nursing: in the middle

For those of us who can’t breastfeed exclusively, but really, really want to, I think there is a special set of social issues and questions. And sometimes it can feel very lonely, like no one else has ever experienced this (which is, of course, not true).

Here is the problem I had:

I support nursing. I support every woman’s right to nurse anywhere that she and her baby have the right to be. Personally, I also support the idea of being courteous if you’re aware that you are making people uncomfortable and maybe finding a quiet corner to breastfeed in or taking care to be discreet, at least if you’re showing a lot of boob, but that’s just me; legally and practically speaking, you can nurse however, and almost totally wherever, you want.

I support your baby’s right to eat in a nice place, not in a bathroom, and I support your right to have the time to pump at work if you’re a working mom.

Okay, straightforward enough, right?

Where this gets murky is that I, personally, had to give my babies bottles. I nursed my son for his first ten months, but he always got bottles, too. And, although it’s taken me years to get to this point, I have finally managed to come to terms with the fact that I am not a failure for that reason. I am a successful mother because I did the best things I could to give my baby a good start in life: nursing, plus adequate food!

But I still felt, every time I got out a bottle in public, like I would be judged for that. This is particularly silly because bottle-feeding is the norm in this area–most moms use formula here. But any time I started to mix a bottle, I felt this weird urge to explain it, to tell anyone who could see that I DID try to breastfeed and I had a real problem and I wasn’t one of those women who give up because it’s inconvenient…and so on and so forth.

Obviously, this feeling is troubled from the get-go because I don’t believe that there are very many women who choose to use formula for bad reasons. If you choose formula because breastfeeding hurts too much, because you are in desperate need of sleep and have to be able share the co-parenting to stay sane, whatever–I respect that. You are the best judge of what is right for you, and your kid is going to be JUST FINE. Even if you choose formula for a reason that I find silly (like, for example, to preserve the perfect symmetry of your lovely little breasts–which doesn’t work since pregnancy does a number on them anyway, by the way), that’s your right and I’m not going to tell you that you’re wrong.

And yet, I always felt that people might be watching and judging me for MY choices, even though I also felt confident that they were the best choices I could make with the options I had.

When I was nursing in public, I always knew that if anyone complained, or gave me a dirty look, or asked me to leave, I was in the right and I could politely decline to move before my baby was done eating. And in any event, I was never once the recipient of any kind of negative behavior for nursing. People were nice about it. They would smile at me and move on, not stare; a lot of mothers would give me that wistful look that said they were remembering nursing their own babies (a look that I have grown to know even more intimately now that I feel it on my own face when I see a mama nursing her baby). No one ever made me feel uncomfortable or asked me to do anything different.

But the idea of someone judging me for bottle-feeding was different, because a person who thought I was a bad mom for using formula wouldn’t ask me to leave. They would just make a decision about what kind of mom I was, based on the bottle.

Of course, there is no reason I should care. A person whose opinion I care about is a person who probably already knows my situation anyway. A total stranger’s knee-jerk judgment about me shouldn’t make the slightest impression on me, especially since they would probably not voice it. But it did, frequently, make me feel uncomfortable and unhappy whenever I had to mix a bottle and feed a baby in public.

I realize that it’s highly unlikely anyone except me even noticed, especially since I do not live in an area where most mothers breastfeed. This particular fear is almost entirely the reflection of my own sense of failure. But the reason I feel self-conscious is that the judgment certainly exists, especially in the “semi-crunchy” communities I tend to seek out when I have the choice.

The only point of this post is to say this: if you feel this way, too, fight it. Don’t let it make you feel like you’re not a GREAT mother. A mom who puts the needs of her kids first, who does what she can to keep them healthy and safe, and who feeds them when they need to be fed is doing a good job.

The fact that the judgment against formula feeding is less vocal than the judgment against moms who nurse in public does not have to mean that it’s any less wrong or socially unacceptable. You can be a voice for the better. Assume, until you know otherwise, that every mom you see is doing the right thing for her family, and say so if asked. You can break down the set of assumptions about the non-nursing (or partially-nursing) mother, just as the big push for acceptance of nursing in public is breaking down assumptions about the breastfeeding mom and opposition to nursing in shared spaces.

If you are one of the mothers, like I was, who nursed AND fed formula, it might feel like you’re in the middle and no one at all understands or supports you. But you can see it the other way, too: you’re in the middle and you can see the value of what every woman chooses. That means that you can help increase tolerance and nonjudgment for all kinds of moms.

breastfeeding failure: the emotional fallout

Have you noticed that all of the information about low milk supply available on the web (and in books, for that matter) says the same thing? “This is not your fault. You are not a failure. Any breastfeeding is better than none. Your child will thrive on formula too.”

It so happens that I believe all of these things.

And yet–none of this addresses the emotional reality of breastfeeding failure.

Part of the problem is just that: while you may call it low milk supply, it feels like failure. Many PCOS women have struggled with their bodies forever–to maintain or reach a healthy weight, to get pregnant, to control blood sugar or acne or hair loss or whatever. And then, when you reach this lovely milestone of having a sweet baby to nurse, you discover that you can’t. Add postpartum hormones washing around your bloodstream and you have the makings of some pretty major grief.

I’m not going to pretend I have answers for this problem. I don’t. I think it’s a struggle that every woman will end up having on her own. But I do want to acknowledge that there are lots of PCOS women in this boat, and give you a heads-up that you are NOT alone in hurting. Especially when:

* …a lactivist says, “Any woman can breastfeed.” This, along with “lack of education is the reason for breastfeeding failure,” “mothers who say they can’t nurse just don’t want to,” and “nursing is natural–any mom can do it if she tries hard enough,” is one of the most hurtful things that can be said to a mama with IGT or other low supply problems. And yet it is said, all the time. An OB said it to me after I had spent $500 on LCs and pumps, plus hours and hours and hours of my life with my sweet new baby, just to produce 6 oz or less per day. I would say, just let it go and ignore it–except that even lactation consultants, doctors, and midwives are often misinformed about this. You don’t have to let it slide. Direct them to material about IGT if you have to, and point out that these statements only undermine your attempts to have a breastfeeding relationship anyway.

* Your baby refuses the breast or cries at the breast. This might be the worst. I didn’t get the hang of the at-breast supplementer; I know that many women find them a godsend, but for me it made achieving a decent latch nearly impossible. I used bottles. My daughter was completely unwilling to nurse by the time she was 6 weeks old (and mostly unwilling long before that). I pumped exclusively for her for months. And every time I sat down to pump, saw another baby nursing, or filled her bottle, it hurt. (My son, on the other hand, nursed enthusiastically for 10 months even though he also got most of his nourishment from bottles. Babies just differ on this.)

* You get a judgmental look (or even what you feel MIGHT be a judgmental look) from another mom, or dad, or whoever, while you’re bottle-feeding. This one was really hard for me, because I am very pro-breastfeeding and it was a big adjustment to be part of the bottle brigade. I had no choice, though, and that’s the reality. Your job is to feed your baby, and if that means bottles, it means bottles. Do not let anyone intimidate you–you’re doing exactly what you must do to keep your baby healthy.

* You confront your own preconceived ideas of what your breastfeeding relationship should have been like. For a long time, it made me very sad to see my nursing pillow sitting there, because during my pregnancy I had imagined, so many times, using it and nursing my baby. And that just did not become reality.

* People tell you to get over it because you have a healthy baby. You can be thankful for your baby and in love with your baby and still feel sad. Grieving for the nursing relationship you’d expected is totally normal.

In a nutshell, being unable to breastfeed exclusively hurts. My daughter is almost 4 and thinking about it still hurts–enough to make me feel a little ill. But facts are facts: there is nothing more I could have done. I tried it all. Formula fed my babies and grew them into the amazing people they are today, and I’m grateful for it even though I am sad that I needed it.

Hormones and Breastfeeding: News

For women who struggle to breastfeed because of low milk supply, a new study suggests that there is little you can do to change that, and that your baby is probably not going to experience a significant disadvantage as a result.

According to Sven Carlsen, Norwegian researcher (who has done research on PCOS as well, including on Metformin), there is a link between high testosterone during pregnancy and lower rates of breastfeeding at 3 and 6 months.

Carlsen’s argument is that many of the benefits usually ascribed to breastfeeding actually come from the hormones that the baby gets in the womb, not from the breastfeeding afterward. To me, this is hardly reassuring, as the suggestion is that your baby has ALREADY missed out on these benefits by birth if you are one of these mothers with higher testosterone and more trouble nursing.  But it does reinforce the fact that you should not feel guilty if you are one of those moms.

Here’s a link to an article about the study by the BBC:

Hormones “govern ability to breastfeed”

For my money, breastfeeding is still fabulous. But I do think that moms who can’t breastfeed–or who, like me, nurse but only provide a small amount of their children’s nutrition–should not feel guilty or consider themselves failures!

breastfeeding: insufficient glandular tissue

Diagnosis

Different women are diagnosed with PCOS for different reasons. In my case, I had no problem getting pregnant (indeed, my daughter was unplanned). But when she was born, it gradually became obvious, over the first week of her life, that I was producing very little milk. We went to lactation consultants; I rented a high-octane hospital-grade breast pump; I started gulping mother’s milk teas by the gallon and taking fenugreek (an herbal supplement that made me smell like maple syrup).

My lactation consultant mentioned the possibility that I should be screened for PCOS. She told me that I had a condition called “insufficient glandular tissue”–sometimes described as “tubular breasts” or “hypoplastic breasts.”

First and foremost, let me be clear: not all women with PCOS will have breastfeeding problems. Of those women who do, not all of them will experience undersupply. (Oversupply is often a problem for PCOS moms as well.)

It’s best to be prepared with information, though, and there are some indications that can point to IGT even before your baby is born. In a mother with IGT, the breasts often:

* are asymmetrical. No woman’s breasts are identical, but a marked asymmetry can be a sign of possible IGT.

* lack normal fullness. Hypoplastic breasts may have the appearance of “empty sacks.” They may be larger near the nipple or bulbous at the tip. You might think of this as “narrow” breasts, especially where they join to the chest wall.

* are widely spaced apart.

* have large areolas.

* do not undergo expected changes in size during pregnancy and immediately postpartum, or exhibit those changes to a lesser degree than normal.

Just being small-breasted is not a sign of IGT. Most flat-chested women breastfeed without any unusual difficulty! Indeed, it may be easier to get a good latch with smaller breasts, at least for a newborn. But if your breasts exhibit the characteristics on the list, it might be worth while to talk to a lactation consultant in case you have difficulty.

When my daughter was born, I assumed that I would breastfeed exclusively, and it never crossed my mind that I might fail. I was going to be home with her for a year, working on a Ph.D., and it was a no-brainer. But over the course of her first week, she lost more and more weight. She cried. A lot. I didn’t know what was wrong, and doctor after doctor said, “Anyone can breastfeed. Just offer the breast more often.” I told them that she was eating almost constantly, but they brushed me off.

She lost weight, and then, more frightening still, she became less active and alert. She had been an amazingly alert newborn, watching everything; she became very sleepy. We went back to the pediatrician and began supplementing with formula. After her first two-ounce bottle, she slept contentedly for four hours, completely worn out by her attempts to get enough milk. I was devastated. I felt like a failure. And of course all of my disappointment and anger and self-blame was heightened by the fact that I had enough postpartum hormones washing around in my bloodstream to turn me into a totally insane person. One of the biggest problems with low milk supply, for mothers of newborns especially, is that the emotional setting of the problem is so intense.

When we went to an appointment with an LC who weighed Mary before and after a feeding,  we found that–in 20 minutes of engaged nursing–she was getting about 1/5 of an ounce. That’s right. One-fifth. I began supplementing her, using a bottle. She refused the breast very soon after that, and I began exclusively pumping for her. Until she was six months old, I pumped for her at least six times a day (nine times, for the first two months). I washed pump parts until I thought I would lose my mind. She got between 4 and 6 ounces of breast milk per day.

When my son was born, he was immediately an energetic nurser. I was prepared for problems (although part of me still harbored the fantasy that this time he would just gain with no problem at all and it would be fine). By day three, it was clear that we would have to supplement. He was committed to nursing, however, and nursed at every feeding for eight months, and then several times a day for two months after that. Even though he was supplemented, we had a satisfying breastfeeding relationship. I know that I did produce more milk for him; however, whether that was because he was actively nursing or because the first pregnancy had helped my breasts create more glandular tissue, I don’t know.

So, if you have IGT, what can you do?

There are a lot of things you can do to help boost your milk supply. None of them, unfortunately, are going to be a silver bullet if you do really have IGT. They can help, though. Here’s my list; most of these things I have tried, although the at-breast supplementer only lasted two days before I gave up on that in frustration, as it was ruining my son’s latch and I couldn’t get the hang of it. For many women with low milk supply, the at-breast supplementer is a godsend.

Nursing Practices

* Nurse as frequently as possible, any time the baby wants to. You may have to offer the breast more often than the baby seems to request it, especially if you have a sleepy baby.

* Consider co-sleeping. I know there is conflicting data about the safety of this. From what I can see, it is at least as safe as putting the baby in a crib; there is a small risk [very small] of suffocating your baby, and that’s what the media leaps all over. But as for actual numbers and statistics, co-sleeping reduces the rate of SIDS a lot more than it increases the rate of any other problem. You can read up on this and make your own call, of course [here’s what Dr. Sears has to say], but I do think that, especially if you sleep topless and skin-to-skin with your baby, it’s the best milk production booster there is. All of those hormones produced by skin-to-skin contact for hours every night are definitely going to help. Do follow all safety rules if you do this, though–I refer you again to Dr. Sears for a safety rundown.

* Wear your baby in a sling or other carrier [personally, I loved my Moby Wrap for my newborn until he was about 20 pounds]. This has the same kind of hormonal benefits as co-sleeping–and the less fabric between you, the better. If you have the leisure to hang around home topless with your [undressed] baby, do it. It will help.

Mechanical Aids

* the at-breast supplementer (for example, the Medela Supplemental Nursing System, or SNS). This is a bottle-and-tube assembly. You fill the bottle with the baby’s supplement (formula or pumped milk), attach it somewhere that you won’t have to hold it, and tape the tube to your nipple so that the baby sucks the milk through the tube during nursing. This can make it possible for your baby to get all of his or her nourishment at the breast even if you cannot produce 100% of the milk. It eliminates the problem of nipple confusion and gets you more nipple stimulation. I recommend that you get help from an LC if you use this, because it can be a challenge to coordinate, as I said.

* breast compressions. Dr. Jack Newman’s site has a great video on how to do this, as well as a great information sheet about it. This can really help you get as much milk into the baby as your breasts can make.

* pumping, using a high-quality breast pump. Usually it’s recommended that you pump after feedings. There is definite value to this, but if you have a baby who likes to nurse, you are probably better off just nursing as much as possible. Definitely, though, if your baby cannot nurse at any particular time [if he/she is in the NICU, if you have to be away during the day for work, if he/she sleeps all night], pump.

Galactagogues [that is, things that you eat or take as supplements or drugs to help boost milk production]:

* Oatmeal. Eat a lot of it. It really helps. Seriously.

* Guinness or other real stout beer. This is a judgment call, since you are nursing [obviously] and your baby could get some alcohol. But I drank half of a pint-sized can of Guinness most nights and it made a measurable difference in my output the next day. I was comfortable with it, although I did try to drink it either right as the baby was nursing or immediately afterward, to allow the maximum time for the alcohol to leave the milk. [Yes, that really happens; no need to pump and dump.]

* High-iron foods. Many mothers of newborns are anemic and that can hurt your milk supply, especially if you bled a lot during the birth.

* Fenugreek. This is a very common herbal supplement; it’s also a spice used in some foods. It smells a bit like maple syrup. If you are taking enough of this to help your milk production, you will also smell like an iHOP. I have never seen any indication that this is unsafe for mother or baby, but it can make some babies very gassy, so your mileage may vary on that.

* Blessed Thistle. Also common. A lot of the research about these herbs [which is unfortunately not very much!] indicates that the two together have a synergistic effect, improving milk supply more than either one would alone.

* Alfalfa. This, I think, is just helpful because it boosts iron; you might get the same effect from any other kind of iron supplement. It is easier on the stomach, though.

* Goat’s Rue. This is a supplement that is reputed to help women build breast tissue–which is exactly what PCOS ladies need. It has the potential to help more than other galactagogues, because those can only work on the ducts that already exist, whereas Goat’s Rue may help produce more ducts. The research on this is spotty, but it’s worth a shot. I will warn you, though–it is quite possibly the most vile substance I have ever tasted. You can get it in tincture form, which is what you want, and it is….well…let’s just say, I only choked it down because I really love my babies.

You can also consider getting Motherlove’s More Milk Plus Special Blend. This is more convenient, because it’s one bottle and you just take your dose. More Milk Plus, the more common tincture from Motherlove, is easily available in health food stores, but I have only seen the Special Blend on the shelf once or twice. You may have to order it online. It contains–in addition to fenugreek, blessed thistle, and goat’s rue–nettle leaf and fennel seed, and water and alcohol. The amount of alcohol is quite small and my pediatrician said that it would not affect my baby, but there are alcohol-free, more expensive formulations of many Motherlove products as well. [I am not affiliated with this company at all; I only post this because I know, as a sleep-deprived new mother, it was really hard for me to get my head around taking dozens of herbal capsules a day].

 

Prescription Galactagogues

* Reglan, which is available easily through your doctor, is an option. It did boost my supply slightly. The side effects were crushing for me, though–I have never felt so jittery, restless, and exhausted all at one time in my whole life–and I discontinued it almost immediately. Some women don’t experience that, so it’s worth a shot if you want to try it. It does have the possible long-term side effect of worsening/causing depression, though, so you should avoid it if you have a history of depression.

 

* Domperidone is generally considered much lower-risk for side effects, but it is not prescribed in the U.S. [except perhaps through a compounding pharmacy?]. If you want to try this, you will have to order it online from overseas. I never tried it, because I am not comfortable with that [I know, I know–herbs are drugs too–but I’m a rule-follower]. I believe, if I understand the law correctly, it is legal to buy it for your personal use, but I am no expert, so check it out. There is information about this at Kellymom.

 

Conclusion

Breastfeeding with PCOS can go just fine, or it can be extremely difficult. If you are one of the low-milk-supply crowd, you have to make a lot of decisions at a time when you are emotionally vulnerable, postpartum. Keep the following things in mind:

* Any breast milk is better than none. Even if your baby only gets colostrum in the hospital and formula from then on out, it’s worth doing.

* There is no shame in supplementation and you should not feel guilty. Feed your baby! Nurse as much as you can, pump if you have to, give the baby what milk is available, and don’t look back.

* A lactation consultant can help you, but if you do have IGT, you may have to face the fact that exclusive breastfeeding is not going to happen. Allow yourself time to be sad about this if you need it. And then remind yourself that you’re still a good mom.

Resources

See the list under the main “Mothering” tab for general breastfeeding resources. Here are some helpful links about low milk supply and IGT.

This article on IGT, from PEDIATRICS, argues that “preserving the ‘every woman can nurse’ myth contributes to perpetuating a simplistic view of lactation and does a disservice to the small percentage of women with primary causes of unsuccessful lactation.” Amen to that.

This article, which includes information about IGT, also has some photos of hypoplastic breasts (so don’t open it at work!).