Jaundice, Part II: What is Jaundice and How is it Treated?

This is the second in a two-part series on jaundice, a relatively common and usually mild condition that occurs in newborn babies. In Part I, I described my own experience with jaundice in my fourth baby. Here in Part II, we'll look at jaundice from a clinical perspective.

What is newborn jaundice?

Jaundice in newborns is caused by rising bilirubin levels in the blood. Bilirubin is a byproduct of the breakdown of red blood cells, which all babies have an excess of at birth. Normally, bilirubin is processed by the liver and excreted through bowel movements. While many babies will effectively and efficiently process this excess bilirubin, some babies have too much bilirubin, or their liver can't handle all of the bilirubin they're producing, which causes it to build up in the blood. When this happens, some of the bilirubin is passed to the skin, which will give the whites of the eyes and the skin a yellow-ish tint. If the bilirubin levels in the blood reach high levels, treatment may be recommended.

There are three basic types of jaundice found in newborns:

• Physiological Jaundice is the normal course of elevated bilirubin caused by the breakdown of red blood cells in the newborn baby. This type of jaundice is normal and not dangerous unless bilirubin levels reach a certain threshold. Most babies will require no special treatment.
• Breastfeeding Jaundice occurs when a breastfed baby isn't getting enough to eat in the first several days of life. Because he is not feeding well, he is not having enough bowel movements to clear out the bilirubin from his system. If bilirubin levels reach a certain threshold, various treatment scenarios may be proposed. Otherwise, assistance with improving breastfeeding is typically all that is needed.
• Breastmilk Jaundice occurs in a very small percentage of babies and is when an exclusively breastfed baby has elevated bilirubin levels but no other symptoms of jaundice and is feeding well and growing as expected. This is not a dangerous condition and will typically resolve within 6 to 10 weeks without intervention.

Notice that all three types of newborn jaundice usually resolve without treatment. Once good feeding is established and the baby's digestive system is kicked into gear, he will clear out the bilirubin on his own. 

Jaundice occurs more commonly in premature babies or babies whose liver may otherwise be compromised. It also may be caused or complicated by blood type incompatibility between the baby and the mother, birth injury, medications, or infection.

My oldest son N with jaundice. You can see how yellow his forehead looks. He was being treated in the hospital and was taken off the lights for a feeding in this picture.

When does jaundice need to be treated?

The trouble with elevated bilirubin is that it is known, at high levels, to cause a totally preventable, irreversible, severe brain damage called kernicterus. Kernicterus occurs when bilirubin literally stains the brain cells. Babies with kernicterus will suffer lifelong mental retardation, which may include both physical and cognitive delays. Kernicterus happens when the bilirubin levels in the blood are so high that bilirubin is conducted into the brain. It is not known what these levels need to be to cause kernicterus, and it is not clear if simple physiological jaundice, breastfeeding jaundice, or breastmilk jaundice alone can cause this terrible outcome or if other complications are involved. It is clear, however, that by reducing bilirubin levels before they reach a high concentration will prevent kernicterus.

To determine if your baby is at risk for needing additional treatment for jaundice, your pediatrician will order a blood test to measure your baby's bilirubin level. This will be plotted on a chart along with the baby's age (see below). There are four identified curves on this chart: Low Risk, Low Intermediate Risk, High Intermediate Risk, and High Risk. If your baby's bilirubin levels fall into the High Intermediate or High Risk zone, treatment will likely be recommended.

Find your baby's age along the bottom and plot the Serum Bilirubin level on the vertical axis 

to see which zone your baby's jaundice risk falls in.

Aside from kernicterus, jaundice may cause other difficulties in the early days of your baby's life, which may prompt your doctor to recommend treatment or management. High levels of bilirubin may cause your baby to become sleepy and uninterested in eating. This will make it more difficult for your baby to clear out bilirubin, and it will mean fewer feedings at the breast, which may cause a delay in your breastmilk increasing in volume, or it may cause a low supply due to lack of stimulation. This, in turn, will mean your baby is not getting enough to eat even when he does wake to eat, which will make him more dehydrated and lethargic, which will make him less likely to wake to feed, which will further reduce the amount of calories and fluids he takes in, which will worsen the jaundice and continue the cycle. This is a very dangerous cycle because you end up with a starving baby and a delay in milk production or a reduced supply. In this case, treating both the feeding issues and the jaundice are priorities.

Most pediatricians will recommend treating any kind of jaundice before bilirubin levels reach 20mg/dL in the blood. Most babies will not reach this critical point, but some may approach it, and it is important to know what the treatment options are so that you can make an informed decision about whether, when, and how to treat your baby for jaundice.

How do we treat jaundice?

The simplest treatment for jaundice is feeding. If your baby has not been feeding well, increasing the number and quality of feedings will help stimulate bowel movements and clear out the bilirubin. Make sure your baby is eating at least 12 times a day and that when he feeds, he is actually taking in colostrum or milk. Watch for signs of a deep suck and swallowing when your baby is feeding. Make sure he is actively sucking and swallowing for at least several minutes at a time. If he falls asleep at the breast after a very short time, try to stimulate additional sucking by massaging the breast while he is latched on. You can try to wake the baby by burping him or changing his diaper and then return him to the breast for further feeding. Also, be sure to monitor diaper output. 

If your breastmilk has not increased in volume by the end of the third day postpartum (72 hours), it is important to feed your baby from some other source, whether donor breastmilk or formula. The number one rule, here, is feed the baby. Ideally, this supplementation would occur at breast using a feeding tube or syringe so that the baby can continue to stimulate milk production while receiving the supplemental milk or formula. A three to four-day-old baby does need more than colostrum, though colostrum is enough for a baby in the first and second days of life.

If the baby is feeding well but bilirubin levels remain in the High or High Intermediate Risk zones on the above chart, phototherapy may be recommended. Phototherapy involves the use of a special blue light that shines on the baby, with a maximum amount of skin exposed to the light. The light breaks the bilirubin down into a water soluble form that the baby can excrete through his urine. This, in addition to regular bowel movements, will bring down his bilirubin levels much more quickly. Phototherapy can be done in the hospital nursery or at home using a portable phototherapy device. Your doctor will likely have a preference as to whether to keep your baby in the hospital (or readmit him) to use the hospital phototherapy bed or whether to have a home healthcare service bring you a home phototherapy machine to use. It typically takes 12 to 24 hours, or up to two days at the outside, of phototherapy to bring down bilirubin levels to an acceptable range. It is important for the baby to continue to feed regularly while under phototherapy. Continue breastfeeding about every two to three hours. Phototherapy is not invasive and not painful for the baby. The baby is kept warm and generally just sleeps while under the lights.

Baby N on home phototherapy. A pad that emits light is against his back, connected to a machine 

by the gray tube you can see emerging from his blankets.

Some pediatricians may recommend supplementing with formula for 12 to 24 hours, or even a course of "interrupted breastfeeding" for 12 to 24 hours, to clear out breastfeeding or breastmilk jaundice. This path only becomes necessary if breastfeeding is not going well and the baby is clearly in need of feeding beyond what he is getting from his mother alone. Supplementation with formula will help to treat the jaundice, as it will cause the baby to pee and poop much more than from colostrum and early milk alone. It will also help to rouse a baby who is lethargic from lack of feedings and/or high bilirubin levels and may be helpful in severe cases. However, be aware that introducing formula may have other long-term consequences to your baby and your breastfeeding relationship. It is important to weigh the risks and benefits of supplementation. If possible, discuss these risks with your pediatrician and a lactation consultant before making your final decision. If you do choose to supplement, be sure you do not reduce the amount of at-breast feeding your baby does. If you cannot be with your baby, you should pump your breasts every two to three hours, or in between feedings, to stimulate your own milk production. It may be possible to supplement your baby with your own pumped milk rather than formula, if you are able to produce for a pump.

How long does it take for jaundice to go away?

Bilirubin levels will generally peak between days four and six of your baby's life and then taper off into a normal range in about one to two weeks. Your doctor may want to monitor your baby's bilirubin levels until they begin to fall by ordering daily blood tests. Assuming your baby is otherwise healthy and feeding well, once it is clear that his bilirubin has begun to fall, no further treatment will be necessary. Typically, once bilirubin levels peak and begin to drop, they will continue this downward trend.

The exception to this is breastmilk jaundice. Babies with breastmilk jaundice may appear yellow and have elevated bilirubin for up to about 10 weeks of age. Breastmilk jaundice is not dangerous and will go away on its own. As long as the baby is otherwise healthy, alert, feeding and growing well, and meeting milestones, you can simply wait until the jaundice resolves. Some pediatricians may recommend interrupting breastfeeding (stop breastfeeding and give formula) for one to three days to clear out breastmilk jaundice. While this will effectively "treat" the jaundice, it may have a negative impact on your breastfeeding relationship as well as introducing other risks of formula feeding. Unless there is other cause for concern, this is probably not a necessary step in simple breastmilk jaundice.

In the first week of life, while bilirubin is still elevated, watch your baby for sleepiness, not waking to feed, floppiness, and dehydration (urine crystals in the diaper, dry mouth, sunken fontanel). Examine your baby in natural light to look for increased yellowing. Contact your pediatrician immediately if you have any cause for concern.

Also, be aware that jaundice tends to run in families. If you have one baby with jaundice, there is an increased chance that a future baby will have jaundice as well. Jaundice is more common in boys than girls, as well. Indeed, all four of my boys had jaundice! 

I hope this information* helps you to have an meaningful conversation with your pediatrician if your baby is diagnosed with jaundice.

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*Please note that I am not a medical professional and cannot offer medical advice. This information is provided for your education only and should not be used in place of the advice of your pediatrician during an in-person examination.

Jaundice, Part I: Baby Boy Turns Yellow

This is the first in a two-part feature on jaundice. In this post, I'll tell you Baby Boy #4's jaundice story, and in the next post I'll address jaundice from a more clinical perspective. Now that Baby Boy has been named, we'll call him Y.

At 5:30 a.m. on Tuesday morning, when Y was about 27 hours old, the nursery did a heel stick to draw blood for his PKU test. This is a standard newborn screening done at approximately 24 hours of age. At the same time, they checked his bilirubin levels to see if he was at risk of needing treatment for jaundice. Most people know jaundice as a yellowing of the eyes and skin due to various problems associated with the liver. In newborns, it's a relatively common condition due to the breakdown of excess red blood cells in the baby's body after birth. Most babies will clear out the bilirubin on their own without needing special interventions, but some babies will have bilirubin levels high enough to elicit concern, as very high levels of bilirubin may cause irreversible brain damage called kernicterus.

But back to Baby Y. When the pediatrician came in to check him over and report on his test results, the first words out of her mouth were, "Did any of your other kids have jaundice?" When I told her all three had, and two had required home phototherapy, she nodded. She showed me his bilirubin level, which was 8.6. For his age, this was considered "high intermediate risk". If the number climbed into the "high risk" zone, he would require treatment. The chart below is the standard risk chart for newborn jaundice. You find the baby's age in hours along the bottom, then plot the bilirubin level on the left and see what curve you fall along. A level of 8.6 in a 28-hour old baby was near the high end of the high intermediate risk zone.

The question then was, do we take a wait-and-see approach, or do we take it on more aggressively, knowing that (a) all three of his brothers had relatively high bilirubin levels, and (b) he was already nearing the high risk zone? Levels usually peak between 4 and 6 days of age and then fall off gradually. To clear out bilirubin, the baby needs to poop, which means the baby needs to eat. Since breastmilk supply doesn't usually increase until day 3, and most babies under 3 or 4 days of age are still clearing out meconium, it takes a few days for the excess bilirubin to be excreted. I was still only producing a small volume of colostrum, and Baby Y wasn't pooping much, so we knew his levels would continue to rise for another day or two, at least. But we didn't know if they'd rise sharply or level off. There's really no way to know what will happen in any given baby.

I had been planning to go home on Tuesday, though I was technically entitled to another night in the hospital if I wanted to stay. The pediatrician suggested that I stay Tuesday night and let Baby Y have jaundice treatment through the night. In this way, we might be able to bring down his bilirubin levels to the low intermediate risk zone and then, even if the levels continued to rise a bit for another day or two, they would likely stay on that low intermediate risk curve. If we didn't treat Tuesday night, we would need to monitor him closely (by taking blood daily to measure his bilirubin levels), and if his numbers rose into the high risk zone, then we would need to treat, which might entail readmission to the hospital for him, meaning I'd have to find a place to stay because I would no longer be an inpatient there.

This put us in a tricky position. On the one hand, I really didn't want to spend another night in the hospital. I wanted to get home to my other three kids, I wanted to come back to life and out of the sickly-feeling, "I'm in the hospital" mode. On the other hand, it seemed the easiest way to ensure that Baby Y's jaundice would be managed with the least amount of hassle. A secondary, but real, consideration was that if his jaundice became severe, his bris would have to be delayed. This had happened with our second baby, and we needed to know if that would be necessary for Baby Y. It seemed that treating him Tuesday night would stave off this potential complication as well.

The pediatrician suggested that we talk it over and that she order another blood test for the afternoon. If the number still placed him on that high intermediate risk curve, or, G-d forbid, was even higher, then that might help us decide for sure whether to stay the night or not. I agreed that this was a good suggestion. So, at 36 hours of age, his blood was taken again, and his bilirubin level was 10.7, still on the high end of the high intermediate range, and likely to continue to rise for at least another day or more. We decided to take the aggressive approach. The goal was to keep him under the "bili lights" for the night, in the hope of getting his bilirubin levels to level off or even drop. If the numbers fell into the low intermediate risk range by morning, then we could feel comfortable going home and not worry so much about having to be readmitted for treatment or taking blood daily to monitor him. A clinical approach, visually examining his color, looking at other symptoms, would be enough to monitor his health, and further testing or treatment would only be required if any other symptoms gave his doctor or me cause for concern. (I will discuss all of these symptoms and risks of jaundice in part II of this article.)

At about 7:00 p.m., Baby Y was whisked off to the NICU to be placed under the bili lights. Basically, bili lights are flourescent, blue lights that break down the bilirubin into a water-soluble form that the baby can then pee out, in addition to the bilirubin being excreted in his bowel movements. It's important to maximize the amount of skin exposed to the lights, so the baby is placed in his bassinet in only a diaper, on top of a pad that shines light up against his back. The bassinet is then placed under a second light that shines down from above him. He wears eye covers to protect his eyes from the bright lights, and he basically just sleeps there. The baby should eat about every three hours but should not be off the lights for more than 30 minutes at a time. The idea is to find a balance between maximizing his time under the lights while still getting milk into him so that he can pee and poop. It's a tricky thing, especially with a newborn who wants to nurse a lot but is still getting colostrum and not the mature milk that will encourage more wet and poopy diapers!

It was strange for me, to spend a night in the hospital without my baby by my side. It was also strange to visit him in the NICU, my otherwise big, healthy boy in there with the sicker babies who needed so much more care. We got off to a bit of a rocky start, too. He was there only about 45 minutes before he was brought back to my room, screaming. "He says he's starving!" my nurse said. I nursed him, then wheeled him back to the NICU to go back under the lights. The nurses there were trying to get him to take a pacifier, but he was protesting it.

I was advised that if he was going to need to eat so often, the lights wouldn't be very effective. The protocol was three hours on, 30 minutes off, but he wasn't willing to go three hours without nursing. And normally I would have been perfectly fine with that! A two-day-old baby shouldn't necessarily go three hours without nursing, both for his sake and for mine! His suckling encourages my milk production to increase, as well as nourishing him and stimulating his digestive system. I was happy to feed him every hour or two, but that would render our night in the hospital ineffective. I was frustrated, and so were they.

One of the nurses told me that giving him a little formula would probably help, since it would fill him up so he could wait longer to nurse again, and it would make him pee. Without peeing, he wouldn't clear out the bilirubin. "You have to decide what's your priority - breastfeeding or treating the jaundice," she said. I felt a bit threatened or judged, like maybe by clinging so hard to the "exclusively breastfeeding" mantra, I might be causing my baby harm or wasting my time (and hers?). I was taken aback. I had made it clear that he was not to receive formula, his case of jaundice wasn't severe (yet?), and I was educated enough to know that giving even one bottle of formula when supplementation wasn't medically necessary could cause long-term harm. But I'll tell you something, in all honesty: I almost gave in. I was desperate for him to stay longer under the lights. I was so nervous about "wasting" our extra night in the hospital. I really wanted this treatment to work. And if a couple ounces of formula was all he might need...I hesitated. I felt like I was already breaking so many "rules." Here I was, a trained Lactation Educator, on my fourth baby, a self-proclaimed breastfeeding advocate and expert, and my baby was spending a night in the nursery, being offered a pacifier, and now I was thinking about delaying feeds and supplementing with formula besides.

I gathered myself. "Breastfeeding is my top priority," I told the nurse. "I don't want to mess up his gut with a bottle of formula if he doesn't really need it." If my head had been more in the game, I would have known what to do immediately, but since I was groggy from two nights without sleep, thrown by this change of plans, and caught off guard by this sudden suggestion of formula, I couldn't think of a solution. "Maybe he'll go longer this time," I said, and went back to my room.

The first thing I did back in my room was Google "formula supplementation for newborn jaundice" on my phone (thank G-d for smartphones!). I thought I remembered reading an article from the Academy of Breastfeeding Medicine on whether formula supplementation for normal newborn jaundice was necessary or standard protocol, and I wanted to refresh my memory. I found exactly what I was looking for (PDF). In short, formula supplementation is not recommended for treatment of newborn jaundice unless there are other complicating factors. Short-term formula supplementation can have long-term risks. While it will help to clear the jaundice, it may interfere with establishing a good milk supply, may cause nipple confusion in a baby who is still learning to latch and breastfeed, and will cause the gut flora to be affected by introducing cow's milk proteins and non-breastmilk compounds into the developing digestive system. My Lactation Educator classes came back to me in a rush, and I remembered what we had learned about jaundice and supplementation. There are indications for short-term "interruption of breastfeeding" under certain conditions, but my baby and my situation did not call for such a drastic measure at this point.

And like that, I knew what I needed to do. I marched myself (figuratively) back to the NICU and found a different set of nurses sitting near my sleeping baby.

"Is the reason you'd want to supplement because you could feed him while he's still under the lights?" I asked.

"Yes," one of the nurses said.

"So, if I were able to pump some colostrum, you could feed him that instead of formula?"

"Sure. We do that all the time. Ask your nurse to get you set up with a pump. You can bring us whatever you pump."

I tracked down my nurse and explained what I wanted to do. She said no problem, and within the hour, I was set up with a pump and had started harvesting that precious, precious liquid gold. I felt if I could get at least 10mL (about a third of an ounce) in any given sitting, that should be enough to tide him over between the every-three-hour breastfeedings. I had a mild concern that giving him bottles might affect his desire and ability to latch, but I felt it was worth the risk. At least by pumping between at-breast feedings, I was giving myself the breast stimulation I'd need to establish a good milk supply, as well as giving Baby Y the colostrum he needed to keep him full and happy and able to pee and poop.

On my first go, I got 10mL from both breasts. Thrilled with my success, I happily delivered my first of what would be five 10mL bottles of colostrum that night. In between 30-minute feedings and 15-minute pumping sessions, I'd conk out, sleep for an hour or 90 minutes, to be awakened from a weird dream or a deep sleep by my nurse wheeling in a crying baby ready to breastfeed again. Tired but pleased, morning came and we eagerly awaited his latest blood test, to find out the result of our night's effort.

Liquid Gold

After 12 hours on the bili lights, at 51 hours of age, his bilirubin levels were down to 9.9, lower than they had been at the previous test, and down into the low intermediate risk range for his age. Yes!

We came home later that morning with instructions to have him seen by his regular pediatrician on Thursday. His doctor checked him over and decided that doing another blood test was not necessary. He told me to keep an eye out for more yellowing, lethargy, or not waking to feed, but as long as he was producing diapers, was waking up when he was hungry, and was feeding well, he was not concerned.

Thankfully, Baby Y's breastfeeding was not negatively affected by the use of a pacifier or by giving bottles. My mature milk appeared, on cue, at about 2.5 days postpartum, and he began gaining weight at an incredible rate. At hospital discharge, he was 7lbs., 14oz., about 8 ounces below his birth weight of 8lbs., 6oz. On Thursday, he was up to 8 pounds even, and on Friday, he had gained an additional 3 ounces in 24 hours, to reach a weight of 8lbs., 3oz. Though he has not been weighed since, I'm certain that he has surpassed his birth weight already, at eight days old.

In the next article, I'll discuss jaundice from a clinical angle. I am grateful that I had the experience and educational background to be able to effectively advocate for myself and my baby. Don't be afraid to do your own research and ask questions. When it comes to your baby's health and your breastfeeding relationship, it's important to speak up!

Kids Need to See Women Breastfeeding

The other day, we were at a community barbecue at the Rabbi's house. I wandered into the living room of the house, where several of my friends were sitting around and chatting. One friend said she was sorry, but she thinks she made a faux pas. I couldn't imagine what she could have done. She explained that NJ had come in while one of the other mothers was preparing a bottle of formula for her daughter. (Not that she needs an excuse for this, but her daughter is 2.5, autistic, and has feeding issues, so she takes a bottle of formula to supplement her food intake.) He said something along the lines of, "I didn't have that when I was a baby!", to which my friend replied that he had. He argued, and she wasn't going to push the issue, so she just said, "Okay."

I shrugged and said, "No big deal. He doesn't know that he was formula fed." It's not that it's a big secret or anything. It just hasn't come up as a topic of conversation. He watches me nurse GI, and I think he has a vague awareness of my having nursed SB, and he's seen several of my friends nurse their babies, and he has always just assumed that (a) that's how you feed a baby, and (b) that's how he was fed. I call him my little five-year-old lactation consultant because he's very interested in breastfeeding and knows that it's the best choice for a baby. I haven't made a big deal of it, just exposed him to it by feeding his brothers. It has imprinted as "normal" on his brain, and I hope he carries that image with him into fatherhood so that he can be an awesomely supportive husband when his wife (G-d willing) has a baby (G-d willing).

I told my friend not to worry about it and that, if he asked me, I would talk to him about it. Apparently the whole episode didn't make much of an impression on him, because he hasn't mentioned it. It does make me wonder if I should sit him down and have "a talk" about it with him, but I mostly feel that it just isn't that important. At some point, it will come up in conversation, or he'll ask, and I'll explain that when he was born, Mommy wasn't as well-informed as she is now, and she was also very sick, and it was very hard for her to nurse him, so he got bottles of formula instead because he had to eat something. I'll tell him that we don't need to judge other mothers for how they feed their babies. (I wouldn't want to deal with the embarrassment of having him say something rude to a mother giving her baby a bottle! And he's the type who would say something, too, if it occurred to him.). I'll just say that some mothers decide to feed their babies formula from a bottle instead of nursing them for whatever reason, and that's their choice to make.

I'm glad that my sons are growing up exposed to women nursing. I think the image of a baby drinking from a bottle is so ingrained in our society that many girls (and boys) grow up thinking that's the only way to feed a baby. I know that when I had NJ, I didn't even really know what breastfeeding should "look like," or how it worked. I didn't know much about bottles, either, granted, but I think if I had grown up with more exposure to breastfeeding women, the idea of breastfeeding might have come more naturally to me. I didn't wrestle with the decision to breastfeed - I had intended to, before the circumstances of NJ's birth led me down a different path - but I didn't educate myself, and that was the mistake.

I think growing up knowing that babies are fed from the breast will serve more than one purpose. First, it will make breastfeeding normal, and that means that when they have their own babies, these children will think first of breastfeeding rather than bottles. Second, they will know how breastfeeding looks. How to hold the baby will come more naturally, because they'll have seen it live. They'll know how it should sound, and what the baby needs to be doing. They might even have talked to someone about how it feels or what problems she might have had. Certainly, they or their wives will need help and support from friends and relatives and medical providers and society as a whole in order to start and maintain a successful breastfeeding relationship, but they'll be motivated to breastfeed and motivated to seek out such support, knowing that their breasts were designed to feed their babies.

Growing up seeing breastfeeding as a regular and normal thing will also decrease the "breastfeeding in public" debate. If breastfeeding is just another thing you see every day, then it is no longer sensational or controversial, so there will be no need for debate. Feeding a baby is feeding a baby. It's not sexual or indecent or offensive. And if a baby suckling from a breast is as ordinary a sight as a child eating french fries, women will feel more confident in starting and continuing to breastfeed because it won't seem weird or unusual or "out there" or uncomfortable.

So, to my little five-year-old lactation consultant, my son who is so concerned for the welfare of babies, thank you for already being so supportive of breastfeeding. Thank you for showing that a child can process the idea of breastfeeding as normal, take it in stride, and establish a vision of baby feeding that will encourage him to champion breastfeeding for his own babies one day. Kids are not offended or put off by breastfeeding. It's kids who will become the next generation of breastfeeding supporters because they have been exposed to it as children and don't find it exceptional at all. And that's what we want.

And, if my son asks me how he was fed as a baby, he will also get to learn that sometimes we do need to use formula, and we don't think less of a mother just because she isn't breastfeeding. Maybe the next generation of "Mommy wars" won't include a breastmilk-versus-formula category at all.

Is It Really About What's "Easier?"

First of all, happy birthday to Jessica on Babies! This blog is officially a year old as of Saturday. I thank my loyal readers for keeping me writing, and my kids for giving me ever more to write about! I expressed interest in conducting a giveaway of my Kindle book in celebration of this milestone, but I need to know if people will participate in the sweepstakes if I run one. If you think you'd want to enter for a chance to win a free copy of my book for yourself or someone you know, please comment below or on my previous post and say so! Thanks! If I don't get any comments, I'll scrap the idea.

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The great debate in infant feeding rages on, especially now that the AAP has updated and clarified its guidelines on infant feeding:

"Breastfeeding and human milk are the normative standards for infant feeding and nutrition. Given the documented short- and long-term medical and neurodevelopmental advantages of breastfeeding, infant nutrition should be considered a public health issue and not only a lifestyle choice. The American Academy of Pediatrics reaffirms its recommendation of exclusive breastfeeding for about 6 months, followed by continued breastfeeding as complementary foods are introduced, with continuation of breastfeeding for 1 year or longer as mutually desired by mother and infant."

The strong statement about breastfeeding as a public health issue, and not just a "choice," is a huge step forward in breastfeeding language and thought within the medical community, and I think the AAP should be commended for taking such a stand.

I often read and hear people debating about which is "easier," formula-feeding or breast-feeding, with fair points on both sides. There are ways in which feeding formula from a bottle is "easier," and there are ways in which feeding human milk directly from the breast is "easier." I'll even outline a few of each for you here, from my own experience.

Some ways in which formula-feeding is "easier" than breast-feeding:

1. Other people can feed the baby without mom having to pump.
2. There is a very short learning curve.
3. You can see how much the baby is eating.
4. Mom doesn't have to worry about what she eats and drinks.
5. Mom can be away from the baby for an extended period of time.

Some ways in which breast-feeding is "easier" than formula-feeding:

1. No bottles to wash or prepare.
2. You don't have to wake up all the way for the middle-of-the-night feedings.
3. Never have to worry about running out of food for the baby.
4. Food is always the right temperature, quantity, and composition.
5. It's cheaper.

When you look at it, it's kind of a silly list. It's all about the bottles and the preparation and who feeds the baby. Is that really what's most important? Is that really what the "choice" is about? What's easier? It's also "easier" to plop our kids in front of the TV all day instead of engaging with them. It's easier to take them to McDonald's every day instead of cooking healthy meals for them. It's easier to let them roll around in the back seat than install car seats and buckle them in every time. It's easier to let them do whatever they want than to try to discipline them. Heck, it's easier to keep them in diapers than to potty train them (believe me). But we wouldn't dream of making any of those choices just because they're "easier," would we? (Gosh, I hope not!)

How and what we feed our children, not just as infants but throughout their childhood, is a small percentage of the enormous body of choices we make for them as they grow. All of these decisions matter, some maybe more than others, but every choice we make for our children affects their health, well-being, happiness, and future. We have absolutely no way of knowing whether a particular choice we make is going to have a long-term consequence or benefit for our particular child, but we can look at statistics and research to make as informed a decision as possible based on overall trends. For example, it is quite clear that, when looking at a total population, people who were fed formula as babies are more prone to a host of diseases and problems, from food allergies to ear infections to diabetes and cancer, than people who were breastfed as babies. Evidence mounts. The risk for your specific child may be somewhat small, and perhaps it is a risk you are willing to - or must - take, given a medical, emotional, or family situation that makes breastfeeding an insurmountable challenge or undesirable option. However, it is important to admit that every choice you make has the potential to deeply affect your child's life.

I don't mean to cause you any terrible anxiety about what you feed your kid for breakfast tomorrow or whether you send them to preschool or what brand of jeans you purchase for them. I firmly believe that, for the most part, as long as we follow our instincts as parents, stick to our own moral codes, and, most of all, show our children that we love them, most of our other choices probably will not have lasting impact. However, the choices that are more likely to have long-term consequences for your child's health and well-being should be considered more deeply. So, while having French fries for all three meals one day is not likely to be a big problem, you probably don't want to get your child in the habit of eating that way on a regular basis. (Hey, I have a three-year-old. I sympathize!)

Since studies and statistics and research have shown that there is clearly a difference between breastmilk and formula in the long-term, this is a parenting decision that we need to think longer and harder about and educate ourselves about more, rather than choosing based on what's "easier."

When We Know Better, We Do Better

I just learned this quote from Maya Angelou today, and thinking about it, among other things going on around me, prompts this post. It's also an apt title.

It's hard, sometimes, not to feel guilty about past choices we've made. To give an example totally removed from pregnancy, childbirth, or breastfeeding, I do transcriptions for a periodontist, among other people. He'll often mention in his letters that 20 years ago, or when his patient was younger, they had a particular dental therapy performed that we would never do today, as now we know it causes problems decades down the line; problems that my client, of course, tries to fix for the patient. To bring the point closer to this blog, doctors used to recommend that women smoke during pregnancy in order to reduce the size of their babies for easier delivery. We used to routinely give antibiotics for every ailment. We used to fire-proof using asbestos. Now we know better. Now we no longer do those things. "When we know better, we do better."

It's hard not to feel guilty for making choices in the past that we now know may have negatively affected our health or the health of our children, even if we didn't know better. This is especially true in childbirth and breastfeeding. Many, many babies in the 20th century never received a drop of breastmilk, because doctors and mothers were convinced that formula, because it was "scientific," surely had to be better than paltry breastmilk. Breastfeeding was for poor women who couldn't afford better, as was giving birth at home instead of at a hospital. Should our grandmothers feel guilty if they did not breastfeed our mothers? Should our mothers feel guilty if they did not breastfeed us?

Maybe "guilty" isn't the right word. Maybe a little guilt is all right, since guilt about a past error can be impetus not to repeat that error. But it should not be a stigma. I didn't "know better" when my first son was born. I followed the advice of the people I trusted - nurses and doctors. Maybe "we" as a society "knew better," but I didn't, so I didn't do the best thing I could. I did feel guilty about it for a long time. How could I have deprived my son and myself of something so precious?

But now I know better, so I do better. I did better, and will do more in the future.

My grandmother was 20 years old when my mother was born, back in 1953. My mother was born seven weeks premature. At that time, premature babies were routinely placed in pure-oxygen environments, as it was believed to help them breathe. It was found that this environment was not, in fact, healthy at all, and caused blindness and other problems for many preemies of the time. Thankfully, my mother was not given this particular treatment. When we know better, we do better. My grandmother wanted to breastfeed her daughter. She had no idea how, had no support from hospital staff, but she felt that it would be best for her baby. The doctors at the time said that surely what a preemie needed was specially developed formula, that breastfeeding her 4lbs-something baby could only be detrimental, and how could she be so crazy as to want to do that. So, bowing to the pressure of the wisdom of the 1950s, my grandmother acquiesced and gave her first daughter formula. My mother is a healthy grandmother herself, now. We don't know if she suffered ill effects from her precarious early days on this Earth. But we do know now that those doctors were wrong. A study released just two days ago by Johns Hopkins reconfirmed that the absolute best food for a premature infant is, shockingly, breastmilk, at least in the goal of preventing potentially fatal necrotizing enterocolitis (NEC).

When my mother's younger sister was born full term, 18 months later, my grandmother again wanted to breastfeed. Though my aunt was full term, she was quite small, barely 5 pounds, and, again, the hospital would not "let" my grandmother breastfeed her own daughter because of her size. She needed to put on weight, you see, and formula was the best thing for that!

Finally, 4.5 years after that, my mother's younger brother was born. I don't know if my grandmother even bothered to ask if she could breastfeed, or tried to breastfeed, after not being allowed to with her first two babies. My uncle, unfortunately, unlike his sisters, is not as healthy as they are. He has Crohn's disease. My grandfather told me that when my uncle was a baby, they tried formula after formula, but all of them caused him distress. My grandfather was a pharmacist, and "the Enfamil guy" promised to hook my grandparents up with the best of the best formula to be had in 1959. Still, this didn't work for my uncle, and he ended up being fed pure cow's milk before he was a year old, as that seemed to be the food he tolerated best. He is suffering from quite a few health problems now, most as a result of the Crohn's disease. I can't help but wonder, if he had been born in 2009 and "allowed" to breastfeed, would he suffer from such severe intestinal problems 40 years down the road? It will be interesting to one day see a study on whether breastfeeding in infancy reduces the risk of developing Crohn's or colitis in adulthood. (This is all speculation, of course!)

Should my grandmother feel guilty about not breastfeeding her daughters and son? Should she in some way feel that she "caused" her children's health problems, especially her son's? For that matter, should she feel guilty for smoking through all of her pregnancies (probably causing her babies to be premature and low-birth-weight, as we now know)? I'm not sure, frankly. I don't see what good it would do to feel guilty. She may have regrets. She may wonder, as I do, how things would have been different. But we can only move forward. We can only say, "Well, now we know that breastmilk is the best food for preemies. Now we know that breastmilk helps prevent intestinal diseases in babies. Now we know smoking during pregnancy can be harmful to the baby." We know better, so we do better.

And when we know better, we can educate the next generation. We can support them in making the best decision with the best information they have at hand. My grandmother fully supported her daughters in their desire to breastfeed their respective children. And she and my mother and aunt fully supported me in my desire to breastfeed my children. And I can send that information on forward to my future daughters or daughters-in-law (G-d willing!).

A friend of mine, in discussing our birth experiences, said that she does regret that she never got the home birth, all natural, water birth experience as she had planned. Instead, she ended up with four c-sections, although not by her initial choice. But, one day, when her daughters or daughters-in-law come to her and say that they want to have natural home waterbirths, of course she will be supportive of that, and will be by their sides if they want her there, and will weep with joy when her grandchildren are born the way their mother's want them to, the way, probably, nature intended.  We can regret. We can feel guilt. But we can use that regret and guilt to make the future better than our past.

Of course there's no sense in wallowing in what may have been. We can't change it. We simply can't. But we can start right now with doing better.

My Nursing Story

First of all, on a totally unrelated note, I'm supposed to have my major anatomical ultrasound tomorrow (20 weeks!), and I'm terribly excited to find out if my boys are getting a brother or a sister. Hopefully baby will cooperate. I'll be sure to let you know as soon as I can. :)

Obviously, I don't have a nursing story about my first son, except what I've already written about. But I nursed my second son until he was 25 months and stopped because I needed to and he was ready. It's hard to remember all the details going back to when he was born, but I want to share with you my experience as best I can. I feel I had a fairly middle-of-the-road nursing experience. Nothing too dramatic, no major struggles, but some frustrations and idiosyncrasies that might make someone else in the same situation feel a bit better about what her baby is doing.

Because I'd had so much trouble the first time with not having all the right information, with my traumatic birth experience and hospital re-admittance, with my general dislike of the brief nursing episodes I had, and without someone to take the journey along side me and encourage me, I was terrified of what might happen the second time around. I had resolved to move mountains to make it work this time if I had to. I knew all about handling food intolerances, avoiding nipple confusion, and I was ready to take on whatever challenge was thrown at me. I hoped.

It turned out, most of my emotional girding wasn't needed, thank goodness. But it's good to know these things even if you don't need them.

When the birth went smoothly and he latched on to my breast for the first time and didn't let go, I knew I had experienced a miracle. The incredible differences between the births of my two sons still fills me with wonder. I think because I was so committed to breastfeeding the second time, I didn't let "difficulties" get me down. That's not to say I didn't get frustrated with marathon nursing sessions, or that I always loved that I couldn't be away from him for more than an hour at a time, or that I liked hardly getting to sleep through the night for over two years. But at the same time, every time I squirted milk at the shower wall in the morning, every time I woke up to a soaked bed (until I started sleeping on a towel), every time I found a new way to nurse more comfortably while I went about my business, I smiled. I smiled because I was so thrilled that my body was doing exactly what it was supposed to do, and I was giving my son exactly what he was supposed to have.

So. As I recall, for the first few weeks, he nursed pretty much every hour during the day. That is to say that sometimes I got no more than a 20- to 30-minute break in between nursing sessions. I had enough milk that he only needed to nurse on one side in any given nursing session, which was kind of nice. I did have a little trouble with his latch in the beginning - he was a bit lazy about always opening his mouth as wide as he should, and I was a bit lazy about correcting him. When you're nursing so often, you just want to let him eat and be done with it. I did go see a lactation consultant when he was about three weeks old, and she showed me how to fix his latch and told me more about the practical side of breastfeeding than I had learned in the two preceding years. I highly recommend taking an actual breastfeeding class before your baby is born, or scheduling a consultation with a certified LC if you think you're having any problems. Sometimes a simple 30-minute consult can make your life with your newborn oh-so-much more bearable!

I tried using a Boppy pillow for support at first but found it cumbersome. I'm...er...reasonably well-endowed, and therefore I was actually more comfortable just sitting cross-legged on the floor and letting his bottom rest in my lap than I was surrounding myself with pillows sometimes. As the baby gained strength in his neck and jaw, he was able to keep himself latched more easily, which meant I could nurse one-handed and surf Facebook or whatever while he nursed. I used to make sure to get in some computer time whenever he was nursing on the left side (so my right hand was free to use the mouse!). This was also a good time to sneak in a meal for me!

For the first few days, I swore I wouldn't co-sleep. I didn't want to get "trapped" into having him sleeping in my bed for three years. But most nights, I'd pull him into my bed to nurse him and fall asleep that way. I remember waking up an hour later and he was still there, latched and happily sucking. So I gave in and "admitted" that I was co-sleeping. He nursed a lot at night, but also a lot during the day. He was what they call a snacker. Lots of little meals instead of a big meal every few hours. It seems this is actually more biologically "normal," but it isn't exactly "convenient." As it were. He's actually kind of still that way, liking to eat snacks and small meals throughout the day rather than sitting down and eating a big meal for breakfast, lunch, and dinner. I guess it's just in his personality.

I did try introducing bottles of expressed breastmilk and a pacifier at four weeks of age (the recommended age to start introducing artificial nipples). He didn't take well to either, although I admit that I didn't push hard with the pacifier because my first son was still addicted to his and still used it 'round-the-clock when he was two years old. I didn't want that to happen again. So, though it resulted in my becoming a "human pacifier" (oh NO!), I did end up with a kid who doesn't use a pacifier. I'm still, 28 months later, not absolutely certain how I feel about that.

As for bottles of expressed milk, in the few weeks after introducing the bottle (and having my husband or mother-in-law feed him), he would drink fairly well, but after mostly being alone with me all day and not needing one, he pretty much rejected it. I still kept milk in the freezer on the off chance that he would take it once in a while if I had a baby-sitter, but mostly the milk collected in the freezer and didn't get used. I think I mentioned before that I donated a few hundred ounces to other moms, and I'm very proud of that and hope to do it again in the future. I also found that expressing and storing was a pain when I could just simply nurse him instead.

Digression: I know some moms like to take a bottle of expressed milk with them when they go out, so they don't have to stop and nurse while running errands, but I found stopping to nurse less trouble than expressing, so it wasn't for me. I'm not saying you shouldn't do it if it makes you more comfortable, though. The main thing to remember is that whenever you give a bottle of milk, you're signaling your body not to have a feeding at that time. If it's not a regular thing, then it shouldn't affect your supply. But, if you always give a bottle at, say, 10:00pm, then you might find that you don't have much milk at 10:00pm if you want to just nurse at that time instead. Most experts recommend pumping near a time when the baby is receiving a bottle so that your body knows to continue to make milk at that time. (Obviously, different advice applies to mothers working outside the home who have to pump to provide expressed milk for their babies to eat while they're at work! I'm not really talking about that here, although I may discuss it in a future post.)

Figuring out how to nurse in the mei tai (front carrier) helped immensely. One gloomy Sunday when my husband was at work, I was trying to figure out what to do with my two kids. We had a zoo membership at the time, so I decided to brave the zoo alone with two kids. I put the baby in the mei tai and took the stroller for the toddler. We were watching the zebras for a while, with no bench in sight, when the baby got hungry. I found a way to pull down my shirt collar far enough for him to get boob access, and I nursed him right there standing watching the zebras. That opened up a whole new world for me. First of all, no one around me even knew what I was doing, and it meant I was still mobile and accessible to my 2-1/2-year-old who wanted to continue exploring the zoo!

I wasn't squeamish about nursing in public (NIP) even though I expected to be. I found very quickly that my attitude was, "Baby's hungry. People would much rather see me feeding him (or avert their eyes) than to hear him screaming." Plus, I found that when we were nursing, I felt like I was in a little bubble. Even though I was aware that there were people around me, I didn't care what they thought. And you know what? I didn't get a single negative comment, a single impolite stare, I was never asked to leave or move to a more "private" location. My NIP experiences were always either neutral or positive. I'm grateful for that.

The couple of times I did manage to get away for more than a couple of hours, I ended up with a plugged duct after missing a feeding. OW! Fortunately, I was able to get them to release relatively easily. Only once, I ended up with the beginning of mastitis, but fortunately I was able to identify the symptoms for what they were and take care of it before I needed any medical treatment. Treating plugged ducts and mastitis deserves a post of its own. If you have a pressing question, though, please feel free to ask in the comments!

Anyway, people kept reassuring me that their babies nursed every hour like that for three months and then spread out their feedings after the three-month growth spurt. Or that they nursed like that for six months and then spread out their feedings. Or that once they started solids, you could put them off longer between feedings.  Well, my son continued to nurse about every hour until he was seven months old, when he finally stretched out to every two hours. He pretty much never slept more than a three-hour stretch, even past one year of age. I wasn't as proactive about giving solid foods as I thought I would be, finding it ever-so-much easier just to nurse than to set him up in the high chair to feed him. Plus, he decided he'd much rather feed himself "real" food than have someone shove purees into his mouth with a spoon, so it was hard to get a full meal into him until he was a bit older, anyway.

A few times, I attempted to teach him to fall asleep "by himself," i.e., without a nipple in his mouth. I failed every time. I finally decided that he wasn't going to stop nursing at night until he stopped nursing altogether, and by the time he was 25 months old (and I was one month pregnant!), he was really only nursing at night, and hardly at all during the day anyway. At some point, I realized he had started eating solid foods on a regular basis and only nursed mostly for comfort and not for nutrition. Sure, I enjoyed that he was still getting the benefit of my antibodies and the healing power of the milk, but he was nursing so rarely and getting so little that it ceased to matter. In fact, when he had a double ear infection on his second birthday (poor baby!), I knew he really wasn't getting much milk anymore. I prayed for a good night's sleep more often than once in a blue moon, and I knew that, being pregnant, I needed it more than ever. So, one day in January, he nursed at about 5:15am and then not again the rest of the day. When I put him to bed, I refused to nurse him and told him that the milk was "all gone." "All gone?" he asked, with wonder. How could there be no more? But I gently told him again that the milk was "all gone," and that he needed to go to sleep. I lay with him until he fell asleep. He awoke a few times during the night for the next few nights, asking to nurse, but he was finally convinced that there was no more milk (and there really wasn't after a point), and started falling asleep on his own. He still woke a few times during the night for another few weeks, but now, for the most part, he sleeps through and falls asleep on his own, with no formal "sleep training" from me. In fact, my two sons have about the same frequency of night wakings, and they were "sleep taught" very differently. It's kind of interesting. I'll probably talk more about sleep in another post, since it's an important topic that deserves more attention than I can give in this paragraph.

Anyway, he slept in our bed until he was a year old, at which point I put him in a crib in a room with his brother. That meant I had to get up and go to him every few hours, and we would nurse on the floor and then I'd put him back in his crib. That was hard, but the advantage was getting to sleep in whatever position I wanted in my own bed! It's a trade-off. I think a year was a fair amount of time for him to sleep with us, though, and it did get frustrating not to have the bed to ourselves.

The other reason I finally weaned was that I was getting recurrent bouts of what I think was thrush about every month for about a week. I would get it cleared up and then it would come right back. It never affected him, but it became very painful for a week or two out of every month to nurse him, and I got tired of not being able to completely get rid of the nipple pain, whatever might have been causing it. The pain of latching the baby on when you have thrush or other nipple pain is kind of indescribable and is enough to make you dread a feeding. This is another topic I'll cover more in-depth in a future post.

I'm not really complaining. Yes, I hope this next baby is "easier" in some sense. I hope that she or he nurses less often and likes food more and sleeps better. But at the same time, I know I can handle it and make it work for me if I have to, even with two other kids to chase around. Yikes?

I think it's all about attitude, really. I was so grateful to have a successful nursing experience, and I saw every ounce of milk I produced as a miracle. It was such a rewarding and wonderful time, and sometimes I do miss just cuddling up with him and letting him nurse. Sometimes I'm sad that he doesn't really even remember nursing and simply stopped asking for it after a reasonably short time. But, I'm looking forward all the more to nursing this next baby, for all the same reasons!

Let's Talk About Breastfeeding - Part II

I got a little clinical in the last post, and one of my goals for this blog is to keep it on a personal level. I do intend to bring in educational information when I find some that I think is interesting or important, and I will certainly include sources and quotes and useful knowledge when it directly relates to something I'm writing about, as with the Pitocin information a few posts back. However, I felt it was important to do a general post about breastfeeding before bringing it back over to my own experience.

Why did I want to breastfeed?

When I was pregnant with my first, I wanted to breastfeed, but I only had a vague notion of why. "It's better for the baby." (Better than what?) "Breast is best." (Breast, as opposed to what?) My mom and aunt breastfed, so of course I should too. It's just what you're supposed to do. Breastfeeding itself was a very abstract activity to me. I think maybe twice or three times in my whole life had I actually seen someone breastfeed, always when I was a small child, and the process and act had never really been directly explained to me. I didn't have a concept of how it worked, or what it should look like, or what the reality of it was. I had only heard how "I loved nursing," and "I nursed for 9 months," and "It's a really wonderful experience," without the accompanying truths, that it takes work in the beginning, that nursing a newborn is not like nursing a nine-month-old, that some people nurse into toddlerhood and beyond. I just didn't really know anything about it.

So when my first son was born and I expressed my desire to breastfeed, somehow I had this idea that I'd bring him to my chest, he'd start sucking, and we'd do that every few hours. I didn't know that milk supply is governed by baby's demand. I didn't know about proper "latch," and that what you eat can get into the breastmilk, and that there are specific ways to hold the baby. I didn't know about not giving pacifiers in the early days so as not to mess with the latch and sucking reflexes, or not to give bottles for similar reasons. I didn't, to be honest, really have a concept of what one might put into a bottle!

And yet, I wanted to breastfeed. Even after trying it, and not liking it, and not understanding it, and feeding formula for weeks, I still wanted to breastfeed. I still regretted "screwing it up" (as I thought of it). I regretted not having the information I needed in advance. I regretted not asking the right people for help. I wanted to breastfeed.

But WHY?

Honestly, I'm not even sure, now. I think part of it was that I felt like I had failed at something that should have been simple, and I'm not the sort of person who fails. I think part of it was that I felt like something was wrong with me, and I wanted to "fix" it. I also think that once I started learning about all the benefits of breastfeeding and breastmilk, once I talked to people in person and online about what breastfeeding is really all about, I really felt that I had missed out on something. Something big. Something important. And maybe, subconsciously, I realized that I had missed out on an important opportunity to bond with my son by not having to care for him in those vital early weeks.

By the time my son was several months old, I had tried and failed to relactate, although I did manage to give him a few weeks more of suckling (nursing is, after all, more than just for food), a few more drops of breastmilk. We moved across country and changed jobs, and I became a work-from-home mother, which meant I was with him a lot more often. I thought maybe at that point I could have been comfortable nursing him, except the one attempt I made to get him to latch, he looked at my breast like it was a UFO and had no idea what I wanted him to do. And that was that.

But, by then, too, we had learned that we had been blessed with a very picky bottle-feeding baby, who would only drink a full meal if it started out piping hot. He hadn't always been that way, but by the time he was about four months old, he literally would refuse a bottle unless it was hot. By then, we had learned the trick of warming the water before mixing the formula, which saved several minutes in the bottle-making process, but that wasn't always possible when we were out and about. We got pretty adept about asking for hot water in restaurants, but we were at a total loss if we were, say, at the zoo, or a gas station, or Walmart when he needed a feeding. Once I was near a Starbucks, so I went in and got a cup of hot water from them. For some reason, I remember that time very fondly. Anyway, my point is that my baby made formula feeding difficult. It also took us until he was 11 months old to figure out that we could carry hot water with us in a Thermos (duh). How nice it would have been to work that one out sooner.  (I realize that not all babies are so picky about bottle temperature, and many people can simply carry pre-measured bottles of water and a can of formula and quickly mix the formula and water and feed it. It wasn't this way for us, and he never grew out of it. He just eventually stopped needing a bottle, and our lives got so much easier.) Oh, also, he didn't digest the regular formula well, and it took us several weeks of trying in the beginning to find a formula that didn't make him terribly unhappy and gassy. It turned out that the kind of formula where the proteins are broken down more worked very well for him, and we were quite pleased to find a generic version of that particular formula, which saved us probably hundreds of dollars. But it was still about $14 per can, and by the age of four or five months, he was going through about two cans a week.

All of this added up to a lot of money and aggravation for feeding this baby. I now look back on that as somewhat of a blessing, because it made me very determined to breastfeed our next child. I had watched several mothers feed hungry babies by just opening up their bra and hooking them up, and I so wished it were that easy for me. Not to mention the number of times we got caught out longer than expected and didn't have a bottle or formula on hand. I once actually went to Walmart and bought a bottle and a can of formula so I could feed him while I was out. Very frustrating, and another problem I would not have had if I had been breastfeeding.

Combine this difficult bottle-feeding experience with everything I was learning about breastfeeding and breastmilk. I found myself spouting off all kinds of random information as I came across it, as if I were some kind of breastfeeding expert. I became a breastfeeding advocate even before I became a "breastfeeder."

It was no mystery, then, why I was so determined to breastfeed our second baby. I was obsessed with the idea. By the time he was born, I had read "The Womanly Art of Breastfeeding" cover to cover, had devoured articles about breastfeeding and breastmilk, had watched videos about how to obtain a proper latch, had learned all about milk supply and demand, how to know if your baby was reacting to something you were eating, growth spurts, night nursing, and why you shouldn't give a pacifier or bottle in the first four to six weeks. I had learned about how supplementing with formula often resulted in eventually terminating the breastfeeding relationship entirely, how feeding a bottle of formula before bed did not, in fact, make the baby sleep better, how formula actually messed with all the benefits breastfeeding had on the baby's gut, and even about things like oversupply and overactive letdown, which I may or may not have needed to know. In other words, I had all the book learning in the world, but I still hadn't actually nursed a baby for any appreciable length of time.

Well, book learning is great, but it's not the same as the hands-on (breasts-on?) experience, let me tell you right now. Having the knowledge is important - if you don't know the rules to basketball, you can't play it, but knowing the rules doesn't mean you can go out on the court and shoot a three-pointer. That takes practice.

So does breastfeeding. As much as I knew intellectually, when they first handed me my second son and put him to my chest, I had no clue how to actually do that breastfeeding thing. I was so determined to make it work, though, that I just nursed him. And nursed him. And nursed him. For the first six months of his life, that baby nursed every hour. (You measure the time between feedings from the start of one feeding to the start of the next, regardless of how long they are at the breast in between.) If I started nursing him at 9:15, he would need to nurse again at 10:15. In the early days, he was sometimes at the breast for 45 minutes. This meant I had 15 minutes between feedings to, say, pee, or eat, or type two-handed. This meant I couldn't so much as run an errand without having to plan to stop and nurse him while I was out. I learned to nurse in public very quickly, because I had no choice. I was going to nurse that baby. At about six or seven months of age, he finally stretched out to going two hours between feedings, and it only took about five to 10 minutes for him to complete a feeding, so things got considerably easier. But to this day, even though I'm not nursing at all, I am envious of those women whose babies start out going two or three hours between feedings.

I think if I had been less determined, the idea of letting someone give him some formula once in a while would have been very seductive. I can see how, despite having no big problems, like mastitis or thrush, bleeding and torn up nipples, low supply, or severe food intolerances, my son's nursing habits might have driven me, or someone like me, to give up. I did go a little crazy after a while, but I couldn't fathom any other option. And because I was with him almost all the time, he didn't even get very many bottles of expressed breastmilk (which I was more than willing for someone to give him if I couldn't be with him when he was hungry.) After a point, he wouldn't even take a bottle.

During the first several months, though, I did spend time every day expressing milk. Usually I did it once a day, obtaining between 2 and 4 ounces of milk between hourly feedings. I quickly learned to hand-express, mainly because setting up the pump, using it, and then breaking it down and washing it was really too much trouble when I didn't really have to do it. I also found hand expression to be more productive for me. I had a terrible, though not completely irrational, fear in those early weeks that something would happen to me like it had the first time around, and I would have to spend several days unable to nurse him. If that were to happen, I wanted to make sure I had a supply of breastmilk stored up in my freezer so that he would have something to eat.

As it turned out, not only was I healthy (thank G-d), but he rarely needed a bottle anyway, since, as I mentioned, I was almost always with him. I managed to store up a few hundred ounces of milk over time, much of which ended up getting thrown away. I gave a few ounces here and there to my older son when he was sick, figuring it certainly couldn't hurt, but he didn't really seem to like it. I did give 50 ounces or so per month to my housekeeper, who had had a baby a few months before me and couldn't pump enough for him when she was off cleaning houses or when her son was with his father. So her son got some of my milk, which makes me a little proud. I also shipped 75 ounces of milk from California to Florida to help out a woman whose baby, at four months of age, simply decided he didn't want to latch on the breast anymore. She was determined that he would not get formula if she could help it, but she was only able to pump about half of what he required and solicited milk donations to help make up the difference. I added my small contribution to her effort as well.

I can't say that I always "loved" nursing. I loved that I nursed, certainly. I love that I was able to provide that extraordinary benefit to my child.

So, why do I want to breastfeed my next baby?

I don't have to answer that one, do I?

Let's Talk About Breastfeeding - Part I

Whew, now that the stories are told, we can get down to business. I think the major theme that ran through those first six posts was "breastfeeding." First, how badly I wish I had, and second, how obsessed with that goal I became, and third, how thrilled I am at how well it went for me the second time. So let's talk about breastfeeding. In Part I, we'll look at the clinical side. What's so great about breastmilk? What are the benefits of breastfeeding for mother and baby? What's "wrong" with formula? And so on. I'll keep it to summary length, as there's plenty of this information out there. In Part II, I intend to make it more personal. Why did I want so badly to breastfeed? What do I feel I got out of it? What do I feel my son got out of it?

I've adopted the philosophy of many breastfeeding-advocacy sites and groups who now like to say that "breastfeeding is normal and formula is an inferior substitute." I put this right up front because what we're most used to hearing is the catchy phrase "breast is best." This implies that any alternatives to breastfeeding are perfectly fine, but breastfeeding is "better." Along with this come the studies that say "babies who are breastfed have fewer ear infections," "babies who are breastfed have a lower mortality rate," and so on. Why not flip it around? "Babies who are not breastfed have an increased risk of ear infections," "babies who are not breastfed have a higher mortality rate." It changes the way you think.

I don't want to put myself out there as a "boob nazi" or "lactivist." Frankly, as I said in my first post, I don't have any real say in what choice you make. I just want you to make an informed choice. I'll admit it does make me a little sad when I see or hear that someone is feeding their baby formula, but I don't always know the whole story, and there are many reasons why you might need to feed formula, from adoption to fostering to a medical issue with mother or baby. I'm sure all of this will come up in future posts. Anyway, I'm hardly one to talk, considering.

Okay, disclaimers out of the way. Let's get to the meaty stuff. Or the milky stuff, as the case may be.

Formula versus Breastmilk
Let's start with the most common alternative to feeding breastmilk: Infant formula. What is it? Infant formula is a complex combination of various proteins, vitamins, minerals, fats, and sugars, and sometimes beneficial bacteria and/or amino acids such as DHA and RHA, derived from natural and artificial sources, usually using cow's milk or soy milk as a base. In the early days of formula, it was simply cow's milk mixed with some sugar and other additives, which you mixed yourself based on a "formula" (or recipe) created by scientists and doctors, but the formulas that are manufactured today are far more complex and, to be honest, much better than those olden-day home-made milks. They are heavily processed to break down and change the protein and fat content of the base milk, then fats, vitamins, minerals, and sugars are added so that the baby is receiving the right balance of all of these ingredients, vital for the development of the brain, eyes, muscles, bones, and everything else.

Babycenter (http://www.babycenter.com/0_choosing-formula-a-primer_1334669.bc?page=2#articlesection4) has a good overview of the main ingredients in a typical baby formula.

Sounds pretty good, right?

Infant formula is a valid, if inferior, alternative to feeding breastmilk if there is an indicated reason to do so. Many, many babies have been raised on exclusively formula and are perfectly healthy, intelligent, successful people. Formula will not kill your child, and you are not a terrible person for using it. I would never presume to say that.

However.

Let's look at breastmilk for a minute, shall we?

I'm only going to cover the bare basics here, because human milk is a fabulously complex, ever-changing, and still mysterious compound containing hundreds of "ingredients," not all of which have been identified! We know that breastmilk contains all of the water, fats, proteins, sugars, vitamins, minerals, and other nutrients that a baby needs for at least the first six months of life, meaning that a baby requires nothing but breastmilk to be totally healthy and to thrive. These nutrients are present in exactly the right balance, and are primed for easy digestion by a baby's immature digestive tract. Also in breastmilk are antibodies provided by the mother's immune system that coat the baby's intestines and help prevent absorption of harmful bacteria and viruses that may cause infections, diarrhea, and other serious illness. Breastmilk also contains stem cells and amino acids. In addition, the nutrients in breastmilk are more bioavailable than the artificially-introduced nutrients in formula, meaning the baby can make better use of them and absorb them better, just as adults can better utilize the vitamins and minerals in natural foods than those in a multivitamin supplement.

The most amazing thing about breastmilk, I think, is that it changes in composition over time. In fact, the breastmilk a mother's body manufactures for a preemie is different from that for a full-term newborn, which is different from that a 10-month-old baby drinks. Different antibodies are present depending on what diseases the mother has been exposed to. Scientists are still discovering all of the compounds present in breastmilk and figuring out what they do. Far be it for me to try to write a treatise on it! A simple Google search will bring up plenty of pages of information about what's in breastmilk and what those things do.

Dr. Sears' website has an interesting chart comparing the ingredients of breastmilk and formula. (http://www.askdrsears.com/html/2/T021600.asp)

Other Benefits of Breastfeeding
There is more to breastfeeding than just the milk the baby receives. While the milk alone is incredibly important, as you may have gathered, there's a lot more to it. The act of breastfeeding, itself, has many positive effects on both baby and mother. Thus, even if a woman is truly unable to produce enough breastmilk to fully support her baby (we'll talk about this in a separate post down the line), continuing to feed from the breast as much as possible while supplementing with formula has additional benefits.

In the early days and weeks of a newborn baby's life, skin-to-skin contact with a parent helps the baby to regulate his body temperature, respiration, and heart rate. (This is also why placing the newborn on the mother's chest directly after birth is so beneficial.) Babies who are touching another human are calmer, less fussy, and show less stress reaction than babies who are separated from their parents or denied skin-to-skin contact. Breastfeeding automatically creates this contact between mother and baby, and the skin-to-skin contact also helps to stimulate milk production in the mother. Here is more about the benefits of skin-to-skin contact (http://www.naturalchild.org/guest/jack_newman2.html).

Then there's the whole "breastfed babies are healthier" thing. It's true. Scientists are still not entirely sure of all of the "whys" of this, but we can probably think of a few obvious reasons. Breastmilk contains all of those antibodies that can help the baby fight infection. Also, the bioavailability of the fats, proteins, and nutrients in breastmilk mean that the baby efficiently absorbs all of those building blocks of a healthy body that are necessary for the body to function normally.

Breastfed babies are less likely to develop ear infections, asthma,  diabetes, obesity, certain cancers, diarrhea, and other digestive issues. There may be many reasons for this, but the statistics are clear. In fact, the journal Pediatrics published an article in April of 2010 that stated that if 90% of American women breastfed their babies for the first six months of life, approximately 900 babies' lives per year would be saved, along with about $13 billion in healthcare costs (per year). (http://pediatrics.aappublications.org/cgi/content/abstract/peds.2009-1616v1)

Breastfeeding also provides health benefits to the mother. Women who have breastfed show lower instances of breast and ovarian cancers as well as diabetes and other health concerns. There appears to be a cumulative effect, in that the more years a woman breastfeeds, the lower her risks of these cancers.

The hormones secreted during breastfeeding also have a beneficial effect on the mother. Oxytocin, the "bonding" or "love" hormone, is necessary for the "let-down" or milk-ejection reflex that causes milk to start flowing. Oxytocin also produces feelings of love and closeness between mother and baby. (Oxytocin is also produced during orgasm, incidentally, probably facilitating the feelings of love between a woman and her partner.) Prolactin, the hormone that regulates milk production, is also known as the "mothering" hormone and stimulates the mother to care for her baby.

It's Natural
I want to conclude with a simple thought. All mammals feed their young their own milk. Humans are mammals. Why should it be different for us? The milk produced by each mammal is uniquely suited to the needs of their young. Why should it be different for us? Indeed, if we consider how much we know about the detrimental effects of processed and artifical foods on the adult body, and how much more benefit we derive from eating foods closer to their natural state, then it makes sense that the same should hold true for babies. How could an artifically-created substance be better for a baby than that which was created (either through evolution or by G-d, depending on what you believe) in nature to uniquely suit the needs of that baby?

I don't claim that this is anywhere close to a comprehensive overview. I also don't claim to be any kind of authority on the matter. I've simply tried to compile a basic summary of the wealth of information out there about breastfeeding and breastmilk into a digestible form. There's more to know, and more to learn, and plenty more information where all of this came from.