- Women who have trouble breast-feeding are often told to try harder or give up
- Some women experience pressure to breastfeed without the support to figure out how
- Doctors can't place where breast-feeding problems should be handled
- Medical professionals are beginning to pay attention to the issue
The doctor blamed it on the baby. "She's not absorbing your milk," he told Colleen Kelly in the days after he daughter was born, as the baby lost too much weight and cried constantly. Lactation consultants said, "She's not latching properly."
Kelly drove through rural Maine for hours to attend breast-feeding support groups and La Leche League meetings, yet the baby went from eight to six pounds and was diagnosed as "failure to thrive." The baby's kidneys were x-rayed and blood taken, but doctors found nothing wrong.
Not once in her travels did someone suggest that perhaps the problem was Kelly herself, rather than her baby or her ability to latch on. She told doctors that her mother hadn't been able to produce enough breast milk -- could that be happening to her?
No, they said. That was an old wives' tale. But they never even looked at her breasts.
"It was clear that none of the doctors or nurses knew enough about breast-feeding to figure out what was happening," Kelly says.
That's because lactation is probably the only bodily function for which modern medicine has almost no training, protocol or knowledge. When women have trouble breast-feeding, they're either prodded to try harder by well-meaning lactation consultants or told to give up by doctors. They're almost never told, "Perhaps there's an underlying medical problem --let's do some tests."
When women have trouble breast-feeding, they are often confronted with two divergent directives: well-meaning lactation consultants urge them to try harder, while some doctors might advise them to simply give up and go the bottle-and-formula route.
"We just give women a pat on the head and tell them their kids will be fine," if they don't breastfeed, says Dr. Alison Stuebe, an OB who treats breast-feeding problems in North Carolina. "Can you imagine if we did that to men with erectile dysfunction?"
ED, she points out, is within the purview of many doctors' services, and insurance will cover Viagra, but lactation dysfunction? It doesn't even exist as a diagnosis, no accompanying health insurance code for which doctors can bill. Within the database of federally funded medical research, there are 70 studies on erectile dysfunction; there are 10 on lactation failure.
No one argues against the idea
that breast is best, but the truth is that breast-feeding is very difficult for many women, and for some, medical problems make it almost impossible without intervention. With the recent bans on giveaways of formula samples in some hospitals, it's all the more important that the medical community have the tools and knowledge to help mothers breastfeed -- or to figure out why they can't.
Until doctors and nurses are properly trained to help, women like Kelly will experience all of the pressure to breastfeed, with none of the support to figure out how.
What do doctors learn about breast-feeding in medical school? "We learned that it's what's best for baby," said my own pediatrician. "But that's it." They're introduced to evidence that prolonged breast-feeding reduces the possibilities of obesity, SIDS and allergies, but the science of it, what's happening at the anatomical level? Not so much.
"It's an hour, or a half a day, and (students) don't remember anything," says Dr. Todd Wolynn, a Pittsburgh pediatrician and executive director of the Breastfeeding Center of Pittsburgh. There were years, he says, when there was literally nothing said about breast-feeding at all.
Why so little heed? "When most of the people who are currently leaders were in training, breast-feeding was really uncommon," says Stuebe.
Many teaching in medical schools today were raised in the better-living-though-chemistry age, when infant formula was thought to trump the attributes of breast milk. (Formula was certainly an improvement over the non-pasteurized cow's milk that killed many infants at the turn of the 20th century, when breast-feeding was not in vogue). "It's generational for doctors to think it would be necessary to know anything about breast-feeding."
It didn't help that formula companies famously sidled up to doctors and nurses and insinuated themselves into hospital protocol; there's a reason that, until the bans enacted in the last few weeks in some cities, new moms left the hospital with so much Similac swag.
In addition, doctors practicing today don't know where to place breast-feeding problems --breasts are attached to the women, so shouldn't they be the province of OBs, say pediatricians. And OBs note that breast-feeding is for infants; shouldn't the baby's doctor handle it?
This leaves breast-feeding problems either to the rare family physicians, or more commonly to lactation consultants who can assist with technical issues -- improving the baby's latch and such -- but can't write prescriptions, check hormone levels or offer a diagnosis.
That's what a breast-feeding doctor -- an OB, pediatrician or family physician with a subspecialty in breast-feeding medicine -- would have done in Kelly's case: a complete physical and medical history (yes, in fact, it is relevant if your mother couldn't make milk) on mom and baby to see if any physical or anatomical factors were affecting supply.
In the mother, they might check the shape of her breasts, to see if they were hypoplastic -- a tubular shape that can indicate underdevelopment of the glandular tissue needed to make breast milk -- or evaluate her hormone levels, ask if her breast size had increased during pregnancy.
Perhaps they'd prescribe a galactogogue, a drug that promotes lactation. Today there are 88 physicians in the entire world who are fellows of the Academy of Breastfeeding Medicine, and have "demonstrated evidence of advanced knowledge and skills in the fields of breast-feeding and human lactation."
But Kelly's doctors weren't trained in human lactation, and they told her what many women with lactation failure have been told before: "We've never seen this before. You're the only one."
Yet Kelly is clearly not alone. Dr. Amy Evans, a pediatrician and medical director of the Center for Breastfeeding Medicine in Fresno, California, says that as many as 5% of all women have underlying medical conditions that prevent or seriously hinder lactation: hypoplasia, thyroid problems, hormonal imbalances and insufficient glandular tissue, among others.
But even Wolynn, who is also a certified lactation consultant, seemed skeptical when I related Kelly's tale -- usually women struggle because they haven't had enough support in the first few days after giving birth, in his experience. "Very few women really can't breastfeed," he said. "That's very, very, uncommon."
It's a "normal mammalian function," he said. Almost everyone can do it.
Because the complexities of lactation failure are so little studied and so often misunderstood, women can often feel that they are at fault, rather feeling like they are suffering from a medical issue for which they need and deserve professional help.
Dr. Marianne Neifert writes in her article, Prevention of Breastfeeding Tragedies, "The bold claims made about the infallibility of lactation are not cited about any other physiologic processes. A health care professional would never tell a diabetic woman that 'every pancreas can make insulin' or insist to a devastated infertility patient that 'every woman can get pregnant.'"
Luckily, doctors are beginning to take breast-feeding on. Wolynn, Evans and Stuebe are all fellows of the physicians' organization Academy of Breastfeeding Medicine (ABM). At Wolynn's practice, all six of the pediatricians on staff are also certified lactation consultants.
ABM has developed 25 protocols to guide physicians in treating breast-feeding problems. They've successfully lobbied to include breast-feeding issues on the exams for the American Board of Obstetrics and Gynecology and the American Academy of Pediatrics.
And the Affordable Health Care Act advises that, as of August 1, health insurance companies should provide "comprehensive lactation support and counseling, by a trained provider during pregnancy and/or in the postpartum period, and costs for renting breast-feeding equipment."
Of course, we're low on those trained providers, but there are more every day, as medical schools begin to adopt breast-feeding curricula. "It's probably the most promising times we've seen," says Wolynn.
"We're in the early phases of what I'm hoping in the next five to 10 years will be more appreciated and more considered a real subspecialty," says Evans. "It's a whole new area of medicine."
Still, there's work to be done. Health insurance companies need to reimburse doctors for the time they spend attending to breast-feeding issues, to cover galactogogues, and to cover donor breast milk for women with lactation failure.
And if we're going to remove formula samples for women to promote breast-feeding, we better come up with a plan to feed the babies of that 5% of women who can't sustain them -- with 4 million births a year, that's 200,000 moms who need extra help.
Doctors practicing today -- especially those treating pregnant women and new mothers --need to know that lactation failure really does happen, and to be familiar with the potential causes of it, so that they can intervene early.
Perhaps most importantly, we need to stop demonizing mothers who can't breastfeed, guilting them into starving their kids with insufficient milk supplies rather than supplementing with formula. Yes, breast-feeding can help prevent SIDS, obesity, childhood leukemia, asthma, and lowered IQ ... but none of those matter if your baby is failing to thrive because of malnutrition.
In Kelly's case, once the baby was admitted to the hospital, she began to use formula, fed through a syringe -- she was told to avoid bottles because the baby would reject the breast. She stuck with formula, her baby gained weight, and today, "she's happy, healthy and fine," Kelly says.
But her guilt and shame continued long after the baby recovered. It wasn't until weeks later, in another doctor's office, that she happened upon an article that calmed her: some women, it said, can't breastfeed, for physical reasons. If only her doctors had read that article, too.