Health and Science News for Parents
May
13

Is Formula Not So “Evil” After All? Could it Boost Breastfeeding Rates?

written by Tara Haelle

I will never forget my first night home with my new son after a few postpartum days in the hospital. Most likely haven’t or won’t forget their first night at home with the new baby, but in my case it’s marked by a level of frustration, helplessness and despair that likely could have been allayed slightly by the findings of a very small study published in Pediatrics today. I will describe the study and its findings shortly, but my own personal anecdote is telling when it comes to the possible implications of the study.

A new study calls into question whether early formula feeds actually hurts exclusive breastfeeding rates. Photo courtesy of Microsoft stock images.

It was after 2 am, and I was sitting in the middle of our bedroom floor, bawling, my body convulsing with my utter desperation and inadequacy, while my husband held our screaming son, who wanted nothing more than the most basic thing I was supposed to provide for him–food.

My milk had not yet come in, so only that liquid gold colostrum could be squeezed from my breasts, but in minuscule amounts that did not satiate my son. He had lost more than 5% of his body weight shortly after birth and had not regained it all yet. They nearly did not discharge him and there was talk of supplemental feeding with a tube-attached-to-nipple contraption that never quite worked and which made me uneasy nonetheless.

See, I had planned to exclusively breastfeed my son and NOTHING would get in my way. I had the irrational conviction that giving him formula was wrong, bad, awful, even though I cannot quite articulate why I felt that giving him even a little bit would have been such a bad thing. I was a little concerned about nipple confusion, but mainly I was concerned about making sure that nothing went into my son’s stomach but his mother’s milk.

The problem is that I had excruciating pain in my nipples from breastfeeding him. I literally was incapable of nursing him unless I was taking 800mg of Motrin, as directed by the hospital staff. Even then, I gritted my teeth, tightened my buttocks and braced myself for the first sixty seconds of his latch, drawing my breath in sharply and trying not to scream, until the pain subsided to bearable, but still aching, territory. I had seen several lactation consultants, and they were baffled. The latch was good. We never figured out what the problem was, but it took weeks for that pain to go away, even when I enjoyed nursing.

And now, in those wee hours of our first night home, I was completely wrung out and dried up. Just his lips touching my nipples felt like a dozen razor blades, and it was all for naught because I simply was not producing enough colostrum for him. Where was my damn milk?! On the counsel of my husband and my far calmer mother, a breastfeeding champion herself, I finally gave in and fed my son some of the pre-mixed formula the hospital had sent us home with. It was only an ounce, but I simultaneously felt relief and like a failure.

The next day, my milk came in. I never had to give him formula again. All was well. I exclusively breastfed until he was 5 months old, and I’m still, almost three years later, nursing him.

I am, therefore, the kind of “success story” described in the Pediatrics study that’s making waves across the lactation community today. As much as I am a breastfeeding advocate, I am not into the mommy-wars shaming of formula feeders, and I think the lactation community should be willing to consider the potential wisdom in this admittedly small study.

The study involved a randomized, controlled trial with just 40 exclusively breastfeeding newborns. All had lost at least 5% of their birth weight. Half were assigned to receive 2 teaspoons of formula by syringe (to reduce the potential for nipple confusion) after each breastfeeding during the first 24 to 48 hours after birth, before their mothers’ milk had come in. The other half remained exclusively breastfeeding.

Then, the researchers checked in one week, one month, two months and three months later to see who was still breastfeeding and who was using any formula. In the group who received that tiny amount of formula in those first couple of days, just two of the kids (10%) were using any formula at 1 week old. In the control group who received no early formula, nine babies (47%) of the 19 were using any formula.

Wait — what? You read that correctly. Almost half of those assigned to exclusive breastfeeding had begun giving their child any formula just a week after birth while those who used formula in the first few days were nearly all exclusively breastfeeding without formula.

Three months later, a similar pattern emerged: 15 of the 19 babies (79%) in the early-formula group were exclusively breastfeeding with no formula, but only 8 of the 19 control group babies (42%) were breastfeeding exclusively.

“Early limited formula may be a successful temporary coping strategy for mothers to support breastfeeding newborns with early weight loss,” the researchers concluded. “Early limited formula has the potential for increasing rates of longer-term breastfeeding without supplementation based on findings from this randomized controlled trial.”

Now, keep in mind, this is an extremely small population study, and there were two newborns lost to follow up. The trial definitely requires replication with much larger participant numbers, but the proof of concept established here is important, especially in the context of the mommy-shaming that can go on among breastfeeding proponents.

Already, lactation consultants and other breastfeeding advocates are crying foul.

“This study goes against everything that’s been published for several years now from very reliable clinicians and researchers about the potential hazards of supplementing exclusively breast-feeding babies with formula,” said Dr. Kathleen Marinelli in Time’s Healthland article. She’s the chair-elect of the U.S. Breastfeeding Committee. “They’re flying in the face of years of research here and doing so rather glibly, stating that this is the new way to look at things,” she said.

I find that perspective wrong-headed and perhaps even a bit offensive because between her words is a fear that a study like this could derail the efforts to increase breastfeeding rates, a goal I strongly support as well. The subtext of that fear, and her words, is “We don’t trust mothers to be able to give their babies a little formula to get through the night and then go on with exclusively breastfeeding.” Or, worse, “We don’t trust mothers to decide, once they are informed about all the risks and benefits of both breastfeeding and formula feeding, to decide how they will feed their children.”

I’m sorry, but this toddler-nursing mama takes serious issue with that level of arrogance.

In some ways, this study reminds of the pacifier study I wrote about a few months back in which researchers were startled to find that pacifier use in hospitals actually appeared to help breastfeeding rates. I was not surprised in that study any more than I am surprised in this one. I will stand on a mountaintop in a cheerleader outfit to champion the benefits and importance of breastfeeding, but I am also realistic and pragmatic. Sometimes a mom needs a break. The last thing we need in those first few days after birth is the pressure of feeling that not popping a boob in the kid’s mouth every time he cries or is hungry (especially when we have no milk) makes us lesser mothers. The Baby Friendly initiative, while having good intentions, may also include some counterproductive measures that could sabotage itself in the long run. Yes, I know that’s blasphemy from a pro-breastfeeding mom like myself, but again, let’s get real, folks.

In some ways, the militancy of some breastfeeding proponents reminds me of the mistake I’ve seen made in the public health community on vaccination. If we are to build public trust in the safety and effectiveness of vaccines, we must be honest and realistic with the public, without insulting their intelligence, and explain that yes, there ARE risks to vaccines, but here is what they are, they are extremely tiny, and they are significantly outweighed by the benefits. This is a far more effective approach than “All vaccines are 100% safe for all babies.” Certainly, the best vaccine proponents do not promote that all-safe line, but some do, and often that is nevertheless the message that new parents hear. It justifiably makes them suspicious enough to take a romp with Dr. Google, with frequently inaccurate and potentially tragic results.

Similarly, the public health community’s all-or-nothing approach to co-sleeping and bed-sharing is intellectually dishonest and therefore can contribute to the problem. If we are to continue reducing the rates of SIDS, we must be honest about what really ARE risk factors and what are not. Telling mothers never to share a bed with their babies no matter what – rather than offering them recommendations on the safest possible ways to do so – is about as worthwhile as going to a high school and preaching abstinence only.

So, I’m excited to see this study, and I hope it leads to additional trials that attempt to replicate the findings, or challenge them, with larger populations. Breastfeeding advocates should not fear these studies any more than vaccination advocates should fear vaccine safety studies that do uncover new or tiny risks with certain vaccines. The goal of public health is to provide accurate, evidence-based information to the public. Even well-intentioned spin will backfire.

17 Responses to “Is Formula Not So “Evil” After All? Could it Boost Breastfeeding Rates?”

  1. Darwy

    I was still in the OR theatre when my husband was handed our son and told, “He’s all yours now.” My son was large at birth (4400g or 9 pounds 10 oz), so the nurses recommended that he be given a bit of formula to ensure his blood sugar levels didn’t tank out before I could initiate nursing.

    My husband fed our son the formula using a small plastic shot glass, without any issues whatsoever, and I started nursing him shortly thereafter. I freely admit we did supplement at other times, because sometimes you do need more than 2 hours of uninterrupted sleep. Do I feel guilty? Not in the slightest. My son is now 5 years old, and the pride of my life. What’s there to feel guilty about?

    • Tara Haelle

      Darwy, you’re absolutely right – there’s NOTHING to feel guilty about. But new moms are often susceptible to a guilt that ultra-pro-breastfeeding proponents engender, whether intentionally or not. I suspect/hope it’s rarely intended to guilt women – I’d like to think better of other moms – but the end result is often the same in that women often feel shamed if they use formula, especially if they intended the exclusively breastfeed.

      We kept formula on hand for any other times when he might need some. I think my mom and/or husband may have given him some a couple times while I was at work and didn’t get back before he was already hungry because even immediately postpartum (7 days later), I was teaching for 3 hours on Sundays. As I gained the confidence that gradually comes with being a mom over time, I lost the feeling of being pressured I had felt sometimes, whether I gave into it or not, related to different decisions I had. But that can take time for many women.

  2. Your story is pretty similar to mine. Milk didn’t come in for 4 days after a vaginal birth. Baby was small (less than 6 lbs, although full term) and by discharge from the hospital at 24hours he was a bit yellow and sleepy. We went to our GP on day three of life with no wet diapers x 12 hrs and a very lethargic yellow guy. Formula perked him right up so he had the strength to practice latching and sucking and saved us from needing bili-lights. Formula saved our BF relationship. I know its an anecdote so I’m very happy to see this study and I hope that other studies are done on this topic. I think the party line of “any formula in the first few days of life will derail you and babies don’t need anything other than two drops of colostrum in the first 48 hrs of life” requires higher scientific justification and support than is currently available because it just doesn’t jive.

    • Tara Haelle

      It’s funny, I saw a tweet this evening from @DrGhaheri, an MD whom I don’t know or follow, but I saw him tweet it in reply to the author of the TIME Healthland article. He tweeted to her “thanks for writing this. Infuriating nonsensical study that borders on unethical in my opinion. Sigh.”

      I thought, “Whaaaa?” What’s infuriating is THAT VERY ATTITUDE. I know nothing about him except that he apparently feels threatened by the ordinary scientific method and the fact that it might – gasp! – turn things up that are different from what some once thought. I can’t imagine how on earth the study would be unethical, but it IS unethical to shame women into thinking that some supplemental formula is going to destroy a breastfeeding relationship. I really hope additional, larger studies are done.

  3. Stephanie Christine Carlson

    Your story is MY story! I first heard of this study yesterday and it made me feel really good. My daughter was exclusively breast fed till she was 5 1/2 old and is still nursing at 11 months.

    • Tara Haelle

      Great! I love hearing stories of moms who continue breastfeeding beyond 6 months. And I don’t judge those who don’t breastfeed that long. As I was writing about this study for my actual job (health writer at dailyRx.com), I told my husband when he walked by my office “I just read a study that, had I read it 3 years ago, would have made our first night home with D immensely easier.” I know it’s small, and it needs back up, but there’s a validation in there :)

  4. Tara Haelle

    During a Twitter conversation about this study just now, someone tweeted this analysis of the study: http://bfmed.wordpress.com/2013/05/13/early-limited-data-for-early-limited-formula-use/ It’s a fantastic, smart, nuanced analysis of the study, its limitations and its potential ramifications. I recommend anyone interested in the issue read it.

  5. SP

    The BFmed article on this study has some great analysis, but the tone is exactly that of “don’t trust mothers” that you talked about earlier, insinuating that this study will lead to six-packs of formula being dumped in each bassinet and leading women into the temptation of feeding their babies too much so that they can get sleep; there’s also some comment about how this is a way for companies to market “expensive formulas.” That shows a kind of knee-jerk mistrust of anything that suggests formula is not all bad.

    • Stephanie Christine Carlson

      We got the six pack of formula but my nurses and the LC were very up front about how much and how often since I was serious about wanting to breastfeed but I can see how easily it could be to fall in love with a baby who sleeps. I had a very hard birth experience so my husband was much more in charge of things than I was at that point and he was super supportive of what I wanted to do with our daughter.

      • SP

        I think everyone who has ever used both breastmilk and formula can confirm that this idea that babies will sleep better on formula is a myth (sadly). If your milk hasn’t come in and baby is hungry, then I guess supplementing helps them stop crying and start sleeping. But thereafter, I never found that baby took more at a bottle feed than a breast feed. Their tummies are small anyway and they refuse it after a point. Anyway, I think the point that your BFing is not doomed if you supplement early on IF baby loses a lot of weight is a useful one.

        • Tara Haelle

          Yes, I picked up on the tone you noted in that piece, and I think that is, again, an unwillingness to consider anything other than the all-or-nothing approach. It came across as jaded more than anything else. It’s just frustrating that the idea that “formula = evil” is so pervasive among many breastfeeding advocates (and I am a bf advocate myself) that it prevents someone from considering any way in which it could be beneficial.

  6. Jessica Brown

    My story is so similar. My son was breastfeeding well, but my milk took 4 days to come in. He had lost 10%, was eating ravenously, and we had to take him to the pediatrician for a Saturday morning weight check to make sure he didn’t lose any more. I was so worried on Friday that we ended up giving him 2 formula bottles. Then my milk came in on Saturday and all was well. I always believed that giving the formula allowed me to “exclusively” breastfeed for 5 months and to continue nursing for the first year. (He got some formula bottles from my husband when I was working.) I think that having the feeling that giving any formula is failure rather than a helpful supplement makes many women give up. It’s just too much pressure.

    • Tara Haelle

      It’s interesting that there are so many who have said they have similar stories. I wonder if the ultra-pro-breastfeeding-anti-formula folks are paying attention.

      • Vaniah

        Another similar story here, I had flat nipples so my son didn’t latch on nor have anything to eat for the first 24 hours of his life. I will never forget how frustrated I got because he was screaming the place down and I just couldn’t manage to provide for him. Finally, I agreed to let the nurse feed him a tiny amount of formula in a little cup, got a nipple shield to help my nipples to stick out and then he managed to feed. I went on to breast feed exclusively for 6 months and his final feed was just before his 1st birthday. I am sure that I would never have been able to manage without that tiny bit of help right at the beginning.

  7. Leslie

    Like you, breastfeeding caused terrible, horrible, excruciating pain in my nipples. I grew to hate feeding my baby — when my husband brought the baby to me, crying with hunger, I’d flinch and recoil with dread. I could only force myself to do it after taking vicodin (left over from who-knows-what), and then I’d make the poor, hungry baby wait 20 minutes until the meds kicked in. My pediatrician confirmed that the baby’s latch was fine, and no one could explain why it hurt So. Darn. Much. It was a nightmare.

    Desperate, I did my own internet research. I discovered that Raynaud’s Syndrome can cause nipple pain when breastfeeding, even in women who don’t otherwise have the disorder. Basically, the pain is caused by blood vessels in the nipple constricting when cold. Treatment is easy — a low dose of nifedipine, a prescription drug considered safe for breastfeeding, solved the problem in just a day or two. It was like magic — breastfeeding no longer hurt.

    Here is a link to the definitive article on the subject:
    http://pediatrics.aappublications.org/content/113/4/e360.full The article is called, “Raynaud’s Phenomenon of the Nipple: A Treatable Cause of Painful Breastfeeding,” by Jane Anderson, MD, et al. (Incidentally, Dr. Anderson was incredibly kind to me. After I found her article, I asked my doctor for nifedipine. He refused, because he’d never heard of the problem. I emailed Dr. Anderson, and she actually replied with information that convinced my doctor it was real.)

    It makes me sad that this problem is so prevalent and easily treatable, and yet not well known or publicized. Please do what you can to spread the word — women who want to breastfeed need not suffer from this or give up breastfeeding in despair!

    • Tara Haelle

      Thanks for this information! I had heard of the term “Raynaud’s” but I know nothing about it. I will definitely look into this and may even write a blog entry about it!

  8. [...] for me personally, that first week was definitely the most hellish for breastfeeding. I’ve shared a bit of my person story on this blog before, and this study quantitatively reveals that my own anecdote is pretty representative of the broader [...]

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