Fed is Best: Infant Feeding Methods

Most mothers will have heard the refrain, “breast is best”, but does it and should it apply exclusively to all mothers and the needs of all infants? In the days of “intensive parenting”, women are increasingly faced with making infant-feeding decisions that will determine their status as “moral” or “immoral” mothers, a symptom of guilt produced by literature and the La Leche League, which promotes the idea that “breast is best” but does not fully underscore the complicated relationship that many women have with breastfeeding their infants.

Scientific studies currently view breastfeeding as the “gold standard” of infant-feeding methods, but that was not always the case. Indeed, formula was once considered the much more scientific (and therefore healthier) approach. The switch to formula milk feeding occurred during the 20th Century when increasing numbers of women were called out of the home to work, necessitating the use of alternative feeding methods.

In recent years, though, formula feeding has been increasingly maligned due to cultural trends, policy initiatives, and expanding scientific research that promotes the “breast is best” approach. Like many other topics in this book, it appears that the modern methods of feeding infants has gone too far to the point of harm. Unlike many of the other topics, the method that has been pushed too far is the completely natural breastfeeding. It is time to demystify the information about breastfeeding and supplementation in order to alleviate some of the guilt mothers experience and to promote the idea that “fed is best”.

Following the adoption of international health policy set forth at the World Health Assembly in 1991, it became the public policy of many countries to promote breastfeeding as the optimal feeding method for infants with the aim of increasing the rates of breastfeeding women at six months post-birth and longer. Most health organizations, including the World Health Organization (WHO), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians recommend that infants are “exclusively” breastfed for the first 6 months of life in order to promote the growth, development, and health of the infant. After these 6 months, WHO encourages mothers to continue breastfeeding (in addition to introducing complementary and safe foods) for up to 2 years or more.

Healthcare officials and government-led initiatives aim to increase the number of breastfeeding mothers from 74 to 82 percent and those who continue to breastfeed past 6 months from 44 to 61 percent. Why? Because of all the benefits described in the previous section. Human breastmilk contains proteins, enzymes, hormones, growth factors, amino acids, and vitamins, making it unmatched when it comes to providing both immunological and nutritional support to infants. And, it is thought to decrease the chances of an infant developing certain respiratory illnesses, asthma, allergies, obesity, insulin resistance, and metabolic dysfunctions.

By contrast, artificially fed infants are reported to have higher rates of acute otitis media (a painful inflammation behind the eardrum which can cause irritability and fits of crying in infants), gastroenteritis, lower respiratory tract infections, atopic dermatitis, asthma, sudden infant death syndrome, and tissue death in the bowels. Higher rates of obesity, type 1 and 2 diabetes, and childhood leukemia have also been reported in children who are not breastfed. In other words, breastmilk provides long-term protection that is currently unavailable in artificial feeding techniques. It is both the most easily digestible and nutrient rich diet for infants.

There are also certain health benefits for mothers who breastfeed, such as a decreased risk of diabetes and, according to some studies, postpartum depression. In addition to being the most economical choice of feeding methods (it is free, after all!) breastfeeding provides a temporary decrease in fertility and promotes “child spacing”. Breastfeeding is also thought to increase infant/ mother bonding.

Many reports suggest that mothers who breastfeed their infants are less likely to develop postpartum depression, a condition which affects about 14 percent of women who have recently given birth. Although evidence suggests that breastfeeding reduces the risk of developing postpartum depression, it can also influence women to discontinue breastfeeding and, in some cases, might even increase the symptoms of postpartum depression.

When it comes to postpartum depression, it seems that intention might be key to understanding the relationship between postpartum depression and breastfeeding. In women with no history of depression, breastfeeding has been shown to decrease the risk of developing postpartum depression for those who intended to breastfeed, but was shown to increase the risk in women who did not intend to breastfeed. What must be remembered is that the relationship between breastfeeding and postpartum depression is far more complex than researchers have hitherto suggested. Even more, socio-economic factors, stress levels, and the amount of support available to mothers have all been shown to directly influence the development of postpartum depression.

A woman’s choice not to breastfeed is often multifaceted and based on a number of cultural, social, and often economic factors. Nonetheless, how women choose to feed their infants is often taken as a “measure of motherhood”, despite the fact that a majority of women do not breastfeed exclusively, especially beyond 6 months.

Because breastfeeding comes with a number of health benefits for the baby and mother, formula feeding is often presented as a risky or unsafe choice. In other words, women who do not breastfeed are burdened with a sense of failure for not ‘maximizing the physical, psychological, and emotional outcomes’ of their babies, leaving mothers ‘vulnerable to moral judgment’. This means that what was once a choice is now a ‘highly moralized and constrained pressure’ in which those who make the decision not to breastfeed often experience feelings of ‘worry, guilt, and “failure”’.

Formula feeding, then, far from being recognized as a necessity for some women, is a practice that must be ‘justified and defended’. The result is that many come to view the use of formula as “uninformed” or even “selfish”, putting the health and development of the baby at risk. But this is not the whole picture.

What should new mothers know about breastfeeding? Perhaps one of the most important lessons is in managing mothers’ expectations. The cultural imperative which demands that women breastfeed also sets up first time mothers for a particular feeding experience that is unrealistic; they anticipate that, because it is what they are supposed to do, it will be easy and, when it turns out to be challenging, painful, or even impossible, women are left with feelings of failure .

Far from being easy or straightforward, many mothers struggle with breastfeeding their children. Some of the most common difficulties include problems “latching”, insufficient quantities of milk, infant weight loss, crying or irritability, disagreements with health care providers, and severe breast pain. There are also a number of common reasons that lactation might be delayed (such as cesarean section, placental retention, obesity, or diabetes), that might make it necessary for women to supplement at the very earliest stage.

The truth is that very few women have no difficulties at all when it comes to breastfeeding. Most report having a variety of feeding experiences ranging from successful to unsuccessful. And yet, even though many women share in these experiences, when breastfeeding doesn’t work, many suffer feelings of inadequacy and powerlessness.

The use of formula in these instances should not be viewed by mothers as a moral dilemma or failure in motherhood. Indeed, it is much more important for the infant to be fed. In fact, formula might even become part of a strategy toward successful breastfeeding and it is not uncommon for this to occur in hospitals. Managing our expectations of the breastfeeding experience will help fend off feelings of guilt and failure in women who intend to breastfeed but are unable to do so without difficulty. Breastfeeding does not need to be understood as an “all or nothing” decision.

Even more, “breast is best” does not adequately describe the reality of many women’s circumstances. When the majority of women work outside the home, breastfeeding exclusively for the full recommended six months might be a problematic or impossible commitment. Even though a mother’s breastmilk is free, it is not always possible for women to stay at home to breastfeed their infants. Breastfeeding is also, inevitably, associated with sleep fragmentation in mothers, already a concern for parents.

Because literature on breastfeeding does not often taken into account the socioeconomic dimensions related to infant feeding choices or, indeed, the long-term outcomes of children, studies that cite the benefits of breastfeeding are, in many cases, at least unintentionally biased. Women who are older, educated, and have strong family or partner support are far more likely to breastfeed. Further, married women and those with higher incomes also breastfeed at higher rates.

As a result of the biased nature of many studies, some researchers have begun to conclude that they might be overstating or oversimplifying the overall benefits of breastfeeding. In one particular study which made use of sibling comparisons, researchers suggested that – although breastfeeding is associated with certain benefits for the child and mother – in some cases, breastfed children are not better off (and sometimes may even be worse off) than their bottle-fed counterparts.

This is not to discourage women from breastfeeding, but to suggest that it is not “all or nothing”. The idea that “good mothers” breastfeed their children is not a rule that should be applied so widely. While most national and international authorities take the position that breastfeeding really is an unparalleled method of infant feeding, some current research is beginning to question whether the benefits of breastfeeding over formula feeding warrants such a heavy handed approach as in North America.

Are there cases in which women should avoid breastfeeding? Yes, and this demonstrates that the “good mothers breastfeed” rule does not always hold true. Certain preexisting conditions or lifestyle choices may prohibit breastfeeding in mothers.

Other conditions in the infant, such as certain metabolic disorders, might also prevent a mother from breastfeeding. Women should feel empowered and encouraged to consult a physician to help analyze the costs and benefits of breastfeeding in order to make the right decision for her and her newborn .

What are the options available for women who choose not to breastfeed? First, it is essential for parents to understand when supplementation might be necessary. Sometimes, both parents and health care providers are disproportionately worried that breastfeeding in the first days after birth will not provide the required nutrients and calories for the newborn. Most healthy, full-term newborns will not require supplementation.

When might it be necessary to supplement? Generally, a weight loss of 8-10 percent in newborns is one reason a mother might need to supplement her infant’s feeding. This can sometimes be the result of a delayed increase in the production of breastmilk or even infant sleepiness. When weight loss is the result of sleepiness in the newborn all that might be needed is for the mother to gently wake her baby. In other cases, some supplementation might be necessary.

Similarly, infants who are ill or weak might find it difficult to breastfeed. They might also experience some sort of “suck dysfunction” or even have a lack of appetite and therefore need supplementation. Other reasons that a baby might need supplementation include hypoglycemia, metabolic disorders or dysfunctions, separation from the mother, dehydration, and significantly low birth weights.

The best and most common alternative to breastfeeding is breast pumping and storing milk. If, due to any number of factors, breast pumping is not an option, women might also consult a milk bank (as long as it follows the guidelines of the Human Milk Banking Association of North America) to acquire pasteurized banked donor human milk. This might be especially useful for women who are committed to breastfeeding but are, for whatever reason, unable to do so themselves. Infant formula is considered by many health care practitioners and researchers to be the third choice. While hospitals can recommend formulas (and many even offer samples), it is important that glucose or sterile water is never used to supplement as this will not provide enough calories or protein for the newborn.

The use of herbal supplements has also become a popular choice for women who are breastfeeding as a means of assisting with lactation. About 15 percent of breastfeeding women in the United States (and 43 percent worldwide) make use of herbal supplements to aid lactation, increase milk supply, or treat common postpartum symptoms like constipation, colds, and depression, though the efficacy of these supplements are questionable.

Some common herbal supplements used by women during lactation include black cohosh, cranberry, Echinacea, evening primrose, garlic, ginseng, melatonin, milk thistle, and St John’s Wort, a few of which have controversial effects on lactation. For example, cranberry is often used for the prevention of UTIs in pregnant or breastfeeding women. Although it does not typically result in adverse effects (unless taken in high doses), the claim that cranberry reduces the occurrence of a UTI is generally inconclusive. Similarly, taking the recommended oral dose of Echinacea is considered safe during lactation, but most agree that more evidence is necessary to determine the overall benefit of doing so.

It is currently recommended that breastfeeding women not take Ginseng supplements as human studies have not yet been conducted. Ginseng has been shown to decrease blood levels as well as cause nervousness, diarrhea, confusion, depression, and breast pain. Similarly, women who have taken St John’s Wort while breastfeeding have also reported higher frequencies of infant colic as well as lethargy and drowsiness.

On the other hand, a daily dose of evening primrose oil has been shown to increase linoleic acid and breast milk concentrations in lactating women, with no indication of adverse effects on the mother or baby. Garlic can be used to increase “attachment” and “sucking” time. However, although limited data suggests that there are no adverse effects, garlic extract might affect medications and, like all supplements, should be used cautiously. Melatonin transfers to the baby via breastmilk, potentially increasing infant sleep and improving irritability. Although this sounds like a benefit, caution is still recommended as long-term use could more permanently alter the development of sleep patterns and infant circadian rhythm.

Some recent recommendations propose to broaden the “breast is best” discourse to include the significant use of formula, destigmatizing the importance of formula when mothers are faced with feeding complications. As one researcher put it, ‘“breast is best” may hold true only when “breast works”’, but that formula use need not be viewed as immoral at the cost of the mother. Ultimately, women must support each other by advocating that all women have the right to choose the best feeding method based on their experience and circumstance, whether that is the exclusive use of breastmilk, formula, or some combination of both.

Breastmilk is clearly the best milk but it’s simply not always an option for every mother. Women must play a significant role in the decision making process in order to alleviate feelings of guilt. So many women accept the breastfeeding discourse as part of their experience as mothers. Indeed, many come to view breastfeeding as the ‘final stage of labor’ and a completion of their reproductive cycles. In the end, a mother must make the right choice for herself and her infant and that means fed is best and breastfeeding need not be pursued at all costs. What much of the research shows is that, like most difficult decisions, the choice of how we feed our babies is not a simple one and might even involve a combination of methods.

Here is our recommendation for new mothers looking for optimal nutrition for their babies.

1. Consider if your baby is getting enough to eat. Insufficient milk supply can occur and it is not as rare as one might think. Recent medical investigation has provided some information on the frequency of insufficient breast milk.
   1. One study found that twenty-two percent of mothers (who intend to breastfeed and who had well-documented lactation support) had delayed onset of breast milk, indicating that approximately one in five babies are at risk for complications of underfeeding.
   2. Nearly one fourth of newborns born to first time mothers in Baby-Friendly hospitals (hospitals who promote exclusive breastfeeding) experience significant hypoglycemia due to underfeeding (less than or equal to 40mg/dL). This level of hypoglycemia is significant because it is associated with brain injury as well as motor, cognitive, and intellectual functioning beyond infancy.
   3. Newborns who are exclusively breastfed have an 11-fold increase for rehospitalization and up to 18 percent of exclusively breastfed infants experience starvation jaundice.
2. Supplement early if necessary. The benefits of breastfeeding can be negated if the young brain is denied adequate nutrients.
   1. Early supplementation can potentially increase the duration of breastfeeding.
   2. Use a syringe at the breast for supplementing if still waiting for milk to come in, that way baby can continue to stimulate milk production.
3. Add probiotics to formula. Much of the infant’s microbiome is colonized during vaginal birth. However, there are probiotics present in breast milk that can nourish the gastrointestinal lining and support the baby’s immune system. When choosing a probiotic, chose strains containing Lactobacillus (particularly rheuteri and rhamnosis)  and Bifidobacterium (particularly bifidum and infantis) which are typically found in the gut microbiome of the breast fed infant.
4. Simulate the breastfeeding experience.
   1. Choose a nipple that is similar to the natural breast and that is slow-flow. This will promote ease of switching from breast to bottle if you are doing both and will also simulate the most breastfeeding-like experience for the infant as the infant typically must “work” harder while breastfeeding than sucking from a bottle.  It may also reduce the risk of overfeeding and promote a calm, slow feed.
   2. When bottle-feeding, hold the infant close to the body (skin-to-skin if possible) and at the level of the breast.
   3. Consider having the mother do most of the feedings, just as she would if exclusively breastfeeding.

Bibliography

Amer, Marwa R., Gabriela C. Cirpriano, Jineane V. Venci, and Mona A. Gandhi (2015). Popular Herbal Supplements in Lactating Women. Journal of Human Lactation, 31(3), 348-353.

Bartick, Melissa C., Eleanor Bimla Schwarz, Brittany D. Green, Briana J. Jegier, Arnold G. Reinhold, Tarah T. Colaizy, Debra L. Bogen, Andrew J. Schaefer, and Alison M. Stuebe (2017). Suboptimal breastfeeding in the United States: Maternal and pediatric health outcomes and costs. Maternal and Child Nutrition, 13, 1-13.

Borra, Cristina, Maria Iacovou, and Almudena Sevilla (2015). New Evidence on Breastfeeding and Postpartum Depression: The Importance of Understanding Women’s Intentions. Maternal and Child Health Journal, 19(4), 897-907.

Braimoh, Jessica, and Lorraine Davies (2014). When “breast” is no longer “best”: Post-partum constructions of infant-feeding in the hospital. Social Science & Medicine, 123, 82-89.

Colen, Cynthia G., and David M. Ramey (2014). Is breast truly best? Estimating the effects of breastfeeding on long-term child health and wellbeing in the United States using sibling comparisons. Social Science & Medicine, 109, 55-65.

Eglash, Anne, Anne Montgomery, and Julie Wood (2008). Breastfeeding. Disease-a-month, 54(6), 343-411.

Ellie J. Lee (2008). Living with risk in the age of “intensive motherhood”: Maternal identity and infant feeding. Health, Risk & Society, 10(5), 467-477.

Pope, Carley J., Dwight Mazmanian, Michel Bédard, and Verinder Sharmra (2016). Breastfeeding and postpartum depression: Assessing the influence of breastfeeding intention and other risk factors. Journal of Affective Disorders, 200, 45-50.

Sabban, Laura F. (2002), Letters to the Editors: Breastfeeding:: Nutrition not the only issue. Journal of American Dietetic Association, 102(1), 24.

Tully, Kristin P., and Helen L. Ball (2013). Trade-offs underlying maternal breastfeeding decisions: a conceptual model. Maternal & Child Nutrition, 9(1), 90-98.

Williams, Kate, Ngaire Donaghue, and Tim Kurz (2012). “Giving Guilt the Flick?”: An Investigation of Mothers’ Talk About Guilt in Relation to Infant Feeding. Psychology of Women Quarterly, 37(1), 97-112.