Book Review: Bottled Up by Suzanne Barston

Of course, Suzanne Barston intended to breastfeed. She intended to be a good mom – and, as the subject of internet-based reality show hosted by Pampers.com, she had incentive to do everything right.

When breastfeeding went poorly and she started supplementing, eventually giving up on breastfeeding entirely, she spent months ashamed over her “failure” before deciding to embrace her ultimate decision as “The Fearless Formula Feeder” (the blog where she can now be found.

Bottled Up follows some of Suzanne’s journey, but it goes far beyond a memoir. Barston argues that breastfeeding is not a good option for many women, does not live up to its extravagant health claims, and is overly politicized.

As an avid breastfeeding promoter (a good portion of my job is helping women understand the benefits of breastfeeding and helping them to successfully initiate and maintain breastfeeding), this book was frustrating, challenging, and sometimes painful – but in a good way.

Barston begins by arguing that breastfeeding promotion is all about fear and guilt: fear that you’ll be perceived as a bad mother (which makes you choose to breastfeed in the first place) and guilt that you weren’t able or willing to breastfeed (when you choose not to breastfeed or end up quitting.) I do not doubt that there is plenty of fear and guilt wrapped up in breastfeeding. There is a lot of fear and guilt wrapped up in parenting in general. But I wonder if this is how the women who enter my office perceive me to be operating. Do they feel that I am trying to use fear to induce them to breastfeed when I tell them about the marvelous immunological benefits of breastmilk and the many childhood ailments that breastfed babies have reduced risk for? Does the suggestion of risk reduction mean fear mongering? Many of these women have no reason to fear postpartum hemorrhage, yet I might still tell them that breastfeeding in the immediate postpartum reduces risk of postpartum hemorrhage. Does this produce fear for an adverse event (hemorrhage) rather than wonder at the marvels of our bodies (what I experience when I think about the effects of the hormone milieu of early postpartum breastfeeeding)? Do the women who didn’t breastfeed or didn’t breastfeed for long with their earlier children feel guilt when I encourage them that every breastfeeding experience is different and that just because they had some difficulties with one child does’t mean they’ll have those same difficulties with the next? Or do they understand that information as I intend it – to empower them to make a decision now unbounded by the fear of past experiences?

Next Barston discusses “lactation failures”, giving herself as a prime example. She started supplementing at two days when her infant had lost 10% of his body weight and was experiencing jaundice from AB-O blood incompatibility. The hospital pediatrician had offered Barston an option: “waiting it out” or supplementing with formula – and Barston chose supplementing, hoping to get herself and her baby out of the hospital as quickly as possible. Based on this experience, and a review of the many medical conditions for which the Academy of Breastfeeding Medicine does not feel supplementation is warranted, Barston believes that the today’s medical community is inappropriately disinclined to supplement and does so at the expense of infants – and their mothers. She argues that the common medical belief that only 1-5% of women experience primary lactation failure is scientifically baseless and that a much greater proportion of women are physically unable to breastfeed.

As a breastfeeding advocate, I frequently remind women that most women can successfully produce sufficient milk for their babies. I believe the 1-5% number, despite it being, yes, just an estimate. The simple fact is that there is no way for us to know, of those women who give up breastfeeding or supplement on day 2, how many of those women were incapable of producing sufficient milk and how many simply hadn’t had their milk “come in” yet (It’s a rare woman who has mature and voluminous milk on the second day postpartum – a more typical timeline is 3-5 days postpartum.) The number of women who enter my office complaining of engorgement after quitting breastfeeding because they “didn’t make enough” is astounding. I believe that there is true primary lactation failure. It exists. Other women (like my sister-in-law) experience secondary lactation failure, where their milk supply suddenly disappears due to extreme stress or starting a breastfeeding incompatible form of birth control. But the majority of women, including the ones who come into my office saying they quit because they weren’t making enough, are physiologically capable of producing breastmilk (and in sufficient quantities to meet their infant’s needs.)

I encourage women not to supplement – especially not in the first two weeks. I discuss what they can expect in those first two weeks. Baby might be really drowsy in the hospital and then “suddenly” be hungry all the time once you get home. That’s normal and not a sign that you don’t have enough milk. Normal babies have tiny stomachs that can’t stretch – they need to eat 8-12 times a day in those early days. Normal babies lose weight in their first few days of life. This is because they started out with a lot of fluid (even more if you had an IV during delivery), it doesn’t mean you don’t have enough milk. Your milk will start out yellowish and if you tried pumping it, you might only see a few drops in the bottle because the rest is stuck in the tubing. This is colostrum, it’s wonderful and he doesn’t need large amounts at a time (remember how little his tummy is?) What’s more, baby is better at getting milk from your breasts than the pump – don’t try to pump to figure out how much you’re making. Etc, etc, etc. I repeat it at least a dozen times in my “what to expect” speech: “That doesn’t mean you’re not making enough milk.” What does mean you’re not making enough milk? I educate them on that too – and I encourage them to let that be a sign for them to drop by the breastfeeding clinic at the hospital where they delivered. Most of the time, I explain, insufficient milk supply at the beginning is correctable. A lactation consultant (free at the hospital you delivered at in Wichita) can help you troubleshoot what’s going on with yours – they can evaluate latch and see if baby has a tongue tie or is pulling his lower lip in; they can do before and after weights to see how much transfer is actually taking place, they can walk through your breastfeeding routine and help you learn how to increase your supply. If your baby is showing some of the warning signs of not enough milk, don’t supplement, instead get yourself over to a lactation consultant!

In other words, I spout the stuff Barston complains about.

At the end of the second chapter, Barston explains how the seventh lactation consultant she and her son saw finally discovered the cause for the pain she had been experiencing while breastfeeding. Her son was tongue-tied. Barston describes how common this situation is and takes it as another proof that breastfeeding advocates are lying when they say that most women are able to breastfeed.

My chest aches and my eyes fill with tears.

I pray that I am not one of the six lactation consultants who offered ineffective advice without truly discovering the cause of breastfeeding difficulties. I pray I’m not one who tells women to just try harder, just keep going, it’ll get better without addressing their real needs.

Tongue tie is a true breastfeeding complication – but it doesn’t make breastfeeding impossible. A skilled lactation consultant can help the mother of many tongue-tied babies to find a position that allows for sufficient breastmilk transfer and avoids pain for the mother and the child. If the first consultant had discovered the tongue-tie, had helped Barston find a good position that worked for her and her child, would this book exist? Probably not.

Like I said, this book was frustrating, challenging, and sometimes painful.

I’m glad I read it. I feel it has given me much more perspective into how women who have “failed” at breastfeeding perceive our current breastfeeding culture – and how the breastfeeding community has let down some vulnerable mothers. Reading this enhanced my belief that most women know that breastfeeding is good for their babies – they don’t need to be convinced of breastfeeding’s benefits. Instead, they need to be educated regarding how to breastfeed, what to expect, how to know if something’s going well or poorly, and how to get help. And they need to receive careful individualized help when they ask for it. As breastfeeding support people, we need to ask questions, listen to mothers, and determine root causes of breastfeeding difficulties before we start handing out prescriptive advice (breastfeed more, put some lanolin on it, eat oatmeal). And we need to stop making the ideal the enemy of the good. We need to admit that many women are going to supplement even though we know exclusive breastfeeding is the best route – and we need to help them give baby as much breastmilk as they are willing or able to give.

I think this is a valuable book for all of us in breastfeeding support professions.

I do not think it’s a good book for mothers in general. Barston swings so far from the “breast is best” that she calls into question pretty much every bit of breastfeeding research that’s ever been done. Now, it’s true that breastfeeding research (like all research, but especially that sort that deals with human choices) is far from perfect, but the bulk of the evidence supports breastfeeding as the optimal feeding choice for both mothers and infants. The undecided reader of this book (or maybe the one who only knows from her friends who latched their baby on once that breastfeeding hurts) might get the impression that breastmilk substitutes are basically as good as breastmilk. And that just isn’t true. Breastmilk substitutes have been a lifesaver to infants whose mothers have been unable to breastfeed for all sorts of reasons. They are designed by scientists to meet an infant’s needs the best we know how. But breastmilk substitutes are to breastmilk what vegan bacon is to real bacon – an awfully poor substitute. If you can give your child breastmilk, it’s by far the better option.

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I realize that this is an emotionally charged issue – and that my unapologetic preference for breastmilk over breastmilk substitutes makes me subject to accusations of insensitivity. Please believe me that I am not judging the women who don’t breastfeed or feel that they can’t breastfeed (and I certainly hope you don’t believe I’m judging the women who actually can’t breastfeed despite their desire to do so!) In fact, I frequently find myself reminding women that every drop of breastmilk their babies did get made a difference – and that they can wear their two weeks of breastfeeding proudly. I cheer for the women whose babies get formula during the day but who breastfeed at night because it’s easier than getting up to make a bottle – Good for them! I sympathize with the women who were told by a doctor or someone else that they needed to start supplementing or else and who found their supply dwindling as a result. And I try to make sure that every pregnant woman who comes into my office has more than just information about the benefits of breastfeeding but the practical help she needs to be successful at breastfeeding – whether that be for the three days she’s in the hospital, for the six weeks she’s at home with baby before returning to work, for six months combined with formula, or for two years with never a bottle to be found.

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Rating: 3 stars
Category: Breastfeeding – social aspects
Synopsis: Barston argues against the current breastfeeding culture and argues that breastfeeding is not necessarily the best choice for moms and babies.
Recommendation: Recommended for breastfeeding support people as a call to compassionate care, but not really recommended otherwise.