Is “Try Formula” the Answer to Breastfeeding Guilt?

“It’s okay to try formula, you know.”

Those are the words our family doctor uttered when I burst into tears in her office when my first born child was four weeks old and still hadn’t latched on once. I’d been pumping every two to three hours around the clock with a manual Avent Isis pump ever since he was born, feeding him the pumped milk, and trying over and over again to get him to latch on; to no avail.

“Yes, I know,” I said, blowing my nose between sobs, “but I don’t want to.”

Annie breastfeeds her son.

I was at my doctor’s office that day on the advice of my International Board Certified Lactation Consultant (IBCLC). She had been working with me for weeks and was running out of ideas.  She suggested that I ask our family doctor for a referral to an Ear, Nose and Throat (ENT) Doctor to see if she could figure out why he wasn’t latching on. She gave me the referral and three long weeks later (after all, my child wasn’t starving and there were other children with more serious problems), I finally got to see the ENT.  Her diagnosis: tongue tie. It wasn’t the first time I’d heard those words. The night nurse, the paediatrician and the lactation consultant had all diagnosed it within 24 hours of his birth and we had the tongue tie clipped in the hospital when he was two days old. Evidently, they didn’t clip enough. The ENT clipped his tongue tie again and that afternoon, at seven and a half weeks old, he latched on for the first time, marking the beginning of a wonderful two and half years of breastfeeding.

—–

“It’s okay to try formula, you know.”

Those are the words my doctor spoke to me and those are the worlds that Dr. Brian Goldman, host of White Coat, Black Art on CBC Radio 1, thinks that health professionals should say more often.  On May 6, the topic of Dr. Goldman’s show was Mother’s Milk (click the link to read a summary or listen to the podcast) and focused on the question: “What happens if you are a mother bombarded with “breast is best” messages, but you can’t?”

In the show, Dr. Goldman speaks with two mothers who wanted to breastfeed but had low milk supply issues and eventually took the “culturally unpopular” (Dr. Goldman’s words) decision to formula feed when it became apparent that their babies were starving. He also spoke with a lactation professional at Toronto Public Health and with a manager from the human milk bank in Vancouver.

At the end of his show, Dr. Goldman concludes:

But, when it’s not working, don’t throw mum and baby out with the breast milk.  When I hear that a newborn is starving because mum isn’t being given the message to try formula – as happened to both the mothers I spoke with on our show – that’s carrying a passion for breastfeeding to irrational extremes.

I understand Dr. Goldman’s concerns with the moralization of infant feeding, but I don’t share his opinion on the root of or solution to the problem.

In my experience, there is a big gaping hole between “Thou Shalt Breastfeed” and “Try Formula”. The gaping hole needs to be filled with affordable, accessible, quality breastfeeding support. Instead, that hole is too frequently filled with pressure and guilt, from society and from within.

Moms who have trouble breastfeeding are often bombarded with Booby Trapsbad advice from friends, family or health professionals who have inadequate training in lactation.  Bad breastfeeding advice often leads to low milk supply and eventually starving babies if the mom doesn’t do something about the problem or supplement with formula or donor milk.  Since most (but not all) low supply problems can be fixed with appropriate breastfeeding protocols, moms are often blamed and made to feel guilty when things don’t work out.  After all, breastfeeding is supposed to be “natural” and if it isn’t working, people will send the mother the message that she just isn’t trying hard enough or just doesn’t care enough. When the void is filled with guilt instead of help, we have a problem.

I read a great post once called Breastfeeding, Bottle Feeding and…. Somewhere In-between…. Why the Guilt? In this post, the author, who has been providing lactation services for more than 35 years, pointed out that you should:

  • Never overestimate a mother’s desire to breastfeed her infant.
  • Never underestimate a mother’s desire to breastfeed her infant.

Among other important points, she came to the conclusion that we need to “support the mother, support the mother, and support the mother.” Telling a mother who wants desperately to breastfeed her baby that she needs to try formula isn’t any more useful than telling a mom who wants to formula feed that she has to breastfeed.

—–

When I walked into my doctor’s office that day, I had a game plan. I wanted a referral to an ENT, as suggested by the IBCLC. In the absence of that game plan, the words “It’s okay to try formula, you know”, may have marked the end of my attempt to breastfeed my baby and the beginning of a guilt-ridden downward spiral. Instead of going on to nurse him for two and half years, I may have simply switched to formula, a move that would have come with financial and health consequences for both of us.  I don’t think that mothers need to be told that they must breastfeed and I also don’t think that mothers need to be told that they must try formula. What would happen if, instead of feeling the need to TELL mothers what to, health professionals simply asked: “How can I support you in your feeding decision?” From there, the conversation needs to combine compassion and knowledge, supporting the mother while also answering her questions and educating her without judgement or pressure.

Yes, health professionals have an obligation to watch out for the health of the baby. But perhaps if they approached that obligation from the perspective of a partnership with the mother, there would be less guilt, more healthy babies, and fewer unhappy moms.

Annie has been blogging about the art and science of parenting on the PhD in Parenting Blog since May 2008. She is a social, political and consumer advocate on issues of importance to parents, women and children. She uses her blog as a platform to create awareness and to advocate for change, calling out the government, corporations, media and sometimes other bloggers for positions, policies and actions that threaten the rights and well-being of parents and their children.

 


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29 Comments | Last revised on 05/31/2011


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29 Responses to Is “Try Formula” the Answer to Breastfeeding Guilt?

  1. Melissa Cline says:

    I think what’s sad is that when most health care professionals say “try formula” they mean as an end to a breastfeeding relationship, not as a way to support one. Supplementation CAN be done with the goal of increasing and resuming breastfeeding, but not if you only go by the average American pediatrician’s advice. My experience is that MDs who are not also IBCLCs need to refer clients out to lactation specialists because the MD’s knowledge is not sufficient to troubleshoot breastfeeding difficulties, even perceived ones.

  2. Lea says:

    As an IBCLC I feel that maybe the phrase “try formula” isn’t quite accurate, but what could be said in the case of babies who have lost weight or do not seem to be gaining adequately is that the baby “needs to eat. How would you like to do this?” This puts the decision making on the parent without guilt. She can choose formula or she can choose donor milk or expressed milk. It is very hard to encourage a baby to breastfeed and support a mother’s desire to breastfeed when the baby is undernourished. A healthy, fed baby is able to learn and has the energy to practice. A mom who has been empowered to make a decision that is right for her regardless of outcome is a happy nurturing mommmy.

  3. Marcy says:

    GREAT post, Annie!! Agree whole-heartedly.

    As an aside, I struggle to comprehend how we have arrived at a place where formula feeding is both “culturally unpopular” and also the norm for the vast majority of (US) babies… There’s a disconnect there.

    • Can I take a stab at explaining this?

      The disconnect has happened because one feeding method is held up as the ideal; what “good” mothers do. When we talk about the pressure to breastfeed and the breastfeeding backlash, we are really talking about one small subset of the national population – financially stable, educated parents. This group may not be the majority in terms of sheer numbers, but it is the most vocal: it is the group which is buying the parenting literature, watching parenting shows, blogging, commenting on websites, etc…

      Yes, the bulk of our population uses bottles. But the bulk of our population is also poor; many are young single moms who could care less what the AAP or the interwebz are saying because they are too busy trying to survive. Being a perfect mom takes a backseat to ensuring the most basic needs for yourself and your child. Now, obviously, this group is being targeted for breastfeeding support (although in my opinion, it’s being approached in the wrong way) but this tends not to be the group we are referring to with the talk of “extreme breastfeeding pressure”.

      For middle-class mom in many areas of America, it’s another story altogether. We have the time and luxury to read Dr. Sears, take parenting classes, and care about things like our “birth experience” and exclusive breastfeeding and “optimizing” our children’s health and intelligence. But we very often don’t have the luxury of staying home longer than 4-6 weeks; we may not have family nearby or money for paid help. So we are then left with a lot of personal and cultural expectations and not a lot of on-the-ground support. And of course the bottle HAS to come in once we go back to work, even though it is most often filled with pumped milk (I really wish breastfeeding advocates across the board would start acknowledging that bottles are a necessity for most breastfeeding moms who work. Not all of these contain formula, and even if they do, it might be because the pump just isn’t cutting it when you’re working 10 hour days..).

      I think the disconnect is understandable when we realize that what we WANT, and what our lived realities end up being, are not always the same. Giving this particular group of women more breastfeeding ‘education’ is not going to do squat. Until we have free, quality lactation support and better research into what is REALLY causing so many lactation problems, “it’s okay to use formula” is going to HAVE to be said. As a physician, it would be highly unethical to allow a baby to starve, and if your patient population is full of women refusing to supplement because of dogmatic beliefs about nipple confusion and the evils of formula, then chances are you feel it necessary to give “permission’.

      I too had a frenulectomy. It didn’t help my son; that may have been because he’d already been on the bottle for a week. But on the other hand, he would have starved to death were it not for an LC who convinced me to pump when she saw how badly things were going. And I’ll take the loss of a breastfeeding relationship over harming my child any day.

    • Jennifer R says:

      It’s not culturally unpopular unless you’re talking about a small group of well-educated moms. Go to Walmart, go to the ghetto, go to McDonald’s in a lower income neighborhood, and just see what you see. Talk to a cashier at a grocery store about it, one in a lower income area. Most of this country does not look down on formula feeding at all, in fact it’s the norm in more ways than one. I know several lower income women, and women of color, who were pressured to stop breastfeeding by friends and family, because it was seen as inferior — both nutritionally and logistically. Look too at the current income distribution in this country — most people are poor now. Along with poverty comes the pressure to fit in with the majority of other poor people, who do not breastfeed and who think formula is just fine.

  4. Emily says:

    When my daughter was four weeks old we realized there was a problem with her latch. After trying everything I knew, I took her to my midwife who of all things says “It’s okay to give her formula. You breastfed for four long weeks.” I asked her if I should continue trying to pump and she told me no! After that I went home and spent some quality time with the internet only to find that she had an upper lip tie! It has since been clipped and at three months we have a wonderful breastfeeding relationship.

  5. mumby says:

    I very very wise midwife. When my baby couldn’t latch because of my own post-partum health problems, she set us up to feed her formula through a tube and syringe. We taped the tube to our fingers, or my breast and she had to work HARD to get that formula out. It is believed that it can be the bottle – not just the formula that can put the breastfeeding future at risk. After a couple of weeks, we resumed normal breastfeeding. The syringe & tube was actually fantastic for my husband too. While she suckled on his baby finger he proudly said “look – I’m breast feeding!”… (Well, not quite… but whatever floats your boat…) made him feel important in those first few weeks!

    I missed this White Coat Black Art. Will have to download the podcast.

    Thx Annie!

  6. KrissyFair says:

    Great post!

    I think in addition to working towards whatever the mother’s goal is, health professionals also need to realize that changing the milk doesn’t mean you have to change every other aspect of breastfeeding. Like mumby said above, you can use a lactation aid so that mom and baby are both getting all of the benefits of the physical connection, so that mom has a chance to work on the root of the problem without starving babe (if she so chooses), and most importantly so that mom doesn’t feel like that relationship that she was hoping for has vanished in one fell swoop – or one fell bottle as it may be.

  7. Jessica says:

    Great article! I also have struggled with breastfeeding, but luckily I have access to wonderful, affordable breastfeeding support. Without it, I don’t know if I could have kept it together enough to exclusively breastfeed. The guilt issues can go both ways, too. Since I don’t supplement with formula, I sometimes feel guilty because my baby’s not gaining a lot of weight. After she was born, she was being treated for jaundice in the NICU, and the nurses convinced me to supplement with formula, a decision that I still feel guilty about nearly 5 months later. I know a lot of mothers that struggle with guilt surrounding feeding decisions on both sides.

  8. Amy says:

    As a mother who was only able to partially breastfeed with the additional support of formula and as a mother who stopped breastfeeding way earlier than desired, I can certainly relate to the experience of “booby traps.” From the university hospital who took traditional medicine to a whole new level whisking my newborn away from me too soon after birth where we weren’t able to engage in those natural instincts from the start, to the NICU nurses who very near cursed my name for trying to exclusively breastfeed and putting me and my child on a very rigid every 3 hours for 20 minutes feeding schedule, to the doctor who gave me a birth control that is known for limiting milk supply without properly educating me on it. So young was I even a mere 2 years ago and how I can see that if I had known a little more, been a little more assertive, and engulfed myself in a more supportive environment things could have gone so differently. Thank you BFB for your continued support for those young (and not so young) moms trying to breastfeed.

    • Jessica says:

      Amy, my NICU experience was startlingly similar. While I was in recovery after 32 hours of labor, a NICU nurse yelled at me for not coming down to feed my baby, and “guilted” me into allowing them to use formula. We were also put on a rigid schedule while she was in the NICU. The implication that I was harming my newborn by choosing to breastfeed was so frightening and nearly overwhelmed me. You are definitely not alone in your experience.

  9. Laura Shum says:

    Breastfeeding does not have to be an all or nothing venture. There are those of us who are dedicated to breastfeeding 110% that despite months of pumping nursing and supplementing we still don’t make “enough” for our babies. I think trying formula should only be suggested if there is proof that there is not enough breast milk for the baby. After all breastfeeding is only best when the baby is gaining weight and thriving. Formula isn’t always the enemy. Supplementing with formula in a way that supports breastfeeding, such as an SNS or lact-aid nurser, enables us to continue breastfeeding while getting the needed calories and nutrients to our babies. However, the suggestion to supplement with formula should only be continued while mom is getting help to increase her supply and keep the baby nursing. Breastfeeding is not all or nothing!

  10. Andib says:

    I am not sure how “unpopular” or frowned-upon formula-feeding is to the average, mainstream mom and the peer groups surrounding her. I too often see the reverse–a disapproval (either tacit or overt) for breastfeeding moms that’s something akin to the eye-rolling given to those who opt for natural births. There’s a constant, steady societal pressure that expresses much more approval for a nice, “normal” bottle instead of a boob. So I’m not sure what this television doctor means when he says women get too much pressure to breastfeed–my experience has been almost entirely the opposite, except when I attended LLL and natural-birthing group meetings. I absolutely had to fight for my right to not be judged for NOT bottle-feeding my children! Once our society can truly accept BF as the normal, default method of feeding children, then everyone who offers advice to a new mom might be more accurately informed about the process. And lactation consultants should be provided free/low-cost/under insurance coverage for every woman who has a baby in North America, so that no one has to try it in the dark and think that it’s just one more scary, gross, needing-to-be-”sterilized” process associated with having a baby.

    • Annie Urban says:

      Andib:

      This was a Canadian radio show. Breastfeeding is “normal” here, but there are still some issues with breastfeeding in public (i.e. people who don’t think that should be done). So any mom feeding her baby in public is open to criticism — breastfeeding moms for “flashing their breasts” and bottle feeding moms for daring to formula feed (even if it is breast milk in the bottle). Moms are expected to breastfeed, but are expected to keep it in private.

      I’m perhaps exaggerating a bit for creative licence, because I was never harassed for breastfeeding in public, but there are still incidents where moms are told to leave or cover up.

      • Andib says:

        Ah, my mistake–I knew you are in Canada but wasn’t sure about the television show you referenced. I’m glad that the culture there is more accepting of breastfeeding, and I completely agree that “support the mom’s choice” should be rule #1 for anyone offering advice!

  11. StorkStories says:

    Excellent post Annie! Thanks so much for the link ping-back!
    Recently working with a 31 wk preemie mom who has built a fabulous supply. Her baby, now 34 5/7 weeks, has been EXCLUSIVELY breastmilk fed since enteric feeds were started! YAY for our little NICU! We’ve been gently encouraging direct feeds at the breast and mom isn’t quite ready or wanting to go there. We have been facilitating a lot of skin to skin time, and boosting her up with pep talks occ. This isn’t always the story you hear with other mother’s of preterm infants. This mama told me (embarrassed and reluctantly)that she really didn’t want to “rock the boat” so to speak and wished to keep feeding her baby pumped milk by NG or bottle.
    She said she was afraid to tell me because I was a lactation professional and pro-breastfeeding. She’s never felt “pushed” or unsupported by anyone on our staff and yet… she was afraid to verbalize her feeding plans. Anyone who knows me knows that it is my motto to support the mother at ALL times and I am NEVER pushy. I inform, educate and support. I’m glad she finally felt comfortable to speak her desires even though we’d ask her each feeding how she’d like to manage it…
    I think my point is that so many different situations exist out there..–different mindsets, goals, values, opinions, health issues for mother or infant— that any one individual can not know what another wants to or is able to do.
    This is why the “never underestimate” “never overestimate” is so valuable in our support of mothers! Thank You!

  12. eva says:

    I am so glad you wrote this Annie. I listened to that WCBA on a podcast a couple weeks ago and was absolutely incensed. Then I read the stupid Margaret Wente column and just about blew up. I wish I could address both as succinctly and eloquently as you have. Thank you.

  13. Rock Star says:

    Sorry to hear you had such a bad time. However, as we have learned over and over and over sounds like it wasn’t your fault. Why was your baby’s tongue-tie not discovered at the very first examination – then followed with each feed and, if necessary, clipped before you left the hospital..?
    If you would like to teach your doctor about tongue-ties – go to
    tonguetieclipit.com

    • My understanding, re: tongue tie, is that there is lack of a agreement as to how to deal with tongue tie and its impact on the breastfeeding relationship. With my daughter, within minutes of her being born the doctor told us she had a tongue tie. From that point on we kept asking nurses and doctors about it and everyone had a different opinion as to a) if she had one and b) if it was a problem. It was finally clipped at 9 weeks. I suspect if it was clipped at 1 week it would have been a bit of a different experience (thought I had a number of factors working against me). Anyway, long story story- I think along with the lack of support there is a huge lack of good education and knowledge on a part of our health care professionals.

    • Annie Urban says:

      Rock Star:

      The tongue tie was discovered and clipped before we left the hospital. As I wrote:

      “The night nurse, the paediatrician and the lactation consultant had all diagnosed it within 24 hours of his birth and we had the tongue tie clipped in the hospital when he was two days old. Evidently, they didn’t clip enough.”

  14. Stephanie says:

    Loved this post. When my daughter was a week old, she lost more than 10% of her weight (my milk hadn’t come in yet). When the pediatrician found out, all he said was, “Why don’t you see if you milk comes in today and then we’re reevaluate on Monday. This is normal for new moms and babies who are breastfed.” What a relief!! I wanted to breast feed and didn’t want to use formula unless I absolutely had to. Having the support of our doctor was so important…

  15. Channa says:

    Terrific article. The one problem is that your suggestions would require doctors to either take TIME to LISTEN to mothers, or that they get some humility and know when to keep quiet and send the mother straight to the lactation consultant. I’m not sure most pediatricians I’ve met are up to either of those tasks.

  16. Grimalkin says:

    I had a related, but opposite, problem. I was determined to breastfeed, but my milk just wasn’t coming in. After four days, my son had lost about 11% of his birth weight and had nearly stopped waking up entirely. It was hard from the start to get him awake enough to try latching, sometimes taking upwards of an hour of baby-torture that would make Guantanamo proud. But at four days, even that had stopped working. He was in full-on starvation mode trying to conserve all his energy. The few times he did wake up, he just rolled his eyes around frantically and cried.

    I talked to my midwife. I told her that I wanted to give him formula to tide him over until my milk finally came in. She said no, and told me to take certain herbal capsules instead. That was it for me. I wanted to breastfeed, but not if it starved my son.

    I sent my mother to the store to buy formula. She asked the attendant which kind was best for a newborn. The attendant, instead of doing her job, lectured my mother, telling her that she was “sabotaging” me by letting me “give up.” I wasn’t giving up, I was keeping my son alive. But my mother was made to feel like a bad mother (at 65!!) for supporting me. My mom, bless her, is the most hardheaded woman I know and, having been entrusted with a task, was going to complete it. She made such a row that the pharmacist finally helped her, but wouldn’t let up. My mom came home feeling completely dejected, like she was complicit in some kind of crime.

    But that night, we fed my son and he actually opened his eyes and looked at us, calmly, for the first time since the day he was born. We only gave him an ounce, just to get him started. Once he had a little food in his belly, he was quite happy to latch on and give the boobs another go.

    I was still determined to breastfeed, so my son and I worked very hard in those first few days to make it work. The rule was that he could have one ounce of formula, up to three times a day, but only if he tried to suckle for at least 20 minutes on each breast first. Once he did that, my husband fed him formula while I pumped. I had something, organic or mechanical, latched to my boobs pretty much every waking minute.

    Then one day, I heard a slurp while my son was at my breast. It was magical! He went at it with renewed gusto and, when he finally pulled away, he had an actual milk moustache!

    We ended up only using formula for about a week, and we used it to keep my son alive while we continued to try breastfeeding him. But from the reactions we got from people who should have been supporting us and helping us ensure that we had a happy, healthy baby, one would think that we were trying to eat the baby rather than feed him!

    That’s what I object to – when people elevate breastfeeding to the level of ideology and put it ahead of what should matter most: the health of the baby. What I needed most was support in trying to continue breastfeeding that didn’t preclude taking care of my child, and I don’t feel like I was ever given that. Instead, had I not been so determined to breastfeed, the attitudes of people like my midwife could very easily have pushed me away from breastfeeding entirely.

    • “That’s what I object to – when people elevate breastfeeding to the level of ideology and put it ahead of what should matter most: the health of the baby.”

      Yes, yes, a thousand times YES. And good for you for having the presence of mind to stand up for your child and yourself.

  17. Sophia says:

    I think that Americans do not understand the culture in Canada, where breast-feeding is normal, and extended breastfeeding is also quite normal. In fact, in my peer group, I am the only person I know who has combination fed. I have been stopped by total strangers in public to be condemned for feeding formula. When my son dropped 43 points off his growth chart in 6 weeks, the entire time I had medical professionals telling me that “breastfed babies don’t starve”, “you wouldn’t be able to soothe him if he was starving”… in his 3rd month of life he only gained 6 ounces. I knew he wasn’t getting enough in my heart, because he did not have enough wet diapers, but no one would listen to me and kept telling me to nurse more, which I did. I nursed and nursed until I was in a black pit of hell. I truly envision that time as a black pit. And the grief and guilt I felt when I had to finally feed formula was terrible. I wish I had been encouraged earlier to give formula. I hope my son did not suffer any permanent developmental damage for the period of time he was STARVING at the breast. It was only after his fontanelles sunk in from dehydration that I was finally given “permission” to formula feed him. I think the doctor on the CBC has a really good point. Are we starving babies in pursuit of an ideal that cannot be met? My baby rebounded within a week of introducing formula, gained weight appropriately, and became a happy, content baby. And I could nurse him and also know he was getting enough food, so I became much happier, myself.

    Combination feeding saved our nursing relationship, and we are still nursing at 13MOs. I think that both sides have a good point to make. But it’s important to meet a mom and her baby where she is.

    • Bettina Forbes, CLC says:

      We completely agree that moms should not be condemned for feeding formula, and think it is awful that no one would listen to you! The appropriate course of action would have been for your physician or health care professionals to insist that you see an IBCLC (international board certified lactation counselor) who could have done a thorough assessment to determine the cause of low milk supply (such as IGT) and helped you to address it. Babies should not have to be starved and mothers should not have to be living in a “black pit of hell” because they are not getting the proper care.

  18. Maranda says:

    Great post Annie. Even though I ‘extended’ BF all my kids, I always appreciate that our Dr asks the open ended question “What is he/she eating?” at well baby check ups. I always thought that was a good question that wouldn’t make anyone feel bad for BFing ‘too long’ or ‘not enough’ etc.

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