When breastfeeding isn't enough...fed is best

[Birthdaypartyangstiness]

Anyone read this? (TRIGGER WARNING: link is about an infant death due to inadequate diet):

fedisbest.org/2017/02/given-just-one-bottle-still-alive/

It is a hard read but seems worth publicising.

I'm biased because I was in a very similar situation with my first child. Also have mild PCOS, poor fertility and produced copious watery milk with a baby who either screamed or "cluster fed" and suffered significant weight loss (dropped off the chart). And I just kept getting the breast is best message, feed him more etc and persuaded not to give him formula. I "gave in" at about 12 weeks and topped him up with formula and he suddenly thrived. I'm an educated health professional and yet the pressure to exclusively breast feed was enormous and I let go of my own common sense. Looking back now it's clear that there was objective evidence that my supply, though copious, was not nutritious. Milk I expressed sat in the fridge, and when separated due to cold had only the slightest "scum" of fat on top, the rest was just grey water. Showed the midwife and HV and just got the party line that all breast milk varies, you are making what your baby needs blah blah blah. Just ridiculous. We accept that there is variation in all other health matters, so why do we persist with the universal message that breast is best? Thank science for formula.

With the studies, you would also need to look at what proportion of the readmissions could have been prevented due to better support/advice being given to the mother.

Screamer I think that is the advice given a lot of the time to a lot of breastfeeding mothers from both HCPs and family/friends. Things like, give a bottle as baby's not getting enough/not sleeping long enough/fussing at the breast etc,etc.

I'm not saying that formula is not necessary in some cases but breastfeeding rates in this country are very low and a lot of women who want to breastfeed are given incorrect advice (which is sometimes to give formula when not necessary) which can lead (usually combined with other factors) to them stopping breastfeeding.

I do completely agree with you that blindly repeating 'breast is best' is not helping anyone.

A study "Physiological weight loss in the breastfed neonate" quotes about 7% of breastfed infants losing >10% birth weight, which is the criteria that HCPs apply for a weight loss that could be concerning. I agree that relevant information from research is quite scant - it's not really a subject where you can do any experiments so everything needs to be epidemiological with all the associated limitations!

Look clearly breastfeeding is optimal, I just wish the message was "breastfeeding is optimal but you may have to rely on formula for a bit in the early days (or longer if you want, it is your choice after all) if things don't go to plan"

Yep totally agree, Screamer1.

I think it must be very hard for the women who had good bfing experiences (either it went well, or they had good support and advice when it didn't) to understand how truly awful it is to have your child starving and every HCP sticking to the breast is best mantra. My own experiences were both completely different, if my second one was all i knew I'd have little to say on the topic!

I understand that brestapo antagonises people. I am equally antagonised by the variety of breast is best messages that are rolled out repeatedly. One of the worst things that happened was when he wasn't even on the chart anymore (having dropped from 50th centile to below the 0.4 line) despite "cluster feeding" and guzzling all day, I asked yet again if we should move to formula or add it in and was told that it was possible he had some sort of gut abnormality or absorption problem and it might be even worse on formula; breast milk is always best and might be the only thing keeping him going. Right now I'd see that for the speculative nonsense it clearly is. Postpartum, it's so hard to see things clearly and it left me feeling like we had little choice but to continue. When I finally did top him up with formula that comment left me terrified. Fortunately that passed with a rapidly fattening, much happier baby.

My disgust with how this is approached by some HCP is separate from my views of breast feeding. I breast fed because it is probably best though my reading of the evidence is that the difference is inflated in the general health promotion message.

HeyRoly I saw that story too. Also anger inducing. I guess the reason I posted the first account in the OP was that almost everything that occurred, and was said was replicated in my situation and that of several friends. I found it to be very valid as a result and I can't agree with others that the story is scaremongering as none of it is unbelievable to me.

I am wondering if the places I have lived have had an influence on the approach I have generally experienced -I have been living in very remote, rural locations. Are MW and HV in these locations more anti-intervention generally? I don't know.

Deaths from dehydration caused by insufficient milk are rare but they do happen, they can also cause brain damage and other life altering disabilities. It's a recognised medical problem and we need to get better at spotting it earlier and intervening with formula rather than pressing on at great risk.

I'm trying to do a comparison with hospitalisations as a result of breastfeeding dehydration vs contaminated formula, but it's proving tricky. There's about 60 hospitalisations in the UK because of breastfeeding dehydration but I can't find any reports of babies hospitalised through contaminated formula. I know in the USA they get around 4-12 possible contaminations a year, but in testing the formula, none have been positive for contamination in the last 15 years.

Given there is a slightly higher rate of general tummy bugs with formula though, I don't know how this affects the overall hospitalisation rate.

My dd1 was breast fed, cluster feeding, lots of screaming, 2.5 hours on the boob out of every 3. We were in the U.K., my mum died of breast cancer and I was told constantly to keep trying to bf. Visiting mws were advising on latch, position, nipple shields, expressing ...... I was a total wreck after a difficult birth and no sleep for a week. Day 9, we were rushed to hospital, dd was grey, dehydrated and still no-one had suggested formula. Soon as we got to hospital she was fed formula and gradually recovered. She's 12 now, smart, funny and kind so thank goodness we started on formula in the nick of time. I still can't look at her baby photos from those first days though.

60 hospitalisations for dehydration per year? I find that very hard to believe. I know 3 babies personally who have been rehospitalisaed for this reason in the last 12months. My own DS only narrowly escaped, having lost 12% body weight and would have been in for sure if I hadn't started formula supplements when I did. Babies who have lost this much weight are dehydrated (at least to an extent) and rehospitalised - this must be far more than 60/year. 60 per year perhaps might be dehydration with hypernatremia (dangerously high salt levels), which can be a severe condition. I think illness from contaminated formula is almost unheard of in developed countries. But is that a useful comparison to make? I think what we really need to know is whether there is a benefit in health outcomes from recommending supplementation with formula when a certain criterion is reached (e.g. Percentage weight loss), and if so, to make sure a more consistent message is provided by MWs and HVs. Just on the basis of this thread, it seems that different individuals are making different recommendations.

Birthdayparty I can see that you are very angry with the poor care that you received from the HCP that dealt with you and your baby. Did you feel able to complain about it via PALS or whichever is the appropriate channel?

I am still not sure what you think should be done more generally to help prevent similar situations to your own?

My own experiences in a large hospital in the south of England was that formula was suggested quickly should there be any issues with feeding. The same with the HV and midwives when discharged at home, and I don't know of anyone whose baby was readmitted for dehydration.

The UK has the lowest rate of breastfeeding in the world, yet 80% of mothers start off breastfeeding and surveys have shown that the majority who stop do not want to.

It's a far bigger problem women being told to give formula when it's not necessary than women being told to continue when it's dangerous. Neither situation is good though and I do understand why you are upset with what happened to you op.

I saw this on Facebook. I also personally know of a baby who was admitted to hospital because of dehydration, as breastfeeding wasn't working. The hardest thing was that relatives and friends could see that the baby wasn't thriving, but the mother was told by HV's, breastfeeding support etc, to keep trying, and no one wanted to disagree or interfere.

I have another friend who refused to have her baby weighed (fair enough, appreciate that the charts aren't great etc), but again the baby was clearly losing weight. He was a few weeks younger than my second Ds, and the difference between them was frankly heartbreaking. She ended up expressing, and bottle feeding, but it took her 6 weeks to get to that point.

There has to be a certain amount of common sense, surely?

I feel like "fed is best" (I don't care for the slogan personally or really just slogans in general) is an important corrective to some of the wilder excesses and extrapolations/hypotheses common in the breastfeeding world... reining it back and reminding us that not all mums can exclusively BF and "in the wild" as it were, those babies would simply... die (if another mum couldn't BF them). But of course, we now have formula, and that is fine. In addition, it's putting out the important message that a fairly significant minority of mums have delayed onset of lactation (esp 1st time mums) - they may be able to get to EBF later on, but just a critical few days later than other mums - and the baby would otherwise die in that time or be critically harmed if we didn't formula feed.
I've seen some pretty big examples of basically wrong ideas being distributed by BF support people (such as the "just one bottle will ruin the baby's gut permanently") and they are actually quite prevalent in the BF community. Bringing it all back to science is important IMHO and judicious use of supplementation, where it's needed, without loading the impression on mums that their babies are getting 2nd best.
(For that matter, another myth that goes around in BF circles is "post-birth weights are meaningless, the chart might show baby has dropped 12% but really they may be just FINE". All this absolutely needs to be called out and corrected).
Oh, another one, "under 1% of mums can't breastfeed" (well, we don't know, and have no way of reliably knowing, what that number is - and it's irrelevant, when it comes to managing a baby and mum properly where there are concerns).
Thankfully, some researchers and clinicians are actually thinking outside the box on this one (eg, pediatrics.aappublications.org/content/131/6/1059) and willing to consider whether small amounts of pre-emptive supplementation might actually help mums to BF later on, and this can only be a GOOD thing as it would lead to more babies being BF!
I'm not crazy about all the Fed is Best ideas though, just think that some of the messaging is an important corrective.

Problem is, some of these sad and sometimes tragic narratives do not differentiate between terrible/negligent maternity care and support for breastfeeding. There is absolutely no justification for otherwise healthy, normal babies becoming ill because of inadequate feeding - inadequate feeding is easily spottable before it becomes a problem - careful observation of breastfeeding, teaching the mother to recognise when things are not right, observation of physical signs and weighing on day 3-4 mean that any issues can be fixed before a crisis hits.

Some of the desperate tales of babies being ill or even dying have massive clinical holes in the narrative, and I am always uncomfortable when people's individual tragedies are used to promote an agenda. It's very difficult to question without sounding heartless , but the truth is we need clear stories that cohere and make sense so we can know exactly what went wrong.

" In addition, it's putting out the important message that a fairly significant minority of mums have delayed onset of lactation (esp 1st time mums) - they may be able to get to EBF later on, but just a critical few days later than other mums - and the baby would otherwise die in that time or be critically harmed if we didn't formula feed."

This is indeed a clinical situation where a baby may well need supplementing, temporarily - I don't like reading here and elsewhere of mothers in similar situations being told by other mothers they should just persevere with bf or eat oats (FFS) or ignore the midwives and all will be well. Clinical issues should not be resolved on internet talkboards or facebook groups.

Risk is, of course, that in some places, HCPs may genuinely not have a clue about how to preserve BF through a crisis, and the mother ends up FF when she did not want to. Unnecessary supplementation with formula does happen, too - when the baby really did not benefit from the formula, 'cos it wasn't a crisis in the first place.

I don't think any of this is the fault of breastfeeding support per se. It is the fault of poor training, lack of confidence and understanding of infant feeding needs and in particular how bf works.

Thanks for your post bigmamapeach. I completely agree. For me it's about informed decision making. Women tolerate such a lack of information through the whole process of obstetric/midwife care. Breast feeding information and support needs to be more scientific and balanced, not delivered evangelically. Digressing: Another area is labour and delivery. There is plenty of evidence that you can predict outcome on the baby's position, for example (pulling numbers off the top of my head) you could be told that if your baby has been consistently back to back you may have, say, a 40% likelihood of delivering naturally, 20% forceps, 20% c-section. Data like this exists yet women don't get given this and invited into a collaborative discussion about how they'd like to proceed when informed consent is the gold standard for virtually anything else that may happen to you in hospital.

AssasinatedBeauty, no we didn't complain. We were quite shell shocked by the experience and like another poster can't even look at pictures of him from the first 3 months. But what should be done? For a start a campaign based on real information. The health promotion message around breast feeding is hyperbolic and evangelical in a manner hardly seen elsewhere in health. Then more frank and honest preparation pre birth about weight, potential use of formula (as the positive life saving substance it can be, not something inferior or poisonous) to prevent that sense of failing when bfing doesn't go as desired/planned/expected. That would be a good start.

I agree that the standard of bf knowledge is woefully inadequate and incredibly patchy across the NHS. They can't trot out cute slogans like "Breast is Best" and think that's enough. There needs to be rigourous, science-based training given to HCP's who can then support women in feeding their babies.

In my experience - and I've had plenty over the years, as I have six children! - there hasn't been a huge push to get me to breastfeed. I've done it, but when I've had problems, I've had lacklustre support from NHS employees. The best, most practical support I've received has been from a LLL leader. She was the only one who looked at the numbers of my baby's weight and said there was a significant problem looming, and if I didn't do X, Y and Z my baby would continue to lose weight and we would end up in hospital. My HV didn't recognise the problem, my midwife didn't say anything, etc.

There are plenty of warning signs before a baby reaches critical, but often they are incredibly subtle as babies who aren't getting enough calories tend to get quieter and quieter in an effort to reduce calorie loss through crying, etc. For example, the societal obsession with "good" babies and sleeping through the night often masks this warning sign. Newborns should be fed regularly around the clock, and sleeping 6+ hours at a time should be setting off alarm bells for a HCP.

Lack of robust and individualised breastfeeding support is likely a huge reason why our country's bf rates are so low.

I totally agree with you OP, that some HCPs seem to be incapable of anything more than robotic "exclusive breastfeeding is what you must do", even when it's becoming detrimental to mother or baby or both.

I got off to a rocky start with BF after a bad birth, but the community midwives I had come out were so fantastic. They helped me, but said they were helping me only so I could do it comfortably if I wanted to and wasn't in pain,otherwise, don't do it. Their support (with no pressure) is why I continued.

But my health visitor was God Awful. And if I'd been relying on her I'd be FF and demented with misplaced guilt.

So I'm very acutely aware of how big a difference HCPs can make to women's experiences, and I hate how women are made to feel about this.

Thanks AyeAmarok

You lost me as soon as you used the term 'breastapo'.

How come the parents (from the article) were not told about wet and dirty nappies? When I was breastfeeding the main question on anyone's lip for those first few weeks was 'how many wet nappies?'.

At one week post c-section I was suffering terrible pain in my chest and upper back, to rule out blood clots I had to have an X-ray which involved radiation put through my veins. (Can't remember the name of the scan!)
When I got back on the ward I was told I couldn't hold my baby (for 24 hours) as he could get radiation poisoning, they also said my breast milk had to be expressed and dumped. This is on a post-natal ward! They made me pump and pump, then throw it away as apparently the milk was 'tainted'. My son was given formula, and I was heart broken, I'd only had him one week and already I couldn't feed him! I must of thrown away over 30oz of milk in that 24 hours. I was so scared I'd 'leave' some in and he'd get ill. I kept asking the staff 'how do I know if there's no more radiation milk left?' They had no clue! Just told me to keep pumping and dumping.

When I got home I found out they were way of the mark with their knowledge. My milk was fine, it was just skin contact that was a risk! I could of given him the expressed milk.
And of course as anyone who understand lactation will know, no matter how much you pump you'll never get rid of it all, it's impossible, there's always a reserve! I caused myself huge problems with over supply and had to combi - feed my son from then on.
Long story but shows the lack of knowledge by midwives about lactation and other procedures post-birth! This was June 2016 at Leeds teaching hospitals post natal ward.

Not too late to tell them your story, ponder. Does not have to be formal complaint. Disgraceful ignorance :(

Ponderland in some of these situations baby feeds a lot, gets massive amounts of poor quality (low fat) milk and continues to produce lots of wet nappies. It seems very likely that despite the party line you can make lots of inadequate breast milk despite all the advice you get. Women with pcos, fertility probs and first baby may be at risk. Was certainly true for me.

Tatiebee, that's fine. I find discussion with special snowflakes who use phrases such as that fairly unproductive anyway. Enjoy your "safe space". I live in a world where I can tolerate hearing things that offend me and enter debate and discussion anyway.

I'm interested in what you say about the risk factors for producing poor quality milk. Is the information about this available from the website you linked in your OP? I wonder why being a first time mother could affect the quality of your milk?

I have genuinely never heard of poor quality breastmilk. Where can I learn more about this issue?

My DS was getting the watery foremilk due to his tongue tie - he didn't have the stamina and a decent latch in order to bring down the fat globules in the milk ducts. His poo was copious, green and frothy, because the milk was whizzing through his digestive tract too quickly. When I did breast compressions, the fatty milk was pushed down so he could access it. Once his tongue tie was separated, he managed this on his own. I don't consider my situation to mean milk was inferior or not nourishing, just that my baby wasn't doing his job. ;) (Tongue tie is my bugbear)

AssasinatedBeauty Yes, there are articles linked through the website with the original story linked. I read it as a combination -PCOS, poor fertility and first time mum, and I think "advanced maternal age" was another factor. But generally most breast feeding specialists will tell you that your mammary glands are more productive and responsive second (third, fourth...) time around anyway.

I have all of those risk factors and it was marginally better second time around. I also got excellent personalised advice from LLL who (having spoken to them in advance) told me to block feed from a single breast. I literally fed from one breast only for 12 hours then switched to the other. The LLL advisor I had told me that with the copious watery stuff I was producing I'd have to persevere with one breast to get to the fat before switching. Absolutely no expressing. The advice I'd had first time around about more frequent switching just had me increasing and increasing my watery, already copious supply, and ensured my DS only got this. MWs and HV were horrified, as was the specialist who came to our local hospital BFing group. I did waver for a few days and fed more traditionally, under pressure from their disapproval, and ended up with a screaming, colicky infant with weight loss. Went back to block feeding and all was well. DS2 was exclusively breast fed until I went back to work. And clung to the 90th centile but for that one blip.

SerialRejoiner I guess it's not strictly poor quality but all about proportion of liquid to fat content, I'm using poor quality as short hand. The watery foremilk stuff still has sugar, antibodies, vitamins etc. It's just that the endless chugging of that is hard work for the infant without the calorific reward. You dealt with this in a way that suited your particular issue and I eventually dealt with mine, as above. But it took real digging and effort to get decent advice and I put a lot of time and energy into that before DS2 was born. If I had been given information to anticipate this ahead of DS1s birth (or supported to use formula) he wouldn't have spent the first few months screaming, thin and hungry.