August 8, 2010

Boob Job—Breastfeeding in the Real World

breasts-oxcart When Amy called, she sounded fine.  She’s in her early 30’s and just had her first child, a great and healthy baby named Henry.  The baby was about a week old.

In pediatric training, I wasn’t taught much about the mechanics of breastfeeding.  Sure, I was taught that it was a good thing.  I was taught to encourage it.  But how the process happens, how the machinery in the breast works or doesn’t, and what some of the key practical issues might be was all unexplained.  Luckily, I used to work with a fabulous nurse-practitioner, who is also a lactation consultant.  She taught me a ton, and I have learned more since.  So I’m no longer afraid of dealing with nursing issues head-on.

Before she left the hospital with the baby, I had told Amy what to expect, in general terms.  I told her that most women who are mothers for the first time don’t usually make a lot of milk for the first few days, maybe more.  But in order to get the factory going, she needed to keep putting the baby to her breasts.  It’s nature’s way to have the baby get hungrier over those first few days.  The baby gets hungrier, sucks harder, sleeps less and wants to nurse more.  This results in more stimulation, causing more hormone release from the brain, causing milk production.  As the milk starts coming, the baby gets some positive feedback from nursing, leading to a completely Pavlovian conditioning system, which leads to the baby wanting to nurse more, leading to more stimulation, leading to more production, and the next thing you know, you’re getting a bill for college tuition. 

Nearly always, I’d give new parents this speech or something close.  I started doing this because again and again I have had to reassure new parents that it was completely normal to have a 2-day-old baby who wants to eat but mom has nothing to give.  Colostrum, the early secretion of a breast, is very healthy for the baby but not very filling.  Though I haven’t found this written about much, it’s just this anxiety which seems to have coincided with abandonment of breastfeeding in patients I saw years ago.  The parents would care so much about the baby that they would draw a premature conclusion that their ability to lactate successfully had failed in some way, and start giving the baby formula.  Formula isn’t poison, no matter what you’ve heard.  Sometimes, it’s necessary and I recommend it.  But once a baby starts eating from a bottle, they learn that this is the way to eat.  It’s much more work for a baby to extract milk from a breast, and takes much more coordination of breathing, and sucking pressure.  So even after there’s a decent milk supply, the baby will nurse briefly and then complain, preferring the bottle.  They are saying that even though they like home-cooking, they’d rather go to the drive-through window and get fast food.

Honestly, I think that taking the time to explain what to expect has resulted in very few breastfeeding failures.  I’m very grateful, as well, for being in a community in which lactation consultants are available and can be enormously helpful.  Though I have a lot of the same knowledge, and am completely comfortable around nursing babies, I’m still a little awkward when it comes to judgmental assessments (‘wow, now that’s an inverted nipple’) and manual intervention (‘OK, push your breast this way, squeeze here, and massage your nipple like this’). 

It may be counterintuitive, but I think one of the smartest things that I do with breastfeeding promotion is give the parents some formula.  Hospitals used to give formula samples, provided by the manufacturers, to all the parents of new babies.  I’m against this.  It sends the wrong message, and some hospitals have stopped doing it.

It’s different when I do it.  I give the parents a small amount.  Sometimes I have premixed little bottles in packages of 4.  I like giving those.  Sometimes I have cans, and that’s OK if it’s all I have available.  I get these from the same manufacturers as the hospitals.  This isn’t formula to feed the baby, though the manufacturers would certainly like me to promote it as such.  It’s an anxiety-relief apparatus, which works at many levels. 

First, by coming from  me, I am implicitly granting permission for the mother to use it if needed.  If she decided she needed it, it would be OK.  I’d tell her that she should just keep it in the kitchen cabinet, just to have it on hand.  I tell parents that I don’t expect it will be necessary.

I’m not much of a back-country camper.  The whole idea of a bivouac is unappealing to me.  But I know plenty of people who love the outdoors and the idea of following a Road Not Taken.  Oddly enough, they still take along a cell phone.  Just in case.  Just because you don't anticipate a problem doesn't mean that you shouldn't have a contingency plan.  Maybe it's the cell phone, maybe that wacky silver emergency blanket.  Just having it along can give you the sense of security you need to go someplace that otherwise would be too scary to go.

Second, it’s a message that I won’t let their baby fail, and neither will they.  When a new baby comes home with a first-time parent, our insular society has precious little support to offer.  Other cultures, and our own of 150 years ago, provided a multi-generational household.  Several generations of women would be there waiting with a deep repository of knowledge and experience in nursing and babies.  If your milk didn’t come in easily, there was other milk available that would get the baby through those first few days.  My experience was that many or most of the women who turned to formula could, in fact, nurse successfully.  What they could not do was wait.  At some point, their anxiety about feeding the baby crossed the high threshold of their desire to breastfeed.  They wanted to make it work, but they couldn’t stand another moment of knowing the baby wasn’t going to get anything to eat.  This wasn’t bad parenting, it was good and loving instinct. 

I wrote a blog post about The Telephone Paradox.  The more I gave my home phone number to patients, the fewer calls I got.  None of my physician colleagues believe it.  I found that when patients knew and really believed that they could contact me at any time, they were empowered.  If the kid had a fever, they wouldn’t call immediately.  They’d try some fever medicine, knowing that if it didn’t work, they could call later.  Usually, it did work, so no call.  The parent was made to feel that they had the power to try what their common sense suggested, and that I was there if it didn’t work out as hoped.

So that formula in the kitchen cabinet usually sits unused until it’s past the expiration date.  The new mom is empowered by it.  Maybe she can get through just one more night with a hungry baby, maybe just a few more hours even.  If she needs it, it’s there.  But for now, she’ll keep putting the baby on the breast, doing what she needs to do to get that machine started.

I asked Amy if the baby was all right.  She said that the baby was fine, but she had a couple of questions.  They didn’t go where I thought they would, but that’s the next post.

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