Tuesday, July 19, 2011

Practical advice for nursing mothers

When you announce on the internet that you're nursing your baby and need advice, women are only too happy to give it to you. However, I've noticed that the women most likely to give advice, the ones who frequent the breastfeeding communities, are the so called "boob nazis." They feel so strongly that breast is best, that even an ounce of formula is criminal. For example, a new mother I know was just "dropped" by her online breastfeeding mentor because she confessed that she started giving her newborn one small bottle of formula at night (for the sake of her sanity).

To me, this seems crazy! If you believe so strongly in breastfeeding, isn't it better to encourage women to at least do it part of the time, rather than reprimanding them for taking measures to make it more doable? I've gotten some ridiculously useless advice from women who refused to compromise their breastfeeding ideals. (i.e. When I started giving my daughter solids, I was advised to have her reverse her sleep cycle to spend most of the night awake so she could nurse during this time. Seriously??)

With that in mind, I'd like to offer some practical tips and advice for breastfeeding and pumping, coming from a working mother who believes strongly in breastfeeding but is not a "boob nazi." You can take this advice with a grain of salt, because this is just based on my own personal experiences:

1) Breastfeeding is actually not that easy. I was amazed how challenging it was the first week. Your nipples hurt, the nursing itself hurts, you get dehydrated, and you never seem to have enough milk. Don't give up after just one week. It gets way easier. Promise.

2) One (or even more than one) bottle of formula will probably not result in terminal nipple confusion or a sharp decrease in supply. Due to an ABO mismatch between me and my husband, we produce very jaundiced babies. They got bottles in the hospital. No evil resulted.

3) You are not a horrible person if you allow your partner to give the baby a bottle at night so that you can get a few consecutive hours of sleep and feel human. I resisted this for as long as I could with my older daughter and finally gave in when my health started suffering. It actually ended up being wonderful because it made my husband feel closer to the baby and more comfortable taking care of her.

4) You don't need to have five gallons of frozen milk stored up when you go back to work. If you do: awesome. But if you don't, it's not the end of the universe. Due to a variety of reasons, I had absolutely no stored breast milk when I returned to residency. Despite this lack of foresight and my daughter's monstrous appetite, she didn't get any formula at all for the first three months I was back at work. Obviously it would have been better if I had planned ahead, but I'm just saying that you can make it work.

5) Expect to hate pumping. I have yet to meet a woman who didn't find pumping really depressing.

6) If you're having a hard time pumping during your maternity leave, try pumping first thing in the morning every morning. Your supply will be highest then and the pumping will be most successful. Nurse one breast, pump the other. One 5 ounce bag of milk every morning for 11 weeks will give you about 400 ounces of milk, even if you don't pump any other time.

7) If you work standard hours at your job (Monday through Friday with most weekends off), your supply will probably decrease as the week goes on and be highest on Monday. Take advantage of this by pumping like crazy on Mondays and over the weekend. I used to nurse on Monday morning AND pump out 10 ounces.

8) Keep well hydrated.

9) If you feel you can't breastfeed and your baby gets formula, your baby will still be healthy and absolutely nobody will judge you except for a few nut jobs on the internet. When I was an intern, a graduating resident told me she couldn't make breastfeeding work because of her hem/onc fellowship. That woman was an awesome resident, a wonderful person, and I bet anything she is a great mother. If nursing is going to make you tired, cranky, and unhappy, and you hate it and are only doing it out of guilt... well, I just don't think it's something worth feeling guilty about.

Anyway, that's all I've got for now, but feel free to add your own practical advice. Hopefully, this will help some new moms or mothers-to-be.


  1. Good advice - the best thing I did the second time around was add a couple of ounces of formula to what I sent to daycare right in the beginning. This took so much pressure off my pumping during the day and was such a relief when I let go of the guilt (put there by the milk natzis...). My advice to nursing moms in my practice is to do what is right for your family and ANY breastfeeding is wonderful (and an accomplishment - especially as a working mom)

  2. Fantastic advice Fizzy, all of which I folllowed as a working mom physician. I wish i'd heard this advice before I had my first. I do wish people wouldn't use "nazi" in association with people who are not actually committing a crime against another person. I think to do so is both unfair to zealous breastfeeding advocates AND minimizes the horrors of what the real nazis did. I think it gets used for dramatic effect, but I think it is not fair on either end.

  3. I also should have added: keep a can of formula in the house.

    Anon: I obviously don't want to minimize what nazis did, but at the same time I do think it's really wrong to tell a new mother that she's a terrible parent for giving her baby formula. Women I know have even been verbally attacked in public. I think they're far worse than that soup guy on Seinfeld, so I'd complain to NBC first.

  4. I would add: if you pump at work, don't be embarrassed about it. Tell people what you'll be doing, and when, and don't make excuses. With my first, I tried to hide what I was doing and not only did it make it stressful on me, but I projected the image that breastfeeding and pumping were something of which I was ashamed. In fact, it gave more credence to the complaints of a few oafish fellow residents who said I was unfairly getting extra time off.

    Second time around, I told my rotation directors and chief residents ahead of time that I would need to pump twice a day, and that I would be going to the pump room to do so. Everyone knew where my bag was and what was in it and I felt much more confident about my decision (maybe because I was more seasoned, who knows). I was efficient- 20 minutes in and out, brought extra shields so I didn't bother washing anything- and that helped, but I like to think I helped normalize the idea to some of my coworkers.

  5. This is all so well said, Fizzy. I think it's such a shame that some women are so invested in what other women are feeding their children that they can't stop to even consider *why* those women may be using formula before they verbally accost them.

    My little sister lives in Brooklyn and due to supply issues, she had to supplement her daughter. There is a very strong "BF nazi" contingent in her area, and in the end she got so tired of having to tell everyone she met "yes, I tried blessed thistle, it put me in the ER; yes, I tried fennugreek; yes I tried raspberry leaf; yes, I tried a nurse-in; yes, I tried..." For crying out loud.

    Awesome list. Bless you for it.

  6. Great advice! Our pediatrician suggested giving our daughter 4 ounces of formula a day when she was one month old (what a fabulously wonderful pediatrician he is, by the way!). The idea was that 1) she would be familiar with a bottle when the time came, and 2) she would be familiar with formula and not reject it on, as he said "the inevitable day when supply does not equal demand." The added benefit, as Fizzy noted, was that my husband got a chance to bond with our daughter early on over something more positive and enjoyable than diapers.

    We also started her on cereal at a week shy of four months, because she was back to eating continuously (60 min out of 90; this is a girl who started at 95%ile for height and weight and never looked back) and I just couldn't take it any more.

    Whatever works.

    Oh, and by the way, the science behind breast is best is SOOOOOOOO weak (all retrospective and very little attempt to account for confounders, which are huge in scope and number). I am a fan of breast feeding, which is convenient (we took our daughter to New Zealand and Australia when she was 8 weeks old, and it would have been a major pain schlepping formula), cheap, and probably has some modest benefit. But, really.

  7. Chiara: Good one. I never felt embarrassed about telling people I was pumping, but I bet a lot of women do.

    Amanda: That's terrible. I don't know why people think they need to offer unsolicited advice to strangers on something so personal..

    HH: Actually, that's a piece of advice I didn't consider and am going to take right now. I've been keeping about 4 oz of fresh pumped milk in the fridge so my baby could get a bottle from my husband if I'm not around, but maybe formula would be a better choice so she doesn't reject it down the road. I don't know all the evidence behind breastfeeding.... I mostly do it b/c I love it (and it helps me lose weight :).

  8. Thank you for the wonderful post! The lactivists made my postpartum experience much more painful than it had to be. Some of the most aggressively hateful people on the internet are promoting breastfeeding -- there's something that's just not right about that.

  9. Great, sane post, Fizzy. Thanks for this.

  10. I wrote a post very much like this in my month community on LJ when I was pregnant with my youngest. Thought two kids worth of nursing would maybe benefit a lot of new mothers. Nope. I got chewed to shreds by the LJ hyenas. How DARE I suggest that nipple confusion was overhyped or that a little formula wasn't the end of the world?

    It doesn't surprise me that the slightly more educated readers of this community are more appreciative.

  11. Lindsey: Every time I see a comment pop up on here, I'm expecting it to be someone chewing me out. But you're right... people who read this blog do tend to be more accepting of posts like this.

  12. I love to see such an understanding, rational, practical post.
    When my first daughter was born, we had a perfect storm of problems: engorgement, one flat nipple and one inverted nipple, mastitis, thrush, a "barracuda baby" (lactation consultant term :)), a painful oversupply, and an underweight full-term baby treated like a preemie; I was told to nurse 20 mins, then pump both breasts empty for every feeding. I was engorged for six months! The first two months were brutal, and as important as breastfeeding was to me, I decided to stop after 3 mo if things didn't get dramatically better. Thankfully they did, and I was able to nurse over two years, but I have a great deal of sympathy for anyone struggling with nursing. I think it's important try, and it turned out to be critical for my daughter due to a life-threatening dairy allergy, but Mom and the family's sanity and health are a critical part of the equation.
    My SIL had to stop BF after 6 wks because of supply issues causing failure to thrive. It broke her heart, but she's one of the best mothers I know, and her son is healthier than my daughter (no allergies).
    And for the attitude when pumping at work - confidence helps. No one ever hassled me, perhaps because I treated it matter-of-factly (or maybe they did, and I was oblivious because I was confident in my choice to pump). I was the first person in my group at work (~30 people, all older male scientists) to pump, so I was definitely blazing trails, but I hope my comfort with it made the others comfortable, too. Obviously that's not going to overcome a clear bias against pumping, but I think it works well in a neutral environment.

  13. Just to change #5 I liked pumping. It was so much better than actually breastfeeding for me.

  14. Kellie (General Surgeon)July 20, 2011 at 3:02 PM

    Great list, Fizzy. I did most of these when I had my son. For the first 2-3 weeks I was adamant that no formula was ever going to pass the lips of my child. My husband and mother in law told me I was crazy> I wasn't sleeping (he would nurse for about 50 minutes, sleep for about 50 minutes and nurse again). He was gaining weight, so it wasn't a supply issue. Also, even though he was eating and growing, I couldn't pump much. A few ounces at tops. Made me feel inadequate.

    I agree that one of the most controversial subjects and one that lends to great arguments is breast feeding. The other, IMO? Circumcision.

    Oh and there was no nipple confusion with my son either. He would nurse or take the bottle equally well (formula or breast milk)

  15. ****Applause**** so nice to read a realistic, helpful and encouraging post about breastfeeding.

    I was one week post-partum and desperately trying to figure out how to continue breastfeeding with a new diagnosis of peripartum cardiomyopathy (EF of 25%) and a handful of new meds (ACE, BB and diuretic). My cardiologist told me it "might" be possible to breastfeed on those meds and encouraged me to call LaLeche. I knew medically that it would not be a good idea to pass those on to my sweet new baby, but really wanted to see if it would be ok. The LL spokesperson chided me for even *thinking* it would not be healthy for the baby, told me I would be SELFISH for not doing it and would increase her chance of being sick, obese, blah blah blah.

    Needless to say, it didn't happen. I needed the rest for recovery and my husband was desperate to help. 12 years later, I have a daughter who is wonderfully bonded to her Dad, is almost TOO thin and who has had maybe one episode of OM.

    The bottom line is if you CAN, then try hard to make it work but don't make life miserable for yourself, your baby or your spouse. Formula never hurt a baby :)

  16. I agree completely with this post. The only thing I would add, though, is that sometimes the argument of "it's ok to add some formula" is used by female physicians themselves to pressure other women in medicine to stop nursing/pumping so they can be more productive at work. This happened to me in training. I was pumping and female attendings (mothers themselves) told me "it's ok to use formula and stop pumping so you can be more available on the floor." I left twice in a 12 hour day to pump for 20 minutes each time. I still got negative comments and it affected my evaluations. I think it's really important that we encourage mothers on both sides of the formula/breast milk divide. For physicians who choose to breastfeed and want to pump, they should be encouraged to do so and not pressured into giving their babies formula so that they can be more "productive" at work. And just to finish my own story -- I decided to pump anyway because breastfeeding was too important to me. I nursed my son for another 5 months after that, and made it to 13 months without having to give him any formula. I am very proud of that achievment, and decided giving him the benefit of breastmilk mattered enough to me that I would withstand the criticism of other physicians. It meant a lot to me as a mom to breastfeed my baby, and sometimes we just have to stand up for what is right for our children and ourselves. This will differ for each woman and I respect the right of women to choose how to feed their babies; I cast no judgment on mothers who formula feed. But I would like to freedom to breastfeed without fear as a physician if I choose to do so.

  17. I've recently found this blog and am enjoying reading it while I breastfeed my second child. I'm an MFM (high risk OB) and talk to people regularly about breastfeeding. It is the hardest thing I've ever done ... But totally worth it. I struggle with supply, though less for the second baby. When I'm feeling like the baby isn't getting quite enough he gets a few oz of formula at night before bed - i think of it as a little desert. Both my kids have been supplemented, and have to take bottles while I work. Neither had "nipple confusion" - and we used binkies too! The pressure to exclusively breastfeed is crazy - and just doesn't work with many of our lives. Thanks for the post - I love seeing all those with similar experiences!

  18. Great post Fizzy- you are right that the meanest worst "advocates" for breastfeeding are on the internet. I am a family physician with 3yrs of BF experience(distributed over 4 children) and I feel like throwing a large can of formula at the head of most lactivists. I don't know why such intense feelings of dislike are brought up, maybe its that I hate seeing women who are already down getting another little kick...

    I want to give a shout out for the website "workandpump.com"- great resource!
    Also agree with the idea that mixed feeding can prolong breastfeeding. "If its worth doing, its worth doing badly"- take that you BF Nazis!

    By the way- I haven't seen an official announcement about your new baby- can we have some details ? Congratulations!


  19. This comment has been removed by the author.

  20. Great post, Fizzy! All things I wish anyone had said to me when I had my first baby as a fellow! I, too, was determined that my baby would have zero formula, and drove myself near crazy with pumping and nursing to the exclusion of all else. As it turns out, my firstborn nursed until 14 mos old. Despite being a full-time heme-onc fellow, I never had to give him any formula, but it came at a tremendous expense to my own well-being, and I vowed to be less "all or nothing" with myself the next time. With babies #2 and #3, who came in fairly rapid succession after #1, I had an abundance of milk--I guess the girls had some memory for how to do it!!!--which enabled me to nurse each of them to age 2 without needing to supplement and even donate some milk to a milk bank. It helped undoubtedly that I started working only 3 days per week after #2 was born which meant more hours with the babies and less need to pump, but I think that my more relaxed attitude probably also helped me to breastfeed/pump successfully as long as I did. (And although I nursed the latter two kids until age 2, I quit pumping when they were 11 mos old...they had some stored breastmilk and mostly solid food when I was away from them by age 1). I wholeheartedly agree with the message that any breastmilk is good breastmilk, and you do the best you can. But I'd also encourage prospective working moms to be optimistic--though you can't always predict in advance, it is entirely possible you'll be able to feed your baby all breastmilk until x age if that's important to you. So have faith in your amazing body and first be good to yourself!

  21. 1. make sure you drink and eat; this will help maintain uptake and is one of the pleasures of BF.

    2. rest as much as you can. I always found my supply with rest was always better. on the weekends, nap with your baby.

    3. don't drive yourself crazy with keeping up a supply. I wish I had taken this piece of advice myself.

    4. don't be ashamed. You are doing what you think is the best for your baby. Be confident and comfortable with both BF whenever you are with baby and pumping at work and you will get less flack from colleagues.

  22. Totally agree with everything. As a neonatologist, I spend a lot of time convincing mothers that they are good mothers even if they cannot breastfeed, mainly due to what they have been told or read about breastfeeding. After having such a difficult time with breastfeeding (and finally solely pumping/bottle feeding for 8 months), I don't think you can truly understand and counsel unless it was a little difficult for you.

  23. Great post! I nursed my daughter and pumped my way through my 2nd year of medical school. I'm now starting my 3rd year rotations, my daughter is 14 months old, and we're still going strong. We were tremendously lucky that we didn't hit too many road bumps in our breastfeeding journey--no bleeding nipples, good supply, ability to pump, only bit me once, etc.

    Regarding your point about pumping being inevitably depressing... Although I was very relieved to eschew the pump when my daughter turned 1 (she now drinks cow's milk during the day), I actually didn't mind pumping. Definitely would have preferred to be actually breastfeeding, but I found that (as a 2nd year med student at least) pumping was a great way to break up a long day of studying. Pretty much every single day of my M2 year, I would head into the lactation room after class, put my feet up, and pump while eating lunch. I at first tried to study during this time, but later figured out the time was best used as a much needed mental break. With the hands-free pump bra, my hands were free to eat lunch, type emails, etc. I actually enjoyed that me-time that I might not have otherwise taken if it weren't for the fact that I needed to pump. And ducking into that quiet room for 20 minutes 1 or 2 times during the day--it was also a great way to create some space between myself and all the annoyingly stressed out med students. Pumping also helped me feel that even though I couldn't be with my daughter 24/7, I was still able to provide for her in a very special way.

    So, there you go! Someone who actually didn't hate pumping!

    P.S. Happy World Breastfeeding Week, everybody!

  24. I realize I'm coming quite late to this party, but wanted to comment just to thank you, profusely, for this post. I wish that every OB/pediatrician would hand a copy of this to their patients... this type of practical, common-sense advice is sorely lacking in the breastfeeding discourse and I strongly believe it is setting women up for failure.

    Interestingly, it seems that most folks in the medical field have a relatively moderate, real-world stance on this issue. I've talked to a fair number of MD's who all support and promote breastfeeding, many of whom breastfed themselves - but they are also aware that it's not easy or possible for every woman, and treat their patients as autonomous individuals rather than just spokes in a public health wheel. But it's really good to hear someone talking about these things online, which as we all know is quite the judgmental little microcosm, you know? ;)


Comments on posts older than 14 days are moderated as a spam precaution. So.Much.Spam.