Light and Momentary

Here in 2023

Today I did a fun thing: I went to help a new mom who was having trouble nursing her baby. I wanted to be the calmest gentlest version of myself while I was there, because the baby's grandma had a terrible first breastfeeding experience and still rolls her eyes about La Leche League. I don't do much hands-on breastfeeding support these days, but the visit left me with some thoughts: 

• The existence of a kazillion kinds of lactation certifications is not doing new moms any favors. Most people don't know what an IBCLC is, and new parents don't know how to evaluate conflicting advice from nurses with just a weekend course in lactation under their belts. 
• There is a lot -- A LOT -- of very persistent bad breastfeeding advice floating around out there. We have known since the 90s that forcefully bringing baby and breast together creates distress and feeding reluctance for a significant number of babies. That whole Chele Marmet* Rapid Arm Movement thing where you are told to R.A.M. the baby onto the breast? Don't do that, actually.
• Early breastfeeding is often not very efficient, and trying to make it efficient can have harmful downstream effects. Sure, you can chart that the baby latched. ("Latched," harrumph.) The number one thing that reluctant nursers need is lots of low-stress, low-expectations opportunities to practice-- preferably in a semi-prone position. This page has some good advice (with helpful pictures!) from my amazing friend Cathy Watson Genna.
• "Don't let the baby use you as a pacifier" is the last thing a nurse should tell a new mom who is (a) not experiencing any pain with breastfeeding, (b) worried about when her milk will come in, and (c) trying to nurse a baby who goes from zero to 60 in no time flat. If you've got a baby who gets mad really easily, frequent small nursings can bring down the pressure to feed him NOW NOW NOW FASTER FASTER. As long as it doesn't exacerbate any nipple damage, it is more than okay to pacify your newborn baby at the breast.

*Lots of respect to Chele Marmet, who pretty much invented lactation consulting. Everybody has the occasional bad idea, though.

An unexpectedly consistent parenting philosophy

About once a year I get a request for breastfeeding help. It's been 11 years since I hung up my La Leche League Leader hat, and although I've maintained my IBCLC credential I don't actually use it very often. Last night I got a text from an acquaintance at church. Her baby wouldn't latch, and a mutual friend had suggested that she contact me.

I suppose if I were a volunteer breastfeeding counselor these days, I would get a ton of requests for help via text. It seems to me like a tricky way to do things, and after a dozen texts I asked this mom if she'd like to get together in person. I went over this morning, timing the visit so the baby would be in the neighborhood of hungry but not starving.

Non-latching babies were always the hardest part of the job when I was offering phone help. Nursing is complicated. Sucking is complicated, swallowing is complicated, and arranging those two tasks around breathing is also complicated. Some babies just can't or won't do it, and you can't make them. But I have learned a lot in the past 11 years about both breastfeeding and mothering, and I had some ideas to share.

One piece of the puzzle was figuring out why the baby might be reluctant. There are lots of possibilities, but I had a hunch that the central issue was flow rate. Another piece of the puzzle was seeing how the mom was holding up. Triple feeding (nursing attempts + pumping + bottle-feeding the expressed milk) is often a nightmarish time suck, and retail pumps are not great for bringing in a milk supply, and exhaustion paired with unrealistic breastfeeding expectations can make the world seem pretty bleak. So I wanted to check in face to face about how she was doing, and the answer seemed to be "reasonably well."

The most exciting change in early breastfeeding management since I was active in LLL is the emphasis on laid-back breastfeeding: stable prone or semi-prone positions that allow babies to take the lead. If you recline the mom and put the baby on her belly with his hands free and his philtrum next to mom's nipple, you will very often see a real improvement in breastfeeding behavior. Too many parenting books are still talking about cradle/cross-cradle/football, but if you have a baby who won't latch, your best bet is to get that baby unswaddled and belly-to-belly with mom.

My recommendation (after making sure this could work for their current family situation) was to offer lots of low-stakes low-stress low-flow opportunities to practice latching. With a baby who's not feeding effectively, there are always three steps to addressing the problem: (1) feed the baby, (2) protect the milk supply, and (3) keep something happening at the breast. I wanted this mom to know what a fantastic job she was doing with steps 1 and 2, and that it was perfectly fine for step 3 to unfold gradually. I left feeling like I should have had a magic bullet up my sleeve (wait, we don't put bullets in our sleeves, do we?), but also acknowledging ruefully to myself that there are no magic bullets. 

We texted back and forth a few times over the course of the day, and this evening she sent me a lovely update: the baby who had never latched successfully in the previous 3 weeks had latched 10 times today. There's still plenty of ground to cover, but that's an amazing step forward.

I was thinking about how much better this approach meshes with my general parenting philosophy than the Rapid Arm Movement/nipple sandwich strategy we were using in the late 90s and early 00s. I've written so many words here about the value of autonomy for kids, and it turns out to be a useful strategy for tiny babies as well. You can't compel an effective suck from a newborn any more than you can compel a sincere apology from a 6-year-old, but you can make them both pretty mad in the attempt. Of course you need to rule out genuine barriers to the behavior you're trying to elicit (tongue mobility concerns, neurological issues, milk supply problems, etc.), but a lot of parenting, in my view, is about creating supportive contexts that let kids show you what they can do, and offering them frequent low-stress opportunities to practice.

It's also, now that I'm thinking more about it, about remembering that progress is often slow and uneven for kids, and taking the long view. Slow and uneven progress will still move you forward, and rushing it can create problems of its own. (I strongly suspect, in fact, that someone else's attempt at a quick fix is at the root of some of the problems this dyad is currently facing.)

It is becoming harder to extend autonomy to kids in this climate where parental protectiveness has run amok. It's so well worth it, though.

Death by Breastfeeding

There's a new article out in Nature, looking at breastfeeding habits in the hominin species Austrolopithecus africanus. The researchers measured barium concentrations in fossilized teeth, which allowed them to estimate the importance of breastmilk in the diet across time. Nifty, right? They learned that A. africanus mothers nursed their babies exclusively for about 6-9 months, and then continued to offer breastmilk along with varying quantities of solid food for about 5 years.

So far so unsurprising, at least from my perspective as a hominin mother who is also a breastfeeding researcher and an IBCLC. These days hominin babies also get interested in solid food around the middle of their first year of life, and they often keep going for a while, augmented by varying quantities of solid food. This is old news. Anthropologist Kathy Dettwyler was publishing in the mid-90s on "normal" breastfeeding duration, and her work suggested that a natural age for weaning would range from 2.5, at the earliest, to about 7, at the latest. You can read a nutshell version of her work here, but the core idea is that we can learn from other species about the markers that indicate it's time to wean. For instance, some primates wean at the time of the emergence of the first permanent molars, which corresponds to an age of 5 or 6 in humans. Just like A. africanus!

(Standard disclaimer goes here: let's all do what works for our own families; let's also agree not to mutter darkly about the motivations of women who breastfeed for more or less time than we might find optimal.)

I was more than a little surprised, though, to see the investigator's take on these findings. Breastfeeding is metabolically costly, he says, and so perhaps the species died out BECAUSE the mothers kept nursing their children for so long.

Given what we know about primate nursing duration, this line of thinking suggests to me that the entire global population of primates ought to have died out in a mass extinction event some thousands of years ago. "Well, Pops," I imagine an early hominin mother saying to her grieving husband, "it was nice knowing you but I am PLUMB DONE IN by breastfeeding our offspring. And now I die." She keels over, like Wallace Shawn in The Princess Bride, while her overly breastfed 5-year-old continues to paw at her stiffening mammaries.

The researcher's comments tie in with a cultural narrative that breastfeeding is too draining, both literally and metaphorically, for women to manage. I first encountered this idea in college, when an older friend's father was telling her how much more rested she seemed when she gave the baby a bottle. I bumped up against it in person when I first nursed a toddler. "Oh, that must be very tiring," said a new acquaintance. (Awkwardly, she was my husband's boss's wife and she found it SO ODD for a 21-month-old to be nursing that her customary British reserve evaporated entirely.) The thing that's exhausting, though, is mothering a small child. Once you get past the initial bumps in the road, breastfeeding is more likely to be the shortcut than the hard road. (See the Swiss army knife analogy in this old post.)

You know who profits from pushing that breastfeeding-chews-you-up-and-spits-you-out business? Not mothers, not babies, not young children, but manufacturers of human milk substitutes and complementary foods. I am not aware of scholarly studies that support this idea of breastfeeding as health hazard -- not in human mothers from food-insecure populations, where the question can be of life-or-death import, and not in animal studies. Could it be that these were just normal primate mothers doing a normal primate thing? Could it be that pathologizing long-term breastfeeding -- though "pathologizing" seems an inadequate verb for "suggesting it is to blame for the extinction of an entire species" -- is a bad idea not grounded in actual science?

I told my kids they should keep an eye out to make sure I don't go extinct from breastfeeding.

Yes, you can!

I used to think of calling my reps as a Big Deal, an intimidating prospect. I am here to tell you that it is not actually a big deal. This is the script I always use:

Hi, thank you for taking my call today. My name is Jamie Gladly, and I am one of Congressman/Senator Lastname's constituents in Gladlyville. My zip code is 12345. I am calling about [issue], because [reasons, sometimes tailored to his/her political leanings]. I would like to ask the representative/senator to [co-sponsor legislation / introduce legislation / vote yea or nay on a bill / issue a statement]. I [would appreciate / do not need] a response from the representative/senator. [pause for aide to say something pleasant and non-committal and to confirm my address] Thank you again for talking with me today. 

Boom, you're done. I can usually make all 3 calls in less than 5 minutes. No one has ever been anything but impeccably courteous to me, even when I am feeling a little rant-y. The last time I called about family separation at the border, I joked with my kids that if they had been listening with a "Mom calls her legislators" bingo card in hand, they would have had an easy blackout.

Today I was feeling more than a little rant-y, and I expanded the [issue] and [reasons] sections of my script accordingly. I am going to post a version of them here, in case anybody who reads here might be feeling cautious about making calls.

I am calling about the front-page story in today's New York Times, reporting a sudden and unexplained shift in a position that has received longstanding bipartisan support. US officials inexplicably opposed a World Health Assembly resolution in support of breastfeeding, and did so by bullying and threatening smaller countries until the Russians intervened to stop them. This behavior is nothing short of bizarre: it flies in the face of decades of research on the importance of human milk as a low-cost means of protecting mothers and babies worldwide. Protecting and promoting breastfeeding is pro-life and pro-economic responsibility [I emphasized this first for the R side of the aisle] as well as pro-science and pro-women's health [I led with this for the other side]. I am especially concerned about the HHS response to the NYT reporter, which clearly reflects the influence of infant formula industry marketing strategies. The only possible explanation I can think of for these events is lobbying by the infant formula industry, which will have serious adverse effects on the well-being of babies and mothers if it continues unchecked. In the wake of the recent scandals at the EPA, I am concerned that HHS has also been the target of hidden industry lobbying efforts.

I would like to ask the senator/congressman to consider doing two things: first, to issue a statement in support of our policy of protecting and promoting breastfeeding in time for World Breastfeeding Week, which is August 1-7. Second, I'd like to ask the senator/congressman to consider calling for an investigation into donations by the infant formula industry that may have influenced delegates to the World Health Assembly meeting and representatives of the Department of Health and Human Services.

Let me know how it goes!

Ignorance is strength, war is peace, and biological specificity is totally overrated

The New York Times reports today that the US government actively opposed a recent World Health Assembly resolution on breastfeeding. Before the vote, widespread consensus was expected; the resolution acknowledged the value of human milk and expressed concern about unethical marketing practices for breastmilk substitutes. Under ordinary circumstances it would have passed with little debate. The story makes clear that these are anything but ordinary circumstances. It's astonishing, even here in the post-astonishment era. Highlights:

• Not only did the US oppose the resolution, its representatives threatened supporters from smaller countries with economic retaliation and withdrawal of military support
• This bullying behavior stopped only after Russian intervention
• The US did, however, succeed in watering down the language of the resolution
• The HHS, when contacted by the NYT reporter, spouted a script that comes straight from the industry playbook

I used to write a lot about breastfeeding in this space, but not so much lately. This is where I'm coming from:

Human milk makes a modest but statistically robust difference in health and neurodevelopmental outcomes across a surprisingly wide array of domains and disorders. Both parts of that assertion are important. Because the differences are modest, I fully support the right of an individual woman to make the infant feeding choices that work best for her and her family, free of side-eye and second-guessing. The world will be a better place when we give each other the benefit of the doubt more regularly. At the same time, because the differences are statistically robust and affect so many different kinds of outcomes, effective individualized breastfeeding support is a non-negotiable public health imperative. If a woman wants to breastfeed, let's find a way to help her make it work. No one reading this post should feel guilty for any reason, unless she is a Nestle or Abbott Labs executive.

But they, my friends, can go right ahead and feel guilty. The infant formula industry has done immense damage to breastfeeding relationships around the globe. You've seen this picture, right, taken the day before faulty information about milk supply resulted in a child's death? We can argue here in the developed world about exactly how important breastfeeding might be, but those discussions are entirely out of place in the developing world. Human milk saves lives everywhere; it is a particularly critical component of efforts to protect maternal-child health in poorer areas. The World Health Organization has been instrumental in responding to unethical formula marketing practices. The idea -- the very idea -- of the WHO Code as some kind of optional frippery that we've moved beyond now -- oh, man, I'm having a little Screwtape-centipede moment here.

Let's talk about that quote from the HHS employee, who said:

"The resolution as originally drafted placed unnecessary hurdles for mothers seeking to provide nutrition to their children." The hurdles involved are pre-existing hurdles, placed decades ago to prevent industry from sabotaging breastfeeding. I am relying on news coverage of the incident because I can't find the text of this resolution on the WHO site, but WHO resolutions focus on public policy recommendations -- not mandating individual behavior. I cannot imagine how this could be an accurate assertion.

"We recognize not all women are able to breast-feed [sic] for a variety of reasons." True, and yet infant formula manufacturers have moved a lot of product over the years by making breastfeeding seem harder, more complicated, more awkward than it actually is. The research on this highly effective strategy goes back at least 25 years.

"These women should have the choice and access to alternatives for the health of their babies, and not be stigmatized for the ways in which they are able to do so." The situations in which equivalent amounts of infant formula* are better than human milk for a baby's health include the following: infants with galactosemia and other inborn errors of metabolism, moms receiving chemotherapy or other genuinely dangerous medications, moms (in the developed world) with HIV, and...um...not a whole lot else. Infant formula companies have tried for years to persuade us that their product can save women from the uncertainties of breastfeeding (how much is my baby really getting? are there EVIL TOXINS in my milk?) and from the indignities of contact with the nipple nazis, but it is new and startling to hear their marketing strategies in the mouth of a representative of the United States Department of Health and Human Services. 

*Phrased that way to acknowledge that formula supplementation can be immensely important when appropriate quantities of human milk are not available. I see you, moms with supply issues. I am also never going to stop being mad at the industry that creates supply issues in some women to foster dependence on its product.

There is no new science driving this change in US policy. There is global scientific consensus on the importance of breastfeeding for mothers and children. We can disagree on the magnitude of the odds ratios, but the body of evidence in support of breastfeeding is staggering. The only possible motivation I can imagine here is behind-the-scenes industry lobbying.

If they get what they want, babies will sicken and die. They will die preventable deaths-- of diarrheal illnesses in Bangladesh, of SIDS here in the US. 

This is not okay.

Tomorrow morning I am going to call my reps. I am going to ask them to issue a statement in support of the government's role in protecting and promoting breastfeeding in time for World Breastfeeding Week, August 1-7. I am going to ask them to call for an investigation of formula industry lobbying, because it seems clear that money is doing the talking here. The US position at the World Health Assembly was anti-science, anti-maternal/child health, anti-common sense, anti-economic responsibility. Did you know it's estimated that every dollar invested in breastfeeding will generate $35 in economic returns? 

Let's push back.

Not so fast

A new study by Colen and Ramey has been getting a lot of buzz: they argue that the long-term effects of breastfeeding have been exaggerated. In their study they looked at discordant siblings, pairs in which one child was breastfed and another was not. They found that the effects of breastfeeding were attenuated and that statistical significance evaporated.

As I've been writing this post in my head, it's been getting longer and longer. I am going to compel myself to be brief, and I also need to be clear that I don't yet have the full text of the paper. I'll report back when I get it. A few considerations:

1. Breastfeeding is not important because it is The Magic Elixir That Prevents All Ills. Breastfeeding is important because it has modest but statistically robust effects across a surprisingly large number of domains. Don't go looking for big effect sizes in long-term breastfeeding studies.

2. Especially don't go looking for big effect sizes in long-term breastfeeding studies of siblings. Of course you're going to see attenuated effects in discordant sibling pairs. Many traits are predicted by a mix of genetic and environmental factors. Siblings share, on average, 50% of their genes and a variable but important proportion of their environment. Breastfeeding doesn't override those predictors with its Magic Elixir-ness; it influences them to a modest but meaningful degree in population-based samples.

Two parents who each have a BMI of 25 are less likely to produce offspring with BMIs of 17 than two parents who each have a BMI at the low end of the normal range. Even if one of their kids is breastfed for 5 years, the mix of other genetic and environmental predictors is really important. It doesn't mean that breastfeeding can't influence BMI across populations just because you don't see big differences in their particular children.

3. "Statistical significance" is a moving target. It is not unusual at all to see attenuated effects and loss of statistical significance when you substantially reduce your sample size, as they did for the portion of the study that looked explicitly at siblings vs. the portion of the study that didn't. Something I can't tell from the abstract: how did they correct for multiple comparisons? When you look at a bunch of different outcomes in a single study, you have to account for the fact that you're running a lot of statistical tests. You don't want to say, "Hey, look! This is significant!" when it's really just random noise in your data. If, hypothetically, I wanted to publish a null finding on breastfeeding, I would look at several outcomes known to have modest effect sizes and use a Bonferroni correction for multiple comparisons. This would mean that instead of a p < .05, I'd need a much smaller (and thus less likely) p value to report statistically significant findings. Highly unlikely that a reviewer would complain; highly unlikely that I'd find statistically meaningful results (Again, I'll report back about what they actually did.) 

4. If you must look at breastfeeding outcomes in discordant sibling pairs, then please don't look at them in the 1979 NLSY cohort. Remember when Der et al. looked at IQ in discordant sibling pairs and were roundly criticized for their methodology? Like Colen and Ramey, they used -- wait for it! -- data from the 1979 NLSY cohort. Again, I can't say for sure what's going on without the full text. But it seems implausible that the issues raised in this comment by Melissa Bartick have been addressed adequately in the present analysis. A brief snip for those who don't want to click over: "All we can conclude from this study is that breastfeeding for a very short duration, with unspecified doses of breastmilk, in non-low birthweight children, had no effect." (P.S. about that quote: No idea if excluding LBW kids was a Der et al. decision that might be different in the Colen/Ramey study or a 1979 NLSY decision that affects both sets of results.)

To sum up: no one should breastfeed her baby because she thinks breastfeeding will cause him to stand head and shoulders above his peers, impervious to pain, suffering, and B-minuses on his report cards. At the very same time, no one should pay a whole lot of attention to a single study examining outcomes in a cohort where the median breastfeeding duration was 3 months. As I said at the beginning of this post, the long-term effects of breastfeeding are modest. Women need to do what works for their families and not worry that they are costing their child 15 IQ points by not breastfeeding him. But the effects of breastfeeding are also statistically robust, even in studies that address problematic covariates. (Half a standard deviation in verbal IQ! Best available study and it still blows my mind.) We owe it to ourselves, and to our kids, to build a culture in which breastfeeding can work for most families.

The Stupid Prize

You guys, I can't even believe it.

I was googling around today, looking for information for a talk I'm giving next week, and I discovered that the federal mandate requiring insurers to cover breast pumps gives them a boatload of latitude in defining the terms of that coverage.

They can say, "We will only pay for a manual pump."

They can say, "We will pay for an electric pump, but only from a specified vendor. Who may or may not carry the one you need."

They can even refuse to provide a hospital-grade pump for a medically fragile premie who is weeks away from direct breastfeeding.

That right there? Is some industrial-grade stupid. High-octane stupid. That's not even penny wise, pound foolish -- that's, like, drachma wise, pound foolish. (If the drachma still existed, there would be 408.5 of them to the pound. I think I need a smaller unit of currency to convey my disdain for this kind of stupid.)

The early days after a baby arrives are a sensitive window, in which a woman is calibrating her milk production for approximately the next six months. If her baby cannot move enough milk to send the appropriate message, it is critical that she have access to a hospital-grade pump.

Do you know how much this would cost an insurer? I'll tell you how much: $65 per month, or $2.17 per day. Do you know how the odds of developing necrotizing enterocolitis compare for breastfed premies versus formula-fed premies? I'll tell you how: formula-fed babies' odds are approximately eleven times higher. Eleven! Do you know how much it costs to treat a bout of NEC? I'll tell you how much: $74,000 if the baby doesn't need surgery, and $148,000 if surgery is required. 

But hey, that insurance company can totally save $2.17 per day by telling the mom to use a manual pump and be grateful for it.

When women don't produce enough milk for their babies, they may feel frustrated and defeated. Sometimes they blame themselves; sometimes they feel defective. But nobody can bring in a full milk supply with a manual breast pump. (I still remember how sore my arms were after one day of trying to use a manual pump for a baby who couldn't nurse.) It's not the mothers who should feel inadequate-- it's the bean-counters at the insurance companies who decided that a $2.17 daily savings trumped a potential $148,000 hospital bill (and that's on top of the substantial baseline costs of the baby's NICU stay).

There's ordinary stupid and then there's dumbfoundingly stupid. Unpredictable piecemeal coverage for equipment that ought to be the standard of care for premature babies-- that's so stupid it burns.

My Body Back

"I just wanted my body back." When I worked with breastfeeding moms I used to hear them say that regularly after they'd weaned their little ones. 

It's been a long time since I had my body to myself. I first nursed a child during the first Clinton administration. I just stopped.

I used to write a lot about breastfeeding: why I nursed my children past infancy, why I nursed them in public places including church, why I loathe those lampshade-apron things that women hide under. It's been awhile I posted about nursing one of my actual children, in part because we're pretty far out in the tail of the distribution at this point. At this point, actually, we're into what most people consider freaky-deaky territory. Even my La Leche League friends, while they might vociferously defend my decision to nurse for this long, mostly found that their children weaned younger than mine.

I've been more hesitant to write about my personal experiences in recent years because it turns out that the years from preschool to junior high last approximately 37 seconds. You blink a time or two and the boy who was deliberating over a weaning present (and then telling the clerk at the register why this particular Lego set was in the cart) is doing calculus. A kid might not want his classmates stumbling across the story of his weaning party. And, too, strangers on the internet get stupid-crazy (or should that be crazy-stupid? whatever the term is for lots of both all at the same time) when they talk about breastfeeding. Having experienced long-term nursing as tender and affectionate and also kind of annoying and clearly temporary and normal for our family, I find it so bizarre to imagine random strangers certain that they can see into my secret heart and determine that I am personally unfulfilled (no) or channeling unmet sexual needs (really??) or failing to permit my children to grow up (see above re: calculus) or whatever pseudo-wisdom they might dispense.

So why am I putting it on the internet that I nursed my children for 201 consecutive months?

Because I will miss the magic. Nursing was an effortless way for me to get it exactly right: to soothe and settle, nourish and nurture. I could nuke the pinkeye pathogens without irritating sensitive little eyes. I could stave off dehydration in a small person who couldn't keep anything else down. I could help to build the brain that would later do the heavy lifting in calculus class. And I could read a book at the same time (except during the conjunctivitis smiting, which required an accurate aim).

Nine years ago I compared nursing to a Swiss Army knife. I have many tools in my toolbox these days, and I have learned a lot about using them well. I will miss my Swiss Army knife all the same.

I have posted more than once about the ways that nursing has brought home to me the goodness of post-Incarnation life in the body. I have written about its reminders that our bodies are not our own, its daily nudges to offer my body and blood (albeit fashioned into a more appetizing substance) eucharistically. For almost 17 years, nursing has challenged me to be more generous than I'm naturally inclined to be.

On the feast of the guardian angels Stella nursed for just a couple of minutes at bedtime. "There's not much milk, Mama," she said. "I'm going to be done." In the moment I didn't know it was a permanent kind of done, but the timing is perfect, I think. Those months of nursing will mean she is less vulnerable to infectious disease and more emotionally resilient in childhood. They may mean she is less likely to develop schizophrenia as a young adult, alcoholism in her 30s, or multiple sclerosis in middle age. They may even mean that when she is an old woman, long after I am dead, she is less vulnerable to heart disease. Like her guardian angel, they will offer her silent and invisible protection for years to come. I am watching her step away from me and towards her future and I am pulling so hard for her: Be safe, sweetheart. Be well. Be loved.

I remember, vaguely, how overwhelming it was to share my body in the early days. Leaking milk into nursing pads. Living life in two-hour blocks, because my first baby nursed every two hours like clockwork. I thought I would be sad when I stopped nursing because I was pretty sure I was going to fail wretchedly at it. I didn't know I would be sad (only a little sad, friends) to stop nursing because it had been such a success. I am thinking back on the 26-year-old me, hunched over an uncooperative Alex in the NICU, and wishing I could tell her it would work out beautifully. I wonder if my future self will look back at the 43-year-old me, the one who is a little wistful and a little uncertain about her ability to guide these growing kids safely to adulthood, to smile and say it will all turn out just fine.

Change is slow

Are you following the Feminist Breeder's Facebook battle? She posted a hilarious picture of her 18-month-old daughter, who was on the fence about nursing vs. bacon. I told my kids the story and all four of the boys burst out laughing. They've all witnessed those 18-month-old nursling antics. The Facebook folks weren't amused, though. They disabled her account.

HuffPo ran a story on the conflict and I did a really stupid thing: I read the comments.

...Hold it, hold it, I am squeezing my skull tightly in hopes that my head will not explode at the memory and it's going to be a near thing...

So. In between DIY cranial repair this evening I have been wondering again about why people are not getting any less weird about breastfeeding. I've been listening to people talk about public breastfeeding since 1996. Things have changed a lot since then. In 1996 there was no state in the US in which a man could marry another man, and the idea didn't seem likely to gain traction any time soon. In 1996 the Unabomber was still on the loose. In 1996 the impeachment of a President was ancient history. The world has changed a lot since then and yet people are still talking about public breastfeeding as a plot for corrupting the youth.

Almost makes me want to dig up all the pictures I have of my little ones nursing and put them in rotation as my profile pictures anywhere that I have profile pictures. Almost but not quite -- a comment along the lines of some I've seen ("you're going to make that child into a sex offender!") would further imperil my delicate cranial sutures.

I stumbled across this cool blog post in my indignant state -- it's about the history of public breastfeeding.

Like a Cow

Today I was talking to a woman who had her first baby about a month ago. She's already back in the office, trying to make breastfeeding work. "That must be tough," I said. "Yeah," she answered, "I feel like a dairy cow."

I've heard this a lot: newly lactating women feel like farm animals. It speaks to me of a culture that is really confused about lactation. Nobody ever says, "I feel like a barnyard animal because I'm gestating." We see pregnancy as normal; this is not, after all, Brave New World. We see lactation, however, as optional. Weird. Degrading.

I have to tell you guys: I had no idea I had been living in a bubble (a breastfeeding-is-perfectly-normal bubble) until last summer. That infamous Time magazine cover coincided with my summer class, in which I had my first exposure to dozens of young women sharing their unedited thoughts about breastfeeding. And what did they think? For the most part, they thought it was weird. Gross. Potentially damaging.

In December I will have been nursing one child or another, or sometimes two of them, for 16 years. (I'd put the odds of Stella weaning before her birthday at about the same as the odds of her reading independently before her birthday. It's not out of the question, but I'd be pretty surprised.) I never post about it these days, though, in part because the public reaction to the Time cover, with the 3yo nursing while standing up, was so shrill. Freakazoid! Pervert!

Stella, who is 3, is nursing standing up as I type this with my freakazoid hands; I am thinking about the sea change in my attitude. I had to pump for Alex because he was on the ventilator, and I remember feeling slightly horrified by the milk spraying out of my breasts. I said, "Hey! It works!" I thought, "Yikes! That's weird!"

It's been a long time since nursing seemed weird to me. Nursing means I have a ready supply of the highly nutritious food that my pickiest toddlers have consumed happily, with no worries about safe storage or spoilage. I have benefited immensely from this potent tool for comforting my kids during the tumultuous transition from baby to big kid. There is an ineffable rightness in the reality that I can build their brains and strengthen their immune systems at the same time that I am building bodies and soothing spirits. It's providential, not perverted.

It's a shame that cultural weirdness about nursing turns it into something women think they have to hide. Last week Stella asked for Elwood when she woke up in the small hours. This is exceedingly rare and I was happy to send him into her room while I slept alone in our big bed. In the morning she said, "I'm so happy to see you, Mama. I don't like Daddy's breasts." It still cracks me up, but it seems a little less share-able than it did before the Time craziness.

Even women who are determined to nurse will often talk about it as a duty they're eager to shed. They want their bodies back, they say. Here in my sixteenth year of lactation that idea is pretty foreign to me. I'm not in a hurry to have my lap back -- I will be a little sad when no one wants to cuddle and read Frances or Curious George or St. George and the Dragon any more. I'm not in a hurry to have my arms back -- a world where nobody wants to be scooped up and hugged will be a sadder world. And although I expect I'll have my breasts back sometime in the next year, I'm not counting down the days. I have been a nursing mother for more than three-eighths of my life. It's not, as you may have deduced, an identity I'm in a hurry to shed.

When I nurse my children I don't feel like a cow. I feel like a woman. I feel like a human. I feel like a mother.

As always, this post is only my own musings about the cultural weirdness that complicates lactation for many women. I'm passing no judgments on women who feel like farm animals while nursing. I've been there; I'm somewhere else now. This post is about the view from where I'm standing. It's fine with me if you're standing somewhere else.

Living with D-MER

[Part 1 is here.]

The night we brought my oldest son home from the hospital, I remember sitting at the dinner table. He had been sleeping and I was hoping he would wake up soon -- I needed him to nurse. I remember a sudden wash of hopelessness, as if a veil had been pulled back and I could see what a hideous place the world really was. Close on the heels of this surge of emotion I felt a not-yet-familiar ache in my breasts.

Over the next few weeks this became a very familiar cycle: a sudden conviction that the world was unremittingly bleak, closely followed by spraying milk. I remember talking about it a few months later with a friend of mine, who found it very surprising. It must be prolactin, we agreed.

It made sense to me at the time. I had read about the calming effects of prolactin, but I also remembered the weepiness I'd experienced after taking Valium for outpatient surgery. Maybe, I thought then, one woman's calm is another woman's depressed. I also remembered my experiences with PMS as a teenager, when I would experience a distinctive, physical kind of sadness. "I feel sad in my stomach," I would think to myself, and I would know to tuck supplies in my purse for the next day. There was a kinship between the PMS sadness and the letdown sadness; it made sense to me that a unique emotional reaction could be tied to a hormonal state.

My D-MER was never devastating, though I just dug up an email I wrote more than a decade ago in which I described it as "overwhelming" in the early days of nursing my oldest son. On a bad day, it could bring tears to my eyes; on rare occasions it made me a little reluctant to nurse. I tried to shape my emotional response by saying, "Calm, calm" to myself when the feelings hit (which never worked, FWIW); I reminded myself that I would feel better very soon; I tried to get a little extra rest or a little time to myself on the days when it really bothered me. I was extremely (you might even say militantly) motivated to breastfeed, and I just figured it went with the territory for me.

Still, I felt a surprising relief when I first read about D-MER on an email list for lactation consultants. It wasn't just me. I wasn't some kind of aberration. There was a reason I had needed to push away those feelings, all those thousands of times.

Fifteen years later, I rarely notice my D-MER. When I do, it's always milder. I don't know what has changed, exactly, though I vaguely remember that it always became less pronounced as my babies grew into toddlers. I started taking fish oil five years ago, and there may be an association between fish oil consumption and higher dopamine levels (can't find a good link, though -- LMK if you know of one, please). Additionally, I've experienced that rush of unhappiness so many times that I recognize it easily and think, "Oh, it's you again" without paying much attention to it.

For the women with D-MER who might read this, I hope to offer a little encouragement that things can get better without weaning. And I also want to mention a little silver lining -- three small advantages to D-MER. First, difficulty dealing with the D-MER feelings can be a cue that I'm not taking care of myself adequately, a sign to look again at what else is going on in my life. Second, D-MER gives me much more empathy for a couple of people in my life with substance abuse problems. Part of the addiction cycle is lower dopamine levels during withdrawal, and do you know what? If the world routinely looked as hopeless to me as it used to in those moments when my dopamine level plunged, I might very well have a substance abuse problem of my own. D-MER offers me a bit of insight into the mysterious potency of brain chemistry. Finally, those early days when the feelings are strongest are also the days when the breasts are most likely to leak. That unmistakable flash of misery was a cue for me to apply discreet pressure in time to contain the spray. I might have felt that I was looking out across an empty and barren world, but at least I could do it with a dry shirt. :-)

Here again is the link to the D-MER site, where there's lots more information for mothers with D-MER and their supporters: http://d-mer.org.

Why some women hate breastfeeding: what you should know about D-MER

This post was prompted by a discussion I observed recently on Facebook. A pregnant woman wrote about how unhappy she had been while breastfeeding her previous baby, and the onslaught of advice started at once. She should encapsulate her placenta this time, they told her. She should take vitamin supplements. She should think about any deep-seated issues that might be causing her problems.

I wondered, though, if it might be D-MER: dysphoric milk ejection reflex.

In most women the milk ejection reflex works like this: the anterior pituitary secretes prolaction, stimulating on-the-spot milk production in response to a suckling baby, and then the posterior pituitary secretes oxytocin, triggering contractions in the myoepithelial cells of the breast. They squeeze the milk out in what's more commonly called a letdown. You can think of it as a baseball team: the center fielder (that'd be the anterior pituitary) whips the ball to the second baseman (posterior pituitary), who tags out the guy from the opposing team (failure-to-thrive heads back to the dugout, shoulders sagging).

For a subset of women, the process unfolds a little differently. It's thought that their dopamine levels plummet in association with this hormonal dance, causing a surge of negative emotion just before each letdown. To continue the baseball example, it's as if the shortshop runs over to get in on the action at second base and injures himself along the way.

There's a range of severity: for some women, it's a mildly unpleasant wave that passes quickly. For others, it's crippling. As you might expect, there's also a range of possible treatments. For some women, just knowing what's going on is enough to make the feelings manageable. Others report that improved self-care can ease the unpleasantness. For women with more severe cases, prescription medication can help. It's important to note that the antidepressants most commonly prescribed for lactating women are unlikely to help with D-MER: Zoloft and Paxil can affect serotonin levels, but serotonin is the wrong neurotransmitter to tackle when D-MER is the problem.

So is it possible that some women hate breastfeeding because they have deep-seated psychological issues? Sure, it's possible. It's also possible that some women might find vitamin supplementation helpful. (All I'm going to say about the placenta encapsulation idea is "to each her own.") But it's also possible to hate breastfeeding because every letdown -- we're talking maybe three or four of them per feeding or pumping, ten or twelve times per day, plus the times when the baby sleeps too long or cries too loudly and her breasts say, "Hey, did somebody need some milk around here?" -- every one of those letdowns triggers feelings of hopelessness or anxiety. Knowledge is power, and ignorance about D-MER is widespread. Find out more here.

[Update: here's a follow-up post on nursing happily despite D-MER.]

Tax dollars at work in Georgia

O citizens of Forest Park, rejoice: you can breathe easy now. Your city manager has set you free from that most monstrous of menaces, that most dastardly of desperados, that most egregious of evildoers: those mothers of older nurslings.

No longer will they skulk in the alleyways, awaiting an opportunity to corrupt the youth and distress the elderly. No more will they watch eagerly for the chance to unleash mischief while twirling their mustachios. Wait. I mean, twirling their pistachios. Wait. Never mind about that part.

Yes, citizens, you must STAND UP for decency, STAND UP against public nudity, and this means, inevitably, that you must BAN Victoria's Secret stores. Wait. No. It means that you must BAN a quiet, peaceable, and utterly normal process which is none of your concern and which is also legally protected in your state, because clearly, the good of the municipality requires it.

P.S. I have written more seriously about older nurslings and public breastfeeding in the past, if you are looking for a response other than derision.

PSA

Have you seen this story about a new study showing that bottle-fed children are more likely to have significant behavior issues? I have to put in an interlibrary loan request for the original paper, but I am throwing up a quick post tonight. It seems inevitable to me that this post will spark nasty exchanges of fire from the trenches of the mama wars, and I suspect the participants will mostly be missing the point.

I have written before about Michael Kramer's fantastic longitudinal study in Belarus, in which he took something like 16,000 women who planned to breastfeed and assigned them randomly to healthcare providers and hospitals. One set of HCPs had been through Baby Friendly training to equip them to offer more effective breastfeeding support; the other set of HCPs hadn't had any special training. Kramer found substantial differences in breastfeeding exclusivity and duration, and he's following the kids longitudinally to see how they're doing. This is the project that found breastfed kids scored half of a standard deviation higher on verbal IQ tests at age 6, a finding (.pdf link) that still blows my mind.

They also looked at the kids' behavior at age 6, based on reports from mothers and teachers. You can read the whole article for free if you're so inclined, but here's the money quote:

On the basis of the largest randomized trial ever conducted in the area of human lactation, we found no evidence of risks or benefits of prolonged and exclusive breastfeeding for child and maternal behavior.

So the moms who are, inevitably, going to be trading horror stories about badly behaved children in response to this new study ("You should see my nephew, Dharma Patchouli -- my SIL breastfed him until he was seven and he knows no limits. He climbed the chandelier at my wedding reception and she laughed about how great it was to watch him exploring" vs. "Well, my poor niece Adelina Lonelyheart felt so little love in those months she spent strapped in her baby bucket with a pacifier shoved in her mouth that now she cries at the drop of a hat.") -- moms who get sucked into exchanges like that are missing the mark here. Breastfeeding duration isn't associated with any differences in average kids' behavior scores. This is a popular idea with some breastfeeding families -- I have an edition of The Womanly Art of Breastfeeding in which a mother of several children says, "The longer we breastfed them, the better they turned out" -- but it's not supported by the PROBIT data.

This new study is talking about behavior that's not average-- kids who are at or above the 90th percentile for a particular type of problem behavior (caveat: this is based entirely on the newspaper report). This makes a lot of sense to me: if a kid is genetically predisposed toward anxiety, say, and then doesn't get the long-chain fatty acids that we know are important for building a healthy brain, he may have more trouble regulating his anxious feelings down the line. It's not about how it makes someone crazy when her nephews burp loudly at the table and CLEARLY it's their mother's fault. This study is about significant anxiety or oppositional behavior or other outside-the-normal-range concerns.

There does seem to be a bit of a contradiction between this study and the PROBIT study, but a partial explanation may be that the great strength of the PROBIT study (the shared intent to breastfeed, which made randomization possible) is also a weakness: every mother who participated was planning to breastfeed her child. All of the PROBIT findings are thus comparing two groups of breastfed children, and we know from the literature on breastfeeding and schizophrenia that even a few weeks of breastfeeding can be linked to differences in long-term psychiatric outcomes.

Now that I've dashed off this post, I'm a little hesitant about publishing it. (The scholar in me is saying, "Neeeeeed the full text! Muuuuuust have full text!") If you disagree with me, please be nice. If I find out more from the actual article, I'll be sure to post an update.

How Sharper Than A Serpent's Tooth

My pal Steve became a dad for the first time in July, and yesterday I got a message from him about his son, who has been biting while nursing. I sent him a speedy reply with a promise of more info soon, but I thought the topic might make a useful blog post.

Biting: Why?

There are three main reasons why nurslings bite. The biggest, especially in a 6-month-old, is teething discomfort. Erupting teeth hurt. Counterpressure helps.

Sometimes biting is related to starting solids and related milk supply issues. Most babies begin showing interest in solids around the middle of the first year, and biting can be a way of saying, "Hey, is there anything else to eat around here?" A variation on this scenario occurs when mom starts solids earlier, and her milk supply drops a bit too quickly as baby nurses less.

A third reason, more common in older babies and toddlers, is unhappiness. Sometimes babies get bored with nursing, especially when mom is trying to put them to sleep. A little nip can be an effective antidote to boredom because it provokes such an interesting reaction. Sometimes toddlers get overloaded -- angry or frustrated -- and bite as a way to say that something's not right in the world.

Biting: What To Do

If baby is biting because his gums hurt, easing the pain will usually reduce or eliminate the biting. Try a teether that can go in the freezer, or a frozen washcloth. (Last night autocorrect turned "frozen teethers" into "frozen terriers" in my message to Steve. Please don't feed your baby frozen terriers.) If you've started solids, try stripping baby down to his diaper and giving him a frozen banana with which to wreak havoc (and, incidentally, numb his gums). Don't forget the stripping down part, or you will be hitting that piece of clothing with buckets of OxyClean and despair. Consider over-the-counter pain reliever if your baby is really uncomfortable.

If you haven't yet started solids with a baby who's around six months old, you could think about trying tastes of mashed banana or sweet potato. Some crunchy parents think that a longer stretch of exclusive breastfeeding must be better than a mere six months, but babies are wired to begin exploring other foods around the six-month mark. (Give or take. Allergy-prone babies may consistently refuse solids at that point.) If you have been enthusiastic about solids and your milk supply has dropped as a result, try some low-key measures to boost supply. Start with breast massage beforehand and breast compression during feedings, and see if that seems to make a difference. Try shorter, more frequent nursings, gently cutting baby off before he has time to bite. Do not -- really, do not -- get all stressed out about your milk supply. It's less likely that you have a sudden big milk supply crisis than that your baby has figured out a new way to get your attention pronto so he can express mild dissatisfaction.

If baby is unhappy, think about why. If boredom is the issue, are you sure he's really tired? Can you try something else to put him to sleep, like rocking or walking or swaying with him in a baby carrier? With an overwhelmed toddler, it can help if you address whatever's making him unhappy, and offer empathy, and teach words/signs like "mad" and "frustrated" and "grumpy."

Regardless of the cause of the biting, it's often preventable. Keep an eye on that little tongue, which should be visibly cupping the breast. To use the lower incisors for biting, baby has to retract the tongue. This gives you an opportunity to unlatch him before you get chomped. If biting is a chronic thing at the end of feeings, try slipping the baby off when his sucking slows down. (The very hardest kind of biting to deal with is the baby who clenches inadvertently as he's easing into sleep. Five children of my own and ten years helping breastfeeding dyads, and I'm still stumped by that one. Ideas welcome, because OUCH I hate that!)

If you miss the cues and baby clamps down, try a completely counterintuitive move: pull him in as close as possible to your breast. If his nose is buried in breast tissue, he'll let go so he can breathe more comfortably. Sounds weird, but it usually works. Be firm but gentle: "OUCH, that hurts Mama. Let's take a little break from nursing." Babies are smarter than we think they are, and they'll usually catch on quickly that biting Mama means no more milk for a bit.

In general, I think it's prudent to moderate one's reaction to a bite. If you have a sensitive baby, you can really frighten him if you yell. On the other hand, some babies think it's interesting to get such a rise out of a usually calm mama and may bite because it elicits a big reaction. I have had both kinds of babies, and so I'll say it again: firm but gentle is the way to go.

To sum up: biting in a younger baby is usually tied to something physical. Biting in an older baby or a toddler may have a physical cause or it may be more complicated. It used to infuriate me to be bitten by a child I thought was old enough to know better, but these days I see it with different eyes. I think it it means, "Something is wrong and I know you can fix it. You're the one who can help when I'm really upset. I'm safe with you."

Nursing covers are part of the problem

I hate nursing covers. I am cranky as all get-out today, so I am not going to insert any disclaimers like "I understand some women feel more comfortable blah blah whatever works for your family." No one here needs me to tell her to do what works for her family, am I right? So these are my shooting-from-the-hip objections:

1. Nursing covers are weird-looking. Aren't people more likely to stare at you if you're wearing an oversized floral apron around your neck? 


2. Nursing covers are one more THING to get in the way of peaceful outings with a new baby, one more $30 item to clutter up a baby registry. Going out? Don't forget the Boppy! Don't forget the Flap Happy! Don't forget the backwards superhero cape with the cutesy-poo elephant print! Puh, I say. Stick a diaper in your purse and hit the road.


3. Nursing covers don't really help uncomfortable observers to feel more comfortable. Most of our collective craziness about nursing arises from people's discomfort with the reality of breastfeeding: babies are sucking on women's nipples. There's also a frisson of "...and ACK I might see some nipple if I don't look away!" -- but my experiences lead me to believe that people object more strenuously to the idea of a baby nursing in public than to the visual of a baby nursing discreetly in public. And aren't people more likely to think you're doing something you need to hide if you act like it needs to be hidden?


4. In fact, nursing covers perpetuate the problems they're ostensibly designed to deal with. The way to get comfortable with breastfeeding is to be around breastfeeding. Maybe you can sit across the museum from the sweet sleepy baby whose mama is quietly nursing him. You can take the pew behind the wiggly baby who settles instantly when his mother lets him nurse. Here's the thing: you have to see it repeatedly for it to look normal to you. If it's hidden under a giant paisley hairdresser's smock, we're not any further forward.
   
   And -- AND AND AND -- the very names of these products convey Failure To Get The Concept. "Udder Covers." "Hooter Hiders." News flash, O foolish manufacturers: they are not udder covers, because lactating women are not and never will be cows. Don't even suggest that I'm a cow. And woe BETIDE the person who calls my breasts "hooters" -- but we should shell out perfectly good money to someone who seems to be stuck in junior high?

Harrumph, she said in her most curmudgeonly voice, while reminding you that all crabbiness herein is aimed at societal cluelessness and stoopid marketing departments rather than at any individual mothers. Also, happy World Breastfeeding Week.

PS Writing this post left me considerably less crabby and I googled Hooter Hiders because I thought I'd heard they had a new and less offensive name. Do you know what I found?? I found this. Women of America, I implore you: keep your lampshades at home. On your lamps.

Breastfeeding makes us stupid

How's that for a title? I do not mean, of course, that breastfeeding makes babies stupid; breastfeeding is important for growing brains. What I mean is that talking about breastfeeding seems to make the grownups stupid. Something about breastfeeding hits the media and the lactivists all say, "Look! Breastfeeding is important!" and the moms who had trouble breastfeeding say, "Don't make me feel guilty!" and perhaps Rebecca Goldin says "I'm a professor of statistics [with an axe to grind] so let me tell you that breastfeeding isn't very important"* and the lactivists say "Yes it is too!" and then somebody says "You only think that because you're a nazi who's planning to demand the right to defecate in public."

And then my head explodes. Again.

Here are two things you might like to know about the study published Monday in Pediatrics. 

1. The authors do not say anywhere that mothers are not trying hard enough. No one needs to read about this study and then run through the reasons why she stopped breastfeeding to make sure they're good enough. You in the pink shirt over there, relax. It's not about whether you suffered enough, not at all.
2. It's all about the fact that modest differences add up to big numbers in large populations. Because of the magnitude of the potential savings, the authors call for improved support and infrastructure for breastfeeding mothers.

Most of the blogosphere buzz about this article has focused on its calculation that six months of exclusive breastfeeding by 90% of mothers would save more than 900 children's lives as well as $13 billion annually. We can't have those kind of breastfeeding rates without paid maternity leave, people are saying, so what's your point, Dr. Bartick?

But they're not just talking about Breastopia in this article. The authors present a range of numbers, and the 90% values have gotten all the press because big numbers make big headlines. No one seems to be talking about the more attainable outcomes: if we could just hit the Healthy People 2010 targets, we would save still save billions annually (billions as in 2.2, but still, billions, plural) and 142 children's lives. Those are reachable goals: they specify that 75% of babies will begin breastfeeding -- a single attempt counts -- and 50% of babies will still be receiving some human milk -- even a tiny fraction of their intake -- at six months old.

We don't need to reform the whole maternity leave system to save lives and dollars. (Not that I'd complain if anyone wanted to tackle the vexed issue of maternity leave in the US.) Here are some things we do need:

1. Increased access to midwifery care. It's not just about birth, though see #2 below. Midwives expect to spend more time with women than OBs do; many midwives (depending on their credentials and their state regulations) can provide care to newborns as well as their mothers. Differential diagnosis of breastfeeding problems takes time, and some problems (thrush, tongue-tie) require coordinated treatment of mother and baby. A woman who calls her OB with a torturous case of thrush may have to work harder at getting what she needs.
2. Increased access to out-of-hospital birth. For a variety of reasons, complicated birth is often followed by complicated breastfeeding, and complicated birth is widespread in the current hospital birth culture. Out-of-hospital birth is not for everyone, but it is a safe option for low-risk women and their singleton vertex babies. (Also, I have never heard of a homebirth midwife shilling for a formula company.)
3. Michael Kramer has shown in a randomized controlled trial that Baby Friendly training for health care providers makes a massive difference for women who want to breastfeed. Remember that .5 SD difference in verbal IQ at school age? We have more than 5800 hospitals in the US.** Guess how many are BFHI-certified. Did you guess 88? Because that's how many. Crazyville, am I right?
4. What if Joint Commission standards addressed lactation consultant staffing? Women need access to board-certified LCs in the immediate postpartum period. RN licensure alone does not equip a person to provide skilled breastfeeding assistance. (Hospital staffing issues are an area in which I have almost zero experience; that's why this one is presented as a question.)
5. We need mandated, hassle-free insurance coverage for outpatient LC services. The cost of an LC visit is roughly equivalent to the cost of one bout of otitis media. Insurance companies should be tripping over themselves to reimburse LCs, because early breastfeeding success will save insurers money both in that first year of life and for a long time afterward.
6. More education. I'm not thinking so much about education for mothers here; I'm thinking about LCs who can go into junior high and high school health classes and talk to kids years before they become those parents facing down an irate baby with a latch problem. LCs who are interested in outreach can talk to college students, RD students, OT students, SLP students, nursing students, medical students. Clearly there's a need for some education among Twin Cities police. Imagine the power of a concise presentation that is rigorously accurate without taking itself too seriously, a presentation that makes students think and makes them laugh and also makes sure they know that most breastfeeding problems are solvable.
7. Last: I think it's important to avoid the echo chamber effect. We do a lot of preaching to the choir in the breastfeeding community, and we don't always notice the women slipping out of the pews even as we crescendo. Sometimes what's billed as a breastfeeding support meeting can become the lactator's equivalent of a pissing contest: I'll see your Birkenstocks and raise you one HBAC and three tandem nurslings. Do we really need to scrutinize each other's choices and second-guess each other's motives? I have come to think that one of the best gifts we mothers can give to each other is the benefit of the doubt.

I put that one last because I want to emphasize it: when a woman who thinks breastfeeding is icky is talking to a woman who waxes rhapsodic about her 4yo's weaning party, it's unlikely that any minds will be changed by the conversation. Each of those women is going to carry on thinking that the other is kind of a wacko. I think what matters here is smaller changes-- when the woman who thought breastfeeding was gross decides to let her second baby try to latch on once or twice. When the woman who was going to wean entirely because her maternity leave was ending decides instead to keep nursing at bedtime. When the woman who thought she'd never breastfeed in public decides to leave the formula at home this time. These incremental changes matter. Breastfeeding duration has been creeping upward, and not because women in America have decided en masse to go granola.

The coolest part of the Bartick and Reinhold article, I thought, was a little table on page 1049. In 1998 when I was first training as a breastfeeding counselor, I remember learning that 6% of US one-year-olds were still nursing. In the early 00s when I first heard about the Healthy People 2010 goals, I remember thinking, "Yeah, good luck with that." But do you know, things are really changing. These days more than 21% of one-year-olds are nursing. Seventy-four percent of mothers initiate breastfeeding; 42% of them are still nursing at least a little bit six months later. That's fabulous news: it means healthier babies, healthier mothers, lower healthcare costs for that segment of the population at a time when cost containment is a pressing issue.

So I think it's important not to let breastfeeding make us stupid. It's easy to lapse into fatalism (it's too hard and it doesn't matter anyway, à la Amy Tuteur) or extremism (lactivists who say "If you weren't willing to work at motherhood, maybe you should have bought a goldfish instead"). Let's not. Let's keep nudging it forward, remembering that there are real dollars and real lives at stake as we do.

_________

*What's up with that social workers comment? Social workers??

**Sorry, I don't know how many of those hospitals have maternity units.

Research shows that lead paint is A-OK!

I am very late to this party, but I am stopping by anyway. I started this post the day I read Judith Warner's screed, but it takes me forever to write anything non-bullet-point-y. Also, becoming a doctoral candidate has had an unexpected effect on me -- I find myself thinking thoughts like, "Should I really hit publish before I understand how they calculated the area under the curve in the lead study? Do I need to be clearer that neither of the studies I'm talking about can claim to be the last word on the topic?" Which is probably a little silly, so here's the post I wrote.

Judith Warner has jumped on Hanna Rosin's bandwagon, where the tune they're playing goes something like this: "I have zero public health credentials but I'm going to broadcast my ignorance to the widest possible audience anyway." There are already plenty of bloggers reacting to Rosin's piece, so I'm going to focus this on one maddening misperception in both pieces: the idea that breastfeeding has no significant impact on cognition.

Tandem Nursing: Notes from the Gladly House

In response to a couple of comments on that last post: I am tandem nursing for the fourth time. All of my sons, in other words, have nursed through and beyond a pregnancy. I am a quiet tandem nurser, because it is an odd choice in this culture. Some people assume you must be a freak doing it for nefarious reasons; others assume you must be a hardcore lactivist passing judgment on the non-tandem-nursing population.

Woe unto me if I ever walk around passing judgment on 99+% of the population. I harbor no illusions that tandem nursing will make for a more peaceable world -- or even a more peaceable household, though that's my hope. It works for us, so that's what we do. I asked Pete the 3yo for his point of view.

What do you think about sharing nonny?
It's good! And the new baby will say "Wummy wummy wummy." And it's good to share, right?

Do you ever wish you didn't have to share the milk, or is sharing no big deal?
It's no biggie, because there's lots and lots and lots and lots.  And it's for nobody else except the new baby and me.

I thought about posting the reasons why I've nursed my children past infancy given the widespread assumption that it must be for freaky kinds of personal gratification, but I'm not sure that assumption is actually very widespread among people who read this blog. Nursing is a happy but diminishing part of a happy and growing relationship with my 3yo: we read books, we do puzzles, we go to the kids' museum and drive the model tractor, and sometimes we nurse. I expect that during the next year, he'll wean peaceably. I also expect that, like his brothers, he'll dimly remember nursing as something that left him feeling safe and loved and content.

For the people who say darkly, "That woman must be getting something out of it for herself," about older nurslings, I will acknowledge that I do get something out of it for myself. I have a vicious oversupply problem, and an older nursling is a huge help in ramping down supply without drowning the new baby, or subjecting her to GI distress, or landing myself in bed with recurrent mastitis. I could pump, sure, but on Christmas Day when I was battling chills and misery it was so much nicer to lie down next to my Petely than it would have been to wash and assemble the parts for my little hand pump, hoping I remembered how they went together and mustering the muscle to move all that milk. (Many of the dark mutterings suggest that mothers of older nurslings get some kind of sexual charge out of the relationship, which is, not to put too fine a point on it, asinine.)

The first time I tandem-nursed, it was really hard. Really really really really hard. But then everything was hard about going from one to two -- not so much going from two to three, or three to four, or four to five. (So far.) As my pregnancy progressed I talked to Pete about what to expect when the baby came. He seems to have listened closely. (When he climbed into our bed in the morning of her birthday, he said, "Is the milk going to spray out now?" Probably tomorrow, I told him.) I don't pay much attention to how often Pete asks to nurse. I almost always say yes in the early days, when the youngest child has just become the big brother, but I don't worry about saying "Not now. Another time." And I'm not worried about weaning -- it will happen. It always does.

Carrying my children a lot didn't delay them when it was time for them to walk. Using words to interpret their early gestures and monosyllables didn't keep them from talking in sentences (and paragraphs and novellas) when the time was right. And being willing to nurse them for a period of years rather than weeks or months won't keep them from weaning in due time.

I was typing this with baby in the sling. She had just finished nursing, which prompted Pete to say, "More nonny?" We just had nonny, I reminded him. How about another muffin? He didn't want a muffin, but he didn't complain about waiting until later to nurse. Instead he leaned over and planted a spontaneous kiss on his sister's fuzzy head. It works for us. It works well.

Once more into the breach, dear friends

On Tuesday I got a copy of Faith & Family in the mail because my Petely's picture is in this issue. I was flipping through it, thinking idly about subscribing, when I saw this sentence in an article on taking kids to Mass:

No one will deny an infant his bottle, and some moms -- appropriately draped of course -- discreetly nurse their babies in a tucked-away space.

If you ever want to push my buttons with a nuclear-powered cattle prod, you can just call me up and read that sentence to me. It is wrong in so many ways I can't even count them, though I'm certainly going to give it a try. Before the counting commences, a quick note for anyone new to this blog: I recognize that women make all kinds of decisions for their families, for reasons that are pretty much never my business. I make no assumptions about why women use bottles, so no need to get your knickers in a twist. Three years ago I posted an essay on the web about breastfeeding Catholic mothers, and craziness ensued. I am too sick and too busy to deal with internet crazies this week. Please be crazy somewhere else.

So let's review: human milk is the food designed for human babies. Babies who do not receive human milk will be more vulnerable to a wide array of pathologies, including but not limited to enuresis, schizophrenia, alcohol-related hospitalizations, and death from SIDS. A nursing mother is conferring long-lasting protection against illness. She is shaping her child's brain, providing the right fats in the right ratio for building the retinas and the cortex with which he will learn about creation. She is shielding him from the subtle damage caused by in utero toxin exposure, and she is cutting his odds of developmental delay.

And it is crucial to note two more things: first, many of these effects are dose-related. A little human milk is great, in other words, and more is better. Second, humans are "carry mammals," meaning that their milk is designed for frequent consumption. God could have made us like bunnies, nursing every twelve hours (much easier to work around the Mass schedule that way). He could have made us like deer, but I have yet to spot any hooves or antlers on the children of my acquaintance. Human babies get hungry often. God has designed them, from top to bottom, to receive milk from their mothers' breasts.

Why then, why oh why oh why, would a magazine aimed primarily at Catholic mothers suggest that bottles should be the default for babies at Mass?

I don't really need an answer to that question. People get tetchy about the fact that human milk is made by humans. No other body fluids are foods, let alone foods with superpowers, and in general we avoid body fluids -- sensibly so. People get tetchy about the fact that breastmilk comes from breasts, when we're used to thinking about breasts as decorative or seductive.

But do you know what? It is not the normal behavior for the species that needs to change. It is the thinking that needs to change, because it is costing us all. Even if you have no children, you are paying for the higher healthcare costs of formula-fed infants (and, to a lesser extent, formula-feeding mothers). It may well be costing you in the workplace, because breastfeeding-unfriendly policies make for higher absenteeism among employed mothers. And I find it preposterous -- painfully absurd, in fact -- that Catholics are buying into the madness of a culture that equates nursing a baby with acts either sexual or excretory, things polite people would never do in public.

"Just pump," some will say. "Just pump" assumes that every woman has the money to buy a pump, and the time and willingness to use it -- a false assumption. "Just pump" is a tacit admission that the speaker thinks misplaced squeamishness trumps a baby's right to be breastfed -- a point of view with which, as you will have guessed by now, I disagree vigorously.

When a Christian woman gestates and births the baby God has given her, she says with our Lord, "This is my body, given for you." When she feeds her baby at the breast, giving him food synthesized from her own blood, she says, "This is my blood, poured out for you." (Those of us with overactive letdown modify it to "...spraying out for you rather like Old Faithful in an especially emphatic moment.") The Victorians hid away their heavily pregnant women, because those burgeoning bellies spelled s-e-x. I submit that we fall into the same error when we tell nursing mothers they need to drape or leave. "ATTENTION, PLEASE!" calls the drape. "Uncomfortable nursing mother, right here in this very spot!" And isn't it more distracting for me to be walking up and down the aisle, as I go back and forth from my private corner, than to be meeting my baby's needs quietly in the pew? (Say, did the Blessed Mother not get the memo about how modest Christian women are supposed to be using bottles or else draping? Maybe she needed Hooter Hiders, you think?)

Believe me, I don't want random parishioners catching sight of my bare breasts, any more than I want them to see my bare pregnant belly. That's why I dress for the occasion when I'm taking a small baby to church, and why I learned when my oldest was tiny how to nurse him without giving anybody an eyeful. It's not hard, especially when you can learn from other mothers around you who are also nursing their babies. Hint: this is more likely if they are sitting across from you at coffee and doughnuts, not hiding in the bathroom hoping there will be a Boston creme left by the time the baby's finished.

Here's the bottom line: we nurse our babies in obedience to God's call. We give them the food Jesus chose to receive himself -- living food that is an echo of the Eucharist in the way it nurtures and protects those who receive it frequently.  And that, in my view, is cause for celebration, not something to hide.