… And when medical professionals aren't sure, what can parents do?
As a hospital-based Lactation Consultant, I see brand new moms learning to breastfeed, moms who are pumping for their premature babies, and moms who are anywhere from one week to one year postpartum. I also hear a LOT about every motherhood-related anxiety imaginable. This includes concerns that don’t ever come to fruition and sometimes concerns that do require medical attention.
Recently, I’ve had many candid conversations with breastfeeding moms in my life, some of my patients, and other medical professionals about one of the most pervasive fears in the back of their minds: Fear that a baby is underfed.
Let me start with one thought: The American parenting culture is, in my opinion, unhealthily fixated on a baby’s size at birth and weight gain thereafter. A baby’s birth weight and growth are often the first things parents are asked by friends and family. Bigger babies in the higher growth chart percentiles earn parents compliments and bragging rights. The truth of the matter is that growth chart percentiles are ranges of perfectly normal baby weights, not measures of how well the parents are doing at their new job. 50% of infants are supposed to fall below the 50th percentile and 50% are supposed to fall above it. One group of infants is not by definition healthier than the other. One group of parents is not doing a better job than the other. *End rant.*
The fear of underfeeding starts in the hospital for most parents. In the first 3-5 days after birth, babies cluster feed to make their mom’s milk “come in.” For some babies, this can mean very long feeds (up to three hours is considered normal) or they may have 5-10-minute-long feeds that occur every hour. The cluster feeding almost always happens at night, when parents’ nerves are fried and all of their helpful visitors have left. This is also when self-doubt sets in for parents. Babies are often difficult to settle during this time, and mom’s milk isn’t “in” yet. So, logically, parents question whether their baby is getting “enough milk.”
Before and during this time I tell parents, “Cluster feeding is your baby’s job right now. Their health depends on it. I get more worried when a baby doesn’t cluster feed than when they do.” They look at me quizzically. If I had to hazard a guess, the next thought that runs through their mind is, “So how do we know that the baby is cluster feeding enough? How will we know that the baby’s next decent nap is normal, or could sleeping mean that something is wrong with them too?”
Yeesh, the stress and uncertainty is almost palpable at this point. “Welcome to parenthood!” I think to myself.
So, I then explain the ways they can know their baby is medically OK with however much they’re eating at the time. These signs include appropriate weight loss/gain and appropriate voiding and stooling (pooping and peeing) patterns for their age. The parents then nod emphatically because this information is more tangible. They can even keep track of it in an app. There are simple numbers that mark their baby as “adequately fed” or “not adequately fed.”
I have these conversations about normal breastfeeding patterns with parents daily. The less common conversations I want to focus on revolve around babies that actually aren’t getting enough nutrition. More specifically, I want to talk about medical professionals’ and parents’ beliefs about why this is happening.
------Disclaimer: I have to admit, some of these stories are cringe-worthy, but they’re important to discuss (anonymously, of course). Moms’ and babies’ health outcomes are on the line. So, we can’t ignore these issues, IMO.------
One conversation I found concerning was with a father who stated to his wife, in front of me, “You almost killed my baby [by breastfeeding instead of giving formula].” He came to this conclusion when he was told that their baby required formula supplementation for low blood sugars in the first 12 hours after he was born. Hospital staff had warned the parents that low blood sugars could lead to seizures, which sounds scary.
In this instance, hospital staff hadn’t explained to either of the parents that their baby was receiving a normal amount of food (colostrum) by breastfeeding, but was having an abnormal reaction to life outside of the uterus, which included low blood sugars. The lowest-intervention way to correct low blood sugars on an ongoing basis was giving their baby more food (formula) than he would’ve otherwise needed. The other treatment option would’ve been admitting their baby to the Neonatal ICU for continuous IV fluid therapy, which certainly isn’t anyone’s first choice.
This happened because of an accidental omission of information on the part of the pediatric hospitalist and nurses.
Unfortunately, it seemed to have profound effects on the parents’ perceptions of the best way to feed their baby. It had undermined both the mother’s and the father’s confidence in breastfeeding. Heck, it even seemed to cause relationship tension between the two of them because the father had lost respect for his wife’s breastfeeding goals. :(
Another conversation I’d like to share was with a second time mom, Susie*, who explained to me that she was anxious about breastfeeding because she had had a “traumatic” experience breastfeeding her first child, Liam*. She recounted that Liam was hospitalized at several months old for Failure to Thrive and severe dehydration. This is the feeding outcome that medical professionals sometimes warn about and parents learn to fear. Susie told me that Liam’s pediatrician had continuously blamed her “low milk supply” for his poor growth. She explained that she knew her supply wasn’t the problem because she could pump more milk than her son needed.
When Susie and I reviewed Liam’s medical history, it became apparent that he’d had symptoms of severe reflux and allergic colitis. Either of these could easily account for his poor weight gain, malnutrition, and dehydration. She explained that Liam’s pediatrician didn’t address these symptoms when she expressed her concerns before he was hospitalized.
During Liam’s hospitalization, formula feeding was required for his recovery. Susie was told to stop breastfeeding because Liam was clearly allergic to something in her breastmilk. Susie recounted her devastation, as she truly loved breastfeeding. Sadly, she was not given the option of removing the most common allergenic foods from her diet so that she could continue breastfeeding Liam safely.
So, what happened that caused this situation to go so dangerously wrong for Liam? Firstly, his pediatrician told a concerned mom that her son’s symptoms of reflux and allergic colitis were normal, and she assumed he was correct. (After all, he’s the doctor...) Secondly, the pediatrician did not thoroughly assess Liam for feeding difficulties and instead jumped to the conclusion that Susie’s breasts must be incapable of making “enough” milk for her baby.
The last conversation I’ll share was with a first time mom, Marie*, who was advised by her pediatrician to find a Lactation Consultant at two weeks postpartum for her baby’s poor weight gain. (“Hurray!” I thought. I’m always a fan of pediatricians who seek lactation advice for their patients rather than trying to put a band-aid on a problem they aren’t equipped to assess or treat optimally.) Marie told me that her baby, Danielle*, had gained weight appropriately for her first week and had gained no weight her second week. Marie told me that Danielle had been extra sleepy this past week and wasn’t breastfeeding often enough or long enough. Her pediatrician had suggested that her breastmilk supply may have dropped and sent her out the door with bottles of formula.
So, Marie and I weighed Danielle before and after breastfeeding to see how much breastmilk she was taking. I rubbed Danielle’s hands and feet for the entire feed to keep her awake. Marie said it was the best feed she’d had all week by far. The before and after weights showed us that Danielle took a fantastic amount of breastmilk for her age. This meant that Danielle’s lack of weight gain was because of her sleepiness and lazy breastfeeding, not because Marie had low breastmilk supply.
I asked Marie to call Danielle’s pediatrician and have her assessed for causes of her sleepiness right away. I suspected that Danielle could have undetected jaundice, or abnormally high levels of bilirubin in her blood. All newborns have higher levels of bilirubin than adults, but for newborns these levels are usually perfectly healthy. In fact, new research suggests that bilirubin’s antioxidant properties may be especially good for newborns.
However, abnormally high bilirubin levels and breastfeeding problems tend to perpetuate each other. This is because high bilirubin levels can make babies sleepy and cause them to take in less breastmilk. Low breastmilk intake makes babies’ bilirubin levels stay higher for longer because bilirubin leaves their body in poop. If they eat less, they poop less, then their body holds on to more bilirubin, and then they get even sleepier. Once this cycle starts, it can be difficult to break. Early detection of abnormally high bilirubin/jaundice and appropriate treatment is key. Unfortunately, Danielle seemed to have fallen through the cracks that week at her pediatrician’s office.
What’s the common thread through all of these stories? Medical professionals and parents too often jump to the conclusion that a baby’s health concerns are caused directly by their mom’s breasts not working right. How rude!
The truth of the matter is that our species wouldn’t have survived this long if breasts failed to feed babies as often as our society assumes they do. The other truth is that most medical professionals, including pediatricians, receive little-to-no formal education about breastfeeding. The 2-3 generations before us barely breastfed at all, so our society doesn’t have much collective knowledge about how breastfeeding works, either. Our lack of understanding produces doubt, and medical professionals impression this doubt on breastfeeding families all the time.
What’s the take-away advice for medical professionals?
It’s so important for us to understand breastfeeding physiology so that we can all keep moms and babies safer. We also need to choose our words carefully when we explain a baby’s health complications to parents. Our words can drastically impact their confidence in their feeding choices. Last but not least, the importance of empowering breastfeeding parents to trust their bodies cannot be underestimated.
What’s the take-way advice for parents?
If one medical professional’s advice doesn’t make sense to you, GET ANOTHER OPINION! If you’re ever told that you have low milk supply, for goodness’ sake, don’t take this as a final answer! The vast majority of medical professionals are not trained or practiced in assessing breastfeeding difficulties. Getting a Lactation Consultant’s advice is often invaluable in these situations.
Happy Feeding!
Lindsey & Megan
*Names, genders and ages changed for privacy
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