Lenore Goldfarb’s Response to “Stressed about the Breast

To the Editor, National Post 
To the Editor, Ottawa Citizen
March 2002

Having gone to great lengths to induce lactation in order that I might breastfeed my premature baby, I was greatly disturbed by Sharon Kirkey’s recent article “Stressed About the Breast”.

There is no need to expound on the virtues of breastfeeding as Ms. Kirkey’s concise yet succinct description hits the target quite accurately. My concern is with the comments supplied by Dr. Dworkin and the damage his misinformed advice may cause to prospective mothers as well as those who are unsuccessful at breastfeeding and may be seeking approval to terminate their efforts. Dr. Dworkin implies that there is a valid choice between breastfeeding and bottle-feeding. This is in direct opposition with the World Health Organization’s code for the use of artificial infant milk which is what formula is.... artificial. The WHO code expressly states that mother’s breastmilk is the first option followed by expressed mother’s milk followed by banked milk with formula feeding listed as the last resort.

Hospital policies that routinely give bottles and formula without the mother’s permission contribute to breastfeeding difficulties. Rather than help the mother with positioning and latch, doctors run to the bottle as a universal panacea. Often there is plenty of breastmilk available but the baby isn't latched on correctly. When the baby doesn't gain weight the doctors and nurses rush to give a bottle. It’s a vicious cycle of inadequate training and response.

Furthermore, nipple confusion is a serious threat to breastfeeding. Under certain circumstances, even one bottle...can seriously affect an infant’s ability to take the breast. This is particularly damaging when a mother’s initial milk supply is low and baby needs to feed often to increase her supply. Giving a bottle at this juncture is sure to cause problems.

The American Academy of Paediatrics advocates exclusive breastfeeding until about the middle of the first year and then breastfeeding to at least1 year. The Canadian Paediatric Society advocates exclusive breastfeeding to 4 to 6 months and then continued breastfeeding to 2 years and beyond. In Sweden and Norway, where hospital routines are “baby friendly”, 98% of women start breastfeeding and 70% are still breastfeeding exclusively at 6 months!

Most mothers are inundated with formula company marketing and formula company samples in the mail, in hospitals, in pharmacies and in their doctors' offices. Mothers are constantly being told that formula is as good for their babies as is breastmilk, a proven untruth.

Mothers need to know how to tell that their baby is getting enough milk while on the breast. A baby who feeds well every 4 hours is better off than a baby who feeds poorly every hour. The most common problem that women have is that their baby is latch on to only the nipple. The nipple is the exit. The baby needs to take in more than the nipple in order to “milk” the ducts in the breast located behind the nipple. There are several websites that offer information on positioning and latch. One is asklenore.info has Breastfeeding videos. Women need to be told the truth about breastfeeding, they need to get good help with breastfeeding, and they need good support to continue breastfeeding. Mothers can learn to tell whether their babies are getting enough milk by the amount of dirty diapers. If it’s coming out, it’s going in. Six to eight soaking wet, diapers per day, and two to five bowel movements per day is a strong indication that baby is getting enough to eat.

In all fairness, Dr. Dworkin may be succumbing to the pressures of pharmaceutical companies or advising patients based on the limitations of his background in the area of breastfeeding. It is a well-known fact that information on breastfeeding is given negligible priority in the hierarchy of a medical education.

The professionals best qualified to deal with nursing issues are those who have been trained exclusively for the job. That is to say, an International Board Certified Lactation Consultant (IBCLC) who is able to function clinically. Good Lactation Consultants are an absolute necessity in today’s world. Due to the insurgence of artificial feeding in the 1950’s, the tradition of mothers teaching daughters to breastfeed has been lost in our western culture. It is perfectly understandable that nursing mothers may experience discomfort and difficulties. Proper technique must be taught and understood. Mothers can find an International Board Certified Lactation Consultant near them at www.iblce.org. When looking for a physician it’s a good idea to ask how many of the doctors patients are still breastfeeding their babies at 1 year. This will give the mother a good indication of whether or not the doctor is breastfeeding friendly.

Breast is best, no qualification. Most mothers produce plenty of milk. Sore nipples can be prevented and treated without taking the baby off the breast. What we need are doctors who read the literature and understand how important breastfeeding is, and a health system where mothers are supported in their desire to breastfeed.

Yours truly,

Lenore Goldfarb 
Montreal, Canada 
Mother of a premature son who breastfed for 8 months.

Stressed about the breast

The breast is best, new mothers are told, as if feeding their babies formula were somehow immoral. An Ottawa doctor who recently challenged that notion was accused of being a danger to his patients

Sharon Kirkey
The Ottawa Citizen

It wasn't listening to the lactation consultant read her the riot act that in the end did it for Lori Thornton. It wasn't the raw, cracked and bleeding nipples, or the recurring bouts of mastitis that left her feverish and exhausted, or that the piston-driven breast pump made her think of the Holsteins on her family’s dairy farm.

The end came as she stood in the shower, weeping, hot water pounding on her chest while she pushed and pressed and kneaded her bruised breasts from her armpits to her nipples, desperately trying to clear the plugged milk ducts. Lori Thornton finally, silently said: Enough.

“The tears are just pouring down my face, and I’m thinking: What has happened to me?” says Thornton, a mother of two.

“The public health nurse finally took me aside and said, 'Lori, you’ve stopped bonding with your baby because you're in so much pain and you're so tired. You're dreading when your baby wakes up, because you see her as a source of pain, rather than a source of pleasure.' And she was right.”

nursing mother and baby 
Eric Chu, Boca Raton News

Pregnant women need better information, says one doctor, on what to expect, the types of problems they may encounter, and where to get help.

So Thornton stopped. She switched her five-week-old daughter to what the anti-bottle proselytizers call “artificial feeding.” She fed her baby formula.

And as beautiful baby Angela thrived, Lori shook off the lactation consultant’s admonishments that she “owed it” to Angela to breast-feed and that with every plastic bottle and artificial teat, she risked turning her child into a sicker, less intelligent, less productive member of society.

“I’m not an incapable person and I’m not a person who gives up easily,” says Thornton, who is an urban planner. “But I had a horrible start, right from the beginning. She wouldn't open her mouth. She opened her mouth big enough to get maybe your baby finger in, but certainly not your whole nipple. And she pinched. She bit. She clamped right down on the very end, and no matter what I did or my mother or my friends who came to help me did, we just couldn't seem to get her mouth opened and latched on properly.”

The lactation consultant was able to steer Thornton in the right direction, but things fell apart the moment she was on her own. “I couldn't do it, I couldn't breast-feed. And I felt like a criminal.”

From the breastfeeding literature that describes mother’s milk as the “superior food” and “God’s design,” to the stock photos of cherubic babies drinking from their mother’s impossibly perfect bosom, the message is unequivocal: breastfeeding is the most natural, loving way for a mother to nourish her infant.

Last year, the World Health Organization increased the recommended time for exclusive breastfeeding from four months to six, with continued breastfeeding (while supplementing with other foods) until at least age two. Health Canada is now reviewing whether to adopt this new gold standard for “optimal duration.” The Canadian Paediatric Society insists there are “rarely reasons not to breast-feed”; the breastfeeding Committee of Canada’s mission is to “protect, promote and support” breastfeeding as the “normal” method of baby feeding.

So fixed is the Breast is Best mantra that, in prenatal classes across Ottawa, information on formula feeding is usually restricted to the last 10 or 15 minutes of a two-hour class. Not even the Canadian Paediatric Society escaped Ottawa’s breastfeeding patrol: According to the Toronto-based Infant Feeding Action Coalition Canada, a video produced by the society titled Baby’s First Months made breastfeeding sound equivalent to formula feeding, so a sticker was once placed on the video advising childbirth instructors to fast forward through the offending section.

That breastmilk is superior to formula in its nutritional composition and health benefits is not in dispute. It contains the right amount of fat, sugar, water and protein for human digestion, brain development and growth, according to the U.S. National Women’s Health Information Center. Breastmilk contains the mother’s antibodies that help fight bacteria, viruses and parasites, and a flood of medical research has linked breastfeeding with a reduced risk of everything from diaper rash and ear infections to asthma, allergies, Sudden Infant Death Syndrome, Crohn’s disease, meningitis, juvenile diabetes, even childhood cancers.

There is evidence the pro-breast benefits extend to mothers as well: A baby’s suckling helps shrink a mother’s uterus, so women get back to their pre-pregnancy weight faster, and they resume ovulation later, meaning more “spacing” between babies. breastfeeding also appears to lower a woman’s risk for developing cancers of the breast, cervix and ovary. And it can be one of the most emotionally satisfying experiences of a woman’s life.

Yet some women, already unspeakably worn out from the stress of childbirth and sleep deprivation from caring for a newborn, can teeter on the verge of physical and emotional collapse trying to do “the most natural thing in the world,” says Liz Porter, who writes for The Age, a newspaper in Sydney, Australia. Some spend days or even weeks desperately trying to get their babies to latch on properly, frantically following the how-to-guides in the baby books, brushing their nipples across their baby’s bottom lip to try to stimulate the rooting reflex, switching between cradle holds and football holds, making sure the nipple is “centred in the space between the tongue and baby’s upper lip”, that baby is brought to the breast, not breast to baby, that every improper latch is immediately popped with a finger and the whole process started over.

And when breastfeeding does not go well, the frustration, helplessness and sense of failure can be enormous. Critics say the “breast at all costs” philosophy can make women feel there’s something immoral about feeding their babies formula.

“New mothers are not fools, but they are nearly always stressed, exhausted and, thus, especially vulnerable to the claims of extremists who tell them that exclusive breastfeeding is the one, true way,” Porter writes in The Age, proving the nipple wars extend halfway around the world. “No matter how tired, they say, thou shalt use no extra bottles of formula.”

Recently, Ottawa Citizen health columnist Dr. Barry Dworkin challenged the dogma of exclusive breastfeeding which warns that even a single bottle of formula can spark “nipple confusion” and irreparably harm a woman’s milk supply. The reaction was swift and stinging. Dworkin, an assistant professor of family medicine at the University of Ottawa, was accused of being irresponsible, insensitive, a danger to his patients.

“I think you really have made a huge error, and I am sorry to say this, but you really do seem incredibly ignorant about breastfeeding,” wrote Toronto pediatrician Dr. Jack Newman, a leading Canadian breastfeeding advocate who in 1984 established Canada’s first hospital-based breastfeeding clinic.

“I had to block him!” Dworkin says of Newman. “He continues to send me belittling e-mails and snippets of e-mails from other people.”

Dworkin’s offence was to suggest that, failing all efforts to establish exclusive breastfeeding, alternating breast with bottle can be a sensible compromise.

Dworkin says the breast-is-best approach now resembles a regimented boot camp. “There is so much emphasis on 'You’ve got to do this, we’ve got to breast-feed, we’ve got to do it every two hours' that it turns a lot of people off. Instead of making it more of a gentle, acceptable means of providing care for your baby, it becomes almost militant.”

While many women praised Dworkin for his “common sense advice” (one obstetrical nurse wrapped him in a bear hug soon after the column appeared), there were “reams” of letters accusing Dworkin, a father of two (breastfed) children, of being everything from irresponsible and delusional to, as Dworkin puts it, Satan incarnate.

“If people react that way to me, how are they reacting to mothers who are questioning what’s going on when they're breastfeeding and they're having problems? Are they being treated with compassion? Or are they being told, 'No, no, no, just keep to it! If you don't do it, you're going to fail, and you're going to hurt your baby.' And this goes on.”

But Newman says if anyone is failing women who want to breast-feed, it is doctors such as Dworkin.

“Women are very, very aware that breastfeeding is better for them and for their babies, but they unfortunately don't get any support from the health professions -- and what Dr. Dworkin wrote there is exactly what pisses me off so much,” Newman seethes over the phone.

“Of course, women support him because they regret, I think, that they weren't able to breast-feed exclusively. But they shouldn't feel regret. They should feel anger, because our hospital system and our medical system make it so difficult for mothers to breast-feed that it’s amazing anybody manages to do it, not that women have trouble.”

The statistics bear him out: While 73% of new mothers initiate breastfeeding, by four months more than half of those have stopped.

According to Newman, mothers and babies are separated in the hospital when they don't have to be, hospital nurseries routinely give babies formula when they don't need to be supplemented, new mothers are “slipped” a few cans of formula when they are discharged, and most of what little training nurses have had on breastfeeding has been “useless.”

He says the La Leche League has worked hard to provide the information that babies don't feed by the clock. “But mothers are going home and they're being told silly things, like you must wake the baby up every three hours in order to feed the baby, you must feed the baby 20 minutes on each side, and garbage like that.

“I get frequent calls from mothers who say, 'The baby won't wake up at three hours, it takes me an hour to wake him up.' I say, 'Well, does he feed well? Is he pooping and peeing lots? Is he gaining weight?' The issue here is not how often or how long the baby is on the breast, but how well he feeds.”

Newman says raw and red nipples are “virtually completely preventable,” and that the majority of breastfeeding problems can be resolved if new mothers get help with positioning and latching the baby. (He says he can cure most nipple problems over the phone.) The trouble, he says, is that most doctors and nurses wouldn't know a good latch “if they ran over it.”

Groups such as La Leche League, which believes “mothering through breastfeeding deepens a mother’s understanding and acceptance of the responsibilities and rewards of her special role in the family,” reject suggestions that they bully women.

“When people say we make mothers feel guilty about breastfeeding, no one can make anybody feel guilty,” says Michelle Bentley, professional liaison for Quebec and Eastern Ontario. “That’s something we put on ourselves. And we don't hesitate to inform people of the dangers of not using car seats, or the dangers of smoking. We need to inform people about the dangers of not breastfeeding.” La Leche recommends exclusive breastfeeding for between six and 12 months, but encourages breastfeeding to continue until toddlerhood.

While some women find the idea of nursing “unpleasant, even repugnant,” according to California breast surgeon and author Susan Love, this isn't proof the woman will be a “bad mother,” rather a reflection of the fact human beings have different reactions to “physical experiences.”

Breastfeeding can be difficult for mothers who work outside the home and have to pump and express during coffee breaks. And every working, nursing mother knows what it feels like to discover you're suddenly leaking through your silk. In her bestselling Dr. Susan Love’s Breast Book, Love describes how one colleague, a surgeon, stopped nursing the day she started thinking about her baby during an operation -- and ended up dripping milk on the patient through her hospital scrubs.

Still other women are growing uneasy with reports of chemicals, from perfumes to pesticides, in breastmilk samples. Last year, one study suggested that the breastmilk of many Western women contain levels of PCBs high enough to harm a child’s immune system, though researchers strongly stressed the benefits of breastfeeding still vastly outweigh any risks and that women shouldn't stop breastfeeding.

Both sides agree that more needs to be done to support women who choose to nurse. The Children’s Hospital of Eastern Ontario (CHEO) has seen an increase in the number of babies admitted through emergency with so-called “volume depletion” -- serious dehydration due to feeding problems, a worrisome trend that has coincided with shorter hospital stays. Today, most new mothers are home before their milk has “come in,” and while hospitals don't turf out mothers and babies until the baby appears to be suckling properly, “until the milk comes in, you don't really know how well it’s working,” says Dr. Robin Walker, chief of neonatology at CHEO.

Dworkin says pregnant women need better information before their babies are born on what to expect, the types of problems they may encounter and where to get help. “And I think there has to be less dogma and more consideration of each individual situation.”

As Love puts it, there are plenty of “emotionally healthy people who were bottle-fed, and many neurotics who were breastfed.” And if you were to ask Lori Thornton which of her two children is the more healthy and self-sufficient -- first baby Angela or her second child, Roslyn, whom she successfully nursed for 14 months thanks to the support of a different consultant (this one a “godsend, an angel”), some early pumping with a hand pump to help get her milk supply up and a lanolin cream that kept her nipples supple and healthy between feedings -- she will tell you it’s the former.

In the end, Love writes, women need to make their own choices, without guilt. “If the various social criticisms make sense to you, consider them. If they don't, ignore them.”

Sharon Kirkey is an Ottawa writer who specializes in health issues.