -- and this with our second child, 2.5 years after a successful battle to master bfing with his older brother who'd gone on to nurse well into toddlerhood.

Our particular son didn't truly need the formula -- it was a concession to try to get him out of a nightmare-of-ignorance nursery situation. (Long story, as I said.) Thank God the lactation consultant was able to talk sense to these people and get him rooming in and nursing on demand, pronto.

So I really wasn't offended, but curious (on a slow brain day) at the mention of possible long-lasting sequelae of a single bottle, since I forgot how discouraging those early struggles can be, how much difference getting off the nursing track can make especially that early on, and how I'm waaay on the "militant [but trying not to be superior about it] breastfeeder" side so many, many well-meaning moms who had at least somewhat wanted to breastfeed might not have had the same outcome after the kind of interruption/supplementation our nursing relationship endured.

Very nice article on guilt and a very very nice article on the public vs individual trade offs of breastfeeding. And you are absolutely right, public announcements are never nuanced, because the target audience sometimes needs to be scared, "guilted" into giving dangers involving their lives and their children's lives at least some thought. That's why I was baffled about how many "tried breastfeeding and failed because of many many miserable circumstances" mothers found the mechanical bull ad "guilt-inducing" for them.

Is "guilt" even the word for women who wanted to bf but stopped because of real difficulties, bad advice, etc.? A parallel: I truly support natural birth and homebirth but to tell the truth I am emotionally -- not willfully -- basically sick of reading glorious homebirth stories (no offense Jamie!), esp. ones that highlight the amazingness of HB compared to other ways of having babies -- because I "tried and failed" at this amazing thing (and with two c-sections in my past, even if I VBA2C next time it will be in the hospital.) I would be intellectually happy and emotionally annoyed to see a big pro-homebirth campaign in the media now. I think it would be very easy for someone in my circumstances to for strongly emotion-influenced reasons just write homebirth and natural birth off altogether as not all they're cracked up to be and riskier than advocates will admit. It is an emotional struggle to stay true to my reasoned convictions on this subject sometimes (helps that I still have a chance at VBAC at all.)

The same way, I could see someone who had "tried and failed" at breastfeeding rolling her eyes and getting all, "Yeah, yeah, some statistical advantages spread out over a big group... let's look at the big picture and real people's lives" at each and every rave review of breastfeeding -- because she was sick of hearing about what her kid was getting being inferior in so many ways (when formula feeding usually does just seem to amount to, "Yep, few people's lives are ideal" and not a catastrophic loss.) I don't know where "guilt" would come in for someone whose bf attempt parallels my VBAC/homebirth attempt. I can think of some significant ways I might have prepared better for a homebirth, but since I gave it an honest shot the negativity/desire to tune out is really just based in not wanting to hear about what could have been.

Wonderfully written, thoughtful and concise - it's a pleasure to have found your blog.

I don't understand why people can't get why such ads might also touch those who tried and failed.

If you really wanted to make something work and it didn't it can be really hard to accept. You'll always remember that it didn't work out.

Any scary information and shock tactics remind you that your child didn't get much breastmilk and you wish it hadn't been that way. It takes you back to that point when you had to make a decision.

It's just like when a song comes on the radio and it reminds you of a sad time, or if you look through photos and you come across a loved one who is no longer with you.

A counsellor once told me - yes personal anecdote time, as that is all I have to offer:
"Guilt is a negative emotion. It is the brain's way of processing an event that involves you. It can be the result of you not accepting yourself or the situation you find yourself in and your subsequent actions and decisions. Allowing yourself to be consumed by guilt can lead to further negatives, such as depression, rather than changing the situation for the better. This negative cycle is hard to break."

Changing the situation for the better is what I have strived for when I have done things I am not proud of or if I find myself in a situation I do not like but am unable to change.

I worry that those who feel guilty - those who chose not to or those who couldn't - will feel guilty about knowing their child had formula and slip into depression and a cycle of negativity.

Supporting depression is also a big drain on our resources, in terms of healthcare and the community. And let's not forget those babies. We want them to be cared for in a happy family unit.

I want it to be clear that I support breastfeeding and informing mothers. I just worry about shock ads and the short-lived impact. I also feel for those that couldn't do it and just want to try and create a bridge of understanding as to why these mothers might feel guilty.

Emily

Emily, I totally understand that part, which is what I was kind of getting at in my previous excessively wordy post. I guess I'm wondering if the word "guilt" is the most useful description though. To me "guilt" is a response to "I didn't try" (in any situation where "trying" was the right thing to do, not bf specifically,) not "I tried and it didn't work out." Of course I am sure there are people who unfairly berate themselves thinking they didn't try hard enough, when they actually did (especially including those suffering from clinical depression.) But since we're hearing a lot from people who say "it didn't work out" I was just pondering the semantics of calling the negative reaction to bf-promotion "guilt." Even when my reaction to a glorious-natural-birth story is negative about myself, like "Guess I'm some sort of deficient freak, couldn't get my own baby out even at home," it's not guilt, it's just a (warped) sense of inferiority.

I'd better clarify that I'm not suggesting the "guilt" is a sign that women who say the ads make them feel guilty actually didn't try hard enough. I'm just wondering about the use of that word where it wouldn't seem to apply. But maybe I am emotionally weird for not experiencing my parallel birth regrets as "guilt."

Interesting point of view. Maybe it is just intense sadness.

In my own case it was the harsh judgements from the useless medical support I had at that time and from some other mothers that led to me feeling guilty and worried about getting a bottle out in public.

But then I guess other people accept guilt more readily than others.

As I mentioned before, survivors of major catastrophes, rape/abuse victims often feel guilty about having to save themselves and make that decision, or, in the case of rape, being in a situation that led to rape. Guilt is their way of absolving and forgiving themselves.

It's just a weird emotion but not one I think that means they are always actually guilty.

I think so many wannabe breastfeeding mothers just need a bit of confidence. The very best breastfeeding advice I ever received was when I was expecting our first. The OBGYN asked me if I was planning to breastfeed and (because of horror stories I had heard and read) I answered meekly, "Well, we're going to try."

My doc said, "No. If you say you are going to try to breastfeed, you are setting yourself up to fail. If you plan to breastfeed, just say that you are going to breastfeed. There is no reason in the world for you to believe it won't work for you"

She was right of course. It is part of God's plan for mothers and babies. For most women there is no reason in the world to believe it won't work. Her words really made me think about my hesitation and uncertainty and then replace those with confidence and a positive attitude. And then I went on to successfully breastfeed 7 babies so far.

To that thought I would also add, however, that in addition to being positive and encouraging about breastfeeding, we need to be honest and realistic about it's less-than-glorious side. For instance, I did a lot of reading up on the subject beforehand but no one in the world told me that beginning to nurse was going to hurt so very much during those first few weeks of feedings and that that was a normal part of "breaking in." If I hadn't had such supportive nurses, that fact alone would have been enough to convince me that I was doing the whole thing wrong and abandon the project altogether.

I agree with some of what you say Jamie
However Danielle may have found it easy to do but I have many friends who have given breastfeeding a good go without success. My gut feeling is if you can do go for it but if you cannot put the kid on the bottle and forget about it
We have the Breastfeeding Association here in Australia and there is too mch fanatical zeal about breatfeeding with silly letters from women trying to breastfeed when it does not seem to work for them.
In my own case I successfully breastfed all 3 of my kids but I found it came easily and naturally. Maybe in a past life I was a cow.
For some women it does not and they struggle along and try far too hard. This extreme trying impacts on them building a relationship with their baby and coping as a mother. Better they had bottle fed their babies and got on with the business of living

Most of the women I've known (and there are a couple of exceptions who had babies with problems related to their suck) who have failed at breastfeeding have failed because of inadequate support at one level or another. Often it was their mother's lack of support, frequently it was their husband's. The first weeks of breastfeeding are not like the first weeks of formula feeding, your body has to adjust, the baby has to adjust, the family has to adjust to what seem like incessant demands of an infant. There is sleep deprivation, there is no energy to do housework, there is at least minimal discomfort from things like engorgement. In a perfect world, or a culture where bf was the norm, those things would be taken in stride. In a culture where people expect a new mom to be back doing her thing within a week or so of the time the baby is born and maybe even back on the job at six weeks it's different. Young couples need to change their expectations of what those first few weeks are going to be like. If you really can hunker down with that baby and sleep when the baby sleeps, have grandma, or Aunt Susie, or the kid next door do housework or (when you have toddlers) mind the other kids bf isn't going to be so hard. The problem is the grandmas and daddies out there who can't wait to get a chance to feed the baby, but who don't want to be relegated to laundry and dishes. What a new bf mom needs is someone to cook meals, do the housework, mind the OTHER kids, change a few diapers, dry her tears, walk the baby when bf is done for the session, and let her feed the baby. In other words the helper needs to mother the mother and let the mother mother her own baby.

The controversy over the Times BFing article has been interesting. I thought the main comparisons, the smoking and mechancial bull, were melodramatic. I have been pondering whether it wouldn't be a better device to compare formula to c-sections. (for the record I had two. I did try and fail at VBAC. The first was breech. And the fact that I am explaining this is a sign that we have too many c-sections in this country and so I feel defensive. I try not to, but...)

C-sections save lives and so does formula for babies whose mothers die or cannot produce milk. And c-sections are decided ultimately by doctors...but BFing could be influenced far more by doctors and HCPs. I know (the UN? the AMA? WHO?) someone has set guidelines to reduce c-section rates in many nations including the US. And this judgment does make mothers defensive, but it doesn't mean c-section should be encouraged as elective. And in parallel, it doesn't seem wrong to me that breastfeeding should be encouraged and formula discouraged. (In full disclosure, I breastfed both of those c-section babies for many months.)

The c-section reduction has been aimed primarily at doctors and hospitals. Perhaps breastfeeding needs to be promoted in similar fashion. (and yes some hospitals do, but nearly every post I have read on this has had so many stories of nurses pushing supplments. And then last month it blew my mind to hear my niece was allowed to think at the hospital that she couldn't nurse because she tried on day 1, before her milk came in, and that meant she had no milk. So she didn't try again. And her milk came in (surprise!) but she still believed BF wouldn't work for her.)

Nurses push supplements because it's far easier than actually working with an inexperienced bf mom. A large number of those nurses have no personal experience with bf themselves. Moms who want to bf need to have a plan in place long before delivery. La Leche League meetings will help, having the LLL leader's phone number in your "take to the hospital bag" could be a real help. Just having basic knowledge about bf physiology before delivery would make a difference.

All of the education in the world doesn't seem to change the minds of some nurses. They remain convinced that bf is too difficult for a lot of women in our culture. Somehow what undernourished third world women can manage to do overnourished American women have a difficult time doing. I suspect that hospital routines continue to plague young mothers. I suspect that they are still being told to nurse on a schedule, not to nurse too often, to nurse for a specified number of minutes. They may even be still being told to only offer one breast at a feeding. The amount of misinformation that I have heard from maternity nurses is downright scary.

We have a young friend who is a nurse. She attempted bf with her first and failed. She didn't even attempt with her second. Then with her third she was in a new marriage and lo and behold she was suddenly able to bf. She wondered why she had failed before. I'm not sure if it was the new marriage or if it was the fact that her unsupportive mother died before that baby was born. All I know is that she went from being a nurse who didn't encourage bf to one who did, and who actually was able to help her patients. Sadly she now works, not on the maternity ward but in a public school as the school nurse. Oh well, hopefully current mothers' loss is future mother's gain.

Random thoughts: I BF both kids (10-12 yrs ago)for 9 months & 1 yr. First 3-4 weeks were excruciating in terms of pain (I remember biting towels to keep from screaming and scaring the baby during latching). I'm guessing this is where we lose a lot of moms and I can't blame them.

Sufficient nutrition? Ha ha. My babies were HUGE. Show me another 21 lb. 3 month old... Please. And they didn't get sick until months after I quit nursing.

Drooping, sagging, stretchmarks? All genetics. Shockingly, I didn't get any of that, but I barely increased from a B to C anyway, I had milk like cream rather than skimmed, but it worked.

I just thought I'd put my 2 cents in the pot just to show that not all experiences are alike.

BTW, husbands side of family thought BF was primitive, gross and unnecessary. I have to admit, I smirked a lot during those first years when my kids proved all their tales against BF wrong.

I don't feel guilty about my decisions re: breastfeeding (pumped for 9 mos, my son HATED breastfeeding - he liked facing out) but I do feel angry that the gov't is focusing the breastfeeding campaign only at mothers. Where is the campaign to get workplaces to be more pumping and breastfeeding friendly? Where is the campaign for acceptance of BIP? Where is the campaign for free lactation consultancy (especially for recipients of WIC?) Where is the campaign for universal maternity and lactation leave even for hourly and temporary workers?

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