Posts Tagged ‘infant formula’

Book Review: Bottled Up by Suzanne Barston

June 23rd, 2014

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, 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.

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.

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.

Formula, Apples, and Oranges

September 4th, 2013

“We had to switch him to Enfamil because he was vomiting up the Similac.”

I clarify. “So he was vomiting on Similac Advance?”

Mom agrees.

“Unfortunately,” I tell her, “we only have a limited selection of formulas we can offer your baby, and that specific formula you’re providing your baby now isn’t one that I can give him. We could try Similac-”

As soon as I say the word, mom visibly starts and begins shaking her head.

I try to push through. “We could try Similac Total Comfort, which is another milk-based formula except that it has some of the proteins broken down so they’re…”

Mom is having none of it. “You can’t give me any Enfamil?”

“Not the type you’re using,” I say. “The only Enfamil product we provide is Enfamil ProSobee, a soy-based formula. That’s going to be different from what you’re using right now because you’re currently using a milk-based formula.”

I never did manage to get it through to mom that the BRAND isn’t the important thing to look at when you’re evaluating formula.

You, dear readers, will listen, won’t you?

When your child seems to be having tolerance issues to a formula, switching brands may help–but the brand isn’t really the issue. The issue–if there’s a formula issue at all (most of my clients wouldn’t believe it, but most of the things people switch formulas over are actually normal parts of infancy and the “improvement” they see once they switch has more to do with baby getting a bit older than with the new formula). Anyway, enough rabbit trails. The issue with the formula is that there’s some ingredient in that particular formula that baby isn’t tolerating.

So, you want to find another formula without that ingredient–except that you don’t know what the ingredient is, so you’re going to be playing a bit of a guessing game.

Almost every formula manufacturer (I’ve used Abbott/Similac and Mead Johnson/Enfamil, the two biggest formula suppliers, for my examples in the following list, but there are other brands of formula available) has at least four or five different varieties of formula*.

  1. Standard milk-based formula
    This formula contains milk proteins (from whey and casein) and milk carbohydrates (lactose). Examples include the aforementioned Similac Advance, as well as Enfamil for Infants. Most babies do well on this type of formula.
  2. Low/No Lactose milk-based formula
    This continues to use milk proteins, but exchanges some or all of the lactose with another sugar. Most of these types of formulas also have other changes (such as adding rice starch or partially or fully breaking down the milk proteins), but one formula (Similac Sensitive for Fussiness and Gas) is virtually identical to the standard milk-based formula except for this change. Infants who have a hard time digesting lactose (which is less common than many parents think) will do better on this type of formula. This type of formula is often used if a child seems unusually bloated or gassy.
  3. Milk-based formula with hydrolyzed proteins
    This type of formula uses milk proteins but breaks them down into smaller pieces, which may be more easily digestible by infants. The proteins may be partially hydrolyzed into small protein fragments (Gerber Good Start does this) or fully hydrolyzed into the component amino acids. Most of the fully hydrolyzed milk-based formulas are also lactose-free. Examples include Enfamil Gentlease and Similac Total Comfort. Hydrolyzed protein formulas are used if a protein allergy or intolerance is suspected, often when an infant experiences constipation.
  4. Soy-based formula
    This type of formula uses soy proteins and a non-lactose form of sugar. Examples include Similac Soy and Enfamil ProSobee. These are used by parents who are vegetarian or when milk-protein allergy or lactose intolerance is suspected.
  5. Formulas for Acid-Reflux
    Maybe you’ve heard the old wive’s tale about adding rice cereal to a bottle to keep baby from spitting up. Maybe you’ve even heard it from a doctor. Like many old wive’s tales, there’s a grain of truth and plenty of risk in following this advice. Added rice starch does seem to reduce acid reflux for many babies. But adding rice cereal to a bottle can pose a choking or aspiration (getting food in lungs) risk and can increase risk of obesity. Choosing a formula specially formulated with added rice starch may help with the reflux while minimizing the risk associated with adding cereal to a bottle. (Please note that there is virtually NO evidence that adding cereal to a bottle will help a baby sleep through the night. All the risks, none of the benefits–DON’T do it!) Examples of these formulas include Enfamil A.R. and Similac Sensitive for Spit Up. Infants with acid-reflux (this is spitting up beyond the normal spit up 0-3 month olds do after every feeding and includes additional symptoms) may benefit from this type of formula.

So, now that you know a little bit about formula, you can educate your friends. If someone is having a problem with their formula, let them know that it doesn’t matter which BRAND they’re using. It matters what KIND they’re using.

Compare apples to apples, people.

*Actually, the big couple have dozens of formulas–but most of the other types of formula NOT noted in the above have changes made to treat specific conditions and should only be used on a doctor’s recommendation.

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