Boob Job—Breastfeeding in the Real World

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.

An Aunt Who Shares

When a baby is born at the local hospital, the clerk in Labor and Delivery calls the pediatrician identified by the parents. The call I received one night about 3:00 AM was a little hard to understand. Granted, I had been awakened. But I asked the clerk for the patient’s name. ‘Oran…,‘ she said, then ‘Oranolantu…,‘ then ‘…bat…. “Do you mean Oranolantubaataar?“ I asked. Relieved, she told me I had a healthy big baby girl to come in and take a look at. I knew the family, and took care of the 4-year old son. I told her I’d be in later that morning. She politely told me that everyone in Labor and Delivery would really like me to come in now. I got dressed and went to the hospital, fearing the worst.

The Charge Nurse for L&D, who is the supervisor of all the nurses and operations of the department except for the obstetricians, and always one of the most experienced veteran professionals there, met me at the elevator, before I entered the ward. She said she’d never seen anything like it and didn’t know if it was OK and wanted me to evaluate this and write a note about it in the chart. She was afraid the hospital might get sued, and maybe a little afraid of losing her job. When I walked into the room, I was not prepared for what I saw.

The mother I knew was smiling happily in bed. Her labor had been relatively short with this second child, born about 2 hours earlier. She greeted me warmly in her broken English. I looked around. “Where’s the baby?” I asked her. She pointed to the chair next to her bed on which was a young woman. ‘Sister’ was her one word introduction. This woman was bare-breasted and nursing the newborn child.

I had never seen anything like it. I met with a group of the nurses, the charge nurse, and others.

The transition from unencumbered adult to parent is always unforeseeably and indescribably enormous. It seems that in recent years, the pressure on new parents has continued to build. The parenting shelf in the bookstore has become a whole section with many aisles. Perhaps it’s a good thing that you now can choose to learn what one author thinks you should have been expecting while you were expecting and another author claims to help you raise a child who is an over-achieving, healthy, gifted, socially adept, high IQ athlete who knows both how to control her temper and who goes to sleep without problems. (My approach to advising parents is almost always to ask the child to provide the right guidance. They usually know.)

Why has this proliferation of parenting advice taken place? The simple answer is that there’s a market for it. Publishers are aware of the demand and are in the business of meeting it. What’s behind this demand?

The desire to produce a text on childrearing isn’t new. Especially with the industrial revolution, the idea gradually took hold that maybe there was a ‘right’ way to raise kids.

Especially for the new parent, and the new mother in particular, these books can seem like an essential reference. There is a tendency for new parents and new mothers in particular to feel that the ‘success’ of nursing the baby, soothing the baby, even bathing the baby is a great burden that falls on them and them alone. If things aren’t going exactly right in the first days and weeks, it’s hard for new mothers not to see that as a personal failure. This is a major contributor to postpartum depression. But what has caused this crushing pressure? Is this part of Eve’s curse (Genesis 3:16)?

I don’t think so. According to archeological evidence, and according to countless cave-people movies, humans most likely never went through a phase of living in completely isolated family units. The idea, maybe born out of the settling of the American West, that there would be settlers who lived a hardscrabble life by themselves on a ranch the size of some European countries, is not one that has typically existed elsewhere in the world. Sure there are subsistence farms and always have been, but they are small and the families live close to other families.

And, finally I’m getting to the point, all the households are multigenerational. With marriage as teenagers, there would usually be grandmothers and even great-grandmothers living with the new mother. There would be sisters and aunts with their babies, too. And despite the considerable work all the women were required to do, some of the work of childcare and an enormous amount of cumulative experience and wisdom would be easily available and given.

Though it’s a good guess that midwives, people with special expertise in childbirth, have been around for a long time, Lactation Consultants are likely a newer breed. Within a multigenerational household, there would be lots of sources of advice about sore nipples and babies who don’t latch well. I suspect that postpartum depression has always been with us, but some of its pervasive contributors--isolation, the feeling that every need of the baby must be met by the mother, the sense of failure if the mother’s milk hasn’t come in by day 3 or 4--would be so very much relieved by having a crew of experienced and trusted peers who know what the heck they are doing.

The baby’s mother was from one of the Mongolian families I take care of. Some speak no English at all. But they all live very near each other in one neighborhood of Oakland. Many bring their kids to me. Her sister had given birth a few months earlier, and was still nursing her own infant. In their culture, this wasn’t unusual--it was simply what was done.

About a hundred years ago, and for millennia before that, wet nurses were common. Women who couldn’t nurse or those who could but had the resources to avoid this task of the masses, would employ a woman whose lactation was maintained by her continued employment. There were few alternatives. (The picture above is from a booklet produced about 1900 by Nestle, for a product called Nestlé's Food, which was among the very first commercial baby formulas. It’s from my collection.) But before there were professional wet nurses, there were women who would share their supply with the less fortunate, or the babies who had survived childbirth when their mothers did not.

One of the nurses asked if it was hygienic. Honestly, I didn’t know. I suppose, in these days of Universal Precautions and doctors afraid to touch you without gloves on, I could see what the concerns might be. There are some diseases which can be transmitted through breast milk, along with many medications. As politely as I could, I tried to get a little medical history from this other woman. She spoke almost no English, and the postpartum mother was translating my questions—I think. She’s the one who told me ‘she OK’ and left it at that.

I told the L&D crew it was OK with me and I would write an order in the chart explicitly allowing it.

The woodcut from 1550 is by Hans Brosamer and is from my collection. It shows the creation of Eve, her temptation, and the expulsion from the Garden of Eden. The poster from the 1958 movie Teenage Caveman was part of the collection I sold in 1992. Produced by—who else?—Roger Corman, I think it was Robert Vaughn’s first starring role.

Newborn Won't Gain Weight

A new baby, especially a first baby, comes as a reward for the inconveniences of pregnancy. New parents feel a rush of exhilaration and relief when the baby is finally there. As every parent knows, however, each achievement of parenthood merely punctuates a transition to another challenge. Maybe you just got your kid through high school. Now what? For good and caring parents, the sense of responsibility doesn't have a natural endpoint.

When I first saw this baby 17 days ago, I appreciated the excitement for first-time parents. Mom was about 40, and she told me there was some in-vitro fertilization involved [IVF]. She didn't have to spell out the details, and they didn't matter too much now that the baby was there. But I knew there was a back-story of frustration trying to get pregnant, wanting to be a parent but thinking it might never happen, having a picture of yourself with a child and thinking that might never come to pass, lots of indifferent intimate medical examinations and blunt clinical discussions of frightening risks, and, of course, the money. Now that the baby was in her arms, it was all worth it.

Now, it's my turn.

The baby looked great. Robust and healthy at a little more than 8 pounds, he did everything right. He moved right, acted right, had all the right reflexes. His heart and lungs sounded perfect. It was really fun to hold him. When I checked his hips he started to cry. The parents looked at me suspiciously, but I picked him up right away and quietly talked some sense into him as I walked around the hospital room. Obviously appreciating my point of view, the baby quieted immediately. The new parents were duly impressed with my persuasion skills.

A couple of days later, they were in the office. By now the baby was a little yellow. That didn't worry me too much, since somewhere over 50% of babies get a little jaundice. It usually peaks at about day 3 of life, but sometimes it's day 5. I sent the baby for a test and the level was moderate. That means not high enough to worry about, but high enough to test again in a day or two. The next level was at a high enough threshold to initiate some phototherapy. I know it sounds like every parent's dream: make your baby better by taking lots of pictures. In fact, it has probably been used for centuries. What was told to me many years ago is that it became standard therapy for jaundiced babies in the 19^th century. Picture the hospital at the time—big wards, like barracks, in which cots with mothers were lined up. After giving birth, the babies were taken to other big rooms filled with cribs. There was no air conditioning at the time, of course, and disease was suspected to be spread by bad airs (miasma). So hospitals were typically put at the top of a hill (for better ventilation) and fitted with large windows. It was noticed at the time that the babies near the windows were less jaundiced than the babies near the center of the room. Some rudimentary experiments confirmed that the natural light reduced the visible jaundice in the baby. We understand the mechanism of how this works a little better these days. It turns out that the chemical bilirubin, which is the yellow pigment, is not very water-soluble, but is oily. So just like salad dressing, the oil doesn't want to mix with the water. In our bodies, watery stuff is typically blood and other fluids, and oily stuff is skin and fat. That's why our skin is fairly waterproof, and generally keeps our fluids on the inside from leaking out. The light changes the chemical structure of bilirubin slightly, but enough to make it more water-soluble. This helps it get out of the skin and into the bloodstream, where it can be digested and disposed of. It's the reason baby poop is so yellow. Our technology hasn't done better than sunlight. I ordered a bili-blanket for the baby, which is a small electric blanket that produces, instead of heat, an absolutely otherworldly greenish glow that would make any visitor to Roswell New Mexico proud. But I still advised the parents to find a sunny spot in their home, and as long as they could keep it warm enough, let the baby have some nice sun exposure. This regimen only took a few days to lower his bilirubin levels sufficiently to have the medical equipment company retrieve the blanket. The parents were relieved that this jaundice issue was over.

With every visit, I always asked how the breastfeeding was going. Apparently, it was going extremely well. Mom didn't have too much discomfort, and the baby was doing perfectly. I observed several feedings and the baby was doing everything he should, latching on beautifully, sucking and swallowing. It didn't surprise or worry me when, at about 5 days of age, his weight was down about 8% or so from his birth weight, to 7 pounds 10 ounces. That's normal I assured the parents. Babies are born with extra fluid, and this helps them get through the first few days until the mother's milk comes in. As they lose this weight, they typically get pretty hungry, and cry aggressively and often. These signals, too, help with the natural production of the mother.

I was seeing the baby every 2-3 days, because the baby was jaundiced and because he hadn't started to gain weight yet. He was still 7 pounds, 10 ounces. When the baby was 5 days old, I didn't think twice about his mild weight loss. He didn't keep losing weight, but when he was 10 days old and hadn't gained even one ounce, I had a harder time reassuring myself and the parents that all was definitely well. Then the baby was two weeks old, he was still 7 pounds 10 ounces, and had not gained a single ounce from his lowest weight. My decision process got difficult. Ironically, I would have had a sadder but easier set of choices if the baby didn't look great. I could have done all kinds of blood tests, looking for signs of infection or rare metabolic diseases which could interfere with the baby's weight gain. I could have admitted the child to the hospital for regimented feeding. It's not breastfeeding-friendly, but it could be crucial diagnostically to figure out if there was something wrong with the baby. I didn't tell the parents this step was now on the not-so-distant horizon. I didn't like any of these options, but would do them if the baby showed any signs of a problem.

Now I was seeing and weighing the baby every day. This was extremely hard on the parents, especially the mother. It's typical enough for new mother to worry if the baby is getting enough, and to conflate their breastfeeding issues with their own sense of success as a mother. Here in Berkeley, breastfeeding is equated with parental adequacy. People breastfeed their kids pretty much through college, it seems. This culture of breastfeeding dogmatism has had both good and bad effects. It's great that breastfeeding is now widely acceptable socially and openly. People talk about it and there's lots of resources available to help with it. Research does show benefits to breastfeeding, for both mother and child. Whether these benefits outweigh the need for therapy resulting from your mother attempting to nurse you at your prom, is unclear. The bad part of breastfeeding as a cultural necessity is the pressure it puts on the mother. The dogma implies that breastfeeding comes naturally to good mothers, and that successful breastfeeding is simply a matter of caring and motivation. In fact, lots of mothers and babies find it to be a little tricky, though many problems can be overcome. There are lots of variations in babies and breasts, so there is no single method or position or technique that works for everybody. Still, it is sad for me to feel the overwhelming sense of failure and inadequacy that some mothers feel when nursing isn't going as easily as in the brochure. This is a contributor, at the most vulnerable time, to postpartum depression.

But this baby was feeding like a champ. His mother was getting all the right signals, and doing all the right things. So why wasn't he gaining weight?

The next day the parents told me that the baby had started to become a little fussier than usual, not sleeping as much, and was harder to comfort.

I decided that I certainly could wait any more and had to take some action. First, I sent her to a lactation consultant. A good lactation consultant, I like the IBCLC certified ones (http://americas.iblce.org/registries.php ), can be a huge help and knows much more than I do. So even though I couldn't see anything wrong, I wanted to get some expert help. (Another resource is www.breastfeeding.com . Their lactation consultants are at http://www.breastfeeding.com/directory/lcdirectory.html .) I also wanted to get some formula into the child.

Formula isn't poison. It had a couple of serious medical uses in the current situation. First, it provides a known volume and known calorie input for the baby. I needed to find out if he was taking in the volume needed to support himself and thrive. If he was, I needed to know if he was absorbing and metabolizing the energy content of what he was getting in an appropriate way. I told the mother to give him formula every other feeding. At the time of the formula feeds, I wanted her to pump. This had the additional advantage of helping figure out how much she was producing. The pumping, though not as effective as a nursing baby, would help to maintain her milk supply. This was important because I was hopeful that we would soon return to exclusive nursing. And of course, we weren't going to waste that milk. I told the mother to freeze it so that dad can do some feeding when she's sleeping.

At first, mom was even more frustrated. The baby didn't want a bottle, and would spit up after bottle feeding when he didn't after breastfeeding. I told her to be patient, and that like all of us, when we're hungry we're not as selective.

Twelve hours later they were in my office. Mom had a great meeting with the lactation consultant, who was concurring with my assessment that the baby is a great nurser. She was optimistic that this would all work out fine. With the new regimen of formula every other feed, used for just 24 hours, 7 pounds 11 ounces. The baby gained an ounce!

Today, 24 hours later, is Saturday and the baby is 17 days old. He still looked a bit scrawny, a little yellowish. We did another bilirubin test today. His parents said he spent a better night, with less fussing and more time awake and alert but not crying. Maybe he was just less hungry. Today he was 7 pounds, 12.5 ounces. It’s a great day.