Thursday, December 23, 2010

A proactive approach to breastfeeding

Desiree of Hitting My Stride, 6 months pregnant with her first baby and planning to breastfeed, recently asked me this question:
Do you know if there's a way to help my chances of being able to breastfeed?  Everything I'm reading says that it's not a problem until it's a problem and there's not a lot you can do proactively.
Great question! I would argue that there is a lot you can do proactively to ensure a successful breastfeeding relationship. A proactive approach to nursing your baby covers three main elements:

1. Individual choices
2. Institutional policies & care provider actions
3. Uncontrollable circumstances

Nursing my newborn son minutes after he was born
Individual Choices
Let's look at the first element, the one you have most control over: your individual choices. These can include your knowledge about and familiarity with breastfeeding, the use or avoidance of pain medications and certain interventions during labor, and your parenting choices.

First, let's discuss knowledge and preparation. Most of us grew up and live in a culture of bottlefeeding. Often, bottlefeeding norms become deeply embedded, without us even realizing it. For example, if we are used to seeing babies drink from a bottle, we might unconsciously hold our babies and position our breasts in their mouths as if we were feeding with a bottle. Bottlefed babies are held on their backs, facing the ceiling. The bottle's nipple is centered in their mouth. Breastfed babies, however, are held stomach-to-stomach, wrapped closely around their mother. They latch onto the breast asymmetrically, placing their chins deep into the breast and taking in a large amount of the lower areola. I love Laura Keegan's illustrations of how bottlefeeding norms affect breastfeeding in her book Breastfeeding With Comfort and Joy.

Unless we have grown up surrounded by nursing mothers, we might lack essential knowledge about breastfeeding: how to get a baby latched on, how to help the baby empty the breast efficiently, normal newborn eating and sleeping patterns, and solutions or preventive remedies for common breastfeeding challenges (plugged ducts, sore nipples, etc). Books, websites, videos, lactation consultants, and breastfeeding support groups fill this role today.

As I mentioned in a Breastfeeding Carnival post about "What I didn't expect when I was expecting", when I was pregnant with my first baby, I read extensively about breastfeeding. My favorite book was Dr. Jack Newman's Ultimate Breastfeeding Book of Answers. I read the book several times and watched the videos on his website. By time I was full-term with my daughter, I knew what a good latch should look and felt like, how to position the baby properly in relation to the breast, how to identify and solve common breastfeeding problems, and when to get help for more serious issues. There are many fantastic breastfeeding resources, too many for me to list here; please refer to my top birth and breastfeeding books or browse through my book reviews.

Next, there are many choices we can make during labor and in the immediate postpartum period. Our choices about pain medications, timing of the birth (i.e., elective induction or cesarean), place of birth, and care provider can influence breastfeeding outcomes. For example, both intravenous and epidural/spinal pain medications during labor negatively affect breastfeeding rates, even among mothers who intended to breastfeed and/or who had already successfully breastfed a previous baby. The amount of skin-to-skin contact right after birth affects breastfeeding success; the more skin-to-skin, the higher the rate of exclusive breastfeeding upon hospital discharge. Breastfeeding rates are also higher in Baby-Friendly institutions; if you are lucky enough to have access to Baby-Friendly care (whether officially recognized or not), this might influence where you decide to give birth. I won't go into detail here about how various labor interventions & practices affect breastfeeding. For more information, read Linda Smith's book Impact of Birthing Practices on Breastfeeding.

Finally, there are the choices we make as we parent our babies: Do we nurse on cue? Do we feed on a strict schedule? Do we sleep close to our infants, either in the same bed or the same room? Do we use pacifiers or introduce bottles, especially in the first several weeks? Some of these choices will help establish a successful breastfeeding experience; some may negatively impact breastfeeding. Take the time to think about and research these options.

Institutional Policies & Care Provider Actions
A second element of breastfeeding success depends on institutional policies and care provider preferences. We have less control over these factors than we do our individual choices. For example, if you give birth in a hospital with a policy of routine nursery observation for healthy newborns, keeping your baby at your side may be an enormous challenge. This is where careful decision-making in the prenatal period is key--to the extent that you have choices, of course. Many of us are constrained by insurance restrictions (only X hospital is covered, not Y or Z), state regulations (whether home birth or birth centers are legally allowed), or care provider preferences (in some areas, no physicians will attend VBACs or vaginal breech births).

Labor management and postpartum routines can influence breastfeeding success. For example, going into labor spontaneously, using non-pharmaceutical pain relief during labor, and having immediate, uninterrupted skin-to-skin contact after the birth all contribute positively to breastfeeding rates. This is not to say that you will not be able to breastfeed if you have an epidural or a cesarean, just that those circumstances can lead to more breastfeeding challenges. Educate yourself about which birth practices or postpartum policies are most likely to enhance your ability to breastfeed and how to overcome challenges that may arise if certain interventions become necessary. Make wise, thoughtful choices--as much as you can given your geographical location, your financial situation, and your insurance coverage--about where and with whom you will give birth.

Uncontrollable Circumstances
Sometimes breastfeeding is challenging due to circumstances beyond our control, no matter how carefully we planned and prepared. Some of these factors might include tongue tie or cleft lip/palate, prematurity, Down's Syndrome, NICU stay, low supply due to hormonal imbalances or insufficient glandular tissue, overactive letdown, and so on. We might have a baby who just won't latch on well, despite all the right techniques! A proactive approach to breastfeeding means knowing how and where to get help if these challenges arise. For example, knowing about tongue tie might help you identify that as a potential culprit if breastfeeding is unexpectedly difficult and painful, despite doing everything right.

Before you have your baby, be sure you know who your local IBCLCs are and if insurance covers their services. Know when and where your local LLL or other breastfeeding support group meets. Ask around about breastfeeding-friendly family physicians or pediatricians, so if your baby has certain medical complications that affect breastfeeding, you'll have someone on your side. Gather together a supportive network of friends or family members who can help if you encounter breastfeeding challenges.

In sum, can you take a proactive approach to breastfeeding? Yes you can!


  1. One more suggestion: before you have your baby, attend as many La Leche League meetings as you possibly can. You will be able to ask question, learn from other mothers, and see women nursing and caring for their babies at the meeting. Watching other mothers with their babies at LLL meetings is a powerful way to learn about being a mother to YOUR baby.

  2. My 3 month old recently had a posterior tongue tie fixed after being told by three different IBCLC, my midwife and a pediatrician that nothing was wrong with her. She got clipped and like magic latched for the very first time. I'm doing what I can to spread the word about this rare but severely underdiagnosed problem since if I hadn't been extremely stubborn and kept at it, this problem would never have been taken care of. Here is a very in depth and fantastic resource for diagnosing tongue tie of every type:

    I wanted so very badly to breastfed I seriously almost killed myself over not being able to (yay hormones) and it's incredibly frustrating that it was a problem that could have been fixed, but nobody caught what was actually a pretty obvious tongue tie. I don't want to see any other moms go through the same thing.

  3. Rixa, I'm glad to see you mention "Breastfeeding with Comfort and Joy" -- that's a huge help to so many moms. Just wanted to let you and your readers know that the author, Laura Keegan, is offering a 20% discount on her facebook fan page. Enter code fbfan20 when you order from her website to get 20% off until Dec. 31.


  4. All fantastic suggestions, Rixa!! The only thing I would add for proactively preparing is to have CONFIDENCE. Having read a lot of the research on predictors of breastfeeding success, and having done some research myself, confidence is one of the VERY strongest predictors of breastfeeding success. Multiple moms have said to me "It was hard at first, but I just knew we were going to make it work and persevered."

    In the hospital working with new moms, the biggest challenge I face is not babies with Down Syndrome, prematurity, NICU stay, etc. The biggest challenge is working with mothers who do not really believe they can breastfeed. They don't think they have enough milk, don't believe they ever will have enough milk, don't believe the baby likes breastfeeding if it is fussy, don't think their baby will latch because their sisters' babies didn't, etc. Too often I see a problem that is real but fixable, and the mom's attitude is more or less "Well, I guess breastfeeding doesn't work out for everyone".

    Last week I worked with a Down Syndrome baby, several preterm babies, and several babies in the NICU. All of those presented challenges that took a lot of work and effort, but were made infinitely easier by the attitude of their moms that breastfeeding was going to work, and their attendance patience and perseverance. This doesn't mean confidence and dedication can overcome every breastfeeding problem, but they make such a huge difference!!

  5. I want to put a plug in for LLL as well. If it weren't for them, my mom probably would have given up on breastfeeding.

    My mom had a hard time establishing a breastfeeding relationship with her first. The nurses at the hospital where she delivered wouldn't help because they "had no time" and told her to just give him a bottle.

    It took ten long days to establish a nursing relationship. She finally called a friend in LLL to help her. That's what finally helped, and my mom went on to nurse that baby for 18 months, and the rest of us for at least a year.

  6. I agree so much on all of this!
    The biggest factors that helped me were personal research. I did as much studying as possible so that I was educated.
    Another was my mom. Having talked to a few friends I have found that whether or not heir mother breastfed really determines what they will do. My mom was a LLL attender and breastfed all of us past a year. She was SOOOO supportive about me breastfeeding my son till 20 months (would have gone longer but my milk was drying up due to pregnancy).
    Lastly, my husband. He did not think breastfeeding was weird or gross. He encouraged it and helped me so much. In fact he was helping me get a correct latch for the first few weeks!
    So many people around me gave me the raised eyebrow when they found out my son was still nursing past 6 months but it did not matter to me because I had a supportive mom and hubby.

  7. Another Desiree! I don't know anyone with "my" name. lol

    I agree with finding a LLL and even start attending before you deliver. If you do not live near one (like myself) then find a good online community to help you out. MDC is a good one. And having your partner be supportive is crucial. It would be great to have your partner read a breastfeeding book before delivery, but not always possible. ;)

  8. Ok--tangent question but I would love to hear what you or your readers have to say. I had a very difficult time getting my daughter to breastfeed w/o huge problems with my own comfort. Eventually, things went smoothly. However, fast forward three years, and she is still very devoted to nursing. It breaks my heart to think of making her go cold turkey, but none of the gentle weaning techniques have worked. I'm ready to be done. Any advice???

  9. This is an awesome post. I wish so badly to breast-feed my next baby but am terrified as I gave up the first time (I was really young, uninformed, and scared to be a new mom). This post helps! Next time I will make sure I am more informed and attend some classes, etc. so I know what to expect. Thank you for all you do!

  10. Thank you so much for this post and all the amazing informative links! I'm going to my first LLL meeting in January!


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