Gisele Bundchen, Nutrition Expert?

Yes!

In a recent magazine article, Ms. Bundchen was quoted saying that breastfeeding should be the legal norm for all babies for the first six months of life.

Of course, this generated a storm of protest about “feeding choices” and whether or not we should listen to someone with her lack of credentials. Lost in the fabricated drama and controversy is the fact the we mustlisten if her advice and high profile can save babies’ lives. I’m sure that this one famous mother’s words will be heard and heeded by more mothers than we pediatricians can possibly reach. (Ms. Bundchen’s statement that post partum weight loss is faster because of breastfeeding is very much in line with current medical literature and will certainly appeal to most new mothers.)

It’s easy to misinterpret a forceful metaphorical statement about “chemical food”–infant formula–and the crucial lifesaving value of breastfeeding for six months. And, that’s exactly what pundits did to turn this into an “us against them” issue. “How dare she . . . ”

While it is tragic that a supermodel-mom dispenses better advice than many doctors and most governmental agencies, it’s impossible to misinterpret what the World Health Organization says about these artificial (chemical) feeding options:

The protection, promotion and support of breastfeeding rank among the most effective interventions to improve child survival. It is estimated that high coverage of optimal breastfeeding practices could avert 13 percent of the 10.6 million deaths of children under five years occurring globally every year. Exclusive breastfeeding in the first six months of life is particularly beneficial, and infants who are not breastfed in the first month of life may be as much as 25 times more likely to die than infants who are exclusively breastfed.”…

There is a common misconception that in emergencies, many mothers can no longer breastfeed adequately due to stress or inadequate nutrition, and hence the need to provide infant formula and other milk products. Stress can temporarily interfere with the flow of breast milk; however, it is not likely to inhibit breast-milk production, provided mothers and infants remain together and are adequately supported to initiate and continue breastfeeding. Mothers who lack food or who are malnourished can still breastfeed adequately, hence extra fluids and foods for them will help to protect their health and well-being.

If supplies of infant formula and/or powdered milks are widely available, mothers who might otherwise breastfeed might needlessly start giving artificial feeds. This exposes many infants and young children to increased risk of disease and death, especially from diarrhea when clean water is scarce. The use of feeding bottles only adds further to the risk of infection as they are difficult to clean properly.”

Moreover, not breastfeeding has been found to double the risk of SIDS (Sudden Infant Death Syndrome)

Read just one sentence above aloud:

“Infants who are not breastfed in the first month of life may be as much as 25 times more likely to die than infants who are exclusively breastfed.”

No parent in America is allowed to let their infant travel in a car in the “second best” way possible: Car seats are the law in all 50 states. A breastfeeding law will not be passed soon, but there is a moral, ethical and medical imperative to get this nutrition information to mothers and families any way we can. Hyperbole is easy to ridicule but, in this case, the hyperbole will prevent the deaths of many, many babies worldwide.

The World Health Organization estimates that one-and-a-half million babies die from lack of breast milk each year. 1,500,000.

If Gisele Bundchen’s magazine interview, comments and the resultant furor cause more mothers in developing nations to breastfeed, thousands and perhaps tens of thousands of babies will be alive a year, two years or five years from now who might otherwise have succumbed to diseases caused or fatally exacerbated by lack of mother’s milk.

I certainly wish that this legal proposal/metaphor had been issued by the government, health insurers or the American Academy of Pediatrics. In lieu of those recommendations, the very intelligent suggestion of a really smart mom will have to do.

November 3rd, 2003 was a big day for Alabama emergency room pediatrician, Dr. Carden Johnston. On that date last month, he was installed as the new President of the 66,000 member American Academy of Pediatrics (AAP) at the prestigious organization’s annual meeting in New Orleans. It was also the date that he sparked what has emerged as a major ethical controversy by inadvertently pulling back the curtains on the powerful influence that a particular corporate interest appears to have in shaping AAP policy and action.

“I have to admit that I never imagined that my presidency would start off with such a bang,” Dr. Johnston says, acknowledging the debate now taking place within his organization.

At issue is a letter dated November 3rd that Dr. Johnston sent to Secretary of the Department of Health and Human Services (DHHS), Tommy G. Thompson, officially expressing the AAP’s concern over the “negative approach” of the federal agency’s soon-to-be-released, pro-breastfeeding advertising campaign. What Dr. Johnston didn’t mention in his letter, however, was that he had developed this sudden and seemingly urgent interest in this issue not via a last minute clinical review of the scientific literature, or even after consulting with the AAP’s own recognized lactation science experts.

In fact, his concern came immediately after aggressive, personal lobbying by representatives of one of the AAP’s biggest financial contributors, the $3 billion U.S. infant formula industry. Within days of a New Orleans meeting with worried formula industry reps, Johnston hurled the considerable credibility and persuasive impact of the esteemed American Academy of Pediatrics into an explicit effort to stifle the most ambitious initiative ever undertaken to promote breastfeeding in the United States.

“Some of us within the AAP have long suspected that the infant formula companies had this sort of direct access to AAP leadership,” explains Dr. Lawrence Gartner, a founding member of the Academy of Breastfeeding Medicine and chairman of the AAP’s Professional Section on Breastfeeding. “Dr. Johnston’s actions have revealed the extent of this influence more clearly than anything else I’ve seen. Many doctors within the AAP are very disturbed by this.”

Reflecting the strong opinions of a number of AAP members interviewed in the past week, Dr. Jay Gordon, a pediatrician and best-selling author of several parenting books, says that his opinion on the AAP leadership’s actions in this matter go beyond “disturbed.”

Dr. Gordon reports that, that in his view, the AAP leadership has “weakened and emasculated (the ads) to suit the manufacturers of formula,” and “as a result of their craven disregard for America’s babies and families, more infants will get sick and die each year. I wish that this greedy, immoral, reprehensible act could be met with criminal charges,” explains Gordon.

The ad campaign currently inspiring such passion among the nation’s pediatric health care providers is funded within the DHHS Office on Women’s Health (OWH), and has been in the works since 2000. Officially dubbed the “National Breastfeeding Awareness Campaign,” the creative end of the OWH project has been handled by Raleigh, North Carolina advertising agency McKinney+Silver, while the entire project is overseen by The Ad Council, the private, non-profit organization that produces, distributes, and promotes public service campaigns on behalf of charitable organizations and government agencies.

In 2002, DHHS described the upcoming breastfeeding initiative as a three-year, multimedia social marketing blitz worth as much as $40 million in advertising dollars. It is alleged by a variety of organizations representing lactation consultants, physicians, nurses, midwives, and public health activists that the AAP’s last-minute appeal to DHHS prevented the much-anticipated campaign launch from taking place as scheduled this month. Additionally, it appears that representatives of the infant formula industry – with the benefit of prematurely leaked information about the specifics of the ad campaign- have been quietly lobbying federal and Ad Council officials to change the ads’ content and tone.

According to the AAP’s own Breastfeeding Section, at least one thousand new scientific and medical papers on topics related to breast and bottle feeding have been published in just the past four years. Taken as a whole, this mounting body of research revealsdramatically different health outcomes for populations of breast and formula-fed babies, even when controlling for socioeconomic and other factors. The new ad campaign was designed to reflect this research and to catapult the issue of breastfeeding into the same category of public health concerns as smoking, carseat use, childhood vaccinations, and SIDS prevention.

While critics of Dr. Johnston’s action strongly disagree that the tone of the DHHS ads is “negative,” they concede that the new campaign does offer a fundamentally different way of looking at the breast-bottle issue. They hasten to add, however, that this new approach was completely intentional. According to those medical professionals who played a role in creating the actual content of the new campaign, the ads utilize a market-oriented and evidence-based approach to the issue, relying for the first time on the proven communications strategies that have successfully impacted other public health behaviors in recent years.

According to those who have viewed them, the ads feature catchy slogans meant to become memorable such as “Breastfeed: It’s too important not to,” and “Babies are born to be breastfed.” Some of the ads also use humor to make their points, including TV spots showing a pregnant woman participating in roller derby and riding a mechanical bull. These absurdist images are used to make the point that, just as no woman would take those sorts of risks while pregnant, mothers of infants should avoid the quantifiable risks to their babies’ health that come with not breastfeeding.

“As I understood it, this was to be the first national advertising campaign that focused on the risks of not breastfeeding as opposed to the benefits of choosing to breastfeed,” explains Dr. Audrey Naylor, a San Diego pediatrician and Executive Director ofWellstart International, as well as a member of the AAP’s Breastfeeding Professional Section, and a past consultant to the World Health Organization on infant nutrition issues. “This would definitely mark a significant change in the way this issue would be presented to the general public. It’s a change to promote breastfeeding as a public health issue rather than simply as a personal parenting choice.”

The area of the website of The Ad Council devoted to a brief discussion of the planned DHHS breastfeeding campaign offers a glimpse into this very different, market-oriented way of viewing the issue of breast vs. bottle, stating that, “Babies who are not exclusively breastfed for at least 6 months will be more likely to contract asthma, allergies, and cancer.” In previous breastfeeding promotion campaigns, this statement would have certainly read “Babies who are breastfed will be less likely to contract asthma, allergies, and cancer.”

In a presentation sponsored by the Breastfeeding Task Force of Greater Los Angeles on the planned campaign, McKinney+Silver was quoted as seeking to move from creating awareness to creating conversion with the ads.

“Shift the language from ‘If you breastfeed, your baby will be healthier,’ to ‘If you don’t breastfeed, your baby will be more prone to…,” noted McKinney+Silver in describing the campaign’s approach. The presentation went on to note that, while most American women seemed informed of the benefits of breastfeeding, few seemed aware of the potential consequences of not nursing their babies. “(There is) no perceived disadvantage if you don’t breastfeed. Many think breastfeeding is like supplementing a ‘standard diet’ with vitamins. Formula, by default, is credited with the status of being ‘the standard.’”

In much of the rest of the world, ads for infant formula directed at consumers are verboten in much the same way that television ads for cigarettes and liquor are no longer acceptable in the United States. This global aversion to infant formula advertising is due to the widespread adoption by governments and private industries outside the United States of the World Health Organization’s Code on the Marketing of Breastmilk Substitutes – known as the WHO Code.

In this country, however, there is only minimal adherance to the WHO Code by public or private entities and as a result, advertisements for different brands of infant formula are a ubiquitous part of the U.S. media landscape.

In years past, various individual government agencies, hospitals, and private organizations such as La Leche League International have attempted to counter the advertising sledgehammer wielded by the well-heeled infant formula industry via a patchwork of relatively low-budget, smaller-scale ads focusing on the “the benefits of breastfeeding.” However, the DHHS breastfeeding campaign to which the AAP leadership has now objected was to be the first national effort to utilize high-end, commercial-quality production values to position the “breast is best” public health message to go head-to-head with even the slickest Madison Avenue-produced infant formula ads.

Clearly, this was not a campaign that was going to play well with the infant formula industry, which has until now managed to create a uniquely advantageous situation in which it has positioned itself as the primary spokesman for its chief competitor in the marketplace, breastfeeding. And this new message is assuredly not the one they want projected into public consciousness.

“Ironically, infant formula companies in this country can honestly say they spend more on what they call ‘breastfeeding education’ than any other single entity,” explains Amy Spangler, a nurse and lactation consultant who currently chairs the United States Breastfeeding Committee, an umbrella consortia of health care organizations interested in breastfeeding that was intimately involved in developing the new DHHS campaign. “They also underwrite much of the research into infant feeding issues. The pay-off for them is that they then get to manipulate the message, which is always “Breastfeeding is best, but… There is always a ‘but,’ and breastfeeding is suggested as a type of ‘bonus feature’ for parenting rather than the norm.”

According to a number of sources within the medical community who were included in meetings during the planning process for the breastfeeding campaign, DHHS officials repeatedly stressed to participants that the specific messages of the ads –which were clearly shaping up to be potentially controversial- needed to be “embargoed” until their official release.

Amy Spangler attended several meetings with DHHS and OWH officials to discuss the Breastfeeding Awareness Campaign and she says that federal and Ad Council officials encouraged participants to avoid speaking publicly about the content of the planned ads before their release.

“It was never said specifically that the need for keeping the ads under wraps until release was due to anything having to do with infant formula companies, but I think we would have been naïve to assume that this was not one of the reasons why,” explains Spangler.

Despite the warnings, however, the infant formula industry did apparently gain access to much of the content of the ads, allowing them to begin an intensive and targeted lobbying effort against their release. DHHS officials are reluctant to discuss the circumstances surrounding the premature leak of the ads, saying only that “a small amount” of information about the campaign was accidentally released on The Ad Council website at some point in November. Hipmama.com has learned, however, that DHHS and Ad Council officials voluntarily met with formula industry representatives at several points during the fall, even as pro-breastfeeding stakeholders were being instructed by the same officials to keep mum in order to preserve the integrity of the ad campaign’s message.

Additionally, most or all of the actual ads were shown to dozens of attendees at a North Carolina medical conference in October, something that Office on Women’s Health spokesperson Christina Pearson says the agency didn’t authorize or even know about until after the event.

According to a variety of sources, members of Congress began hearing complaints about the pending ad campaign from infant formula manufacturers as early as the first week of October, but it was at the AAP convention in November that the industry was able to aim what is arguably the biggest weapon in its lobbying arsenal –the clout of the American Academy of Pediatrics – directly at the breastfeeding campaign.

“The reason why the infant formula industry is so successful is because they have managed to manipulate health care providers into providing them with a cloak of credibility,” explains Amy Spangler. “The bottom line here is that the president of (an infant formula company) doesn’t have to send a letter directly to a federal official when he can get the President of the American Academy of Pediatrics to do it for him.”

Public health advocates and many individual physicians, nurses, midwives, and lactation consultants have long criticized the cozy financial ties between infant formula manufacturers and major medical organizations such as the AAP, the American Medical Association, the American Academy of Family Physicians, and the American College of Obstetrics and Gynecology. The infant formula industry – part of the larger pharmaceutical industry lobby – is also recognized as one of the most effective and powerful lobbies on Capitol Hill.

Critics of this relationship between baby doctors and formula makers note that because the U.S. infant formula industry –with sales of $3 billion annually – clearly has a commercial interest in impacting parents’ infant feeding choices, the industry should not play any role in crafting public health messages relating to the industry’s clear competitor in the marketplace, breastfeeding.

“It is simply not appropriate for these companies to have a say in how publicly-funded health education campaigns present breastfeeding issues,” argues Marsha Walker, RN, IBCLC, and Executive Director of the National Alliance for Breastfeeding Advocacy (NABA), a non-profit group promoting breastfeeding. “It would be like inviting a cigarette manufacturer to have a say in the message of a government sponsored anti-smoking campaign.”

OWH spokesperson Christina Pearson disagrees, however, insisting that DHHS has made it clear all along that the agency wanted to hear from “all sides” on the issue.

While it may be reasonably asked what “sides” exist when speaking of a public health campaign promoting a free or low-cost, healthy alternative over another, expensive and less healthy alternative, the AAP leadership decided that their organization was going to take sides. In a phone interview with Hipmama.com on December 3rd, AAP President Dr. Johnston readily admitted that he was approached by representatives of infant formula companies during the annual AAP convention in the first week of November, and asked to attend a “private,” “not on the agenda” meeting to discuss some concerns that the industry had with the planned DHHS breastfeeding campaign. He says that he and the three other members of the American Academy of Pediatrics Executive Committee, Dr. Joe Sanders, Dr. Carol Berkowitz, and Dr. E. Stephen Edwards, immediate past president of the AAP, met for approximately 45 minutes with “two or three” representatives of Ross Products “and maybe one other company” to hear their concerns.

“This was the first I had heard about this planned breastfeeding promotion campaign,” says Dr. Johnston. “Sad, but true. I didn’t know it was in development until after these folks told us about it.”

Dr. Johnston’s account of his interest in and knowledge of the DHHS ad campaign differs from the version reported in the December 4th edition of the New York Times. In a story entitled “Breastfeeding Ads Delayed In Dispute Over Content,” reporter Melody Peterson writes that Dr. Johnston and Dr. Sanders “…said that they had decided to send their letter before (infant formula company) executives expressed their concerns at the Academy’s national conference, held last month in New Orleans.”

In his interview with Hipmama.com, Dr. Johnston said that he became alarmed at the tone and message of the ads after viewing samples shown to him by the infant formula company reps in New Orleans.

“They showed us more than ten but fewer than twenty printouts of something that looked like ads. It was my impression these were copies of some of the ads,” says Dr. Johnston. “A lot of the ads looked fine to me, but I shared their concerns about the negative approach overall. It worried me, as it did them, that parents whose kids got cancer or grew up dumb might feel guilty if they did not breastfeed.”

Dr. Johnston says that he did not find it inappropriate or even remarkable that a commercial interest would have advance advertising copy from a planned multi-million dollar federal public health campaign designed to convince Americans to buy less of their products.

“I never asked them where they got this stuff,” says Dr. Johnston. “I just had the feeling that their relationships within Health and Human Services were better than ours at the Academy. I was actually embarrassed that this was the first time I was being made aware of the problems with this advertising campaign. Of course, they have to be concerned about issues that impact their shareholders.”

Dr. Carol Berkowitz, who will become AAP President in 2004-2005, confirms that she also attended this meeting, however in a phone interview on December 3rd, she told Hipmama.com that the meeting was noted on her personal conference schedule when she arrived in New Orleans.

“The meeting was on my own schedule that they handed me when I arrived,” says Dr. Berkowitz. “I assumed it had been set up in advance at AAP headquarters. I saw nothing remarkable about it; I attended many such meetings while I was there and I’ve been friends with many infant formula representatives for years.”

Dr. Berkowitz says that she too was concerned about the tone of the ads based on what formula industry representatives told her when she met with them at the AAP Convention.

“At the end of the meeting, Dr. Edwards asked what they wanted us to do and they told us that they had just wanted to make us aware of the situation, ” remembers Berkowitz.

Apparently, the AAP leadership’s freshly heightened awareness led to almost immediate action on behalf on the formula industry. In a letter dated November 3rd –- while the AAP convention was still underway in New Orleans and on the very same day he was installed as President — Dr. Johnston signed off on a strongly worded statement to DHHS objecting to the ostensibly still-under-wraps breastfeeding advertising campaign, based solely on what he had been shown and told by infant formula company lobbyists.

In the letter, Johnston notes that it has “come to his attention” that an ad campaign is about to be launched, and that he formed his opinions “after reviewing the Web Page of The Ad Council.” He does not mention that his concern was, in fact, prompted by a private meeting he had just concluded with representatives from the infant formula industry. Dr. Johnston told Hipmama.com that, despite the wording in his letter to Secretary Thompson, he is not certain that he personally viewed The Ad Council webpage before signing the letter, and that he didn’t actually draft the letter himself; staff at AAP offices near Chicago did. But he says that he was comfortable signing his name to it.

“I felt that we needed to send a letter immediately because the people we met with told me that these ads were about to be released,” explains Dr. Johnston. “They conveyed a sense of urgency to me and I shared their concerns. I thought many of our members would be disturbed if these ads were released in that format. I felt we needed to act.”

Meanwhile, members of the U.S. Breastfeeding Committee and other medical professionals with an interest in the DHHS advertising campaign had no idea that the new President of the AAP had taken such an action. Within a week of the AAP convention, however, sympathetic sources within DHHS began contacting interested medical professionals around the country and quietly reporting that “something was up” with the breastfeeding campaign.

“We started hearing from people that the infant formula companies had begun an intense lobbying campaign against the ads within DHHS and other government offices, including Senator Bill Frist’s,” says Marsha Walker of NABA. “They were saying that they were unhappy with ads that told of consequences of not breastfeeding as opposed to stating the benefits.”

By mid-November, Dr. Lawrence Gartner had been alerted by a DHHS staffer to the existence of the Johnston letter sent on behalf of the AAP. Gartner says that he was very disturbed that the AAP’s own Breastfeeding Section had not been consulted or even notified about the contents of Dr. Johnston’s letter to Secretary Thompson, even though he and his colleagues in the AAP’s Breastfeeding Section had also attended the AAP Convention earlier in the month. After investigating the matter, Dr. Gartner felt compelled to send his own letters to Secretary Thompson, as well as to other AAP members.

In his letter to fellow pediatricians across the country, Dr. Gartner wrote that, “ There is every reason to believe that (the infant formula companies) are pulling out all the stops to get this ad campaign buried, or, at least, modified to be less effective… This entire affair is a very serious matter, which raises many questions about the leadership of the AAP and the influence of the formula industry on AAP activities.”

Mardi K. Mountford, Executive Director of the International Formula Council, a trade group representing the interests of infant formula manufacturers takes issue with Dr. Gartner’s assertion that her industry is seeking to discredit or delay the DHHS campaign.

“We strongly encourage mothers to breastfeed if they can, but we don’t believe that women need to be subjected to scare tactics like the ones that are in these ads,” explains Mountford. “Our only interest in reviewing the scientific claims in the ads is that they be accurate so that parents have the information they need to make their own decisions about what’s best for their families”

Mountford’s remarks highlight something that public health advocates have long noted; namely, that the infant formula industry’s tactics in lobbying against initiatives such as FDA regulation of their product, standardization of ingredients in their product, and now, the DHHS breastfeeding campaign are remarkably similar to the strategies employed by tobacco companies in the early years of the anti-smoking public health movement.

According to PRWatch.org, the tobacco industry created what eventually became known as the Council for Tobacco Research(CTR) in 1953, claiming that the organization’s mission was to ”find out whether smoking was dangerous…’” During the 1980s, internal CTR memos revealed that “ the CTR actually worked at “promoting cigarettes and protecting them from these and other attacks,” by “creating doubt about the health charge without actually denying it, and advocating the public’s right to smoke, without actually urging them to take up the practice.” Just as the infant formula industry currently pays for much of the research into breastfeeding in the U.S, for many years the CTR funded most research into tobacco health issues and attempted to insert itself as a “concerned” corporate citizen into the government’s earliest anti-smoking campaigns.

While Dr. Johnston’s letter to DHHS referred only to a “negative tone” in the ads, infant formula industry lobbyists had been contacting DHHS and Ad Council officials since Spring, 2003 and insisting that the specific scientific research upon which some of the language of the ads were based was faulty. OWH spokesperson Christina Pearson confirms that the infant formula industry raised these concerns with DHHS officials, and concedes that the ads have now been modified to remove references to specific statistics that quantify the higher risks for certain diseases. However, she says that this change was in no way the result of pressure from the infant formula industry.

Several sources within the Ad Council, which relies heavily on funding by pharmaceutical companies that also produce infant formula – such as Mead Johnson – claim otherwise. They say that Mead Johnson threatened to pull its millions from The Ad Council’s budget if the references to specific risk numbers were not removed from the ads. The Ad Council declined to comment on this report, instead referring all inquiries to Christina Pearson at OWH, who says her agency can neither confirm or deny this alleged incident.

According to Dr. Gartner, the industry’s complaints about a “negative” tone in the ads, as well as its questioning of the science behind the campaign are just red herrings designed to delay and water down the campaign for as long as possible.

“As far as a negative tone goes, most successful public health campaigns rely heavily on making the public aware of negative consequences of certain behaviors. While it may be a new way to approach breastfeeding promotion, it’s a common advertising device.” says Dr. Gartner. “We don’t tell parents about the ‘benefits’ of carseats. We tell them that studies indicate that if they do not use a carseat, their baby has a greater risk for being injured or killed in an accident. And telling them this has worked. Thousands of lives are saved every year because this message works.”

Dr. Johnston admits that he now regrets not having discussed the letter he sent to Secretary Thompson with his own “breastfeeding experts” within the AAP, including Dr. Gartner. But notification is as far as it should have gone, says Johnson. He stands by his concerns about the ad campaign.

“I rely on the breastfeeding experts to help me learn more about breastfeeding issues, but some of the science behind these breastfeeding claims is shaky. It’s just not solid yet, and you know how some of these breastfeeding enthusiasts can lack objectivity,” noted Dr. Johnston.

When asked whether this lack of scientific objectivity he has observed extends to members of the AAP breastfeeding section, he replied “some, not all.”

Dr. Gartner says that he finds Dr. Johnston’s statement about objectivity among the physicians in the AAP’s Breastfeeding Section “outrageous.”

“I’ve read thousands of scientific papers on breastfeeding and formula feeding in just the past few years and so have my colleagues in the Breastfeeding Section within the AAP,” notes Dr. Gartner. “I challenge Dr. Johnston to discuss the hard science behind this issue with me any time. I would welcome the opportunity. Frankly, I do not believe he is qualified to comment on the research because I doubt he’s read much of it except –it appears – possibly what the infant formula companies have shown him.”

According to many lactation consultants and physicians who have played a consulting role in crafting the DHHS ad campaign, an earlier release date offered by DHHS officials was to be in October, 2003, to correspond with World Breastfeeding Week. That date came and went and participants were next told that the date for the campaign’s official roll-out would December 3rd, to correspond with a meeting of breastfeeding and infant health experts that was scheduled to take place in Washington. In its December 4th edition, the New York Times cited an Ad Council newsletter that named a December, 2003 release date for the campaign.

Christina Pearson of OWH disputes the claim that there has ever been a true release date set for the ads and emphatically denies that any changes have been made to the campaign’s message as a result of pressure from the AAP or infant formula industry representatives.

“The campaign is still on the drawing board and as far as we are concerned it has never come off the drawing board,” explains Pearson. “Anyone who thought we were about to release the ads was simply mistaken. We will continue our review of the message and the content until everyone feels comfortable that we have it right.”

Katie Allison Granju is the author of “Attachment Parenting: Instinctive Care for Your Baby and Young Child” and her essays can be viewed on her website at Loco Parentis.

2. Don’t be thrown by growth spurts. They are normal and short lived. The only accurate way to gauge how much the baby is taking in is by counting wet and dirty diapers.

3. Buy yourself a tube of Lansinoh.

4. Get through the first 2 to 3 weeks. After that it is SO much easier!!

5. Have phone numbers of breastfeeding-friendly people to help you.

6. Remember that your breasts are never truly empty of milk. You make milk as your baby nurses.

7. Always let the baby end the feeding himself. That way, he will get all of the hindmilk he needs.

8. If you feel discouraged or like throwing in the towel, read this list or 101 Reasons to Breastfeed. It has always helped me and I could never quit after being reminded of why I was breastfeeding.

9. Check to see if you have inverted or flat nipples while pregnant, because you can start correcting them before the baby is born.

10. The first few days till milk comes in, colostrum is really all a baby needs. Nurse often on each side (every 90 minutes) to make sure baby gets enough colostrum and to ensure milk will come in soon.

11. Watching the clock, timing nursing sessions, and switching breasts after x amount of minutes might just drive you and baby crazy. Don’t worry so much about the time, and feed baby on one breast till she’s satisfied before offering the other, which she may or may not take at the same feeding.

12. It is not supposed to hurt to breastfeed. If it hurts, you have one of two things happening, most likely:
a) A bad latch. Work on that first.
b) Thrush.

13. In the beginning and any time you have sore nipples, use Lansinoh (USP modified lanolin, ultrapure medical grade) in the purple tube from the pharmacy. If you have a sore or cracked nipple, keep nursing on it and it will get better.

14. If it hurts for the first 30 seconds to a minute after latching on and goes away, you are not doing anything wrong. It will get better in a couple of weeks and be gone by 6 weeks. Sometimes let-down can be painful in the beginning. That, too, goes away. Severe or long-lasting pain, however, needs to be looked into; it’s probably very solvable.

15. A newborn who is pulling back and crying at the breast is not rejecting you. It could be a growth spurt, forceful letdown, thrush or just a tired or gassy baby. All can be dealt with.

16. A baby, especially newborn, is SUPPOSED to nurse all the time (even every hour or two). That it is normal and does not mean that your milk supply is low.

17. If a baby, especially newborn, is sleepy; she is growing. Don’t let a sleepy baby scare you into thinking she isn’t getting her nutrition. Jaundice might be a reason that baby is sleepy; keep a close eye on her and contact your pediatrician if you suspect that (see next tip). If she goes a long time without nursing, try using a wet cloth or undress baby to wake her up during feedings.

18. Jaundice is not a reason to substitute formula for breastmilk, no matter what the doctor wants you to think. A baby with a bilirubin level of less than 20 is perfectly fine. Breastfeeding MORE during jaundice, not less, is beneficial. Question anyone who tells you differently and do your own research.

19. Nursing a newborn at least 10 to 12 times a day is a good rule of thumb, and that doesn’t mean the feedings will all be evenly spaced. The number of feedings will decrease as baby gets older. Also look for 6 to 8 wet diapers to ensure baby is getting enough to eat. Some babies have BMs more often than others, but when they do occur, they should be mustard yellow and a bit seedy and loose.

20. Putting a baby, especially newborn, on a schedule may decrease your milk supply, ending breastfeeding altogether. Feed on baby’s cue (sucking hand, quietly fussing, etc.), even if you think she just ate and can’t be hungry. She is growing, needs the comfort and nutrition, and you need the milk stimulation in the early weeks.

21. Some newborns will cluster nurse: feeding often for a few hours then resting for several more. This is normal.

22. A baby being “big” does not mean he needs to be supplemented. Your milk supply will be more than enough for him. Simply nurse him as often as he wants to in the beginning, but don’t think that this “constant nursing” will last forever. He’ll become more efficient and your milk supply will increase to appease him.

23. There are things you can do to increase your supply if need be. Drink plenty of water. Rest. Take fenugreek or another herbal supplement if the problem is serious.

24. Get a sling. It’s a lifesaver. Maya Wrap slings and Over The Shoulder Baby Holder slings are great ones!

25. Leaking: If you leak a lot, don’t worry; this will subside over time. If you don’t leak much, don’t worry; this is NOT an indication of low milk supply.

26. Know when and what to expect during a growth spurt. (10 days, 3 weeks, 6 weeks, etc.) Baby may pull off breast, be a little fussier, and/or nurse more often, building up your milk supply. Nursing more often does not mean you aren’t making enough milk and baby needs formula; just the opposite — baby is increasing your milk supply for you by nursing more often.)

27. After 6 weeks, your breasts may not feel as full. This is not an indication that you aren’t making enough milk, just that your body has adjusted to your milk supply. Around this time, baby may nurse more because of a growth spurt. Don’t let the feel of your breasts and the increase in nursing make you worry.

28. Pumping is not a good indicator of how much milk you normally make. Baby sucks more efficiently and differently than a pump. Also, all pumps are NOT created equal.

29. Every bottle of formula given to a baby can:

a) decrease your milk supply, making one think that further supplementing is needed since mom isn’t “making enough milk”.
b) increase the risk of nipple confusion.
c) even kill forever many of the immunities breastmilk offers, once foreign substances enter the body.

30. Using a pacifier instead of nursing a baby may hinder your milk supply.

31. Unless they have “IBCLC” after the “MD”, NEVER take accept as accurate ANYTHING a physician or nurse tells you about breastfeeding; that is not required training for a pediatrician or OB. Hear them out, but find a qualified lactation consultant, excellent reference materials and a support group (online or in real life) of breastfeeding women to get second, third and fourth opinions.

32. If your baby is choking or throwing up during and after eating, it could be you have a forceful letdown. The best way to fix this is to nurse leaning back. This letdown will ease up over time, and your baby will also get used to it.

33. Nurse laying down whenever possible, even if you don’t want to cosleep. Baby gets fed, you get rest.

34. Mom eating dairy might cause a baby discomfort in the early weeks and months.

35. Dads can bond in every other way with the baby other than feeding. Offering a bottle early on for dad to bond may interfere with the nursing routine and risk ending it altogether.

36. Regardless of any problem you might encounter, there is a solution that does NOT involve formula. If you hit a road block it’s merely a matter of getting accurate help. Talk to an Internationally Board Certified Lactation Consultant (IBCLC) if you need serious help. Only 3% of women medically CANNOT breastfeed; that means 97% of women can do it quite successfully, even if there are initial problems.

37. Regardless of what one might think, formula, too, has its downfalls and inconveniences that may not show up till later, including inferior nutrition, increased health problems and cost. Best to get the rough stuff out of the way now and have an easy breastfeeding relationship later on.

38. Surround yourself with supportive people (and good books and online help) and ignore the well-meaning non-supportive ones.

39. When pumping at work, always pump at least as often as your baby would nurse. Add an extra pumping session early in the morning, not at the end of the day, to increase supply.

40. Just because you are young does not mean you can’t make the best choices for your child — and breastmilk is the best choice. Don’t let anyone try to tell you that you’re too young to make enough milk, or make nutritious milk. You WILL make enough, and it will always be more nutritious than formula.

41. Trust yourself. Other people may try to tell you that you are feeding your baby too often or that you should be feeding solids or formula, but you will know what is best for your baby.

42. Educate yourself. This is the best way to know when you are given bad advice from doctors or well-meaning family members. Read as much as possible before baby is born.

43. Drink at least 64 oz. of water a day.

44. Eating peanut products while nursing can lead to potentially fatal peanut allergies later in baby’s life.

45. When pumping and working you will need to drink at least 80 oz. of water per day. This does not include sodas or caffeinated drinks. If you drink these you need to drink even more water.

46. When pumping and working, your baby can make your work day his longest stretch without nursing, up to 6 hours, as long as you feed every 2 hours during the night.

47. When working, if at all possible, go to your baby for your lunch hour to nurse.

48. If you sleep with your baby you can nurse and sleep at the same time if you do it lying on your side. You may not want to do this in the beginning just to make sure you are awake enough to see that he is eating enough. After 6 or 8 weeks you should have a good breastfeeding relationship and can feed while sleeping.

49. Never hesitate to get help, even if you are not sure that your problems are feeding related.

50. Feeding on demand is the best way to relieve or avoid engorgement. It “teaches” your body to make the right amount for your baby.

51. Enjoy breastfeeding. He will only be a baby for such a short amount of time. Let yourself love it!

52. If the situation arises where you lose your milk, know that you have the possibility to relactate. If women who have never lactated can induce lactation for adopted children, a formerly nursing mom can relactate!

53. You may come across some well-meaning, but unsupportive people who try to give advice and possible misinformation. There are many myths about breastfeeding which most people still believe. Just be prepared to smile, nod and get your own information.

54. Take a class or go to a support group to get yourself ready before the baby is here.

55. Keep in mind that although you have heard stories of women who were “unable” to breastfeed, almost all women can. We know more about breastfeeding now than ever before, and have learned that there is a solution to almost all breastfeeding problems.

56. Pump first thing in the morning because this is when you have the most milk.

57. Remember that the evening is when you have the least amount of milk. This doesn’t mean that you are losing your supply.

58. Before a growth spurt your baby will want to nurse more often because he will be signaling your body to make more in order to accommodate his growth spurt. Feeding on demand is the only way to weather a growth spurt. This is the time when it is most important to not supplement because that will signal your body to make less.

59. During growth spurts baby may sleep a lot, become fussy and pull away from the breast crying (especially in the evening.) Don’t be alarmed, this is normal. The best thing to do is provide a lot of skin-to-skin contact and nurse, nurse, nurse.

60. Once you get past the first few months it will become second nature to you, and you will find that it is so easy to breastfeed. You never have to give feedings a thought because the food is always right there, ready when baby is.

61. When you nurse in public it is helpful to have a sling because the baby feels safe and it is totally discrete. Or you can nurse and do housework at the same time!

62. It is very rare for a breastfed baby to “need” supplements. If someone tells you he does, do your own research before believing them.

The mothers from the Breastfeeding and Breastfeeding Support boards on AOL have contributed some things that they found helpful when they were new to NIP. We hope that it will provide you with tips for making the transition to NIP an easier one for you.

Most of all, remember, that nursing your baby is completely normal and natural to do, regardless of where you are when your baby is hungry. It’s how our bodies were designed to nurture our precious children. It’s just that some folks haven’t figured that out yet. Set a good example for another new mom that may be watching you and just nurse your baby.

- Cherri

2. Get completely physically comfortable before latching on. There’s nothing worse than having to hold a bad pose because the baby isn’t finished.

3. I like crossing my legs to lift the baby up a bit.

4. Chairs with arms are nice when you have to support the baby’s weight for a longish nursing session.

5. Learn to NIP without special nursing clothes. That way you’ll never have to worry about what you’re wearing when you leave the house. I recommend a loose top worn on the outside of your pants.

- Sharon

Choose where to sit carefully. If you try to go away from other people, you will be sitting alone in a sea of empty tables, drawing attention to yourself. If you sit more with a crowd, the activity going on around you will distract any onlookers from what you’re really doing.

By placing a diaper bag or large purse on the table, you can block the view of your chest without a blanket. Think about lines of sight. If someone seems inappropriately curious, place the bag between him and you.

Keep doing what you’re doing. If you’re talking to friends, eating lunch, or what-have-you, you will look normal and inconspicuous.

- Ivy

- Jane

2. If you sit at a booth in a restaurant make sure it is roomy enough to accommodate the baby in front of you without him being smashed up against the table. That being said, booths are more private than tables.

3. If the weather is nice, go to a park. I used to stroll him and sling him on the walking paths and then sit down on a park bench. This gave me exercise and I began to sit closer and closer to other people as my confidence grew.

4. Invest in a cassette tape that does progressive relaxation (I had one for childbirth.) Listen to it at night before bed. Use the techniques you learn from the tape to relax when you are all nervous, the baby is crying, and you think everyone is looking.

5. Don’t let family members tell you that you can’t nurse somewhere. My mother said I couldn’t nurse in church so I told myself, “watch me”, and practically begged the baby to fuss.

6. It is all in your attitude and determination to do what is best for your child. This is one of your first chances to be your child’s biggest advocate. He will get the best nutrition available and you will not be a wimp!

- Claire

- Nicole from PA

- Christine Cosmo

- Jennifer

In the beginning, try to find a dressing room in department stores. The mirrors are usually large and make it easy to see how much you are really showing.

I sometimes use a lightweight blanket/shawl type thing just for latching since my son likes to “play” for a bit before getting down to business.

There are usually at least a few benches that are kind of in secluded areas in most malls, not to hide, but usually quieter and less traffic.

- Min

- Sarah J.

I thought all was great, until a few minutes into the feeding. Three 40ish aged men turned around and kept staring at me. They were acting like I had whipped my boob out and was showing it to the crowd, then the one guy said so that I could hear it, “That poor kid is going to be confused when he grows up. I would die if my mother had done that to me.”

My heart sank and out of reaction I ended the feeding immediately. I sat for a few minutes with a confused son on my lap. He had no clue what was going on. Then I realized what an idiot I was being by stopping the feeding. I started getting mad and I realized how ridiculous that it is that I keep running to the car or to a dressing room when my son gets hungry in public. Jerks like these guys are in the wrong, not me! So I started over, and this time. I was LOUD about it. “Ooohhhh honey, are you hungry! I bet that tastes good Aidan.”

The guys were, like… so grossed out, and for the rest of the game we were having to deal with them looking back to see if I was nursing, and I nursed two more times during the game. It was a truly liberating experience — no more hiding for me. If I can nurse at a football game with 13,000 people there, I can do it anywhere!

- Shaye

So I asked my husband to sort of block the view with his body while I latched our daughter. He was so reassuring, “Jo, you can’t really see anything from this angle.” After that, I was able to NIP with or without him present to block the view.

As my father-in-law said while I nursed at the airport, “If anyone looks, all they are going to see is a mama loving her baby the way nature intended!”

- Jo

- “Lactalina “

I have always enjoyed scanning medical databases for new breastfeeding articles but this collection was gathered by Ginna Wall, MN, IBCLC and Jon Ahrendsen, MD, FAAFP who have given their kind permission for its presentation here.

For a frank discussion with your dentist, skip right to the dental caries articles. Families with premies need to look hard at the RSV research and the NEC articles among others. Neonatologists need them, too.

The brain grows better with breastmilk as has been shown over and over again in research about IQ, motor development and vision.

The articles about decreased incidence of malignancy and diabetes are worth a read in their entirety when you have a chance to get to MEDLINE or Pubmed.

Diarrhea
An episode of diarrhea was significantly less likely to last for six or more days if an infant was breastfed for three or more months.  Baker D et al.  “Inequality in infant morbidity: causes and consequences in England in the 1990s.”  J Epidemiol Community Health 1998 Jul;52(7):451-8

The risk of developing diarrhea increases as the amount of breastmilk an infant receives decreases.  When compared with exclusively breastfed infants, infants who were exclusively formula-fed had an 80% increase in their risk of developing diarrhea.  Scariati PD et al.  “A longitudinal analysis of infant morbidity and the extent of breastfeeding in the United States.”  Pediatrics 1997 Jun;99(6):E5

Among babies born at more than 30 weeks gestation, confirmed necrotizing enterocolitis was rare in those whose diet included breastmilk; it was 20 times more common in those fed formula only. Lucas, A., Cole, T.J., “Breast Milk and Neonatal Necrotizing Enteral Colitis”. Lancet 1990; 336:1519-23

Significantly increased risk for acute otitis media as well as prolonged duration of middle ear effusion were associated with male gender, sibling history of ear infection and not being breast fed. Teele, D.W., Epidemiology of Otitis Media During the First Seven Years of Life in Greater Boston: A prospective, Cohort Study”. J of INFEC DIS.1989.

In infants who were breast fed until at least 12 months of age, the percentage of any otitis media was 19% lower, and of prolonged episodes (> 10 days) was 80% lower than formula-fed infants.  The mean duration of episodes of otitis media was longer in formula-fed than breastfed infants (8.8 vs 5.9 days, respectively).  Dewey KG et al.  “Differences in morbidity between breast-fed and formula-fed infants.”  J Pediatr 1995 May;126(5 Pt 1):696-702

The risk of developing an ear infection increases as the amount of breastmilk an infant receives decreases.  When compared with exclusively breastfed infants, infants who were exclusively formula-fed had a 70% increase in their risk of developing an ear infection.  Scariati PD et al.  “A longitudinal analysis of infant morbidity and the extent of breastfeeding in the United States.”  Pediatrics 1997 Jun;99(6):E5

Infants who were not being breast fed were 17 times more likely than those being breast fed exclusively to be admitted to hospital for pneumonia.  Cesar JA et al.  “Impact of breast feeding on admission for pneumonia during postneonatal period in Brazil: nested case-control study.  BMJ 1999 May 15;318(7194):1316-1320

Odds of respiratory illness with maternal smoking were 7 times higher among children who were never breastfed then among those who were breastfed.  Woodward A et al.  “Acute Respiratory Illness in Adelaide Children: BreastFeeding Modifies the Effect of Passive Smoking”.  J Epidemiol Community Health 1990 Sep;44(3):224-30

A birth cohort was followed-up to age 4 years.  By age 4 years, 27% of the children had symptoms of allergic disease.  Family history of atopy was the single most important risk factor for atopy in children.  Sibling atopy was a stronger predictor of clinical disease than maternal or paternal atopy.  Formula-feeding before 3 months of age predisposed to asthma at age 4 years (OR: 1.8). Tariq SM, et al.  The prevalence of and risk factors for atopy in early childhood: a whole population birth cohort study.  J Allergy Clin Immunol. 1998 May;101(5):587-93.

Eczema was less common and milder in babies who were breast fed (22%) and whose mothers were on a restricted diet (48%). In infants fed casein hydrolysate, soymilk or cows milk, 21%, 63%, and 70% respectively, developed atopic eczema.  Chandra R.K., “Influence of Maternal Diet During Lactation and the Use of Formula Feed and Development of Atopic Eczema in the High Risk Infants”. Br Med J. 1989

Children who had consumed mother’s milk by tube in early weeks of life had a significantly higher IQ at 7.5 to 8 years, than those who received no maternal milk, even after adjustment for differences between groups and mothers’ educational and social class.  Lucas, A., “Breast Milk and Subsequent Intelligence Quotient in Children Born Preterm”. Lancet 1992;339:261-62

PKU IQ
School-age phenylketonuric children who had, as infants, been breastfed 20-40 days prior to dietary intervention scored significantly better (IQ advantage of 14.0 points, p = 0.01) than children who had been formula fed.  A 12.9 point advantage persisted also after adjusting for social and maternal education status.  Riva E et al.  “Early breastfeeding is linked to higher intelligence quotient scores in dietary treated phenylketonuric children.  Acta Paediatr 1996 Jan;85(1):56-8

In 771 low birth weight infants, babies whose mothers chose to provide breastmilk had an 8 point advantage in mean Bayley’s mental developmental index over infants of mother choosing not to do so. Morley, R., “Mothers Choice to provide Breast Milk and Developmental Outcome”. Arch Dis Child, 1988

Erythropoietin stimulates production of red blood cells and is used in the treatment of anemia of prematurity.  Human milk contains considerable amounts of erythropoietin which resist degradation after exposure to gastric juices at physiologic pH levels. Kling PJ et al.  “Human milk as a potential enteral source of erythropoietin.”  Pediatr Res 1998 Feb;43(2):216-21

Preterm infants demonstrated a higher oxygen saturation and a higher temperature during breastfeeding than during bottle feeding, and were less likely to desaturate to <90% oxygen during breastfeeding. Blaymore Bier JA et al.  “Breastfeeding infants who were extremely low birth weight.  Pediatrics 1997 Dec;100(6):E3

In this study of 330 8-year-old children from Southern Tasmania, those who werebreastfed had higher bone mineral density at the femoral neck, lumbar spine and total body compared with those who were bottle-fed.  This association remained significant after adjustment for size, lifestyle factors and socioeconomic factors.  Breastfeeding for less than 3 months was not associated with increased bone mass at any site.  Jones G, Riley M, Dwyer T.  Breastfeeding in early life and bone mass in prepubertal children: a longitudinal study.  Osteoporos Int 2000;11(2):146-52

Women who were breastfed as infants, even if only for a short time, showed an approximate 25% lower risk of developing premenopausal or postmenopausal breast cancer, compared to women who were bottle-fed as an infant. Freudenheim, J. “Exposure to breastmilk in infancy and the risk of breast cancer.” Epidemiology 1994 5:324-331

Children who are artificially fed or breastfed for only 6 months or less, are at an increased risk of developing cancer before age 15. The risk of artificially-fed children was 1-8 times that of long-term breastfed children, and the risk for short term feeders was 1-9 times that of long term breast feeders. Davis, M.K. “Infant Feeding and Childhood Cancer.” Lancet 1988 13;2(8607):365-8.

A statistically significant protective effect against Hodgkin’s disease among children who are breastfed at least 8 months compared with children who were breastfed no more than 2 months.  Schwartzbaum, J. “An Exploratory Study of Environmental and Medical Factors Potentially Related to Childhood Cancer.” Medical & Pediatric Oncology, 1991; 19 (2):115-21.

A total of 1744 children with acute lymphoblastic leukemia (ALL) and 1879matched control subjects, aged 1-14 years, and 456 children with acute myeloid leukemia (AML) and 539 matched control subjects, aged 1-17 years, were studied.  Ever having breast-fed was found to be associated with a 21% reduction in risk of childhood acute leukemias.  The inverse associations were stronger with longer duration of breast-feeding.  Shu XO etal, “Breast-feeding and risk of childhood acute leukemia.  J Natl Cancer Inst 1999 Oct 20;91(20):1765-72

In interviews with the mothers of 2,200 children affected by either acute lymphoblastic leukemia (ALL) or acute myeloid leukemia (AML), the infant-feeding history of each of these children was compared with that of over 2,400 healthy controls.  The investigators found that a history of breastfeeding was associated with a reduction in risk of childhood acute leukemias.  Babies who are breast-fed for as little as one month have a 20% lower risk of childhood leukemia than bottle-fed babies, and babies breast-fed for more than 6 months have an even lower risk — 30% less. Robison L et al.  Journal of the National Cancer Institute 1999;91:1765-1772.

This study estimated the prevalence of early childhood caries and related behavioral risk factors in a population of low-income, Mexican-American children in Stockton, California.  Data was collected on 220 children ages six years or less using a parent-completed questionnaire and clinical dental examinations.  Mean age at weaning from breast-or bottle-feeding and patterns of bottle use during sleep did not differ significantly between children with caries and those without. Ramos-Gomez-FJ et al.  “Assessment of early childhood caries and dietary habits in a population of migrant Hispanic children in Stockton, California.”  Journal-Of-Dentistry-For-Children 1999; 66 (6): 395-403, 366

This in-vivo and in-vitro study showed that human breastmilk is not cariogenic.  Erickson PR, Mazhari E.  “Investigation of the role of human breastmilk in caries development.”  Pediatr Dent 1999 Mar-Apr;21(2):86-90

Children who were either never breast-fed or only until 3 months exhibited a significantly higher caries prevalence than those breast-fed for a longer time.  Mattos-Graner RO et al.  “Association between caries prevalence and clinical, microbiological and dietary variables in 1.0 to 2.5-year-old Brazilian children.  Caries Res 1998;32(5):319-23

A strong association was found between exclusive bottle-feeding and anteroposterior malocclusion.  Davis DW, Bell PA.  “Infant feeding practices and occlusal outcomes: a longitudinal study.”  J Can Dent Assoc 1991 Jul;57(7):593-4

Among breastfed infants, the longer the duration of nursing the lower the incidence of malocclusion. Labbok, M.H. “Does Breast Feeding Protect against Malocclusion? An Analysis of the 1981 Child Health Supplement to the National Health Interview Survey”. American Journal of Preventive Medicine, 1987.

Children who developed IDDM in New South Wales, Australia, were compared to healthy children of the same sex and age. Those who were exclusively breastfed during their first three months of life had a 34% lower risk of developing diabetes than those who were not breastfed. Children given cow’s-milk-based formula in their first three months were 52% more likely to develop IDDM than those not given cow’s milk formula. Diabetes Care 1994;17:1381-1389, 1488-1490.

The breastfed group had significantly higher antibody levels than two formula-fed groups together. Breastfed infants thus showed better serum and secretory responses to perioral and parenteral vaccines than the formula fed, whether with a conventional or low-protein content.  Van-Coric, M. “Antibody Responses to Parental & Oral Vaccines Where Impaired by Conventional and Low-Protein Formulas as Compared to Breast Feeding”. Acta Paediatr Scand 1990; 79: 1137-42

Osteoporosis
The odds ratio that a woman with osteoporosis did not breastfeed her baby was4 times higher than for a control woman.  Blaauw, R. et al. “Risk factors for development of osteoporosis in a South African population.” SAMJ 1994; 84:328-32.

Whether or not women had ever breastfed, total duration of breastfeeding and duration of breastfeeding per child were not associated with reduced bone mineral, but breastfeeding for more than 8 months was associated with greater bone mineral at some sites.  Melton L et al.  “Influence of breastfeeding and other reproductive factors on bone mass later in life.”  Osteoporos Int 1993 Mar;3(2):76-83

Mothers who breastfed exclusively or partially had significantly larger reductions in hip circumference and were less above their prepregnancy weights at 1 month postpartum than mothers who fed formula exclusively.  Kramer, F., “Breastfeeding reduces maternal lower body fat.” J Am Diet Assoc 1993;93(4):429-33

A retrospective review of 800 pregnancies at one family practice revealed an association between lack of breastfeeding and physical and sexual abuse of the mother and/or her children.  This anecdotal association has not been previously reported, is worth further study using more rigorous methods.  Acheson, L., “Family Violence and Breast-feeding” Arch Fam Med July 1995; Vol 4,pp 650-652

Food Expense
The cost to supply artificial baby milk (ABM) to one child is between $1,160 and $3,915 per year depending on the brand.  Even mothers on WIC need to buy approximately 200 cans of concentrate to feed her infant in the first year.  Breastfeeding Support Consultants, Information on Infant Feeding Costs, April 1998  (based on Illinois and North Carolina suburban supermarket prices).

Compared with formula-feeding, breast-feeding each infant enrolled in WIC saved $478 in WIC costs and Medicaid expenditures during the first 6 months of the infant’s life.  Montgomery DL, Splett PL.  “Economic benefit of breast-feeding infants enrolled in WIC.”  J Am Diet Assoc 1997 Apr;97(4):379-85

If women breast-fed each child for at least 6 months, the total projected savings over a 7.5-year period ranges from $3,442 to $6,096 per family.  This translates into an estimated yearly savings of between $459 and $808 per family.  Savings were calculated based on estimates of the resulting decrease in infant morbidity, maternal fertility, and formula purchases.  Tuttle CR, Dewey KG.  “Potential cost savings for Medi-Cal, AFDC, food stamps, and WIC programs associated with increasing breast-feeding among low-income Hmong women in California.  J Am Diet Assoc 1996 Sep;96(9):885-90

View the entire contents of this report by clicking here:
Outcomes of Breastfeeding Versus Formula Feeding

Infections of the breast present themselves typically in two manners. Mastitis is a bacterial infection in the breast, typically involving a considerable quantity of mammary tissue. A plugged duct is an individual duct that is blocked, swollen and often presents as a hard knot in the breast. A plugged duct can lead to mastitis, but the two are not always presented together. The treatment for both includes many of the same measures. The differentiation is often seen in the level of a fever and length it sustains. If a woman is familiar with the symptoms of either, and begins treatment immediately upon noticing the first symptoms, it can almost always be resolved before antibiotics are necessary. I encourage all breastfeeding moms to become familiar with the symptoms, so as to be in a position to catch the first signs and avert a long and painful battle.

Symptoms

1. Tender, aching breast
2. Hard knot in breast
3. Skin hot and red, often in a spot right above a knot
4. Flu-like body aches
5. Fever
6. Red line visible on breast
7. A blister on the nipple is often associated with a plugged duct

Treatment

1. Increase nursings on the affected breast.
2. Point baby’s chin at any red, hot spot you may have.
3. Prior to nursing, immerse breast in very hot water and massage toward the nipple. As often as possible, do this in a bathtub to get excellent immersion. If needed, a sink can be used with washcloths to assist.
4. After nursing, ice the breast. You can use a bag of frozen peas set aside for this purpose and wrap it in a thin dishcloth.
5. Massage toward the nipple while nursing.
6. Go to bed with baby and rest and nurse if at all possible.
7. If your entire breast is sore, alternate nursing positions to rotate baby’s chin around the breast.
8. Take ibuprofen to assist with pain and reduce inflammation.
9. While nursing, use a hot rice pack on your breast. A simple rice pack is to take a tube sock, place rice in it and tie a knot at the end. This can be heated in the microwave.
10. Stop wearing a bra while fighting mastitis.
11. Keep track of your temperature and watch for a red streak on your breast. If your fever goes up considerably or if you feel very weak, you may need to consider antibiotics.
12. Make sure you are drinking 64 oz. water a day!
13. If you have a blister on your nipple, it can be opened with a sterile needle. Be gentle and don’t tear the skin, merely open it. Then massage toward the nipple and the “plug” is often discharged in the form of a thickened milk that has been backed up in that duct.

Prevention

1. Take Lecithin 1200mg three or four times a day.
2. Wear a comfortable, loose nursing bra. Avoid underwire styles. Make sure you have plenty of room in your nursing bra to expand as various times of the day according to how long it’s been since nursing.
3. Eat a diet low in saturated fats.
4. Rest with baby every day. Resting is vital to keeping your body healthy and producing milk easily.
5. Limit the length of time spent doing errands in a day. Resist heading out the door with a detailed map of how you’re going to accomplish a dozen tasks in speedy fashion. You will inevitably come home exhausted and that state of exhaustion has the potential for setting you up to have a breast infection.
6. Drink 64 oz. of water daily.
7. Be careful regarding sleeping positions.  A sleeping position that puts pressure on your breasts is likely to contribute to plugged ducts. If you are a tummy sleeper, try sleeping on your side and put a bed pillow between your knees — it helps to keep you from flipping over onto your stomach.
8. Be aware of how your seatbelt fits across your chest and adjust it as needed to alleviate pressure on the breast itself.  Many vehicles have adjustable heights, but if yours does not you may want to use a folded washcloth or cloth diaper to place underneath where a belt presses against your breast to redistribute the pressure.  Another obvious solution is to limit how long you are out in the car, whenever possible, and nurse well while massaging that area when you are through driving.

Recommended Reading:

• Blocked Ducts and Mastitis
• Articles from LEAVEN: Mastitis–Plugged Ducts and Breast Infections
• The Womanly Art of Breastfeeding by LLL

If there is a rule that would help moms survive growth spurts with a smile, it would have to be, “Don’t Watch The Clock!” Don’t watch the clock for how long baby has been nursing. Don’t watch the clock for how long it’s been since baby last wanted to nurse. Don’t watch the clock for how many times you’ve been awakened that night to nurse.

Growth spurts happen. They happen with all nursing dyads. Some babies protest more about them and others seem to sail through them with the greatest of ease. Some books will tell you they happen at so many weeks or months. They may tend to, but the truth is, they can happen anytime.

Signs of a Growth Spurt

• Baby is nursing often or almost nonstop
• A baby who was previously sleeping through the night is now waking to nurse several times
• Baby will latch and unlatch, fussing in between

These signs are all signals to the mom’s body to “MAKE MORE MILK NOW!” Our bodies listen very well if we will merely respond to the baby’s needs. The extra suckling will stimulate your body to make more milk.

Often Observed After a Growth Spurt

• Baby sleeps extra for a day or two
• Mom is a bit fuller than usual for a day or so
• Baby calms down at the breast
• You may see an increase in wettings with the increased supply baby is drinking

Growth spurts seem to throw new moms for a loop. Just when they thought they were beginning to understand their baby’s signals, they abruptly changed. The frequent requests to nurse can be confusing as well as the frequency with which growth spurts happen within the first few months. The key is purely and simply to go with the flow (pun intended!) If you respond to your baby’s signals to nurse during a growth spurt and do not interfere with them in any manner, your body will quickly respond and increase supply. Typically it happens within 24 to 48 hours. Sometimes growth spurts seem to drag on for a week. This would be a good time to make sure you’re drinking plenty water.

Don’t allow a growth spurt to rob you of your confidence in nursing. Instead, allow it to instill confidence in your ability to read your baby’s cues. Your confidence will be further rewarded as your supply increases and your baby settles back down into a happy breastfeeding baby again, with a smart mommy who knew that sometimes baby really does know best and our job is to listen.

I hear from moms regularly that are planning on using both breastfeeding and bottle feeding. Some of them are well informed about the many dangers of formula and have a pump ready to use to provide expressed breastmilk. Some are not, and the first place we begin is with a lesson on the many inadequacies of infant formulas. For the ones that do know that breastmilk only is the goal, but want their husbands to “bond” with the baby, our lesson begins with all the many, many ways in which fathers can interact with their babies without using a bottle.

Regardless of what is being put in the bottle, there are several areas of impact that remain the same.

Using an artificial nipple risks nipple preference.

Nipple preference, or nipple confusion (though this term is more commonly used, I don’t like it as much, since the baby is obviously not confused about it at all, but quite clear on their “preference”), is a serious risk when any artificial nipple is used. This includes any bottle nipple, regardless of “how like breastfeeding” it is considered to be by the individuals in charge of marketing for that company.

A bottle nipple drips milk out, and with very little effort, a baby can get a steady flow of milk going. There is no need to wait for a letdown upon initial “latch.” It begins pouring out immediately. THIS is why the nipple preference is exhibited. Our babies are very intelligent and even one exposure to a bottle can be enough for them to figure out that the bottle is faster. This is also the reason why nipple preference can happen at any age.

Some babies exhibit nipple preference from one exposure to a bottle. Some babies will exhibit it after several exposures. Some babies will go back and forth without any difficulty. Some go for a while without difficulty and then suddenly show nipple preference. Some babies seem to do fine going from bottle to breast, but there are subtle problems hidden in supply issues for mom. Even if EBM (expressed breastmilk) is being used for all bottles, it can become a supply struggle for the mother in that a pump will never offer the stimulation that the baby at the breast will.

Signs of Nipple Preference

• Compromised latch that makes mom’s nipples sore
• Fussing at the breast (Hey, Mom, it isn’t working fast enough)
• Flailing arms and legs (this is the “why isn’t there milk pouring out” motion)
• Pushing away from the breast with hands (this is the “I’m going to MAKE it come out motion)
• Latching and unlatching over and over
• Crying and turning head away
• Outright screaming and complete refusal to latch

A pacifier can cause nipple preference as well.

The risk of nipple preference with pacifier use is less, in that there is no milk dripping out of a pacifier to make it a tempting option. However, there are some babies that will happily suck on a pacifier in the early stages of hunger. This will have an effect on breastmilk supply. It can cause a compromised latch, which will cause soreness for mom and potentially effect supply as well.

Use of bottles affects mom’s breastmilk supply.

If mom is using formula to supplement breastfeeding, she is telling her body, with every ounce of formula, to make less milk. Her body is not receiving all the signals it needs to make the perfect quantity for her baby, if she is interfering with those signals.

If mom is using EBM, she is still giving her body mixed signals, in that the pump does not provide the stimulation that the baby does at the breast. Mothers who have chosen to work and continue breastfeeding, do so with a serious mission to provide breastmilk for their babies. It takes a lot of stimulation from baby in the hours that mom is home to make up for the hours that a pump takes over. It is very possible to do, and I encourage any mom that is returning to work to do it.

Breastfeeding works optimally with feeding at the breast only.

The bottom line is that the supply and demand system that provides the perfect amount of breastmilk for your baby works optimally with baby at the breast. The use of a bottle compromises that perfect system. Some moms find a way to make it work. Some don’t and the breastfeeding relationship has slipped away from them before they even realized the source of the problem.

If you are returning to work, seek out some help from experienced working breastfeeding moms, La Leche League and/or an IBCLC to find some alternative feeding methods and special “tricks” that will help you make breastfeeding a success.

If you are at home with your children, there is no need to run the risk that the use of a bottle is to the breastfeeding relationship.

Thrush is a yeast infection that can present itself in your baby’s mouth or on your nipples. When thrush is in either of these locations, you may also find the yeast deep in the breast tissue, vaginally or on your baby’s diaper area. When the yeast infection presents itself, it may be in all or one of these locations.

Symptoms of thrush may include:

• Unusually pink or red nipples.
• Cracked or bleeding nipples
• Itching or burning nipples
• A shooting pain deep within the breast
• Pain that continues throughout a nursing session
• White patches inside the baby’s mouth. (the inside of his cheeks is a “thrive” zone and an easy to identify location)
• Yeast infections in other locations (diaper area, vaginal)

If you or your infant contract thrush and present yourself to your Pediatrician, you are likely to be sent home with a prescription for Nystatin. It is the most commonly used medication when dealing with thrush. There is a liquid medication for giving to the baby, and a cream that can be placed on your nipples. Other treatments used are Gentian Violet and Diflucan.

My reservations with beginning with the above medications are that the Nystatin liquid contains sugar to make it palatable enough that baby will swallow it. However, yeast feeds on sugar. This may be the reason why it is often not effective. Gentian Violet is effective, but stains skin purple for several days. I have some lovely photos of my twins with purple faces! Diflucan is very effective, but can cause intestinal distress in mom and/or baby. For these reasons, I prefer to begin with Grapefruit Seed Extract as the first line of defense. I have found that the use of Grapefruit Seed Extract as recommended almost always brings rapid relief and an elimination of the yeast imbalance.

Grapefruit Seed Extract is a broad-spectrum antimicrobial compound synthesized from the seeds and pulp of grapefruit. It is an extremely potent and effective broad-spectrum bactericide, fungicide, antiviral and antiparasitic compound. Tests have shown that GSE is dramatically more effective than Colloidal Silver, Iodine, Tea Tree Oil and Clorox bleach against five common microorganisms. In studies performed by Dr. John Mainarich of Bio-Research Laboratories in Redmond, WA, samples of each of the common antimicrobials or sanitizing agents were evaluated for effectiveness against Candida albicans, Staphylococcus aureus, Salmonella typhi, Streptococcus faecium and E. coli. The other antimicrobials tested were considerably less effective than the GSE.

GSE is extremely effective in the treatment of thrush. I also find it to be the easiest place to start. If used diligently, it typically will clear up thrush within a couple of days.

Treatment of thrush with GSE

• Make a mixture of 10 drops of Citricidal Grapefruit Seed Extract to one ounce of water. The use of distilled water to make your solution is very important.  The chemicals placed in your local tap water to kill bacteria can reduce the effectiveness of the active ingredients in GSE.

• IF thrush is not markedly improved by the second day, increase the mixture to 15, or even 20 drops of GSE per one ounce of distilled water.   If after reaching up to at least 20, and a full day of hourly treatment with it, you see no improvement, I would consider using Diflucan.  If you are prescribed Diflucan, continue to treat topically with GSE during the course of treatment.
  
• Use this solution with an absorbent swab on mom’s nipples and baby’s mouth once every hour during all waking hours. Swab baby’s mouth priorto nursing and mom’s nipples after nursing.  Applying it to baby’s mouth prior to nursing will help them to  avoid the possibility of baby associating the bitter taste with nursing.

• If diaper area is affected, put the same strength solution into a spray bottle or swab as above at every diaper change.
  
• If the infection is particularly rampant or you are having difficulty getting rid of it, mom may need to take acidophilus or GSE capsules to get rid of it systemically.
  
• GSE solution can also be used in laundry or as a surface cleaner to kill yeast hiding and waiting to multiply again.
  
• It may be necessary for Mom to eliminate sugar from her diet until the yeast infection is gone.

If treatment with GSE seems to leave your nipple area dry, I suggest applying a light coating of Vitamin E oil in the following manner: First apply the GSE solution, allow that to dry or use a hairdryer to dry it completely, then apply a light coating of Vitamin E oil.  I would suggest doing this 3 to 4 times a day until the dryness is gone.  It should only take a couple of days to show significant improvement.  The Vitamin E oil should absorb into the skin thoroughly prior to the nursing following the application.  I’m a big fan of Lansinoh, but do not use it when dealing with thrush, because it provides a moisture barrier that is counterproductive to getting rid of thrush.

Since learning of the powerful antimicrobial that Grapefruit Seed Extract is, I have always kept a bottle in my home for many uses.

For more information on GSE:

• Nutriteam: Grapefruit Seed Extract
• Grapefruit Seed Extract
• Treating Candida with GSE (Positive Health Magazine)
• Citricidal Ordering Information

For prevention of thrush while taking antibiotics:

There are times over the course of nursing when a nursing mother needs to take antibiotics.  While taking antibiotics, good bacteria are destroyed  along with the bad. The absence of the good bacteria, which usually keep yeast in reasonable balance within the body, is what can leave a nursing dyad with thrush.   There are several options that may help to avoid this imbalance:

• Take acidophilus/bifidus capsules with doses being as far away from the dose of antibiotics as is possible.  There is dairy free acidophilus available for those needing dairy free products.  Check labels for ones requiring refrigeration.
• Take Florastor, which can be taken with the antibiotic dose.
• Eat yogurt with active live cultures.  Make sure you get unsweetened yogurt as you don’t want to feed the yeast with sugar.

All of these probiotics help to reintroduce to the gut the good bacteria that will help to regain control of the yeast overgrowth in the system.

If the infant or child is the one taking the antibiotics, they usually fare better at avoiding thrush while taking antibiotics because breastmilk has a bifidus factor.  It promotes the growth of Lactobacillus, a harmless bacterium, within the gut.  Growth of this bacteria helps to eliminate the overgrowth of yeast.  A toddler or child can also take acidophilus.  The powder itself has a pleasant creamy taste and most are happy to lick it off your finger, take it with spoon or you can mix it into a food.

When in the course of a happy breastfeeding relationship you notice a supply change, it can cause momentary panic. The first course of action should be to assess a few basic things. Are you resting enough? Getting a good night’s sleep? Taking a nap if necessary? Are you drinking at least 64 ounces of water a day? Are you eating a good, healthy diet? These are some of the basics of a nursing relationship that have to be maintained to the very best of your ability. Our bodies aren’t necessarily so forgiving of being pushed to the limit when we’re nursing. They tend to give us a clear signal. One of those ways is with a dip in supply. Listen to your body and take some action.

Make sure you are:

• Resting adequately
• Drinking at least 64 ounces of water a day
• Eating a nutritious diet
• Choosing a night time sleeping arrangement that allows for the best sleep for all involved
• Nursing frequently

Make sure you are not doing things that can inhibit supply:

• Smoking
• Allergy medications
• Sleeping on your stomach – compressing the breasts at night
• Wearing a bra that is too tight
• Wearing a sling with the rings pressing back against the breast instead up near the shoulder

The first and simplest way to increase milk supply is to nurse your baby more often.  The extra stimulation will signal your body to increase milk supply to meet the demand.  If you are wanting to boost your supply try nursing your baby every 60-90 minutes from beginning of nursing to beginning of next nursing.  Most mothers’ supply will respond to this increased nursing stimulation with a supply boost within 24-48 hrs.  It can also help for mom to have a “nurse in” and snuggle down on the couch or in bed with the baby with water, snacks and diapers at hand and nurse as often as baby will nurse.  This provides not only more nursing, but extra rest for Mom, which also helps to increase milk supply.

Even with all the above steps as it should be for optimal milk supply,  you may still find your supply is not what you feel it should be. The next step is to see how often your baby is wetting. Often what is perceived as a supply problem really isn’t a supply problem at all. Observing how much your baby is wetting will tell you whether it is reality or merely a perception.  After the first week of life an infant should have 6-8 wettings per day.

Another area to analyze has to do with pumping. There are times when you see a drop in what you are able to get at the pump. This may not be so much a drop in supply as it is a change in your reaction at the pump. The baby may have no trouble at all getting letdown, but the pump just isn’t fooling your body into one as well as it once did. Making some changes at the pump in the way of heat, massage prior to pumping, massaging in long sweeping motions down toward the nipple while pumping or altering positioning may be the trick that works for you.

If you are supplementing, even a single bottle a day, and are struggling with your milk supply, you need to consider ceasing all supplementing. For some women, supplementing even one bottle a day will have a drastic effect on their milk supply due to the reduction of stimulation by suckling with a nursing that is replaced by a pumping.

If all the above has been tried with little success, it may be time to consider using a galactagogue. Galactagogues are a wonderful tool, but should NOT be considered until the above measures have been taken first. It is always prudent to remember that, on the whole, your body knows what it is doing in responding to your baby and providing adequate milk. Galactagogues are a wonderful thing when they are truly necessary but they should be a last resort. There is often an assumption that since herbs are natural, they are safe. That isn’t always the case, and in fact, some herbs can be quite dangerous. Please use caution when using herbs and observe your body’s reaction to them carefully.

Some of the more common galactagogues (and there are many used over the centuries) are:

Fenugreek
Fenugreek is one of the most commonly used galactagogues.  It works very quickly in most cases.  It can be taken in capsule form with the recommended dose being up to three capsules three times a day.  It can be used in conjunction with Blessed Thistle, again working up to three capsules three times a day. The dosage needed varies according to the mother, so experimentation with lesser doses and increasing them if needed is a good idea.  One capsule three times a day may be enough to boost one mom’s supply when another may need three capsules three times a day.

It is important to be aware that fenugreek can affect blood sugar levels, so much so that it is effectively used to treat diabetes.  Knowing this, a nursing mom with hypoglycemia or diabetes needs to watch blood sugar levels if fenugreek is her galactagogue of choice.

The only side effect to make note of is mild gastrointestinal distress when fenugreek is taken in high doses.  Typically that would be seen in the mother, but in rare cases it is seen in the infant with an exhibition of some gastrointestinal difficulty which can be as mild as gassiness in the bowels.  Animal studies have found fenugreek essentially non-toxic.

Fennel
Fennel isn’t actually a galactagogue, but rather it assists with triggering the letdown reflex.  It is particularly useful for working Moms who have found that they’ve stopped responding well to the pump. Fennel is best as a tincture, 2-4 ml up to three times a day, but can be taken in capsule form.  Caution should be used with fennel because it can act as an appetite suppressant. Keep a careful eye on your caloric intake. Also, fennel contains phytoestrogens which if taken in excess can have a negative effect on your supply.

Rescue Remedy
This is a homeopathic remedy that is useful for triggering the letdown reflex. You take four drops under the tongue up to five minutes before pumping or nursing. Rescue Remedy can have a slight sedative effect, so use with caution.

Ignatia 6x
This is a homeopathic remedy that can work well in combination with a mild galactagogue. Dosage would be two tablets three times a day.

Mother’s Milk Tea

This tea is a very mild galactagogue containing fenugreek.  Some women find that drinking several cups a day is all that is needed of fenugreek to boost their supply.  An easy way to drink it is to brew a few cups very strong and cool it.  It can be drunk either iced straight or mixed half and half with apple juice.

Continued Use
As with commercial medications, when taking herbs you should always start with the mildest and work your way up, always starting with the lowest dosage possible. Also, keep in mind that galactagogues should be used for boosting supply, not maintaining. Once your supply has established itself at an adequate level, you should try weaning back off the herbs and see if your supply will maintain where needed.  They can always be resumed if necessary, but excessive use can lead to unwanted side effects. If you find that you’re in a situation where you need to take a galactagogue on an extended basis you should do a program of six weeks on and three weeks off. If you do not give your body a break it will become resistant to the herbs and they will become ineffective.

Milder Galactagogues
If you are looking into trying a galactagogue, start with things like:

• alfalfa, work up to four capsules three times a day
• marshmallow, work up to four capsules three times a day
• nettle, work up to two capsules three times a day
• dill, use two teaspoons of raw dill seed on your lunch and dinner or use it to brew a tea
• blessed thistle, work up to three capsules three times a day.

These are much safer herbs. Most galactagogues are more effective when used in combination. Combining two or three is much more effective than just using one.

Pregnancy

Sometimes a mom finds herself needing to maintain a supply in order to nurse through a pregnancy. In some cases mom finds that the supply and demand system works out nicely and they have no problems nursing right through pregnancy. In other cases mom finds she needs a little help. There are mild galactagogues that are safe to take in pregnancy. These herbs can also be used in combination of two or three.

Nettle up to 2 capsules 3 times a day
Dill up to 2 ml tincture 3 times a day
Marshmallow up to 4 capsules 3 times a day

DO NOT take fenugreek, fennel, or blessed thistle while pregnant.

There are a couple of prescription medications that have been used with success in situations of serious supply problems. (Reglan and Domperidone are two of these meds) They should be used with prudence and never considered until other basic measures of rest, water, nutrition and nursing frequency have been examined and remedied if necessary. We owe it to ourselves and our children to take care of our overall health, which is most cases, allows our bodies to provide breastmilk to our children.  These medications are available in those situations in which the mother has adequate rest, good nutrition, frequent nursing and still finds that supply is a problem.

Genotoxicity testing of a fenugreek extract.
Food Chem Toxicol. 2004 Nov;42(11):1769-75.

Fenugreek seeds have been used in traditional medicines as a remedy for diabetes. Rich in protein, fenugreek seeds contain the unique major free amino acid 4-hydroxyisoleucine (4-OH-Ile), which has been characterized as one of the active ingredients in fenugreek for blood glucose control. Current use of fenugreek in foodstuff has been limited to its role as a flavoring agent, and not as an ingredient to help mitigate the blood glucose response for people with diabetes. As part of a safety evaluation of novel ingredients for use in blood glucose control, the potential genotoxicity of a fenugreek seed extract (THL), containing a minimum of 40% 4-OH-ILE, was evaluated using the standard battery of tests (reverse mutation assay; mouse lymphoma forward mutation assay; mouse micronucleus assay) recommended by US Food and Drug Administration (FDA) for food ingredients. THL was determined not to be genotoxic under the conditions of the tested genetic toxicity battery. The negative assay results provide support that addition of THL from fenugreek to foodstuffs formulated for people with diabetes is expected to be safe. A wide safety margin is established, as anticipated doses are small compared to the doses administered in the assays.

Diosgenin, a steroid saponin of Trigonella foenum graecum (Fenugreek), inhibits azoxymethane-induced aberrant crypt foci formation in F344 rats and induces apoptosis in HT-29 human colon cancer cells.
Cancer Epidemiol Biomarkers Prev. 2004 Aug;13(8):1392-8.

Trigonella foenum graecum (fenugreek) is traditionally used to treat disorders such as diabetes, high cholesterol, wounds, inflammation, and gastrointestinal ailments. Recent studies suggest that fenugreek and its active constituents may possess anticarcinogenic potential. We evaluated the preventive efficacy of dietary fenugreek seed and its major steroidal saponin constituent, diosgenin, on azoxymethane-induced rat colon carcinogenesis during initiation and promotion stages. On the basis of these findings, the fenugreek constituent diosgenin seems to have potential as a novel colon cancer preventive agent.

Protective effect of fenugreek (Trigonella foenum graecum) seeds in experimental ethanol toxicity.
Phytother Res. 2003 Aug;17(7):737-43.

The study investigates the effect of aqueous extract of fenugreek seeds (Trigonella foenum graecum) on lipid peroxidation and antioxidant status in experimental ethanol toxicity in rats. The ability of the seed extract to prevent iron-induced lipid peroxidation in vitro was also investigated. Ethanol feeding for 60 days resulted in significant increases in the activities of serum aspartate transaminase, alanine transaminase and alkaline phosphatase. The levels of serum lipid hydroperoxides and thiobarbituric acid reactive substances in liver and brain were also significantly elevated. Significantly lower activities of superoxide dismutase, catalase, glutathione peroxidase, glutathione S-transferase and glutathione reductase were observed in liver and brain accompanied by depletion in glutathione, ascorbic acid and alpha-tocopherol concentrations. Activity of Ca(2+) ATPase in brain was significantly lowered. Simultaneous administration of aqueous extract of fenugreek seeds with ethanol prevented the enzymatic leakage and the rise in lipid peroxidation and enhanced the antioxidant potential. The seeds exhibited appreciable antioxidant property in vitro which was comparable with that of reduced glutathione and alpha-tocopherol. Further, histopathological examination of liver and brain revealed that, aqueous extract of fenugreek seeds could offer a significant protection against ethanol toxicity.

Supplementation of fenugreek leaves lower lipid profile in streptozotocin-induced diabetic rats.
J Med Food. 2004 Summer;7(2):153-6.

The present study was undertaken to evaluate the lipid-lowering effect of fenugreek leaves in diabetes mellitus. Albino Wistar rats were randomly divided into six groups: normal untreated rats; streptozotocin (STZ)-induced diabetic rats; STZ-induced rats + fenugreek leaves (0.5 g/kg of body weight); STZ-induced rats + fenugreek leaves (1 g/kg of body weight); STZ-induced rats + glibenclamide (600 microg/kg of body weight); and STZ-induced rats + insulin (6 units/kg of body weight). Rats were made diabetic by STZ (40 mg/kg) injected intraperitoneally. Fenugreek leaves were supplemented in the diet daily to diabetic rats for 45 days, and food intake was recorded daily. Blood glucose, total cholesterol, triglycerides, and free fatty acids were determined in serum, liver, heart, and kidney. Our results show that blood glucose and serum and tissue lipids were elevated in STZ-induced diabetic rats. Supplementation of fenugreek leaves lowered the lipid profile in STZ-induced diabetic rats.

Therapeutic applications of fenugreek.
Altern Med Rev. 2003 Feb;8(1):20-7.
Basch E, Ulbricht C, Kuo G, Szapary P, Smith M.

Fenugreek has a long history of medical uses in Ayurvedic and Chinese medicine, and has been used for numerous indications, including labor induction, aiding digestion, and as a general tonic to improve metabolism and health. Preliminary animal and human trials suggest possible hypoglycemic and antihyperlipidemic properties of oral fenugreek seed powder.

Mechanism of action of a hypoglycemic principle isolated from fenugreek seeds.
Indian J Physiol Pharmacol. 2002 Oct;46(4):457-62.

Mechanism of action of an orally active hypoglycemic principle isolated from water extract of seeds of Trigonella foenum graecum (fenugreek) was investigated in alloxan induced subdiabetic and overtly diabetic rabbits of different severities. The active principle was orally administered to the subdiabetic and mild diabetic rabbits (five in each group) at a dose of 50 mg/kg body weight for 15 days. The fenugreek treatment produced significant attenuation of the glucose tolerance curve and improvement in the glucose induced insulin response, suggesting that the fenugreek hypoglycemic effect may be mediated through stimulating insulin synthesis and/or secretion from the beta pancreatic cells of Langerhans. Prolonged administration of the same fenugreek dose of the active principle for 30 days to the severely diabetic rabbits (n = 5) lowered fasting blood glucose significantly, but could elevate the fasting serum insulin level to a much lower extent, which suggests an extra-pancreatic mode of action for the active principle. The fenugreek effect may also be by increasing the sensitivity of tissues to available insulin. The fenugreek hypoglycemic effect was observed to be slow but sustained, without any risk of developing severe hypoglycemia.

Effect of Trigonella foenum-graecum (fenugreek) seeds on glycaemic control and insulin resistance in type 2 diabetes mellitus: a double blind placebo controlled study.
J Assoc Physicians India 2001 Nov;49:1057-61.

To evaluate the effects of Trigonella foenum-graecum (fenugreek) seeds on glycemic control and insulin resistance in mild to moderate type 2 diabetes mellitus we performed a double blind placebo controlled study. METHODS: Twenty five newly diagnosed patients with type 2 diabetes (fasting glucose < 200 mg/dl) were randomly divided into two groups. Group I (n=12) received 1 gm/day hydroalcoholic extract of fenugreek seeds and Group II (n=13) received usual care (dietary control, exercise) and placebo capsules for two months. CONCLUSIONS: Adjunct use of fenugreek seeds improves glycemic control and decreases insulin resistance in mild type-2 diabetic patients. Fenugreek also has a favorable effect on hypertriglyceridemia.
Enhancement of circulatory antioxidants by fenugreek during 1,2-dimethylhydrazine-induced rat colon carcinogenesis.
J Biochem Mol Biol Biophys. 2002 Aug;6(4):289-92.
Annamalai University, Annamalai Nagar, Tamil Nadu, India.
We have investigated the modulatory effect of fenugreek seeds (a spice) on circulatory lipid peroxidation (LPO) and antioxidant status during 1,2-dimethylhydrazine (DMH)-induced colon carcinogenesis in male Wistar rats. Enhanced LPO in the circulation of tumor bearing animals was accompanied by a significant decrease in the levels of ascorbic acid, vitamin E, reduced glutathione, glutathione peroxidase, glutathione S-transferase, superoxide dismutase and catalase. Inclusion of fenugreek in the diet significantly decreased LPO with simultaneous enhancement of circulating antioxidants. We report that fenugreek exert its chemopreventive effect by decreasing circulatory LPO and enhancing antioxidant levels.

Effect of fenugreek seeds on blood glucose and serum lipids in type I diabetes.
Sharma RD, Raghuram TC, Rao NS.
National Institute of Nutrition, Indian Council of Medical Research, Hyderabad.
Eur J Clin Nutr. 1990 Apr;44(4):301-6.

The effect of fenugreek seeds (Trigonella foenum graecum) on blood glucose and the serum lipid profile was evaluated in insulin-dependent (Type I) diabetic patients. Isocaloric diets with and without fenugreek were each given randomly for 10 d. Defatted fenugreek seed powder (100 g), divided into two equal doses, was incorporated into the diet and served during lunch and dinner. The fenugreek diet significantly reduced fasting blood sugar and improved the glucose tolerance test. There was a 54 per cent reduction in 24-h urinary glucose excretion. Serum total cholesterol, LDL and VLDL cholesterol and triglycerides were also significantly reduced. The HDL cholesterol fraction, however, remained unchanged. These results indicate the usefulness of fenugreek seeds in the management  of diabetes.
Fenugreek Animal Studies
Effect of fenugreek seeds on the fasting blood glucose level in the streptozotocin induced diabetic rats.
Mymensingh Med J. 2004 Jul;13(2):161-4.

In this experiment defatted Trigonella foenumgraecum (fenugreek seeds/methi seeds) has used as the antidiabetogenic herbal medicine. The experiment was carried out in Bangabandhu Sheikh Mujib Medical University and BIRDEM from 1996 to 1998 on a total of 58 Long Evans rats of either sex. They were 50-60 days young rats with average body weight 72-174 gm. Among the total, 10 rats were treated with only vehicle called as non-diabetic control rats, 48 rats were treated with Streptozotocin (STZ) at a dose of 90mg in 1ml of citrate buffer solution per kg body weight, among which 20 were diabetics. Ten (1 died, 1 escaped) diabetic rats were again treated with fenugreek called as Fenugreek-treated diabetic rats and the rest 10 diabetic rats were called as diabetic control rats. The change in the mean fasting blood glucose (FBG) level in different groups of rat from day 5 from streptozotocin injection were higher in diabetic control group and in fenugreek-treated diabetic group than in non diabetic control group. The FBG level on day 13 the mean in non-diabetic control group was 5.21 mmol/L. In diabetic control group and in fenugreek-treated diabetic group the mean FBG level were 24.33 mmol/L and 9.89 mmol/L respectively. So, from this experiment it may be concluded that fenugreek decreases the FBG level considerably by improving diabetes mellitus.

Supplementation of fenugreek leaves to diabetic rats. Effect on carbohydrate metabolic enzymes in diabetic liver and kidney.
Phytother Res. 2003 Dec;17(10):1231-3.

The present study was designed to evaluate the effect of supplementation of fenugreek leaves, an indigenous plant widely used in Indian Ayurvedic medicine for the treatment of diabetes mellitus, in streptozotocin induced diabetic rats. Supplementation of the diet with fenugreek leaves showed a significant effect on hyperglycaemia, hypoinsulinaemia and glycosylated haemoglobin in streptozotocin diabetic rats. Fenugreek leaves improved the body weight and liver glycogen. Fenugreek leaves also showed a significant effect on key carbohydrate metabolic enzymes in diabetic rats. The effect of fenugreek leaves was found to be similar to that of glibenclamide. Thus, fenugreek leaves exhibited antidiabetic action in streptozotocin-induced diabetic rats. Insulin restored all the parameters to near normal levels in diabetic rats.

Many pregnant and nursing moms want to stay as far away from synthetic medications as possible. As a result, they look into using herbs and other natural remedies as an alternative. Herbs can be a wonderful alternative and many are very helpful. The problem arises when the assumption is made that just because herbs are natural, they are 100% safe. This simply isn’t true. Herbs can be very powerful, some are potentially dangerous, and all should be taken while under the supervision of your doctor or a certified herbalist.

One of the herbs nursing women ask about most frequently is ginseng. Many new mothers find themselves stressed out and fatigued. They start to look for anything that will help them get through the next harried day and sleepless night. Ginseng seems to be the answer. However, most forms of ginseng are unsafe for nursing mothers.

There are two different categories of Ginseng: those that are true, or Panax ginsengs, and those that are referred to as ginsengs simply because they produce the same adaptogenic effects as true ginsengs. The true Panax ginsengs are Chinese Ginseng, Korean Ginseng, and North American Ginseng. The two other most common ginsengs are Siberian Ginseng and Indian Ginseng. Both of these have no true relation to ginseng.

Ginsenosides are one of the sets of chemical compounds in Panax ginseng. These ginsenosides make up the active ingredients in true ginsengs. Ginsenosides have quite a few effects on the body. They alter blood flow to the brain, raise blood pressure, lower blood sugar levels, and stimulate the immune system. Ginseng also contains several steroid compounds that mimic the effects of anabolic steroids. One in particular, Panaxtriol, has very similar effects to estrogen use, which is why Panax ginsengs are unsafe for prolonged use in premenopausal women and shouldn’t be used at all during pregnancy.

There have also been reported pediatric cases of tachycardia and hypertension that appear to be in direct correlation with the breastfeeding mother’s use of Panax ginsengs. However, as with most herbs, no official studies or research has been done to determine the extent of any effects Panax ginsengs, transferred through human milk, might have on an infant. Logic would allow, though, that because Panax ginsengs contain such strong chemical compounds, it would not be wise to expose a baby’s developing system to the effects.

If a nursing mother still wants to take a Panax ginseng she should use extreme caution. Watch the baby closely. Signs of adverse side effects would be nervousness, shakiness, heightened anxiety, insomnia, skin rashes, and diarrhea. She should also inform her baby’s pediatrician that she is taking Panax ginseng so that baby’s heartbeat and blood pressure can be closely monitored. The mother should also be aware that Panax ginsengs could contribute to a low milk supply.

It is highly recommended, though, that if a mother feels she needs help fighting stress and fatigue she choose something other than Panax ginseng. Siberian ginseng has the same adaptogenic effects on stress levels and fatigue that any of the Panax ginsengs have. It does not, however, contain the ginsenosides or steroids that Panax ginsengs do and is safe for nursing mothers. Indian Ginseng is also an adaptogen, and though not quite as effective, is also safe for nursing mothers.

If breastfeeding is going to be combined with working, there are some things to consider that will give you greater success. A working mom can provide breastmilk for her baby without having to resort to the use of ABM (artificial baby milk). She has many balls in the air and every trick that makes any aspect of pumping a bit easier is worth consideration. Whether you’re planning on returning to work, or you’ve hit a bump in the road, I hope you’ll find a tip here that will make life easier and the milk flow.

Pumping Routine
Establishing a routine schedule for pumping is one of the best ways to consistently get an excellent MER or milk ejection reflex (letdown). Think of it as teaching your body a pattern that you would naturally fall into if you were with your baby all day. One of the favorite tricks of many working moms is to rise prior to baby waking and pump with a plentiful morning supply. Your breasts will kick into action and continue producing milk so that your baby will achieve plentiful MER’s on his own during the first nursing. Another good trick is to pump on one side during that first morning nursing while nursing the baby on the other. This takes advantage of the baby establishing MER for you and is often the best way to get maximum ounces in a brief period of time.

Pumps
Your choice of pump will be crucial to your success as a working mom. There are many options available that are excellent. For a fulltime working mom, a double electric pump that has adjustments available both for the strength of the suction, as well as the speed of the cycle, is a must. Take a look at what is out there, talk to other successful nursing working moms, and don’t be afraid to spend a little money to get a good model. You will be spending many months using it and a quality pump will make your life much easier. There are pumps available for rent if you’d like to have an opportunity to use a certain brand before purchasing it. Your local LC (Lactation Consultant) or IBCLC (Internationally Board Certified Lactation Consultant) should be able to assist you with renting one if you so desire.

It’s a good plan to have a few extra pump parts stashed at work, in case a small but crucial piece gets lost in the shuffle. File this under something else that a working mom does not need to have to deal with, and prepare for it so it never happens to you. Another little tidbit is to be careful where you put your parts in the dishwasher. Dishwashers are great for “eating” pump parts. It would be a good idea to get a basket designed for small pieces for your dishwasher if you plan on using it regularly to wash your pump parts.

Pumping on Days Off
The last thing that a working mom wants to see on her day off is her pump. There’s a distinct love/hate relationship with the pump. The love comes from this machine that allows you to provide your wonderful breastmilk for your baby even though you are separated while you are at work. The hate comes from the pump being a poor substitute for your precious baby at the breast. It may be necessary, in order to maintain a good supply for your work days, to pump even on your days off. Some mothers have no trouble maintaining a supply while only nursing on their days off. Some mothers at least pump the early morning session while home.

Supply Dips
I often receive the panicked contact from a nursing mom whose freezer supply is running low and fresh supply isn’t meeting the baby’s needs. The assumption is often made that there is a dip in the milk supply. I propose that the supply itself may not be a problem at all, but rather the reaction to the pump. Using a pump instead of the baby is already a matter of “fooling” your body. Sometimes the pump calls your bluff and you have to find a new trick.

Some tricks that may work when your reaction to the pump isn’t:

• Massage your breasts prior to beginning a pumping session
• Massage toward the nipple while pumping
• Lean forward and “shake” your breasts to encourage MER
• Look at a favorite photo of your baby that provides warm fuzzies
• Smell an item of clothing that your baby wore the previous day
• Bring a bottle of shampoo or lotion that you use on your baby to smell while pumping
• Breathe deeply and imagine that every breath flows into your lungs and out your nipple as milk. Another one that works well is to have a glass of water and take a swallow of it and imagine it flows right down and out your nipples.  I know that imagery can sound strange, but just try it.  They are merely relaxation techniques and using the imagery to help your body relax and work with you.
• Rock your shoulders gently forward and back. Then stretch your head forward and gently roll to relax the muscles in your upper back.
• Hand express for a couple of minutes prior to pumping
• Find some soothing music or nature sounds that relax you
• Read and take your mind off of the task at hand
• Twiddle your nipples between your forefinger and thumb until you achieve letdown and then begin pumping. Use imagery to assist you by closing your eyes and imagining your baby is nursing.

Freezer Supply
Providing your baby with fresh breastmilk should be your ultimate goal. Fresh breastmilk maintains nutrients at optimal level. Cooling milk will reduce those and freezing will further reduce them. Regardless of the manner in which your breastmilk will be stored, it is definitely a far superior choice over formula. I consider a freezer stash to be a matter of “insurance” and a bit of a stress reducer for mom in knowing that there is an “extra” stash in case it is needed. If your caregiver is not in your own home, consider leaving a small stash in their freezer for emergencies. The last thing that a mom needs to be worried about at work is whether the EBM (expressed breastmilk) she left is going to be enough. Alleviate this concern with a small freezer stash. Once you’ve returned to work, a good way to create a freezer stash is to pump on your days off during baby’s naps.

Storage
Consider storing your breastmilk in a variety of increments, some in two ounces and some in four or more. The caregiver can then become accustomed to approximately how much your baby takes at different times of the day. It is never a problem to warm an extra two ounces of EBM, but it is a true shame to waste the same amount. Mom has worked too hard to pump it to risk not using it. It’s important that the caregiver is on your team with this concept.

If it’s possible to have a standing freezer unit, EBM is stored for longer periods than when in a freezer unit attached to a refrigerator.  EBM is good for two weeks in a freezer compartment located inside a refrigerator, for 3 to 4 months in a separate door refrigerator/freezer and for 6 months or longer in separate deep freeze at a constant temperature of 19 C (0 F).  When storing your EBM in the freezer compartment attached to a refrigerator, you have to bear in mind that many new units have a frost-free cycle that periodically turns the freezer off.  To help identify if your unit goes through such a cycle, put an ice cube in a small dish and allow it to sit in your freezer compartment for several days and observe any changes.  Many frost-free units use a periodic heating of the walls of the freezer to defrost.  In that case, do not store EBM against the walls of the freezer, but stack them in a container kept in the center.  It’s also a good idea to keep an ice cube in a small ziplock bag in the freezer to identify, in the event of a power outage, if defrosting has occurred.

For further tips on storing EBM, see Common Concerns When Storing Human Milk.

The Flavor of EBM
A crucial element to using expressed breastmilk for your baby is to take the time to do a taste test. This may seem strange to you, if you’ve never heard that upon expression some women’s milk takes on different flavors. Some women notice that their EBM has an unpleasant smell or flavor. This can be caused by vitamin or mineral supplements, or some medications including strong antibiotics or nasal sprays, but typically they do not cause this effect. However, there is a situation involving the lipase in a mother’s milk that does alter the flavor. Lipase is what breaks down the fat in breastmilk, and the presence of high lipase content can cause the milk to take on a soapy flavor. It can be noticed not long after expression, after cooling or after freezing. It is for this reason that I recommend a taste test prior to returning to work. If you happened to be one of these women with high lipase content, you wouldn’t want to find out after having accumulated a large freezer stash.

Setting up a simple taste test will let you know if lipase content is an issue for you and your baby. Experiment by expressing some milk and letting it set at room temperature for thirty minutes. Express some fresh EBM and compare the taste. If there is no difference in taste, refrigerate the EBM. After the EBM is cooled, repeat the taste comparison with fresh EBM. Continue in this manner through the process of freezing and thawing. The predominance of women will find that the milk may taste slightly different, but does not take on an unpleasant flavor. Much in the way that a vegetable cooked fresh has more in depth flavors than the same vegetable after having been frozen.

If you find that your milk takes on a very soapy flavor at any step along the process, there are a couple things you can further experiment with. It may be as simple as cooling the milk before placing it into the freezer, or allowing the EBM to thaw in the refrigerator prior to warming it in a cup or bowl of hot water. Alter the process in these simple ways to see if it will bring about the change needed. If the milk still has a strong soapy flavor, you may need to give your EBM a very, quick scald prior to cooling. Be careful not to bring it to a boil. Heat it quickly to just this side of boiling and take it off the stove immediately, pouring it out of the pan into a heat safe glass container to cool. When the EBM is cooled, you may place it in the storage container of your choice and put it into the refrigerator to cool further, before transferring it to the freezer if needed.

Lunch Breaks
If it is at all possible to leave work and be with your baby during your lunch break, it will make life much easier for you. Not only will you not have to provide milk for that session, but the stimulation of even one nursing during the long day you’re at work will make a big difference in your supply. When making arrangements for care for your baby, this is something to keep in mind. The closer to home you can be employed, the easier this will be to accomplish. Think outside the box and see what you can arrange. If it cannot be set up for your family, you will still be able to maintain a supply regardless. It is truly a matter of effort and commitment and can be accomplished even in less than perfect circumstances.

Caregivers
It is crucial that whomever is the caregiver for your baby while you are at work understands that feeding should not be used as the first option when baby seems fussy. Sit down and have a serious discussion with them about how hard it can be to pump and provide the EBM for your baby. Encourage them first to hold, rock, sing, dance, walk or play with the baby. If baby is merely bored or in need of loving arms, one of these will fit the bill. If baby is truly hungry, they will not. In this way, there is never a precious drop of breastmilk wasted. Make sure they understand that you are not asking them to schedule your baby, but rather to learn to recognize baby’s needs rather than presume each cue is one of hunger.

Bottles or Cups
The most difficult initial decision to make as the time draws near for your return to work is what to use to feed your baby when you are not there to nurse. If a bottle can be avoided by using a sippy cup, soft-feeder or other feeding methods that do not utilize an artificial nipple, it will eliminate the risk of nipple confusion/preference. Even very young infants can learn to use a sippy cup with some patience both in experimenting with different kinds and in teaching the caregiver how to tip it back and forth to assist the baby. If a bottle is used, it is best to consistently use a newborn or slow flow nipple regardless of the age of the infant. This will help to reduce the risk of nipple confusion by keeping the flow of the EBM from the bottle at a slow pace. Graduating up to older infant nipples will provide a very fast flow which runs the risk of baby choosing the faster flow over nursing and exhibiting a full blown strike to go along with it. When you are with your baby, always nurse. You need the stimulation for your supply that a baby at the breast provides.

Nurse Often at Home
Remember on your days off that you are maintaining and stimulating your supply. Take it one step further than you would normally and nurse more often than if you were with your baby fulltime. You need the opportunity not only to provide stimulation for the sake of your supply, but also to love, snuggle and cuddle with your baby while nursing. It helps to balance out the time spent at the pump during work days. Resist the temptation of over scheduling your days off. You need to make nursing a priority on those days, particularly in the early months, to ensure that you have a long and continued nursing relationship.

Watch What You Drink
We all know that water is very important to our overall health. It is even more vital to the fulltime working and pumping mom. It may be from merely providing the adequate and excellent hydration that sixty-four ounces provides any adult. There is controversy on the impact of water consumption on milk supply amongst lactation professionals. I may not stand with the popular opinion on this issue, but I’ve seen the negative effect of too little water consumption on the ounces at the pump and an almost immediate increase with a minimum of sixty-four ounces of water consumed daily by the pumping mom too often to not admit to the correlation. I also caution against drinking too many dehydrating drinks, both due to sodium content and caffeine. Any that are consumed need to be counteracted with at least that much water to make up for their dehydrating effect. I realize that a morning cup of coffee is the mainstay of many working moms, but it does need to countered with an equal amount of water. Other liquids, such as juice or herbal teas, may not be a dehydrating problem, but should be consumed in addition to your sixty-four ounces of water a day, not as part of them. Water alone serves the ultimate purpose of keeping your system flushing toxins and well hydrated. Staying well hydrated assists greatly in keeping your body in optimal functioning order, and optimal functioning order is definitely required for a fulltime working nursing mom!

Rest
It is very important that any nursing mom stay well rested, because her bodies is not only maintaining her own health, but spending 500 – 800 calories a day in the production of milk. That’s a lot for one body to do on less than optimal sleep. Make rest a priority. Consider naps on your days off. Schedule one day a week with a completely lazy morning. Make this a priority from the beginning. It’s crucial.

Your Diet
Maintaining a good, healthy diet is another important factor for everyone, but particularly working moms. Candles are burning at both ends and meals often suffer for it. Plan ahead. Cook large meals on the weekend and freeze leftovers to use when you’re in a hurry. You need the good foods for energy to accomplish the many tasks required of you.

Galactagogues
Should your reaction to the pump decrease and all the above methods have been tried without success, there are galactagogues (herbs or medications that stimulate milk production) that will assist with increasing supply. There are many herbs that have a history of success, however, you must use herbs carefully. They can cause reactions that range from mild to strong and should be used under the advice of a professional that is familiar with them. I would recommend checking with an IBCLC (Internationally Board Certified Lactation Consultant), a certified herbalist or doctor of homeopathic medicines for guidance in selecting which herb is right for you and in what form. There are also medications that a physician can prescribe to increase milk supply. Again, there are side effects, and every other tip should be tried before resorting to an herb or medicine to increase supply.

For more information, see: Increasing Milk Supply

Handling Managers and Coworkers
Your commitment to pumping may be met with a variety of reactions. You need to remember that you have made an excellent choice by providing EBM for your baby and it is a choice that does not need defending. Do not feel the need to educate your peers on breastfeeding and why you pump. The best approach is to succinctly tell them that you will be using your breaks to pump. Period. You aren’t asking permission. You’re informing nicely. It is your right to use your breaks in this manner, so there should be no argument. The logistics of exactly where you will pump will have to be worked out. Find the most relaxing environment for you that is available. Whether it be in a private locked office, the break room or in your car, the important thing is that you are comfortable with the location. The more relaxed you are, the easier your task of pumping will be.

Some mothers meet with resistance in the workplace. La Leche League International website has information on it pertaining to legislation regarding the workplace. Many states offer incentives to employers for providing a breastfeeding friendly environment. Should you receive pressure regarding pumping, don’t panic. Find the information you need for your state and present yourself as a positive role model for other mothers and your employer. Stand up for your rights in the workplace in the gentlest way possible to get the job done. You may be paving the way for many mothers behind you.

When it’s time to take the leap and return to work, consider starting on a Thursday. That will give you an opportunity for a dry run that only lasts two days as opposed to what may look like a very long week stretching before you if you start on a Monday.

You may also consider speaking with your supervisor about rearranging your schedule to work four days a week. Working on Monday and Tuesday and then again on Thursday and Friday would allow a much friendlier schedule for a mom of a young nursing infant. It is not possible in all work situations, but is certainly worth considering if there’s a possibility of a modified schedule as an option for you. Function on the “it never hurts to ask” policy with this. The worst thing that could happen is that you would be told “no”.

It will be much calmer for your return to work if you take the time to make all pumping arrangements regarding where you will pump prior to returning to work. Take the time to have a brief meeting with any superiors if this is needed and get this solved ahead of time. The last thing a mom needs when she is making the transition to returning to work is to spend a moment worrying about exactly how pumping is going to play out for her. Step back into work with the confidence that these plans are set.

Additional Information:

• FAQ on Mixing Human Milk and Artificial Baby Milk (Formula)

The identification of a strike, versus weaning, is simple. Weaning is something that happens gradually over several weeks or months with baby or child dropping a single nursing at a time. A strike is something that happens abruptly. Baby or child is nursing several times a day and suddenly stops completely. Sometimes it is impossible to ascertain the cause of a strike, but the solution is the same regardless of the cause.

Things that can cause a strike:

• A separation from mother that is longer than the child is typically accustomed to having between nursing sessions
• An illness that is causing a stuffy nose, making it difficult to breath while nursing
• An illness causing a sore mouth or throat
• Nipple confusion caused by artificial nipples and/or pacifiers
• Teething pain
• Pain while in the nursing position, due to an ear infection or injury
• Too many distractions in the nursing environment, such as other children, phone, etc. drawing the baby’s attention away from nursing
• A dramatic reaction to baby having bitten you while nursing

Tips for surviving a strike to nurse again:

• Don’t force it. Offer the breast OFTEN but don’t try to force baby to nurse if he doesn’t want to. Remain cheerful. Say “Ok, we’ll nurse later then.”
  
• Do NOT offer any bottles or artificial nipples!!!! This is VERY important. If you want to offer some water or EBM, do so only in a sippy cup.  By keeping nursing as the only means by which they can meet their sucking needs, it will help to draw them back to nursing.
  
• Offer the breast when baby is sleepy or even asleep. Sometimes “unconsciousness” allows them to forget why they refused to nurse.
  
• If baby likes baths, get in with him and offer to nurse in the bath. Often times a change of pace/place will encourage a baby back to the breast.
  
• DO NOT REPLACE NURSINGS WITH SOLIDS OR ABM (formula). He will not starve and he will not dehydrate in the few hours to couple of days it takes to break a strike. If you replace his nursings with other things, he has no motivation to return to the breast. He must grasp the message that his needs MUST be met at the breast. Your supply will not be irreparably compromised in the time it takes to break a strike, but you must commit to break it if you want to emerge on the other side nursing.
  
• Sling him. If you don’t have a sling at least carry him often. Keep him close to you and close to your breasts. Try to sing to him to keep him calm and comfortable. Try walking with him in your arms/sling and nursing him while walking.
  
• If your baby’s nose is stuffy, use a few drops of breastmilk in the nose prior to nursing. It will help to clear out the congestions by loosening it as well as provide some of the wonderful antibacterial qualities in breastmilk to fend off a sinus infection. A baby that is stuffy feels like they are being suffocated when they attempt to nurse. Alleviating that feeling that they will smother will help them latch on with less fear.
  
• If you suspect teething is the cause for the strike, you may want to consider a pain reliever. Acetaminophen or Ibuprofen  (for babies older than six months) or a combination of the two in alteration may give enough pain relief that baby can latch on. There are other ways to get some pain relief, like putting a wet washcloth in the frig or freezer and giving to baby to suck on prior to attempting to latch. Some babies like their gums rubbed. Experiment and find a way to give some relief
  
• Try other positions. Avoid the usual “nursing chair” because if he’s upset, he’ll associate you sitting in that chair with whatever’s hurting/uncomfortable about nursing.
  
• Remember that a striking baby is no happier about the situation than you are. They want to nurse but for some reason can’t or won’t.
  
• Try not to worry. This is HARD!!! You can feel rejected, hurt, scared, and confused. It’s normal. But remember – he’s uncomfortable – he’s not rejecting you. If you help him he will return to the breast. He wants you to help him through this. You must be more stubborn than he is.
  
• This is not weaning. It helps to remember that. Weaning is a slow and gradual cessation of nursing. A strike is sudden and abrupt. He needs your help to return to the breast. He wants to, he just needs a lot of reassurance that it’s ok. It’s your job as a mother to know that it’s too early for him to wean and is in the best interest of his health and emotional welfare to return to nursing.
  
• You may need to pump to keep yourself comfortable if baby won’t nurse at all. If you do, that’s ok. Just pump and store your milk, or hand express it if you don’t have a pump. You can offer it to him in a sippy cup or freeze it for an emergency stash. This will also help if you’re concerned about supply. But you’ll need to take care of yourself so you don’t get engorged and end up with plugged ducts or mastitis. Take ibuprofen or acetaminophen for any discomfort and don’t forget to keep drinking your water.
  
• Try to nap/sleep with baby. A strike is an exhausting time for you and baby and you need to be well rested physically and emotionally to get through it.

• The gastrointestinal (GI) tract of a normal fetus is sterile.
• The type of delivery has an effect on the development of the intestinal microbiota.

* Vaginally born infants are colonized with their mother’s bacteria.

* Cesarean born infants’ initial exposure is more likely to environmental microbes from the air, other infants, and the nursing staff which serves as vectors for transfer.

• Babies at highest risk of colonization by undesirable microbes or when transfer from maternal sources cannot occur are cesarean-delivered babies, preterm infants, full term infants requiring intensive care, or infants separated from their mother.
• Breastfed and formula-fed infants have different gut flora.

* Breastfed babies have a lower gut pH (acidic environment) of approximately 5.1-5.4 throughout the first six weeks that is dominated by bifidobacteria with reduced pathogenic (disease-causing) microbes such as E coli, bacteroides, clostridia, and streptococci o babies fed formula have a high gut pH of approximately 5.9-7.3 with a

variety of putrefactive bacterial species.

* In infants fed breast milk and formula supplements the mean pH is approximately 5.7-6.0 during the first four weeks, falling to 5.45 by the sixth week.

* When formula supplements are given to breastfed babies during the first seven days of life, the production of a strongly acidic environment is delayed and its full potential may never be reached.

* Breastfed infants who receive supplements develop gut flora and behavior like formula-fed infants.

• The neonatal GI tract undergoes rapid growth and maturational change following birth.

* Infants have a functionally immature and immuno-naive gut at birth.

* Tight junctions of the GI mucosa take many weeks to mature and close the gut to whole proteins and pathogens.

* Open junctions and immaturity play a role in the acquisition of NEC, diarrheal disease, and allergy.

* sIgA from colostrum and breast milk coats the gut, passively providing immunity during the time of reduced neonatal gut immune function.

* Mothers’ sIgA is antigen specific. The antibodies are targeted against pathogens in the baby’s immediate surroundings.

* The mother synthesizes antibodies when she ingests, inhales, or otherwise comes in contact with a disease-causing microbe.

* These antibodies ignore useful bacteria normally found in the gut and ward off disease without causing inflammation.

• Infant formula should not be given to a breastfed baby before gut closure occurs.

* Once dietary supplementation begins, the bacterial profile of breastfed infants resembles that of formula-fed infants in which bifidobacteria are no longer dominant and the development of obligate anaerobic bacterial populations occurs. (Mackie, Sghir, Gaskins, 1999)

* Relatively small amounts of formula supplementation of breastfed infants (one supplement per 24 hours) will result in shifts from a breastfed to a formula-fed gut flora pattern. (Bullen, Tearle, Stewart, 1977)

* The introduction of solid food to the breastfed infant causes a major perturbation in the gut ecosystem, with a rapid rise in the number of enterobacteria and enterococci, followed by a progressive colonization by bacteroides, clostridia, and anaerobic streptococci. (Stark & Lee, 1982)

* With the introduction of supplementary formula, the gut flora in a breastfed baby becomes almost indistinguishable from normal adult flora within 24 hours. (Gerstley, Howell, Nagel, 1932)

* If breast milk were again given exclusively, it would take 2-4 weeks for the intestinal environment to return again to a state favoring the grampositive flora. (Brown & Bosworth, 1922; Gerstley, Howell, Nagel, 1932)

• In susceptible families, breastfed babies can be sensitized to cow’s milk protein by the giving of just one bottle, (inadvertent supplementation, unnecessary supplementation, or planned supplements), in the newborn nursery during the first

  three days of life. (Host, Husby, Osterballe, 1988; Host, 1991)

* Infants at high risk of developing atopic disease has been calculated at 37% if one parent has atopic disease, 62-85% if both parents are affected and dependant on whether the parents have similar or dissimilar clinical disease, and those infants showing elevated levels of IgE in cord blood irrespective of family history. (Chandra, 2000)

* In breastfed infants at risk, hypoallergenic formulas can be used to supplement breastfeeding; solid foods should not be introduced until 6 months of age, dairy products delayed until 1 year of age, and the mother should consider eliminating peanuts, tree nuts, cow’s milk, eggs, and fish from her diet. (AAP, 2000)

• In susceptible families, early exposure to cow’s milk proteins can increase the risk of the infant or child developing insulin dependent diabetes mellitus. (IDDM) (Mayer et al, 1988; Karjalainen, et al, 1992)

* The avoidance of cow’s milk protein for the first several months of life may reduce the later development of IDDM or delay its onset in susceptible individuals. (AAP, 1994)

* Sensitization and development of immune memory to cow’s milk protein is the initial step in the etiology of IDDM. (Kostraba, et al, 1993)

• Sensitization can occur with very early exposure to cow’s milk before gut cellular tight junction closure.
• Sensitization can occur with exposure to cow’s milk during an infection-caused gastrointestinal alteration when the mucosal barrier is compromised allowing antigens to cross and initiate immune reactions.
• Sensitization can occur if the presence of cow’s milk protein in the gut damages the mucosal barrier, inflames the gut, destroys binding components of cellular junctions, or other early insult with cow’s milk protein leads to sensitization. (Savilahti, et al, 1993)

References

American Academy of Pediatrics, Work Group on Cow’s Milk Protein and Diabetes Mellitus. Infant feeding practices and their possible relationship to the etiology of diabetes mellitus.  Pediatrics 1994; 94:752-754

American Academy of Pediatrics, Committee on Nutrition. Hypoallergenic infant formulas. Pediatrics 2000; 106:346-349

Brown EW, Bosworth AW. Studies of infant feeding VI. A bacteriological study of the feces and the food of normal babies receiving breast milk. Am J Dis Child 1922; 23:243

Bullen CL, Tearle PV, Stewart MG. The effect of humanized milks and supplemented breast feeding on the faecal flora of infants. J Med Microbiol 1977; 10:403-413

Chandra RK. Food allergy and nutrition in early life: implications for later health. Proc Nutr Soc 2000; 59:273-277

Gerstley JR, Howell KM, Nagel BR. Some factors influencing the fecal flora of infants. Am J Dis Child 1932; 43:555

Host A, Husby S, Osterballe O. A prospective study of cow’s milk allergy in exclusively breastfed infants. Acta Paediatr Scand 1988; 77:663-670

Host A. Importance of the first meal on the development of cow’s milk allergy and intolerance. Allergy Proc 1991; 10:227-232

Karjalainen J, Martin JM, Knip M, et al. A bovine albumin peptide as a possible trigger of

insulin-dependent diabetes mellitus. N Engl J Med 1992; 327:302-307

Kostraba JN, Cruickshanks KJ, Lawler-Heavner J, et al. Early exposure to cow’s milk and solid foods in infancy, genetic predisposition, and risk of IDDM. Diabetes 1993; 42:288-295

Mackie RI, Sghir A, Gaskins HR. Developmental microbial ecology of the neonatal

gastrointestinal tract. Am J Clin Nutr 1999; 69(Suppl):1035S-1045S

Mayer EJ, Hamman RF, Gay EC, et al. Reduced risk of IDDM among breastfed children. The Colorado IDDM Registry. Diabetes 1988; 37:1625-1632

Savilahti E, Tuomilehto J, Saukkonen TT, et al. Increased levels of cow’s milk and blactoglobulin antibodies in young children with newly diagnosed IDDM. Diabetes Care 1993; 16:984-989

Stark PL, Lee A. The microbial ecology of the large bowel of breastfed and formula-fed infants during the first year of life. J Med Microbiol 1982; 15:189-203

There are times when a nursing mom needs to take certain medications.  Many physicians are simply not well educated on medications and the safety of taking them while breastfeeding.  They may give information that is inaccurate and/or recommend that a mom wean to take a medication.  Breastfeeding is so very vital to an infant’s health and development and should be guarded more vigilantly by our medical community.  There truly is a small number of medications that are contraindicated for breastfeeding.

Dr. Thomas Hale is the leading expert on breastfeeding and medications.  If you have been prescribed a medication and been instructed to wean to take it, take the time to get the accurate information on that medication and how it pertains to nursing.  Your proactive manner of handling this could be what saves your breastfeeding relationship!

There are other categories listed in the “How to Use this Book” section of Dr. Hale’s book.  They include:

Theoretic Infant Dose:

This is an estimate of the maximum likely dose per kilogram per day that an infant would ingest via milk.  Because the literature is highly variable, I used several methods to calculate this estimate.  First, if the authors provided milk AUC information, I used this data to estimate the dose to the infant as it is much more accurate.  But more commonly, the only data provided was the peak milk level, also called Cmax.  In these cases I used this data to derive the theoretic infant dose.  For determining dose I used the standard milk intake of 150 mL/kg/day multiplied times the concentration of medication in milk (Cmax/Liter X 0.150 mL/kg/day = TID).  Please remember, this is generally the maximum concentration that would be transferred.  Most often the actual dose to the infant would be much lower.  If you know the maternal dose, calculate the Relative Infant Dose using the formula on page 12.  It may prove very useful.

Adult Concerns:

This section lists the most prevalent undesired or bothersome side effects listed for adults.  As with most medications, the occurrence of these if often quite rare, generally less than 1 – 10% of the time.  Side effects vary from one patient to another and should not be overemphasized, since most patients do not experience untoward effects.

Pediatric Concerns:

This section lists the side effects noted in the published literature as associated with medications transferred via human milk.  Pediatric concerns are those effects that were noted by investigators as being associated with drug transfer via milk.  They are not the effects that would result from direct administration to the infant.  In some sections, I have added comments that may not have been reported in the literature, but are well known attributes of this medication and are useful information to provide the mother so that she can better care for her infant (“Observe for weakness, apnea”).

Drug Interactions:

Drug interactions generally indicate which medications, when taken together, may produce higher or lower plasma levels of other medications, or they may decrease or increase the effect of another medication.  These effects may vary widely from minimal to dangerous.  Because some medications have hundreds of interactions, and because I had limited room to provide this information, I have listed only those that may be significant.  Therefore please be advised that this section may not be complete.  In several references, I have suggested that due to the large number of interactions the reader consult a more complete drug interactions reference.  Please remember that the drugs administered to a mother could interact with those being administered concurrently to an infant.  Example:  Maternal fluconazole and pediatric cisapride.

Alternatives:

Drugs listed in this section may be suitable alternate choices for the medication listed above.  In many instances, if the patient cannot take the medication, or it is a poor choice due to high milk concentrations, these alternates may be suitable candidates.  WARNING: The alternates listed are only suggestions and may not be at all proper for the syndrome in question.  Only the clinician can make this judgment.  For instance, nifedipine is a calcium channel blocker with good anti-hypertensive qualities, but poor anti-arrhythmic qualities.  In this case, verapamil would be a better choice.

Adult Dosage:

This is the usual adult oral dose provided in the package insert.  While these are highly variable, I chose the dose for the most common use of the medication.

T 1/2 =

This lists the most commonly recorded adult half-life of the medication.  It is very important to remember that short half-life drugs are preferred.  Use this parameter to determine if the mother can successfully breastfeed around the medication, by nursing the infant…then taking the medication.  If the half-life is short enough (1 – 3 hrs), then the drug level in the maternal plasma will be declining when the infant feeds again.  This is ideal.  If the half-life is significantly long (12 – 24 hrs), and if your physician is open to suggestions, then find a similar medication with a shorter half-life (compare ibuprofen with Naproxen).  I have provided “Family” tables in the back of this text, so you can compare family members for half-lives and other kinetic parameters.

PHL =

This lists the most commonly recorded pediatric half-life of the medication.  Medications with extremely long half-lives in pediatric patients may accumulate to high levels in the infant’s plasma if the half-life is exceeding long (>12 hrs.).  Pediatric half-lives are difficult to find due to the paucity of studies.

M/P =

This lists the Milk/plasma ratio.  This is the ratio of the concentration of drug in the mother’s milk divided by the concentration in the mother’s plasma.  If high (>1 – 5) it is useful as an indicator of drugs that may sequester in milk in high levels.  If low (<1) it is a good indicator that only minimal levels of the drug are transferred into milk (this is preferred).  While it is best to try to choose drugs with LOW milk/plasma ratios, the amount of drug which transfers into human milk is largely determined by the level of drug in the mother’s plasma compartment.  even with high M/P ratios and LOW maternal plasma levels the amount of drug that transfers is still low.  Therefore, the high M/P ratios often provide an erroneous impression that large amounts of drug are going to transfer into milk.  This simply may not be true.

PK =

This lists the time interval from administration of the drug, until it reaches the highest level in the mother’s plasma, which we call the Peak.  In pharmacology literature it is most commonly abbreviated Cmax.  The peak is when you do not want the mother to breastfeed her infant, rather, wait until the peak is subsiding or has at least dropped significantly.  Remember, drugs enter breastmilk as a function of the maternal plasma concentration.  The higher the mom’s plasma level, the greater the entry of the drug into her milk.  If possible, choose drugs that have short peak intervals, and don’t let mom breastfeed when it peaks.

PB =

This lists the percentage of maternal protein binding.  Most drugs circulate in the blood bound to plasma albumin.  if a drug is highly protein bound ti cannot exit the plasma compartment as well.  The higher the percentage of binding the less likely the drug is to enter the maternal milk.  Try to choose drugs that have high protein binding, in order to reduce the infants exposure to the medication.  Good protein binding is typically greater than 90%.

Oral =

Oral bioavailability refers to the ability of a drug to reach the systemic circulation after oral administration.  it is generally a good indication of the amount of medication that is absorbed into the blood stream of the patient.  Drugs with low oral bioavailability are generally either poorly absorbed in the gastrointestinal tract, or they are sequestered by the liver prior to entering the plasma compartment.  The oral bioavailability listed in this text is the adult value; almost none have been published for children or neonates.  Recognizing this, these values are still useful in estimating if a mother or perhaps an infant will actually absorb enough drug to provide clinically significant levels in the plasma compartment of the individual.  The value listed estimates the percent of an oral dose that would be found in the plasma compartment of the individual after oral administration.  In many cases, the oral bioavailability of some medications is not listed by manufacturers, but instead terms such as “Complete”, “Nil”, or “Poor” are used.  For lack of better data, I have included these terms when no data is available on the exact amount (percentage) absorbed.

Vd =

The volume of distribution is a useful kinetic term that describes how widely the medication is distributed in the body.  Drugs with high volumes of distribution (Vd) are distributed in higher concentrations in remote compartments of the body, and may not stay in the blood.  For instance, digoxin enters the blood compartment and then rapidly leaves to enter the heart and skeletal muscle.  Most of the drug is sequestered in these remote compartments (100 fold).  Therefore, drugs with high volumes of distribution (1 – 20 liter/kg) generally require much longer to clear from the body than drugs with smaller volumes (0.1 liter/kg).  For isntance, whereas it may only require a few hours to totally clear gentamycin (Vd = 0.28 l/kg) it may require weeks to clear amitriptyline (Vd = 10 l/kg) which has a huge volume of distribution.  In addition, some drugs may have one half-life for the plasma compartment, but may have a totally different half-life for the peripheral compartment, as half-life is a function of volume of distribution.  For a complete description of Vd, please consult a good pharmacology reference.  In this text, the units of measure for Vd are liters/kg.

pKa =

The pKa of a drug is the pH at which the drug is equally ionic and nonionic.  The more ionic a drug is, the less capable it is of transferring from the milk compartment to the maternal plasma compartment.  Hence, they become trapped in milk (ion-trapping).  This term is useful, because drugs that have a pKa higher than 7.2 may be sequestered to a slightly higher degree than one with a lower pKa.  Drugs with higher pKa generally have higher milk/plasma ratios.  hence, choose drugs with a lower pKa.

MW =

The molecular weight of a medication is a significant determinant as to the entry of that medication into human milk.  Medications with small molecular weights (<200) can easily pass into milk by traversing small pores in the cell walls of the mammary epithelium (see ethanol).  Drugs with higher molecular weights must traverse the membrane by dissolving in the lipid bi-layers, which may significantly reduce milk levels.  As such, the smaller the molecular weight the higher the relative transfer of that drug into milk.  Protein medication (e.g. Heparin, Insulin), which have enormous molecular weights, transfer at much lower concentrations and are virtually excluded from human breastmilk.  Therefore, when possible, choose drugs with higher molecular weights to reduce their entry into milk.

Note:  If you have a chronic disease or condition for which regular medications have been necessary, I would suggest purchasing a copy of Dr. Hale’s book to take with you to all doctor appointments.  Many doctors and specialists simply aren’t aware of how compatible most medications are with breastfeeding because it just isn’t their specialty.  Take the responsibility upon yourself to arrive with the information in hand that may be needed for your appointment and you will save yourself many headaches.

From:  Medications and Mothers’ Milk (2002) by Thomas W. Hale, PhD

“If you don’t give a bottle to your baby in the first two months, he may never take one,” said an article. Wouldn’t want that to happen, I thought. I knew that I should not give artificial nipples in the first six weeks. To be safe, I decided to wait seven.

By seven weeks, nursing was quite familiar and pain free. I made the decision that it was time to try a bottle experiment. I hand-expressed about an ounce into a bottle and sat down to see if David would drink it. After some initial hesitation, he took it and then happily went back to my breast. I breathed a sigh of relief. I thought I could go back and forth from the bottle to the breast with no problems. A week later, I gave him his second bottle.

Uh oh. There’s trouble in paradise. David wouldn’t open his mouth wide enough to nurse. When he did open his mouth, he immediately stuffed his fist into it and then was furious that there was no milk there. I swaddled him to keep his hands confined but he kicked off his blanket. After a great deal of effort, I’d get him to latch only to hear the dreadful clicking sound. He was sucking his tongue instead of properly latching. When he did latch, I was afraid to take him off even if I was in pain. It took so much work to get him latched, even if it wasn’t a good latch, that I didn’t want to stop and start all over again. The bad latch continued. The blisters came back. The pain came back.

Nights were the worst. Time after time, I sat trying to get David to latch on. I tried all sorts of variations: lying down, sitting up, with or without the Boppy. Time was ticking away and still my baby was hungry. He was screaming, I was wailing and my husband was about to break down, too. The frustration of the whole situation was about to overwhelm us all. At one point my husband asked me “Are you going to feed him or not?” “I can’t feed him,” I sobbed back, “he has to feed himself.”

After forty-five minutes, David finally latched on and soon he is asleep. An hour and a half later we were doing it all over again.

Looking back at it now, I have no idea why I didn’t just give David a bottle. In my exhaustion I simply sleepwalked out of the realm of reason. Instinct took over and the bottles were not an option. I just knew that I had to put my son to the breast if I wanted to feed him. By sheer luck I avoided the slippery slope of nursing sessions replaced with bottles, increased nipple confusion and perhaps progressing to decreased supply and a premature end to breastfeeding. I danced on the edge of a cliff and didn’t even realize that it was there.

I was just plain lucky that David never rejected the breast. Perhaps waiting those seven weeks did that much good. It was obvious that he knew where the good stuff was and he wanted to get it. It just seemed as if he had forgotten how. That quickly, after only two bottles a week apart and with a spoonful of milk each, he was confused about how to latch. I never realized that nipple confusion could grab a hold so quickly or fiercely. I didn’t know that even an occasional bottle could jeopardize my entire nursing relationship.

I don’t remember how long this nightmare lasted. Time sort of suspends itself when you are struggling with your baby. I know that the worst was over within ten days. A month later it was all a distant memory as I was telling a friend how smoothly our breastfeeding relationship had started.

Two and a half years later, I start my days with my son snuggled against my breast. If I needed a reward for holding out against nipple confusion, I couldn’t have asked for a better one.

As a full-time working woman and part-time pumping mom, I’ll be the first to admit that pumping breastmilk for my baby can be a bit inconvenient. But then again, babies can be a bit inconvenient.

When I was originally nervous about whether I’d be able to keep up, another pumping mom at my job gave me her perspective.

At the time, I was exhausted and hugely pregnant. It was while making my regularly scheduled waddle to the bathroom that I bumped into Amy. She’d been taking over the ladies room of our small loft office space for about eight months to pump milk for her son. Some of the younger employees would smirk when they saw her with her pump bag and a door sign that simply said “Bathroom in use for 15 minutes.” She took it all in quiet good humor.

“Amy,” I said, “I gotta be honest with you. I don’t know if I’m up for that pumping thing.”

She stopped, and with a warm smile of the maternal sisterhood, gave me what was likely my first lesson in parenthood.

“Sharon, let me tell you, I don’t like that I have to leave my baby during the day and I do feel guilty about it. But three times a day, I take 15 minutes to do something for him. Something that I can do even though I’m not with him. I sit, think about nothing but him and produce the perfect food for him. Then when I get home, I drop my bags and reach for him. We nurse to re-connect in a way that we probably wouldn’t if we were formula feeding. The pumping is for him and for me.”

She hugged me and we both had a short little “hormonal moment” thinking about our respective babies. I thought a lot about what she said, because it made perfect sense. As it happened, my first real lesson in parenthood was about listening to your heart. My heart said that I had to give pumping an honest try.

Later on, she and another mother at work organized a group to pitch in for what I now think is the perfect shower gift for a working mother: a Medela Pump In Style.

I’ve been pumping for awhile now, and it has actually gone smoother than I imagined. Three times a day, I now take over our ladies room with my door sign and pump bag. I sit, relax, and think about my baby. Regardless of what kind of workday I have, I go home happy with the gentle heft of the bottles of breastmilk in my cooler bag to remind me that I accomplished something important today.

I make my long commute home, walk in the door, drop my bags, and reach for my baby girl. We baby-waltz to the couch where she nurses herself into a stupor. I watch her rolling her eyes in ecstasy and relax for a few minutes, awash in the stress-reducing hormones that nursing releases. I still hate leaving her, but I love coming home to nurse her.

If you haven’t decided about whether or not pumping is for you, please think about it. You may find that it’s the one thing that keeps you sane while trying to juggle the incredible load of full-time mother and full-time employee. Remember, the saddest thing is in giving up before you even try.

I suppose that many would say that worrying about how your formula fed your baby is ridiculous.  It’s over and done with, and there’s nothing you can do to change what’s done. However, I still worry.  Why? My daughter is eight now. She suffers from allergies; some food and some environmental.  Dairy is one of them.  As a small child, she had almost constant ear, nose and throat infections: Bronchitis, pneumonia, ear infection, ear infection, ear infection. Now that I know what I do about cow’s milk based formulas, I believe her early weaning could have caused these problems.  I accept my portion of the blame.

Here’s what happened.  My daughter was born on a fine April evening.  The labor nurse helped me latch her on right after delivery.  It was wonderful.  She was an expert nurser right from the start. We exclusively nursed until it was time for me to return to work. That is when the troubles began.

I had a pump. However, I wasn’t a great pumper, and no one around me could help me figure out how to pump enough to avoid formula while I was away. Soon, I stopped pumping, because it was too much of a hassle, and everyone around me said that formula was “just as good”.  I was still nursing at home, but soon that dropped to only once in the morning and once at night before bed.  At six months, my supply had dropped so badly that my daughter refused the breast.  I now know more about the dangers of supplementing to a nursing relationship, and  believe she had a case of nipple preference. So we weaned.  Just like that.  The end.

I truly thought there was nothing I could do to reverse the situation, and I really didn’t think there was any reason to.  Formula was fine.  Baby was fine. Or so I thought.

Now, let’s fast forward to my second child.  My pregnancy was a nightmare.  I was on bedrest  because of preterm labor.  I was petrified that my baby would be born prematurely, and THEN what would I do??  Well, I started researching and everywhere I read I saw more on the benefits of breastfeeding a premature baby.  They need the physical contact.  They need the breastmilk that only the mother of a premature infant can make. Breastmilk drastically reduces the risk of NEC (Necrotizing Enterocolitis). Breastmilk is easier on a premature infant’s digestive system.  Breastmilk provides immunities that formula cannot. The benefits go on and on and on.

An  anger began to build within me.  I was becoming furious. Why??  Why had I been led to believe that formula was just as good as breastmilk? Why had no one told me before that there was any difference?  No one told me.  NO ONE. How could I have been so ignorant?  How could I have fed my precious child formula?? And what was I now to do with this rage within me?

I determined that I would overcome any obstacle, and I would nurse this second child. Thankfully, he was NOT born prematurely.  We latched on for the first time at the hospital seconds after his birth, and we haven’t looked back since.  He is, at the time of this writing, fourteen months old.  Never in my wildest dreams would I have imagined that one day my baby and I would be where we are today.  It is beyond joy to look at my darling son and know that I have been able to give him the very best.  Not a drop of formula has passed his lips.

I thank all those who helped educate me.  I thank that nurse at the hospital that helped us latch for the first time.  I thank my son for loving the gift that only I, his mother, can give  him.

I am thankful, because I have learned my lesson.

In April of 1998 my husband and I found out we were expecting our first child. There were, of course, the usual feelings of excitement and trepidation. We thought about clothes, strollers, car seats, and diapers, but we never thought much about what we would feed our precious baby. That is, until we started natural childbirth classes.

There we were, learning breathing techniques and that breastfeeding was best. Curiously enough though, our Lamaze teacher never told us why breastfeeding was best. We were also told that not every Mom or baby could handle breastfeeding, and that we shouldn’t feel guilty if we had to use formula. I remember seeing a phone number for La Leche League on a pamphlet, but no one ever told me what La Leche League was or how it could help me.

On November 25, 1998, I gave birth to a beautiful baby girl. I was quite amazed to find that after all those hours of labor I wasn’t ready to sleep. In fact, I felt strangely energized and ready to hold my little girl and get off to a good start breastfeeding. I took her and laid her tiny little head in the crook of my arm and offered her my breast. I expected to feel a little strange at first, but all I felt was strangely complete.

Then came a long night of constant nursing. I felt like she was permanently attached to my breast, and what’s worse, it was really starting to hurt. The next day the pain was so bad I called the nurse for help. The nurse asked me how often I had been feeding her. I told her I’d been nursing every time she seemed hungry, which was at times every 45 minutes. The nurse said, “Oh my, no wonder you’re sore!  Didn’t anyone tell you that you should only be nursing every 3 hours?”

I cried, I felt like I was already messing things up. The nurse left with the promise of sending in a lactation consultant to make sure Lily was latching on correctly. A few hours later, the lactation consultant came to check things out. It seemed her timing was perfect, I had just put her to the breast. The lactation consultant stood in the doorway, watched a minute and then left saying that everything looked fine. I remember thinking I’d just have to deal with the pain until my nipples toughened up.

The nipple pain, though, soon became only one of a whole host of problems. I was discharged from the hospital 12 hours after giving birth with orders to take my daughter to her pediatrician in two days for a 48 hour checkup. So, I went to the pediatrician thinking I would be in and out in no time. We went back, she was weighed and we were put in a room. A little while later the doctor came in with a grim look on his face. She had gone from her birth weight of 7 lb. 7 oz. to 7 lb. 1 oz.

The pediatrician said she had lost too much weight and that I needed to supplement. All I could do was sit and cry. I had failed again. I was trying so hard to be a good Mommy and do the right thing, but I was failing miserably. At least that’s how I felt at the time. I walked out of the pediatrician’s office with a box of formula samples and a very heavy heart.

I started supplementing. I gave her an ounce of formula after each nursing, still making sure I was only nursing her every three hours. She seemed content on the formula and happy with the bottle, but nursing her got more and more difficult as the days went by. My nipples were not just sore anymore, they were cracked and bleeding. Still, I continued to nurse before every bottle, crying in pain the whole time.

At her two week appointment she was up to 8 lb. 1oz. The pediatrician was quite happy. I asked him if I still had to supplement and was told that I might be able to drop one or two bottles, but that formula was what was making my daughter gain weight. So, I left with more formula samples.

A month later things got even worse. My nipples hadn’t gotten any better and she was refusing to take the breast at all. I went out and bought a breast pump in the hopes of continuing to give her at least some breastmilk. I didn’t have very much luck with the pump and it was murder on my still cracked and bleeding nipples. I hung in there though, until she started getting extremely sick every time she got a bottle of expressed milk.

At her three month well baby visit I finally broke down and could barely tell the pediatrician what had been going on because I was crying so hard. He told me that my daughter was allergic to breastmilk and I’d have to switch over to formula completely. That’s when I felt like the biggest failure of all time. I also felt like such a bad mother for giving my daughter something she was allergic to for what I perceived as my own ego. I wanted to breastfeed, but Lily had been showing a preference for the bottles of formula for a while. Why had I been so blind to Lily’s needs?

So, we switched to formula. Then two months later I found out I was pregnant again. A few months into the pregnancy we moved. I had to find a new OB and a new pediatrician. When I took her in to the new doctor he asked me why I wasn’t still nursing. I explained everything to him. He then proceeded to tell me how sorry he was that I had gotten so much bad advice from the start. I, of course, got defensive. Who was he to say that all those other people had been wrong? But, I left his office with an explanation of what La Leche League was and how to contact them.

My mother taught me at a very young age that a person should always be willing to learn. Being pregnant, I decided to contact LLL and see what kind of information they could give me. Maybe this new pediatrician was the one that was right after all. I owed it to the new baby to find out.

It turns out he was right. I learned so much that I got angry. Why had I been given such horrible advice? Why didn’t the nurses at the hospital where my daughter was born know that newborns should never be put on a schedule? Why didn’t they know that sore nipples weren’t caused by nursing too much, but rather by a bad latch on? Why didn’t the lactation consultant tell me about the different nursing holds and that the cradle hold is one of the most difficult when you’re learning? Why didn’t her first pediatrician know that it’s normal for breastfed babies to lose up to 15% of their birth weight and not really start to gain it back until a mother’s milk comes in? Why didn’t he know that babies aren’t allergic to breastmilk, but can be allergic to things Mom eats that are passed on in breastmilk? Why didn’t he know about nipple confusion? Why on Earth would he tell me formula was just as good as breastmilk? Why didn’t anyone tell me what to do about my cracked and bleeding nipples? There were so many why’s and only one answer. Most medical professionals are grossly uninformed about breastfeeding.

I decided I was going to learn all I could possibly learn. I read everything I could get my hands on. I went to La Leche League meetings regularly. I met and talked with other nursing moms. There was still only one thing to overcome, my guilt at putting my precious daughter on formula when I really didn’t have to. Guilt is a very powerful thing. It took a while before I could look at her without feeling like I had let her down horribly. But life moves on and what kind of person would I be if I didn’t learn from my mistakes and do as much as I could to turn a negative experience into something positive.

On January 18, 2000, I gave birth to a handsome baby boy. This time I knew better. When I got bad advice from the hospital nurses, I took the time to educate them in the hopes that they’d listen and learn. I can only hope they didn’t turn a deaf ear; the fate of many nursing relationships start in their hands.

My son is 14 months old and still happily nursing. And, when my milk came in with him, I started giving my daughter cups of expressed breastmilk. Better late than never, right? I hit a few bumps in the road with him, but I knew where to go to get help. My husband and I are expecting our third in May. I have to say I look forward to tandem nursing and all the challenges it will bring.

When I found out I was pregnant with my first child I was so very excited. I signed up for all the classes that the hospital offered. Among them was a four hour breastfeeding class. It was broken down into two weeks worth of sessions, each two hours in length. I couldn’t imagine why anyone would need that much instruction!!

The classes were run by an Internationally Board Certified Lactation Consultant (IBCLC), and she seemed like such a warm caring lady! I remember during one of the classes someone asked her how long she nursed her babies. I was intrigued when she answered “probably what most would consider a long time.” I had no idea what she could mean.

The first class that was given dealt mainly with getting breastfeeding off to a good start and how to be successful at continuing. The second class was on working and nursing. Up to that time I hadn’t given much thought to what one does when she is working, and nursing. I am so thankful now for that class. I never would have been able to work and nurse my babies if it weren’t for that IBCLC! She gave us handouts covering what kind of pumps are available, spoke with us on milk storage, what to wear to work, to facilitate pumping and more. She made herself available to us by phone in case questions came up later.

One disadvantage for me with this breastfeeding class, was the lag time between the class (August) and when I actually went back to work (January). By that time, some of the finer points were fuzzy, and I relied heavily on library books to keep me going. I knew no one else who had worked and pumped for more than a few weeks. I am honestly not sure what kept me going. The first few weeks back at work were so difficult. I worked twelve hour shifts, so would be away from home for fourteen hours on average. Fortunately I worked only seven out of fourteen days. My baby would get up every two hours to nurse, and I was exhausted. One day in desperation, I laid down to nurse her, and didn’t wake up until morning. As I awoke I remember looking down to my peacefully sleeping babe, who had her mouth still open, just an inch from my nipple. I giggled, thinking of the all night buffet that must have gone on while I slept peacefully. After that I never got up to feed her again. She slept with me, and nursed at will all night. Both of us were better rested!!

Another “learning experience” for me came with the type of pump I was using. On the recommendation of my LC, I bought a Medela Mini-electric. At the hospital they had given me a Medela hand pump as well. Trying to save money on a pump, I decided to use the two together to “double pump” since I knew that would help my milk supply. I’m sure I was quite a sight that first week!! I managed a system to hold the mini electric in the crook of my arm, while operating the hand pump with one hand, and holding it with the arm that was holding the electric in place! By the end of the first week I went out and bought a second mini-electric. These pumps worked very well for me, even though they are not rated for full time use. After eight months of using the two mini electrics, a friend loaned me her Medela Pump in Style. It was wonderful and I used it until I quit pumping when my daughter was fifteen months old. I bought one for myself when I had my second daughter.

In the same way that nursing a baby is a little different for every mom, so is pumping for your baby. After reading all you can, and talking with anyone you can find that has done it, it comes down to what works for you. Here are a few personal tips that worked for me:

• Keep a “goodie bag” at work with extra supplies. This helps increase confidence, and often makes a minor setback one less hassle to deal with. In my goodie bag I kept: extra breast pads, an extra shirt, non-perishable snacks, some money (for those days I forgot my lunch!), extra pump parts and a hand pump that didn’t require electricity.
  
• Develop a support network. I worked with almost all women, few of which had nursed a baby, and none had pumped for more than a few months. While they couldn’t give me ‘been there, done that’ kind of support, there were several who were supportive anyway. You will probably quickly learn who you can count on, and who doesn’t really understand why you are doing this. It is also important to find a support network outside of work. My husband was very supportive, as were my LC and parents. You need someone who will keep you going during the hard times, not help you find a way to quit.
  
• Freeze milk in small quantities. I found that this reduced waste, and was easier to thaw. My husband was the primary caregiver for my second daughter and had a fear of feeding the baby a bottle, only to have her want more, and scream endlessly until he could get it defrosted. I, on the other hand, had a fear of him wasting the milk. Small portions seemed to be a good compromise for us. I froze in ice cube trays–each one was approximately one ounce. They defrosted quickly, and later were the perfect size to cool off a bowl of oatmeal, and get it to the right consistency for a baby on her first foods!!
  
• Have confidence in yourself. One of the things that helped me the first time around, is that I didn’t realize that I could fail. I was naive, and didn’t know about all the things that could go wrong. When I ran into a problem I remember thinking to myself “that’s funny, wonder what is up”, and keeping on. I never kept formula in the house, and just didn’t think of that as an option. In my weakest moment at the pump I remember thinking “so what if I don’t bring any milk home? What if I’m tired of all of this?” then I thought of the alternative (formula) and figured my hubby would be disappointed, and so would I after I got some rest!!
  
• Get a dishwasher. Sounds silly, but it was such a wonderful thing for me. When I got home from work, the last thing I wanted to do was take apart my pump and carefully wash it so I could have it ready for the next day. It was glorious to be able to toss the parts in the dishwasher and have them ready in the morning! Whether you get an automatic dishwasher, or designate the duty to your husband, this is something I highly recommend.
  
• Get a routine for your homecoming. There was one occasion–ONE only when my milk got left out all night. I had asked my husband to get it out of my pump bag, and put it away, and he didn’t hear. You can only imagine the weeping that happened over that milk!! Get a routine down for putting away your milk and prepping the pump for the next day. While that is the last thing you want to do, it is important!!
  
• Enjoy your baby. This sounds obvious, but it is so important!! When you are working and nursing, often there is so much extra work given to feeding the baby, that we forget to pure and simple enjoy her! Granted, pumping creates some extra work, but it is important, and we shouldn’t lose sight of why we are doing it. Take time to enjoy the baby–even if it means taking a sick day now and then. You and your baby deserve it.