Quest for Health: Breast is Best... Unless it's Not

We've all heard the well-intentioned slogan "Breast Is Best" in reference to supporting breastfeeding. Breastmilk is made just for our babies, so yes, it is a great source of nutrition. But it isn't the only option and there are many reasons mothers give formula and even with exclusive breastfeeding there comes a time that infants need additional sources of nutrition.

I decided to write on this topic because I see so many mothers struggle to feed their baby and they feel like a failure if they don't exclusively breastfeed. And then to top it off I saw a blog that encouraged exclusive breastfeeding without any foods or supplements until one year of age. I knew someone had to counter that thought before it becomes popular. It shouldn't be a badge of honor to breastfeed to the point of potential harm to the infant, and some ultra-crunchy moms are bragging about it as if it is.

You're not a failure if you feed your baby, regardless of what you feed your baby as long as it's age appropriate. Your baby needs nutrition and hydration. While most babies under 6 months of age can get all their nutrition from breastmilk, some need a boost, especially at the beginning of life. If you’re not producing enough milk, you’ll need to give your baby some formula as well (or use a milk donor). Usually this is temporary - just until your own milk supply increases or until your baby starts enough solid foods that the supplement isn’t needed. I'm not suggesting that every newborn who struggles at the breast should be supplemented, but if your doctor says the baby's blood sugar is low or the baby is losing too much weight, it's not only okay, but it's necessary to supplement.

breastfeeding, infant feeding, newborn, formula

Benefits of Breast Milk

Most of us have heard by now the many benefits of breastfeeding for the baby, including:

Immune system benefits. (Which means fewer infections, meaning not only helping babies stay healthy, but also leading to fewer lost work days for working parents and fewer sleepless nights for all parents.)
Decreased risk of Sudden Infant Death Syndrome.
Decreased risk of asthma in a child who has breastfed.
Decreased risk of diabetes when the baby grows up.
Decreased risk of obesity as the baby grows up.
Decreased risk of certain cancers in the child, such as leukemia.
Improved cognitive development of the child.

Benefits for mothers include:

Less bleeding, both in the immediate postpartum period from contracting the uterus after birth, and fewer menstrual cycles during breastfeeding.
Decreased risk of getting pregnant while breastfeeding - though this is not 100% effective! If you're not wanting to get pregnant don't rely on breastfeeding alone.
Easier return to pre-pregnancy weight.
Decreased risk of ovarian and breast cancers.
Decreased risk of Type II diabetes.
Decreased risk of postpartum depression.
Decreased risk of heart disease.
Less missed work (see immune system benefits above).
Cost - breastmilk is free and formula is expensive. Breast pumps should be covered by insurance.

When Breast Milk Isn't Enough, Isn't Desired, or Isn't Safe

Despite the benefits, breastfeeding not always possible or desired. In the US, 8 out of 10 mothers start breastfeeding during the newborn period. Only half are still nursing at 6 months, and less than a third are still nursing at 12 months.

The American Academy of Pediatrics (AAP) recommends exclusive breastfeeding for approximately 6 months, followed by continued breastfeeding for 1 year or longer, as mutually desired by mother and child. Some AAP sources indicate starting foods at 4-6 months. The American Academy of Allergy, Asthma & Immunology (AAAAI) recommends introducing foods between 4 and 6 months to prevent certain allergies.

There are very few contraindications to breastfeeding:

Classic galactosemia. Classic galactosemia is a rare genetic condition in which a baby is unable to metabolize galactose. It is one of the conditions we screen on the newborn screen. Galactose is the sugar made from the lactose in milk. When galactose is not metabolized, it will reach high levels in the blood and become toxic, causing cataracts in the eyes, damage to the liver and kidneys, and brain damage. The galactosemic baby will fail to thrive on breast milk or formula based on cow's milk. The treatment for this condition is to remove all sources of lactose from the baby's diet and give soy formula.
HIV. Mothers who have HIV and are able to feed formula made with safe water should not breastfeed according to current guidelines. However, there is growing evidence that HIV positive mothers who take proper medications can safely breastfeed.
Untreated active tuberculosis.
Chemotherapy or radiation treatment.
Certain drugs. Most medications are compatible with breastfeeding. You can look on Lactmed to learn if a particular medicine is safe or what other options are recommended.

Some mothers do not want to breastfeed for various reasons. That's okay. It isn't for everyone. No one should say things that make these mothers feel guilty. They brought new life into the world. That alone is an amazing feat. As long as the baby is fed age-appropriate and formula that has been approved for use in infants, it is great.

Babies can thrive on formula. Just be careful of the many alternate formulas and milks that are advertised online. Discuss with your child's pediatrician if you plan on making your own formula or giving another alternative milk. There are many concerns with these, as discussed in Please Don’t Feed Your Baby Homemade Formula!

Some mothers really want to exclusively breastfeed but they have problems. Working with a lactation consultant and physicians (both mother's and baby's doctors) might help if there is a correctable condition, such as

insufficient breastfeeding attempts per 24 hours - not feeding frequently decreases supply
tongue tie treatment can improve latch and milk transfer from the breast into baby
jaundice, which makes baby sleepy and not feed as effectively
identifying and treating hormonal problems in mother
identifying and stopping medicines or herbs that might be inhibiting milk supply
stopping nipple shields as soon as possible - the use of nipple shields can decrease breast stimulation and lower supply
avoid unnecessary supplements - supplementing with formula can decrease supply overall because the mother's breast makes milk based on how much is used (This does not mean you should avoid formula if it is medically necessary.)

Even when breastfeeding goes well for both Mother and Baby, it is not sufficient to be the sole source of nutrition for the entire first year of life. There are some mom blogs that support exclusive breastfeeding for the first year of life, and that is not safe. I'm not linking any of them here because I don't want to promote them, but if you don't believe me just do a quick search and you will find some.

While breast milk is fantastic for young infants, it does not have the nutritional components to exclusively feed for the second half of the first year. Feeding with food from fingers or a spoon also encourages healthy development of fine motor skills.

It is important for older infants to learn to eat from a developmental standpoint. Once they can sit fairly well, turn away from food or open their mouth in response to food, they are showing signs that they are ready to start eating. They don't need teeth to move foods around in their mouth and make chewing motions.

They are much less averse to new things typically when they're younger, so if babies are delayed past a year they are much more likely to be picky eaters and not get the nutrition they need during childhood.

Then there's the research that shows that delaying certain foods past a year increases the risk of allergy. If you've ever seen a child with anaphylaxis to peanuts, you won't want to increase this risk for your child! See the AAP's guidance on introduction of high-risk allergenic foods.

Babies need a source of iron after about 4-6 months of age. If they are not eating foods rich in iron (meats, legumes, egg yolk, leafy greens) they will need an iron supplement. Many of the bloggers who support exclusive breastfeeding do not want any supplements at all. Just breast milk. It simply isn't enough to support the older infant's growing brain and body.

Vitamin D is important for us all, but it is not passed through breast milk well unless a mother is taking at least 6400 IU/day. Historically we could make vitamin D with the help of the sun, but we now know that sun damages our skin so it is safer to protect against excessive sun exposure. This puts us at risk for vitamin D deficiency. The AAP recommends that newborns begin supplementing with 400 IU/day of vitamin D soon after birth, and increase to 600 IU/day at 6 months of age. The supplement should continue even if they transition to Vitamin D fortified cow's milk at 1 year of age.

Any problems feeding should be discussed with your child's doctor

If your baby struggles with feeding, whether it's breastfeeding, formula feeding, or eating foods, please discuss it with your child's doctor. There are many reasons feeding might not go well, and we need to insure that your baby is being adequately fed. We will look at your baby's overall growth and development in addition to discussing the specific details of the problems.