Tale of Two Births

Melissa Bartick, MD, chair of the Massachusetts Breastfeeding coalition, wrote a great series on breastfeeding in the US.  I recommend this article that describes two hypothetical births--one in a baby-friendly hospital and one not, because it shows how our society, communities, and medical system all come together to set a new mom up for success, or failure.

A higher level of barriers

In a previous post, I talked about the most common reasons moms quit breastfeeding: latching problems, breast refusal, low milk supply, and pain.   Looking back, I realize that I stopped because of extreme pain caused by latching problems from extreme engorgement and a frenetically, energetically hungry baby with a very strong suck.

United States Breastfeeding Committee commissioned a new report to help "combat the barriers to breastfeeding success."  It lists the major barriers as "hospital practices, provider skills, social and workplace support, and media and marketing."  These are the societal barriers that either cause or hinder solutions to the many personal or physiological problems (like pain) that new moms deal with when trying to breastfeed.

At the time my son was born, I felt that my hospital gave me good support, I think because I was so emotionally overwhelmed that I mistook good emotional care for good medical care.  (The hospital where Sam was born is not recognized as a Baby-Friendly Hospital by Unicef, though they did meet many of the Ten Steps.)  But with a year of hindsight, asking myself whether the medical services did the best they could for me and my baby, the answer is no. Here's why:

1. There was one lactation consultant on staff at the hospital, but she was also a full-time nurse with regular shifts and only saw nursing moms in her spare time between rounds or as overtime.  During my stay at the hospital, I saw her once a day, and afterward, once a week.  What I needed was access to a certified lactation consultant round the clock while at the hospital (anytime I tried to nurse) and on call at home.  Initiating breastfeeding is an hour-by-hour challenge.
2. The other nurses tried to help with breastfeeding, but their advice was, though well-meaning, inconsistent and not very helpful, except for the emotional aspect.   A commonly-cited article from the Journal of Obstetric, Gynecological, and Neonatal Nursing reported that "nurses have limited knowledge of breastfeeding, although no variable consistently predicted breastfeeding knowledge."  (Anderson, 1991.)
3. The nurses gave Samuel colostrum mixed with glucose water, despite medical recommendations against glucose water to prevent hypoglycemia.  (Orr, 1997.) 
4. One of my symptoms was edema, which made engorgement worse and latching extremely difficult.  The lactation consultant said the IV fluids I was given contributed to this, but I don't recall edema being one of the potential side effects of my pain treatment.  (Walker, 2000.)
5. I expected my doula to see when there was a problem and help me find solutions, but her job was done after the baby was born, except for one follow-up visit.  Next time I will secure my own help (from doula or otherwise) for longer.

These fall under "hospital services" and "provider skills," I could also list other problems I experienced under "social and workplace support" and probably even "media and marketing."  What combination of problems did you experience, and which of the higher-level barriers (hospital practices, provider skills, social and workplace support, and media and marketing) did they fall under?

1. Orr, Edie and Crase, B.  "Hypoglycemia and the Breastfed Newborn." From NEW BEGINNINGS, Vol. 14 No. 4, July-August 1997, pp. 107-8

2.  Anderson, E., N, MS and GEDEN, E., RN, PhD, FAAN^{.  "}Nurses' Knowledge of Breastfeeding."  Journal of Obstetric, Gynecologic, & Neonatal Nursing, Volume 20, Issue 1, pages 58–62, January 1991.

3. Walker, Marsha, RN, IBCLC.   "Breastfeeding and Engorgement.  from Breastfeeding Abstracts, November 2000, Volume 20, Number 2, pp. 11-12.

International travel while breastfeeding

I'm heading to Paris and London in a week for work and am worried about managing pumping breast milk.

First, I am anxiously eying my freezer supply to make sure there is four days' worth of milk for the time I am away.   Then, I am uneasy about the flight there, during which I will most certainly have to pump in public.  Breastfeeding in public is one thing, but the almost bovine aspect of pumping is altogether another.  I will need to get over this unease, fast.  Next, once I arrive at my destination, I will either need a power adapter or a boat load of batteries to keep the pump running for four days.  I started looking into the power adapter option but it's so complicated that I think I'm better off buying a big pack of batteries and hauling them in my suitcase.  I'll also have to bring supplies to wash parts in the hotel.

But the biggest worry is what to do with all the pumped milk, probably 80-100 oz.  The most sensible and convenient option is to dump it.   But can a breast milk fanatic mom like me actually bring herself to do this?  I am imagining complex ways around dumping: I could buy a good cooler bag, milk storage bags, and lots of Ziploc bags, continually refresh the ice from the hotel ice machine, assuming my room has no refrigerator.  Then there is the matter of getting back through security with the milk.  (I should be thankful that it's not 2004, when the TSA barred more than 3 oz. of breast milk unless you were traveling with a baby.  Except if a mom is traveling with her baby, she wouldn't need to bring a pump and all the pumped milk!)  And what if after all this the ice doesn't hold up for the 12-hour trip?  I would probably just check the baggage and hope for the best.

What would you do?

Breast pump recommendations

The right breast pump is an important part of a breastfeeding plan and can even bail you out in the case of latch problems like I had.  (Disclaimer: I am not a doctor or lactation consultant and all views below are from my own experience and research.)

Your first question might be: do I need a pump?  Some say no if you are not planning to be apart from your baby, but I would suggest every nursing mom should have one on hand in case of unexpected separation or problems nursing.

The next question is whether you need an electric or manual pump.  Do you plan to be away from your baby for more than a few hours at a time at any time during the period you hope to breastfeed?  If so, you need a double electric pump (double means can pump both breasts at once) to maintain your supply and make regular pumping realistic and manageable.  If you will be home with your baby, you may be able to use a manual pump for brief outings--these are fairly inexpensive, $30-$60.  Electric pumps cost more ($60-$350) but are generally faster and more effective at extracting milk. 

My desk with PISA.

Double-electric pumps can be rented from some hospitals, and home models are almost as good at extracting milk.   A good way to start your search for an electric pump is by calling your hospital or birthing center and asking what pumps they provide to new moms, because you may end up taking home from the birthing center a set of parts that will fit home pumps, too.  For example, Medela parts that a hospital provides will fit home Medela pump, a cost savings and convenience.  You could also inquire about rental. (It's also just good to ask your birthing center what they do to help new nursing moms--whether they offer pump instruction, have lactation consultants on staff to help you, etc.  You will rely heavily on these services in those first few days.)

Finally, decide which brand/model is right for you.   I use a Medela Pump in Style (PISA) and have been pleased with it, though there are several good brands of double electric pumps.  When reviewing your options, here are some features to consider.

• Hands-free: some pumps offer hands-free devices so you can read, use the computer, drive, etc. while pumping, which is important as pumping sessions can be long and boring.  However, I found it easy to make something like this for my PISA out of an old tube top or sports bra.
• Bottles: you may want to choose a brand that has bottles you like for feeding so that you don't have to pour milk from one kind to the other.  Some bottles are interchangeable with other brands' nipples and vice versa.  For me, I prefer a wide-mouth-style bottle for feeding (Born Free) but Medela bottles are narrow-mouth, so I "store and pour."  (Bottle choice could be a whole other post, but in short, some bottles have research behind them that shows them to be better for babies who switch back and forth from bottle to breast; other considerations include air management, number of parts that need washing, BPA-free, etc.)
• Portability/style: If you work, this thing will be over your shoulder a lot.
• Power: Look for a model that has an alternate power source such as a car charger or battery pack because you will almost certainly face having to pump in a bathroom stall, storage closet, car, etc. during your time as a breastfeeding mom.

I do not recommend purchasing or borrowing a used pump since there is a risk of disease transmission through home pumps' open airflow system, unlike hospital-grade pumps which have a closed airflow system.  If cost is prohibitive for you, I suggest looking into renting a hospital pump, or putting your pump (or cash toward a pump) on the top of your baby shower list.

Afterward, if you choose a pump and find it's not working well for you, you may need to fine-tune the horn sizes, power, or even try another pump.  Different arrangements work better for different people.

The bottom line: if you don't set yourself up for success in maintaining milk supply, which requires frequent emptying of the breast by baby or pump, you could be looking at making another big investment: baby formula.

(For more information on pumping, kellymom.com is a great resource.)

Balance

Many of my readers have encouraged me to leave guilt behind.  There's no question they are absolutely, unequivocally right, and when I look at it in a logical moment, I am proud of what I've done for my baby.  Part of the reason I write this blog, though, is to acknowledge that new moms often face powerful emotions that defy logic and influence decisions.  Guilt, in particular, arises out of the perceived trade-off between one's self-interest and one's child's interests.  Before I was a parent, for the most part, I was the only one who experienced the consequences of my actions, good or bad.  But as a parent, there's someone else--someone whose future is in your hands, and someone who you love more than you ever loved anything before or ever thought you could--who experiences them too.

This perceived trade-off permeates big decisions and trivial ones alike.  For example, do you feed your baby formula or breastfeed him despite serious inconvenience, difficulty, or pain?  Do you take a few moments for yourself while your toddler watches TV, or do you sit down to read him a book?  Do you take him to a playgroup even though you're not big on socializing with other parents?  Do you put him in a better school much further out of your way?  Do you dip into your retirement money to send him abroad to study? The happiest families are probably great at finding a balance of sacrifice and self-care, and finding solutions that are win-win for parent and child.

In this way, my experience with breastfeeding has been the ultimate crash course in parenting.

Humbled by a milk supply struggle

In a previous post, I talked about how it is easy to see why milk supply can be such a concern for new moms.  But recently, I've gained new perspective and been humbled by a supply problem of my own.

After dropping to three pumps per day a few months ago, my supply dropped, and I started dipping into my  freezer stash.  I had envisioned that by age one, Sam would reduce his milk intake in favor of solids.  To the contrary, he's thirstier than ever.  Then a few weeks ago, I got hit with a nasty cold and suffered another drop.  I decided to up pumps to try to increase supply.  A week went by, then two, without an increase; meanwhile, we were topping off bottles with cow's milk left and right.  I started to feel like throwing in the towel and just letting him have 75/25 or 50/50 human/cow--and feeling pretty bad about it right after my post deriding cow's milk for babies.  You get to a point--and I remember this from the early days--where you start changing the story you tell yourself about how important breast milk is, and guilt rears its head, too.  One minute you've convinced yourself it's totally fine, and another you are reading a study showing a correlation between extended breastfeeding and intelligence.  It's so not fun, and gives me new respect for moms who persevere despite supply issues.

In the end, the milk ticked up, but only after three weeks of trying.

A flexible machine

It's amazing to think about how flexible our bodies are about energy input.  We can fill up on almost anything and the engine will keep on going for a good long while.  Imagine if you could put any old liquid in your car--gasoline, Coke, tequila, milk--and it would just go!  But we know there is a price to pay for less than perfect nutrition.  So we try to eat well and hope for the best.

But there's one group of humans for whom we DO understand perfect nutrition: babies.  Millions of years of evolution have perfected human milk.  This seems like a unique opportunity.  

There are some big differences in animal milk and human milk.  Human milk has a much smaller percentage of protein and calcium and more iron and fat.  Goat milk is a little closer to human milk on these, but it's closer to cow's milk than human milk.  According to trusted breastfeeding resource kellymom.com: "All the nutrients of human milk are significantly more bioavailable than those of cow's milk because it is species specific (not to mention all the components of mother's milk that are not present in cow's milk). "

So to this opportunity for perfect nutrition, I say game on until life dictates otherwise.