U.S. Study Shows Baby-Friendly Hospital Initiative Does Not Work

by Christie del Castillo-Hegyi, M.D.

On October 14, 2019, the Journal of Pediatrics published astonishing findings regarding the effects of the Baby-Friendly hospital certification on sustained breastfeeding rates as defined by the 2020 Healthy People Goals of: 

  1. any breastfeeding at 6 and 12 months
  2. exclusive breastfeeding at 3 and 6 months. 

They did so by measuring the relationship between statewide breastfeeding initiation rates data and the above breastfeeding rates. They then measured the contribution of Baby-Friendly hospital designation on these same breastfeeding outcomes.

According to the study authors, the increase in hospital designation in the Baby-Friendly Hospital Initiative (BFHI) began in 2011 when the U.S. Surgeon General issued a call to action for maternity care practices throughout the U.S. to support breastfeeding. The Centers for Disease Control (CDC) became involved in promoting the BFHI policies in hospitals and health facilities, as breastfeeding was thought to be associated with lower rates of childhood obesity. The assumption was that by increasing breastfeeding rates through the BFHI, there would be a concomitant decline in childhood obesity. Upon initiation of this program, the CDC initiated surveillance of state-specific data on breastfeeding outcomes after discharge including BFHI designation rates. This data is made available to the public through the CDC Breastfeeding Report Card, which provides annual reports from 2007 through 2014 and biennial reports from 2014.

As expected, they found that states with higher breastfeeding initiation rates had higher rates of these sustained breastfeeding outcomes. You cannot have high breastfeeding rates unless mothers are given education and successfully initiate breastfeeding. However, when they measured the effects of Baby-Friendly certification, this is what they found.

“Baby-Friendly designation did not demonstrate a significant association with any post-discharge breastfeeding outcome (Figures 1, B and 2, B). There was no association between Baby-Friendly designation and breastfeeding initiation rates.” Continue reading

World Health Organization Revised Breastfeeding Guidelines Put Babies at Risk Despite Pleas from Experts—Informing the Public “Not a Top Priority”

By the Senior Advisory Board of the Fed is Best Foundation

A key recommendation of the 1989 World Health Organization Ten Steps to Successful Breastfeeding which guides the Baby-Friendly Hospital Initiative (BFHI) is: “give infants no food or drink other than breast-milk, unless medically indicated.” This has led to serious complications from accidental starvation of babies, including dehydration, hyperbilirubinemia (jaundice) and hypoglycemia (low blood sugar) — known causes of infant brain injury and permanent disability. Last week, the WHO issued draft revised breastfeeding guidelines, failing to revise this recommendation. These guidelines define the standard of care for breastfeeding management in all healthcare facilities worldwide. Nearly 500 U.S. hospitals and birthing centers and thousands more worldwide that meet the criteria of the BFHI are certified as Baby-Friendly, adhering to the application of the WHO’s Ten Steps.

On Sept. 22, 2017, senior members of the Fed is Best Foundation, and guests including a neonatologist from a leading U.S. tertiary care hospital and a pediatric endocrinologist, Dr. Paul Thornton, M.D, from Cook Children’s Hospital Fort Worth, lead author of the Pediatric Endocrine Society’s newborn hypoglycemia guidelines, met via teleconference with top officials of the WHO Breastfeeding Program: Dr. Laurence Grummer-Strawn, Ph.D., Dr. Nigel Rollins, M.D. and Dr. Wilson Were, M.D. to express their concerns about the complications arising from the BFHI Ten Steps and to ask what, if any, monitoring, research, or public outreach the WHO has planned regarding the risks of accidental starvation of exclusively breastfed newborns. The Foundation members who attended were 1) Christie del Castillo-Hegyi, MD, Co-Founder, 2) Jody Segrave-Daly, RN, IBCLC, Co-Founder, 3) Julie Tibbets, JD, Partner at Alston & Bird, LLP, Pro-Bono Attorney for the Foundation, 4) Brian Symon, MD, Senior Advisor, and 5) Hillary Kuzdeba, MPH, former quality improvement program coordinator at a children’s hospital, managing infant feeding projects and Senior Advisor.

Emails confirming meeting between the WHO and the Fed is Best Foundation available here.

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If I Had Given Him Just One Bottle, He Would Still Be Alive.

by Jillian Johnson with commentary from Dr. Christie del Castillo-Hegyi

Landon would be five today if he were still alive. It’s a very hard birthday–five. It’s a milestone birthday. Most kiddos would be starting kindergarten at this age. But not my little guy. I wanted to share for a long time about what happened to Landon, but I always feared what others would say and how I’d be judged. But I want people to know how much deeper the pain gets.

I share his story in hopes that no other family ever experiences the loss that we have.

Jarrod and I wanted what was best for Landon as every parent does for their child. We took all of the classes. Bought and read all of the books. We were ready! Or so we thought….every class and book was geared toward breastfeeding and how it’s so important if you want a healthy child. Landon was born in a “Baby-Friendly” hospital. (What this means is everything is geared toward breastfeeding. Unless you’d had a breast augmentation or cancer or some serious medical reason as to why you couldn’t breastfeed, your baby would not be given formula unless a prescription was written by the pediatrician.)

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I Dropped my Baby in a Baby-Friendly Hospital While I was Alone Recovering from a Cesarean Section

 

Step 7 of the Baby-Friendly Hospital Initiative (BFHI) policy requires parents to room in with their baby 24 hours a day immediately after delivery.

Mothers are commonly sleep-deprived and profoundly exhausted after labor and delivery, some laboring for > 24 hours, some recovering from major surgery. They are required to nurse and care for a newborn almost immediately after delivery with few exceptions. Maternal exhaustion has lead to tragic and preventable accidental newborn falls from bed and suffocation from falling asleep while breastfeeding in bed. These accidents have resulted in brain injury, severe disability, and rare deaths in previously healthy infants. The elimination of newborn nurseries by hospitals has increased as a result of the Baby-Friendly policy. These tragic events received the attention of pediatricians and the Neonatology Section of the American Academy of Pediatrics who has published their concerns in the medical journals of JAMA and JAMA Pediatrics and Pediatrics.

In this recent article that was published in pediatrics, In-hospital Neonatal Falls: An Unintended Consequence of Efforts to Improve Breastfeeding, falls that occur when caregivers fall asleep is a consistent theme in the reported series. In a review of patient safety data over a 9-year period, Wallace reported that 150 of 272 neonatal falls occurred after a caregiver fell asleep while holding the newborn.7 Several smaller series report that 36% to 66% of in-hospital neonatal falls involved caregivers falling asleep.1,3,4,12 Not surprisingly, these falls transpired most commonly during the night or early morning hours. Similar to our series, Galuska13 described 5 cases at a single center in which all neonates fell from their mothers’ arms in the early morning hours, continuing to implicate fatigue as a factor.

Nicole Writes:

I delivered my baby shortly after midnight via emergency c-section at 36+4 weeks. I was doing lots of skin-to-skin contact and breastfeeding with assistance, but his blood sugar was low, and formula milk was needed to stabilize his blood sugar.  It felt like we had to force him to drink it and that concerned me.

Thankfully, my mom was staying with me to care for me and my baby on the first day. I was medicated with narcotics every few hours for pain from my surgery and I developed body shaking and my skin was itching constantly.  My mom had to leave for a bit, so I was alone; but my mom told the nurses, so they knew I was alone caring for my baby in this condition.

 I hadn’t slept in 36 hours or eaten in 24 hours, and I was profoundly exhausted, emotional, and in pain and was expected to care for my baby anyway.

I hadn’t seen a nurse in a while, so I called my mom to see when she would be back, and she said it would be an hour. I woke up to my mom shaking me and two nurses hovering over my baby. I dropped him from my bed. I was so sleep-deprived and very sedated from being medicated that I didn’t even hear him screaming.  According to my mom, I was completely unresponsive. The nurses took my baby to the NICU to check him out, and I couldn’t even react; I didn’t know how to. I just kept going over everything in my mind. 

What if I killed my baby? What if I hurt him? What if he has a brain injury? Do I even deserve to have this baby? What if he gets taken away? He literally fell a few feet from my arms to the ground. A tiny, not even 24-hour-old preemie.

 Why are new mothers expected to take care of their babies when they are recovering from major surgery? Why isn’t there a nursery to take your baby to when you need one, for safety? Why hadn’t the nurses checked on me?  I hadn’t seen them in at least 1 hour before I fell asleep. Why didn’t they check on us when he was screaming bloody murder? The nurse’s station was right outside my room and my mom heard him all the way down the hall.  Why was I given a dangerous amount of Percocet and expected to take care of myself and my baby?  I WAS ANGRY!

Because I was medicated and profoundly exhausted and alone with my baby, he fell out of my hospital bed easily.

In this recent article that was published in pediatrics, In-hospital Neonatal Falls:An Unintended Consequence of Efforts to Improve Breastfeeding, falls that occur when caregivers fall asleep is a consistent theme in reported series. In a review of patient safety data over a 9-year period, Wallace reported that 150 of 272 neonatal falls occurred after a caregiver fell asleep while holding the newborn.7 Several smaller series report that 36% to 66% of in-hospital neonatal falls involved caregivers falling asleep.1,3,4,12 Not surprisingly, these falls transpired most commonly during night or early morning hours. Similar to our series, Galuska13 described 5 cases at a single center in which all neonates fell from their mothers’ arms in the early morning hours, continuing to implicate fatigue as a factor.

What is more ludicrous is that the 24-hour rooming-in policy has been shown to have no effect on increasing sustained breastfeeding after discharge. The 2017 WHO revised breastfeeding guidelines reviewed all the data regarding this policy and showed no effect of 24-hour rooming-in on breastfeeding rates at 3-4 months. Despite the negative short-term effects of this policy on parental sleep and rare serious effects on the infant in the form of falls and sudden unexpected postnatal collapse (SUPC), neither the WHO nor Baby-Friendly USA has changed this recommendation. In fact, health professionals are scripted to try to discourage parents from sending their infants to the nursery if they express the need for sleep, which ultimately puts infants at risk by perpetuating the unsafe condition of being cared for by an impaired parent. 

Nicole continues:

I don’t know how he wasn’t severely hurt, but I was beyond thankful.  Minus being slightly hypothermic, his exam was normal.  Despite being high risk, 4 weeks early, having low blood sugar, and being dropped, we avoided a NICU stay. I had a super easy recovery at home, having a little trouble gaining weight, we are both doing wonderfully. He is growing, meeting or exceeding all of the milestones, and I couldn’t be more in love with him.


More information and stories about newborn falls:

Breastfeeding Improvement Initiatives May Increase Risk of Newborn Falls

 

“Is Baby-Friendly Baby Safe?,” Fetus & Newborn Conference 2018

My Baby Was Put in a Dangerous Situation By Rooming-In with an Exhausted Mom

Neonatal Nurse Practitioner Speaks Out About The Dangerous And Deadly Practices Of The BFHI

 

Breastfeeding initiatives can have unintended consequences

U.S. Study Shows Baby-Friendly Hospital Initiative Does Not Work

 

Nurses Are Speaking Out About The Dangers Of The Baby-Friendly Health Initiative

Nurses Quit Because Of Horrific Experiences Working In Baby-Friendly Hospitals

NICU Nurse Discloses Newborn Admission Rates From Breastfeeding Complications in BFHI Unit

Pediatrician and Other Physician Views on the Baby-Friendly Hospital Initiative

Baby-Friendly Protocol Complications in the Media

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The Letter Not Only Protected Me; It Protected The Nurses Too

The Letter was from my psychiatrist. It was our way of beating a system that neither of us agreed with, or believed was good for my mental health. It provided protection for me to make decisions that went against the Baby-Friendly Hospital mandates. 

The amount of stuff a pregnant woman brings to the hospital for delivery gets progressively smaller, the more children she has. With my first child, I brought three bags; I ended up ignoring 90% of the contents and gave my husband fits when he loaded the car for the ride home. By the time I packed the hospital bag for my third child, everything fit neatly into a small duffel. Even then, I felt like I was overpacking. As long as I had a phone charger, some lip balm, and the Letter, I knew I’d be fine. 

The Letter was new; I didn’t have it for my other two birth experiences.  It was the result of a long, painful journey, and it embodied all of the knowledge I’d gained over the past several years. It represented a feeling of hope I carried with me as I walked onto the labor and delivery floor at my hospital. Things would be different this time. 

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I Had Asymmetric Tubular Breasts; My Breastfeeding Story

Written By: Rachel

 As a young girl, I knew something was wrong with my breasts when they began to develop.   I had asymmetric tubular breasts, and it quickly became my biggest insecurity. At the age of 20, I saw a doctor who told me a breast augmentation would “fix” them. Trusting her medical opinion I had breast augmentation surgery. Now they were double the size and sagging from the weight of the implants. It was worse than what they originally were, making my anxiety and insecurities heightened. After a few years, I decided to get them removed by another doctor who specializes in reconstruction surgeries. I got the implants taken out, a lift of the skin and fat removed from my stomach to fill the empty pouches. With two surgeries comes many scars and of course trauma to the breast tissue. 

What are Tubular Breasts

“Tubular breasts” is the name of a condition caused by breast tissue not proliferating properly during puberty. The condition is also called tuberous breasts or breast hypoplasia.

While not extremely common, tubular breasts cannot be considered rare because many women don’t seek treatment. While tubular breasts don’t pose any direct threat to your health, some womenmay seek to correct it. Tubular breasts can also present problems for women who wish to breastfeed. (source Healthline)

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Dr. Nicole King Warns About Dangers of Baby-Friendly Hospital Initiative at USDA Dietary Guidelines Meeting

On August 11, 2020, Dr. Nicole King, Anesthesiologist, Critical Care Intensivist, Patient Safety Expert and Senior Advisor to the Fed is Best Foundation spoke at the USDA Scientific Report of the 2020 Dietary Guidelines Advisory Committee meeting warning of the dangers and patient rights violations of the Baby-Friendly Hospital Initiative. Watch her address below.

Good afternoon, my name is Nicole King and I am a mother and a physician.  As an anesthesiologist and intensive care physician, I am faced with life and death circumstances every day.  In no way did I ever consider breastfeeding my child would be as stressful as supporting a COVID patient through their critical illness.  Five years ago, I realized how wrong I was.

As a new mother who had had a breast reduction and a physician, I should have known better, but I did not. I fed into the same propaganda, misinformation and fervor around breastfeeding that has grown over the last 30 years as a result of the Baby-Friendly Hospital Initiative and the WHO’s Ten Steps [to Successful Breastfeeding]. I was not informed of its risks and followed the exclusive breastfeeding guidelines, and as a result, my newborn lost excessive weight and was readmitted for dehydration and jaundice.

The current USDA guidelines are filled with the same soft science riddled by confounding factors, that has led to the shaming of women who are unable to exclusively breastfeed for 6 months. The guidelines are an ableist and elitist narrative and read as an invitation to admonish women for failing to produce enough milk for her child. It blatantly ignores research that clearly shows that delayed lactogenesis of mature milk is common, found in up to 40% of first-time mothers and 22% of all mothers, even those who are motivated to exclusively breastfeed.  Never mind the 15% of women who are incapable of sustaining breastfeeding past the first month, even with lactation support.

If you are ill and in the hospital, nutritionists are there to calculate the calories needed to feed you in order for you to thrive and recover. Why then are we so easily fooled into thinking an infant who is building muscle, fat and brain cells can be sustained on far less than their caloric needs, purported by the Baby-Friendly policy? If the “biological norm” is put forth as a reason to exclusively breastfeed, then why are exclusively breastfed infants being admitted daily for dehydration, jaundice, and hypoglycemia? Why do we continue to insist on a policy that increases the risk of harm to infants while vilifying supplementation that prevents serious complications? Every day, I protect my patients with medications, machines and nutritional alternatives to overcome so many failures of the “biological norm.” I do this because I too am human and understand that we care and love for each other regardless of our ability to live up to a standard of perfection. Yet we allow babies to become seriously ill by pressuring mothers to achieve this standard of perfection that millions cannot safely achieve. If judicious and humane supplementation is the difference between a hospitalized and a safely breastfed child, then we have failed all mothers and infants in this country by disparaging its use.

The USDA draft policy continues to ignore these realities and thus fails to protect countless infants.  National guidelines should never encourage a policy that is directly responsible for the leading cause of rehospitalization of healthy term infants. And most importantly, as a national guideline, it should apply to all mothers, regardless of her ability to breastfeed, across all socioeconomic demographics.

As a mother who followed these guidelines and was led to rehospitalize her own infant, I beg you to consider the plight of all mothers and infants in this country. Every infant deserves to be protected from hospitalization and the complications of an exclusive breastfeeding policy.   And their mothers deserve to know that breast milk is but one way to best nourish their children.  The USDA is responsible for every child in the US and their policy should reflect this responsibility.


Dr. Nicole King, M.D. is a patient safety expert and Senior Advisor of the Fed is Best Foundation. She is a board-certified anesthesiologist and critical care intensivist.

Hospital Drops Baby-Friendly Program After Doctor’s Baby Was Harmed

Baby-Friendly: Failure and the Art of Misdirection

Information for Hospitals: Ensuring Safety for Breastfed Newborns

Fed is Best Statement to the USDA Regarding the Harms of the Baby-Friendly Hospital Initiative

 

 

Our Close Call with Our Baby’s Life While Exclusively Breastfeeding Haunts Us

Written By Ansley T.

When my baby was 5 days old, I got a call from the pediatrician we chose before birth. As soon as I answered, she started speaking very fast and explained that Northside Hospital had notified her that one of our son’s Newborn Screening Test results had come back with an abnormal reading;  he needed to be evaluated by a doctor urgently, but in the meantime, I needed to be sure to feed him every two hours. I couldn’t even compute all she said, but I explained that we were already in the NICU at Children’s Hospital because of his low body temperature on the first night home from the hospital.  We found out that day our son has medium-chain acyl-CoA dehydrogenase deficiency (MCADD).

WHAT IS MEDIUM-CHAIN ACYL-COA DEHYDROGENASE DEFICIENCY (MCADD)?

Medium-Chain Acyl-CoA Dehydrogenase Deficiency, or MCADD, is a rare genetic metabolic condition in which a person has difficulty breaking down fats to use as an energy source while fasting. It is estimated to affect one (1) in every seventeen thousand (17,000) people in the United States. All babies have a newborn screening (NBS) blood test to check for various genetic and metabolic disorders such as MCADD, but it can take five or more days until the results are reported.

Our close call with our baby’s life haunts us, but it propels us to advocate and educate others—about MCADD, yes, but also about the risks of exclusive breastfeeding, before the onset of copious milk production or insufficient colostrum amounts before those crucial Newborn Screening test results are back, which typically takes 5-7 days. We share our story openly and widely, passionately trying to dispel the myths propagated by the “Breast is Best” movement.

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Is My Baby’s Weight Loss Normal Or Excessive?

The Newborn Weight Loss Tool can provide an answer.

Parents are taught that it’s normal for babies to lose 7–10% of their body weight in the first few days after birth, but is this true? Well, that depends. According to the AAP, a baby who loses more than 7% of his body weight may be losing excessive weight and requires a comprehensive lactation evaluation to rule out delayed onset of copious milk production, primary lactation failure, and/or infant oral anomalies that prevent adequate colostrum/milk transfer.

From the American Academy of Pediatrics HealthyChildren.org website. Breastfed newborns should lose no more than 7 percent of birth weight in the first few days after birth before starting to gain weight again. (Accessed July 16, 2020)

Weight loss has typically been assessed using simple percentages, but now there is a much more precise and accurate way to track excessive weight loss in newborns and many hospitals, pediatricians, and lactation consultants are adopting this method for greater accuracy in making clinical recommendations. The Newborn Weight Tool, or NEWT, is an online tool, the first of its kind, to help pediatricians determine whether exclusively breastfed newborns have lost too much weight in the first days of life. The tool was developed at Penn State College of Medicine through research conducted jointly with University of California, San Francisco. It was developed using a research sample of hourly birth weights from more than 100,000 breastfed newborns. For a quick synopsis of this tool from the lead investigator and one of developers of the tool, Dr. Ian Paul, watch the video below.

Source: Penn State Health News

In this video, Dr. Ian Paul, professor of pediatrics and public health sciences at Penn State College of Medicine and pediatrician at Penn State Hershey Children’s Hospital, talks about how NEWT fills an important void.  Determining whether an exclusively breastfed newborn is losing excessive weight is important because higher weight loss almost always reflects suboptimal milk intake. It is also associated with increased risk of medical complications such as low blood sugar, jaundice, and dehydration, which can result in the need for medical interventions and future health and developmental problems. This weight-loss tool shows that how quickly babies lose weight is just as important as how much they lose.

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The Loss Of Our Son Has Devastated Our Family – This Time I Will Be Supplementing With Formula After Every Nursing session

I had a beautiful, healthy pregnancy with Bryson, with the help of Clomid (a fertility drug), like my first pregnancy with my daughter. After about 31 hours of induced labor, Bryson was here. Seven pounds, twelve ounces, and seemingly healthy! He latched like a champ immediately, and we had zero complications of any sort while in the hospital. He had wet and dirty diapers and was breastfeeding well, every 2–3 hours. His discharge weight was 7 lbs, and I had a follow-up appointment scheduled for two days later.

NEWT is the first tool that allows pediatric healthcare providers and parents to see how a newborn’s weight during the first days and weeks following childbirth compares with a large sample of newborns, which can help with early identification of weight loss and weight gain issues. Bryson was discharged with a weight loss of 9.7 percent at 36 hours of age. The NEWT graph indicates his weight loss was excessive.

The first two days at home were easy. He was a sleepier baby than my daughter was, and unless wet or hungry, he was calm. I continued to breastfeed him for 20 minutes every three hours as instructed. I did begin to notice that his newborn onesie seemed quite big on him. His wet diapers did slow down on the third day, and he hadn’t pooped since the third day either. At two in the morning on July 29th, at four days postpartum, I tried to breastfeed again, but he was just too sleepy to nurse, and he would not latch no matter how hard I tried. I tried so many times, different ways, different positions. I thought he would eventually latch but he just wanted to sleep. I thought, well I can’t force-feed him, so I’ll try again after he rests a little more. I tried several times after that, and he was just less and less interested.  He had started to get pale and lethargic. It was also the day of his two-day post discharge checkup at the hospital, so I decided to take him in early, since I was getting concerned. 

During the whole drive there, I felt in my heart that time was of the essence. After the nurse checked him, she said he would have to be admitted, as he didn’t look too good, and his weight had dropped to 6 lbs 9 oz; he had lost over a pound in the four days since his birth. She turned her back, and I noticed he stopped moving. I hesitantly asked, “Is he breathing?” She turned around and yelled, “no!” then fumbled and fumbled to open a plastic bag; I finally screamed at her: “do something!” She picked him up and ran him down the hall. 

Bryson’s weight loss was 22 percent.

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Why this Lactation Consultant Smuggled A Pacifier To Her Patient Who Requested One

“Can I have a pacifier?” 

After helping a third-time mother latch her new baby, she requested the comfort tool she had used with her other two babies, whom she successfully breastfed until she went back to work and chose to wean. Our hospital policy is to educate patients on the many ways pacifiers can disrupt breastfeeding, rather than simply respecting the mother’s choice. The problems with this approach are twofold: there is recent good quality research showing pacifiers do not disrupt breastfeeding and actually reduce the risk of Sudden Infant Death Syndrome (SIDS). Even the WHO agrees—in 2018 they changed their Ten Steps to Successful Breastfeeding to reflect the fact that pacifiers are compatible with breastfeeding. 

Breastfeeding and pacifier use have a protective effect on sudden infant death syndrome

In responding to my patient, I had to choose between scientific evidence and maternal autonomy on the one hand, and our hospital protocol on the other. I chose to sneak her a pacifier at her request. To do otherwise would have been disrespectful towards this experienced mother, denying her autonomy over her baby and her body, and would have been contrary to my Code of Professional Conduct as an IBCLC, which emphasizes evidence-based practice. 

Cochran Review: Pacifier use versus no pacifier use in breastfeeding term infants for increasing duration of breastfeeding.

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I Am Back From My Breastfeeding Battle And Here’s What I Have Learned

Hopefully, my experiences will help another family avoid the psychological trauma that I endured while breastfeeding my daughter. This is what I learned:

  • Sacrificing your mental health or your baby’s health (or both!) to exclusively breastfeed is not worth it. 
  • Some breastfeeding advocates don’t see (or don’t want to see) the risks of exclusive breastfeeding which include a baby who isn’t gaining weight sufficiently, an emotionally suffering mum, or a strained mother–baby relationship.  
  • Seek help from lactation professionals who are open-minded enough to suggest combo-feeding as an option and are willing to support your choice because sometimes exclusive breastfeeding is not an option.

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Liquid Courage Sometimes Comes In The Form Of Baby Formula

Written by: Sarah L. R.

“I think it would be very courageous for you to do this.” 

My psychiatrist leaned forward in his chair, clasped his hands together, and smiled at me. 

Grabbing a tissue from the box on the table, I sniffed, “Then why do I feel like the biggest coward for making this decision?!” 

“Sarah, what’s braver than making sure you’re the best mother you can be?”

It took several more conversations and even more tissues, but eventually, I made the decision to forgo breastfeeding entirely, and feed my daughter formula milk from birth. In doing so, I hoped to avoid postpartum depression and anxiety that haunted my earlier experiences as a new mother. 

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