Breastfeeding Medicine

Physicians blogging about breastfeeding

Don’t throw the baby out with the bath water

with 20 comments

A new study out of Scotland is making headlines today that current recommendations for 6 months of exclusive breastfeeding are “unrealistic.” It’s an irksome claim that is prompting breastfeeding advocates to suspect another formula-company-funded misinformation campaign designed to mislead mothers and undermine public health.

In fact, however, the Hoddinott paper, which follows a select group of mothers, partners, sisters, and grandmothers from pregnancy to 6 months after birth, offers a great deal of food for thought for those who care about supporting the wellbeing of families in the months after childbirth.

The study’s authors make the case that, despite increased commitment to exclusive breastfeeding in national and international policy, progress has been slow, and few interventions have moved the dial on breastfeeding. The aim of their study, which was funded by the National Health Service, was to ask mothers what would have been helpful to them as their navigated feeding their infants in the first six months.

Several themes come through. Before birth, mothers were unimpressed with classes that demonstrated breastfeeding with dolls and listed the ingredients in breast milk vs formula. One mother said,

Woman: The class on breastfeeding, the midwife or health visitor that did it brought out a doll and, you know, it was like something you would’ve done at playschool, it was quite kind of. you know, made it seem.. I don’t know what the word is I’m looking for [laugh] but it wasn’t practical, it wasn’t kind of realistic. (ID 1040. Antenatal interview)

The Rules” were another frequent target of criticism – parents were frustrated by all-or-nothing recommendations that asked them to ignore their own judgment to follow what felt like an arbitrary recommendation. They said they would have welcomed an interactive discussion, including parents who had “broken the rules,” prior to birth, who could share realistic stories of what to expect with early parenting.

After birth, mothers craved hands-on support from providers who would take the time to observe an entire feeding. One mother said:

Woman: [describing qualities of the ideal helper] Patience. Tolerance. Listening, listening to you. Showing you without force. Someone that can focus all their attention on you and the baby and the task at hand. (ID 1210. Interview 24 weeks after birth: breastfeeding, with formula introduced at 1 week and solids at 21-24 weeks)

The authors also explored the tension between the long-term risks of formula-feeding and the immediate perceived benefit of stopping breastfeeding:

Woman: I did feel a bit guilty at first [about stopping breastfeeding]. But then I thought well he wasn’t settling and he needs to make sure he’s getting fed and I’ve obviously got to look after myself as well to be able to look after him. (ID 2255. Interview 3 weeks after birth: formula feeding, introduced at 1 week, breastfeeding stopped at 1 week)

For mothers like this one, abstract information about long-term risks and benefits was not helpful — they needed concrete support to navigate the sleep-deprivation of early parenthood.

The authors note that participants encountered “pivotal points” when they felt that the only solution was to stop breastfeeding – and nthat these moments are missed opportunities for health care providers to help mothers navigate difficulties and sustain breastfeeding. They write:

What would make a difference? Our interpretation is that infant feeding care would improve by providing more proactive rather than reactive care, anticipating mismatches between ideals and reality that underlie pivotal points and providing skilled family-centred help to resolve difficulties.

This study is not perfect. The authors invited more than 500 women to participate, and only 72 responded. It’s possible that the women who agreed to join had preconceived notions about breastfeeding that biased their answers, and that the other 400+ women were delighted with their care and breastfed exclusively for six months without encountering any obstacles or resistance. But given the dismal rates of exclusive breastfeeding in the UK, I suspect that there are some real issues out there. Moreover, their findings resonate with a meta-synthesis of qualitative studies that similarly found women valued realistic information and empathetic support, rather than strict rules and didactic instruction.

This study raises a number of provocative questions for all of us who strive to enable mothers to make informed decisions about infant feeding and achieve their personal goals. As the study’s authors comment, “more of the same approach to promoting and supporting breastfeeding would seem unlikely to be effective.”

I encourage you to sit down, with patience and tolerance, and listen to what these mothers are saying. The full text of the BMJ paper is online here:

A serial qualitative interview study of infant feeding experiences: idealism meets realism

The full report from the study team is available from HealthScotland:

A prospective study exploring the early infant feeding experiences of parents and their significant others during the first 6 months of life: what would make a difference?

What do you think would make a difference?

Alison Stuebe, MD, MSc is a maternal-fetal medicine physician at the University of North Carolina at Chapel Hill and a member of the board of the Academy of Breastfeeding Medicine.

Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.

Written by astuebe

March 15, 2012 at 3:40 pm

20 Responses

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  1. I have been a Certified Breastfeeding Educator since 1996. One of the reasons I did not become an IBCLC was because, at that time, Lactation Consultants were perceived as “overbearing and making moms feel guilty” if they were having difficulty breastfeeding(notice that I did not say this is what they were doing…but it was perceived this way by the patients). In my practice, I use a counseling approach, I am available 24/7 via phone ( video consultation if needed) and I walk them through their situation at that particular time. Yes, I may get several phone calls, with different issues, from the same patient…..but mom feels that she has the ability to gain control of the issue, has increased confidence and feels empowered to breastfeed!

    Secondly, I would like to mention that after leaving the hospital…moms who are trying to breastfeed feel “left out in the cold”….they do not receive the follow-up support that they should have! We are so consumed with titles, associations, and a healthcare system that does not work together to accomplish the goal of enhanced and extended breastfeeding. It is time we put politics aside and start putting the patient and her baby’s needs first…if we, in fact, want to accomplish the goal of every baby receiving the known benefits of breastfeeding.

    Thirdly, I would like to address the topic of breastfeeding education. I agree that having a class, explaining the process with a doll, is NOT very effective. In my breastfeeding classes, we discuss briefly, the anatomy and physiology, and concentrate more on possible issues and solutions to those issues. I also spend MOST of my class time discussing newborn behavior. The knowledge parents gain from understanding newborn behavior is invaluable. Not understanding newborn behavior is one of the key factors in weather or not enhanced and extended breastfeeding is accomplished.

    Fourthly, I would like to address the cost associated with breastfeeding counseling and education. Those providers that are charging excessively for a mom to receive this service…should re-evaluate their true intentions. They are providing a service, and yes they should be paid….but it should be within a price range that the average person can afford. I realize that WIC (provided through medicaid) does provide some counseling….and that is a wonderful service…but this does not help the mom who is awake in the middle of the night who needs support THEN as opposed to later!!

    The bottom line is we need to revamp our entire concept of how to accomplish the ultimate goal of all moms and babies receiving the benefits from breastfeeding!!

    Pamela Mckimie, D(AAIM), CBE, CHE, CMBSS

    March 15, 2012 at 4:42 pm

    • I would also like to clarify that when I was referring to the politics of healthcare…Associations and titles are important in the since of establishing educational standards, protocols, and one’s scope of practice….but we should respect all providers who are working to accomplish the end result, be willing to learn from each other and respect each other for the common good! Although, I have been doing this for 16 years…I have learned many techniques from those who have been doing this for a shorter period of time. The Academy of Breastfeeding Medicine is a great association, with established protocols that are available for all providers, at all levels providing support services to breastfeeding moms! The physicians within the association have dedicated their specialty to breastfeeding medicine…so when we have issues that are beyond the consultant or educator’s scope of practice…we now have physicians that we can refer to beyond the OB/GYN or Pediatrician! I encourage all providers to utilize the information and knowledge these physicians have to offer!!

      Pamela Mckimie, D(AAIM), CBE, CHE, CMBSS

      March 15, 2012 at 5:15 pm

  2. Pamela, for the most part I agree with you EXCEPT for the part you say that WIC does not provide in-the-middle-of-the-night services. I am a peer counselor for WIC and I am availabale to mothers 24/7 as well. Moms can call me anytime and I am more than happy to help. I am aware that each state is different but here in MA we make ourselves highly available to mothers and babies in need.

    I think that this should be the case in every state, I hope that a policy can be made that calls for every state to offer this to breastfeeding moms. I find that moms most often just need someone to listen, to help them know what’s normal and what may not be and to build their confidence in themselves and their babies. Being a mother is often a thankless job, one thing I always do is make sure to let them know how wonderful they are doing especially when they think they are not.

    Dayna Markley, CLC, WIC Senior Breastfeeding Peer Counselor

    March 15, 2012 at 5:11 pm

    • Dayna, thank you so much for letting me know that each state is different with regard to the 24/7 availability of WIC Counselors. I agree, it would be great if we could establish a policy for this to be available in all states!! Thank You for YOUR dedication to breastfeeding moms and their babies!! You sound like a wonderful counselor! Have a great evening!!

      Pamela Mckimie, D(AAIM), CBE, CHE, CMBSS

      March 15, 2012 at 5:24 pm

      • Thanks Pamela! Thank you for your work and dedication also! I totally agree with your comment at 5:15 as well. Having knowledgeable support surrounding mothers makes a world of difference. I am thankful every time I hear a mom tell me about a doctor who has supported her in breastfeeding, I actually send them thank you cards to let them know and encourage them as well.

        Dayna Markley, CLC, WIC Senior Breastfeeding Peer Counselor

        March 15, 2012 at 7:55 pm

      • I LOVE the idea of sending thank you cards!! Thank you for the idea…a great way to encourage providers to support breastfeeding!!

        Pamela Mckimie, D(AAIM), CBE, CHE, CMBSS

        March 15, 2012 at 8:35 pm

  3. I’m a breastfeeding peer counselor at The Baby Cafe in El Paso, TX. Many of the mothers who come into our facility are carrying newborns, five and six days old (and sometimes younger). With the help of our IBCLC Libby Berkeley, I assist these mothers and bring them the information they need in order to successfully breastfeed. In nearly every single instance, mothers are looking for one thing: reassurance that they are normal and they are doing the right thing for their babies. Thus assured, you can see them relax – and we all know the physiological consequences of being relaxed (the hormones, etc). Confidence and success aren’t far away when moms feel like they’re in control again!

    Feel free to check us out!

    Alison Westermann

    March 15, 2012 at 9:17 pm

    • Thank You Alison for the information…and you are so right!! Moms are looking for that reassurance. It is great that we can all talk and gain knowledge from each other! I love the site….thank you for sharing and have a wonderful day!!

      Pamela Mckimie, D(AAIM), CBE, CHE, CMBSS

      March 16, 2012 at 4:32 pm

  4. Oh – and I meant to say: The Baby Cafe was started in the UK, and mothers who utilize its services tend to breastfeed their babies for longer than the average and feel supported to nurse even longer (upwards of 2 years, depending on the mom!).

    Alison Westermann

    March 15, 2012 at 9:19 pm

  5. Thank you, Alison, for this blog. It really gives food for thought and urges us to think over how we communicate with new parents, not pushing our agenda but looking at their needs and encourage them, support them and accept them in trying to reach their own goals. The research of Pat Hoddinott et al shows us, that much more work needs to be done here.
    For all who want to discuss this paper with the author itself: Pat Hoddinott will be one of the main speakers at the 4th ABM European Regional Meeting on May 19-20, 2012 in Trieste. More information: or


    March 16, 2012 at 5:19 am

  6. Thank you Dr. Steube for alerting lactation professionals and others to the honest reactions of mothers, as in the study you refer to. I have learned so much by really listening without judgement to mothers who are struggling with the complex issues of caring for a newborn in a culture that is not very supportive of new mothers and where mothers are deluged with misinformation that leads to problems and that also makes it difficult to overcome those same problems. To the responder who spoke about the value of explaining infant behavior (for example, feeding and satiety cues, infant body language, etc.): I couldn’t agree more! Any information that empowers parents, that helps them see how they are the expert for their own baby, is far more helpful than lists of rules that mislead parents that there is one right way, one right “recipe”, one way for babies and parents to be.

    Susan Iwinski

    March 16, 2012 at 7:46 pm

    • Hi Susan, I just wanted to say that I love how you articulated that parents are misinformed at times to believe there is only one right way, “one recipe”, one way for babies and parents to be… In our society, this is a BIG problem! Thank you for the work that you do, and for making the point that a list of rules IS NOT the answer!! Have a wonderful weekend!!

      Pamela Mckimie, D(AAIM), CBE, CHE, CMBSS

      March 16, 2012 at 10:42 pm

  7. I have postgraduate papers in public health and have been a volunteer LLL Leader for 12 years, and have also run a young parents breastfeeding group (for parents under 25 years) with partial public health funding for the last five years in New Zealand (NZ). I believe that group based breastfeeding support is the most effective way to offer breastfeeding support before birth and after 3 weeks. In NZ we have strong midwifery care, which effectively supports mums around the time of the birth, and in the early weeks. Pregnant mums who attend breastfeeding groups receive visual role modelling, hear mothers talk about the wide range of normal baby behaviour, and learn how to cope with breastfeeding in front of others, all at the one discussion. Social media based around mother to mother support can be a wonderful additional tool :)see!/pages/Young-Parents-Breastfeeding-Group/203580630925
    In contrast, learning about breastfeeding without direct input from mothers and babies could perhaps be likened to trying to learn to ride a bike from reading about in a book.
    Mothers will not tend to continue with breastfeeding unless they can breastfeed alongside others in a social group 😀

    Susan Procter

    March 17, 2012 at 3:33 am

  8. Note that in the end only 36 families participated. Your points about listening to these voices is still valid. And yet, this is fewer women than an average LLLL sees in a few months. As a way to hear the voices of breastfeeding mothers, this report leaves a lot to be desired.


    March 17, 2012 at 6:39 am

  9. @Susan Procter…I think moms attending social breastfeeding groups is a great idea….especially for young moms! Moms often feel isolated in the first month…and this is a great way to help them overcome those feelings! Thank you for sharing this…and thank you for the work that you do for moms and their babies!!

    Pamela Mckimie, D(AAIM), CBE, CHE, CMBSS

    March 17, 2012 at 11:42 am

  10. @Monique I agree that 36 families is not a very large group! However, it is important for us to listen to all voices of all moms, so we providers are able to find solutions to their concerns…I would love to hear your ideas on how you would address the concerns of these women! Everyone’s input is helpful and gives each of us a chance to learn from the other! Have a wonderful day!!

    Pamela Mckimie, D(AAIM), CBE, CHE, CMBSS

    March 17, 2012 at 11:59 am

  11. Alison,
    Thank you for this well written piece. I just became aware of the Scottish study while reading a blog post on KevinMD. See the link below.
    I have posted a link to your article in the comments section (it still needs to be approved).

    Ann Friedmann MD

    March 26, 2012 at 6:37 pm

  12. I am a peer supporter and go onto the post natal ward and into the support groups to help women feed. We can give the ladies our undivided attention whilst we are with them unlike the busy midwives and so many women say that we are lifesavers in that even if we just chat with them we often give them the light at the end of the tunnel. As volunteers we are not able to spend enough time on the ward and out of 10 bf mums we will only see a couple in two hours. If there were more volunteers or even professionals who spend all day on the ward just focusing on bf then this would help massively.

  13. Hi all,
    I’m just a mother with 2 babies now. I remembered when I had my first child, I went to all breasfeeding classes. I loved the idea, but when I started breastfeeding, I decided to believe my baby wasn’t eating enough and started giving him formula. After a week, I went to a nursing support group where a lactation consultant saved me. Yes, I. Called her my savior.
    I stopped the formula and breastfed for 9 months (my goal was a year).

    Now with my second baby, it’s the most natural thing. We both love it. It’s not easy when you work full time, but I skip meetings or move them around to not miss my “pumping” minutes while I’m at work. I feel stronger now that I can make it to the year!!!!
    But I have to say people look at me like I’m a monster because I don’t give food or water to my 4 months old daughter. My answer….. She doesn’t need it! I encourage all my friends to breastfeed and get help, because all of you who dedicate your time to help us breastfeed are angels. Thank you all!!!!! We nned you! Keep doing an awesome job 🙂


    April 1, 2012 at 2:32 am

    • Hi Ana…Thank you so much for your encouraging words! Just remember, it was your dedication to breastfeeding that really made it happen…and thank you for encouraging other moms to breastfeed! You are great mom for having such strength and dedication!

      Pamela Mckimie, D(AAIM), CBE, CHE, CMBSS

      April 1, 2012 at 5:20 pm

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