2 day old Sullivan nursing with the help of a nipple shield
I have to admit that I don't really want to write this post. Well. That's not true. There is a lot I want to say but I'm never sure who it is I need to say it too. Parents? Healthcare providers? Other support people? Or really what exactly I'm trying to do by saying it. Encourage other parents? Call out bad healthcare providers? Challenge those who support pregnant and breastfeeding women to think about things in a different way? Demand better support and care for women and children in general?
What I can be sure of is that by writing this and publishing it online I will no doubt be spending the next few hours/days/weeks moderating comments and emails from people who think I am being hard on or unfairly 'judging' parents who formula feed their babies even though I'm writing this entire paragraph to say that I AM NOT.
What I am doing is addressing some of the suggestions and questions I have been getting since my second son was born 6 months ago. All of which boil down to the same thing. 'Why don't you just switch to formula?'.
A little history: after having breast reduction surgery in my late teens breastfeeding my first son, Oliver, in my early twenties went relatively smoothly, a few bumps in the hospital that resulted in unwanted, coerced and non-evidence-based formula supplementation and latch issues that left us reliant on a nipple shield for over 5 months but over all he gained weight (slowly), blebs & plugged ducts happened here and there but were never serious, and we "successfully" breastfed for over 4 years.
I use the quotations around "successfully" because when I became a doula and learned more about breastfeeding through other birth and lactation professionals I found that many if not all of the trouble my oldest son and I did have could be traced back to a tongue and lip tie. And as it turned out many things I was told were 'normal' or dismissed as 'not a big deal' were actually huge red flags that we had some serious problems. Everyone survived so I'm not going to think on it more than lessons learned, we struggled but we managed and I don't regret it for a moment.
Pregnant with my second son, Sullivan, I did a lot of research, identified the red flags I had missed the first time around and was very glad when a dentist in my area started offering laser frenectomies in his practice.
I cannot begin to say how thankful I am that Sullivan was my second. While Oliver and I had struggled a little and he was, in hind sight, a slower gainer than he should have been, he never lost any weight, he always filled diapers regularly, he was alert and met milestones early or on time.
Sullivan, on the other hand, struggles with the scale constantly, when my supply drops in the slightest he immediately stops dirtying diapers, and he regularly goes through phases of being sleepy at the breast eating just enough to take the edge off his hunger but no more. Had he been my first, had I not known that I was capable of nursing a baby well into childhood, had I been less aware of not only the risks of formula use but the absolute joy that the breastfeeding relationship brings, I would have folded at my ten week midwife appointment when my midwife looked me in the eye and told me no one would blame me for giving up if all the work I was doing to breastfeed became too much for me.
(Note: while that statement may be technically true, that no one would have blamed me and it would be 'ok' to switch, suggesting that, as a professional, to a tired new mom when that's not what she's asked you is about as helpful and supportive as telling a labouring woman it's 'ok' to have an epidural when she has expressed that she wants a natural birth. And if you don't know why THATS not helpful or supportive I suppose I'll have to write a whole other post about it.)
Nursing with a homemade at-the-breast supplementation system
Instead, under the close supervision of an IBCLC, I max out doses of herbs like fenugreek, blessed thistle, alfalfa, fennel, and lemon balm. We limped along with a nipple shield (properly this time) to get him feeding without swallowing too much air and transferring milk effectively, I pumped regularly every day to supplement his intake with an at-the-breast-supplementer off and on for months. I feed him almost hourly at the slightest cue of hunger doing breast compressions to make sure he gets enough without tiring too quickly. I have not used any artificial nipples what so ever, no soothers, no bottles, not even my fingers, if he wants to suck he does it at the breast. I weigh him every day to make sure he's on track. Sullivan has now been to the dentist for frenectomy not once but twice and we have been seeing an osteopath regularly to improve the mobility he needs to feed effectively. He is growing, he is happy and fed, but it doesn't come 'easy' like it did the first time around.
So why do I do it? Why not 'just switch to formula'?
Because to me making the switch to artificial milk should not ever be the first suggestion or made out to be the easiest or best alternative when breastfeeding hits a bump. There are literally dozens of other ways to manage supply issues and other common problems.
Because using artificial milk, even prepared properly (which most people don't), has very real and sometimes serious health risks for both mothers and babies.
Because breast feeding isn't just about health and nutrition. It is an integral part of the way I parent my children. It provides biological protection for my babies in our family bed, it soothes them when they are hurting or teething, it settles them when they're overstimulated, it provides security and builds trust, it forces me to slow down and engage my children even when life gets hectic.
Because becoming reliant on artificial milk would be a huge financial burden on my family, thereby negatively impacting my older child and my family's food security in general.
And mostly because the way we start our life is important. Everyone needs to stop discounting that.
Do I expect that every mother should work as hard as I did to breast feed exclusively no matter her situation or support network? NO, absolutely not, I get that it is my privilege and my connection to a network of well trained birth and lactation professionals that allows me to do so.
But I do expect that every single person who works with, provides any type of care to, or even comes in the slightest contact with mothers and babies understand that when we do things to interfere with or damage the breastfeeding relationship between mother and child we are interrupting vital biological systems that can drastically effect not just the health and development of that baby, but also entire communities. So maybe there is a small part of my brain that just wanted to prove even with multiple factors that can negatively impact breast feeding, bottles and formula don't have to be a part of the management plan.
We need to stop treating breastfeeding like it's a great thing to do 'if it works out', and start treating it like a vital biological system that must be protected and maintained. It isn't binary, and bottles of formula aren't the inevitable conclusion when things don't start off or continue to go well.
In short; If you are a mother who's baby isn't doing well and the only advice you are hearing is EITHER "just keep feeding, just keep feeding, you can do it, he's just small" OR "you're starving/harming your baby, you need to give him formula right now" know that there are amazing care providers out there who can give you real answers and help you find a management plan that will help you achieve YOUR goals. If you are one of the people handing out the above advice on either side, please search out the amazing professionals who have real answers and let them educate you.
"Why not just switch to formula?" Because you don't really have to. Not if that's not what you want, and you can find the right support.
To find a qualified IBCLC you may search for your area at:
If you are expecting a baby, whether that baby is your first or subsequent baby, the question of breastfeeding will no doubt arise eventually. A good friend, a family member, a medical professional, or a complete stranger, someone is going to ask you the question.
“Are you going to breastfeed?”
If you have previously had breast or nipple surgery the seemingly casual question can be quite a loaded one. Chances are you have recently come to the realization that a decision you made for many valid reasons years or even decades ago could have consequences that you had not considered then. Maybe you have been told that you can’t, or may not be able to breastfeed exclusively. Maybe your chances of successfully breastfeeding have been given a totally arbitrary number like 50/50.[1]
Chances are you have also heard what we all have heard about breastfeeding. “Breastfeeding is superior to artificial baby milk; it is the absolute best start you can give to your baby. Breastfeeding promotes closeness and bonding and has health advantages for both you and your baby. Breastfeeding is wonderful, natural, eco friendly and economical” Chances are that the person asking you “Are you going to breastfeed?” has heard all of the same things. It may be hard to explain that you may not be able too, because chances are you may already be mourning this possible loss.
Perhaps mourning isn’t really the right word, the feeling is overwhelming, lonely, and can be quite hopeless. You may be feeling guilty, you may feel as though any mention of breastfeeding is an attack, you may even feel as though you have failed yourself or your child before you’ve even had the chance to try. These feelings are normal. We live in a society that tells women ‘breast is best’ but doesn’t acknowledge that there can be challenges that take a mountain of hard work and support to overcome.
So how do you answer such a loaded question?
You have been asked a “yes” or “no” question to which there is no “yes” or “no” answer, because breastfeeding after breast or nipple surgery is not so black and white. There is nothing certain or given about breastfeeding after breast or nipple surgery (BFAR). The truth is that you cannot, and will not know until you try.
After all of the emotional wrestling with yourself about the decisions you have made, and your reasons for making them, you may come to accept that what’s done is done and you will do your absolute best with the resources you have; at some point you may take a leap of faith and decide to try. When you make the decision to try, know that you are not alone, and know that there are a number of things that you can do to prepare for a rewarding BFAR experience with your new baby.
1) Research Research Research!
It’s a sad reality that there is far from enough fact based and accurate lactation training in the medical field. Many doctors, even OBGYNs have little more than a basic working knowledge of lactation and infant nutrition, most have even less information about BFAR. Many may dismiss the possibility outright, or may give you the standard 50/50 chance answer without ever examining your medical history or scar tissue. The fact is that your ‘chances’ of breastfeeding vary greatly depending on a number of factors. Educating yourself will help you prepare to breastfeed your baby and to find the right support.
I started my research at my local La Leche League chapter. Upon discussing my situation (Breast reduction surgery at the age of 16) my Le Leche League leader lent me the book “Defining Your Own Success” by Dianne West. This book is a GREAT place to start as it combines personal stories and medical research and information to provide a great overview on the subject of BFAR.
My research and preparation for BFAR also included acquiring a detailed record of my breast reduction surgery. Your ability to produce milk after breast surgery depends on the type of surgery performed, the amount of tissue that was removed or damaged, time passed since the surgery, and many other factors. A detailed account of your specific surgery can shed some light on what to expect in terms of milk production.
Lastly I researched various supplementation methods including at the breast supplementation, for use in the event that I was unable to make enough milk for my baby. It is a myth that breastfeeding is a binary function. Conventional wisdom tells us that there are two ways to feed an infant, either with breast milk or bottled infant formula, you either breastfeed or you don't, but Infant feeding does not have to be “either/or”, and if BFAR is important to you then it will be helpful to know when and how to offer supplements if needed without damaging your breastfeeding relationship.
2) Define your own success
The title of that very first book, that shining star of relief and hope that I received is absolutely the single most important part of preparing for BFAR.
While research into the technique and circumstances of your surgery will give you a better idea of your ability to produce milk for your baby, it will not shed any light on your ability to feed your baby at the breast. Whether you produce all of your baby’s milk, just a few ounces or none at all you can still feed your child at the breast.
What this step came down to for me was preparing for the worst, and hoping for the best. There was a very good chance that, because of the time elapsed since and the type of surgery I had, I would be able to produce milk for my baby. But I knew that worst case scenario meant being unable to produce all of the milk that my baby would need to grow, if that should happen and supplementing my milk with donated human milk or infant formula became a necessity I wanted to be able to do so at the breast. For me, the use of a SNS at the breast would be considered a success.
For some; success may be having their child suckle at the breast a few times a day while providing a majority of nutrition with donated human milk or infant formula. Success could be pumping all the milk you can to feed by bottle, or success could even mean feeding exclusively donated human milk or formula while practicing traditional breastfeeding behaviors like skin to skin feeds or infant led cue feeding.
What you define as breastfeeding success after breast surgery is not something that anyone but you can find. It takes many hours of soul searching, research, and reflection.
There were days before my son was born where I didn’t think I could take the disappointment of trying and failing to produce enough milk, there were days I accepted it as a reality and looked forward to my husband getting the chance to feed occasional bottles to our son, there were days where I would look at the SNS and cry tears of mourning for the simplicity, grace, and ease with which other women fed their babies. Other days I would look at the SNS and thank God that such a thing had been invented.
The process of finding your own definition of success can be a long and difficult one. Coming to terms with the reality of what your breastfeeding relationship may look like is far from easy but it is very important.
3) Build Your Team
Once you’ve done all the research, be sure to share it with your partner and encourage them to do some research of their own. Let them in on your journey to defining your success and talk about what BFAR means for your family. Make sure your partner knows how important BFAR is to you because when it comes down to it your partner isn’t just any old cheer leader, they’re your co-captain, your best and most accessible support, and… well, they’re your partner!
Along with your partner, it is beneficial for any woman who wants to breastfeed to surround herself with people who love and support her. To build the rest of your support team I have four suggestions:
1)If at all possible, seek out and hire a Board Certified Lactation Consultant who has knowledge of and experience with BFAR mothers. Make sure that this IBCLC has the information you researched regarding your surgery and circumstances, talk to her about your breastfeeding goals, and then put her number in your speed dial!
2)Make sure that the friends and family you surround yourself with before and after your baby is born are supportive of your decision to breastfeed. Breastfeeding isn’t always easy for those with ‘normal’ breasts; there is no doubt that the first few days/weeks/months will be difficult for a BFAR mother. It is absolutely essential that you have support people around who will NOT simply hand you a bottle of formula when the going gets tough. (You may find it helpful to discus ahead of time the different ways your family and friends can help you should you run into trouble.)
3)Find your local Le Leche League chapter and, even if there are no members or leaders with BFAR experience, start attending before you give birth. I realize that this may be hard; watching women breastfeed and hearing them talk about breastfeeding can leave a bitter taste when you’re unsure if you’ll ever be able too, but trust me, it is important to find support and reaffirm all the reasons why breastfeeding is important to you.
4)Make sure that everyone attending the birth of your child and involved with your post partum care (midwives, doulas, doctors, nurses ect.) know about your intention to BFAR. Finding an OB who is supportive of you may be difficult depending on where you live but make them part of your team by stressing to them that you have done your homework and know that you can breastfeed. Do not let them assume that you will bottle feed simply because of a notation on your medical history.
4) Give yourself the opportunity
For women in North America with ‘normal’ breasts getting through the first few days or weeks of a baby’s life without supplementing with formula is hard. (Unless the birth takes place at home or in a baby friendly birthing centre or hospital.) There are many ‘reasons’ why formula is routinely given to newborns in hospital even when their mothers state that they are going to breastfeed. The fact of the matter is that much of the time these supplements are unnecessary and can have long lasting devastating effects on what would have otherwise been a successful breastfeeding relationship.
If you are a BFAR mother the pressure to supplement your infant with formula in the early days may be even greater. Many doctors do not know or do not believe that BFAR is possible and may insist on giving formula. You will also likely be nervous about your child getting enough milk even after all of your research. It is totally normal for you to feel this way, but it is also important to know that unnecessary supplementation could cause milk supply and other problems where their may not have been any problems before.
Unless you know for a fact that you will not be able to produce any milk make sure you give yourself and your body the chance (at least a week) to breastfeed exclusively. If you are producing colostrum, know that it is designed to be enough for your baby until your ‘milk comes in’. (Colostrum gradually changes into mature breast milk in the first 2 weeks of your baby's life) In those first days, put your baby to breast as often as possible, and, if possible, pump or hand express between feedings, the more colostrum your baby gets, the more your breasts are stimulated by your baby (something he won’t do as effectively if he’s full of formula) the more milk you are likely to make. Keep track of wet and dirty diapers and resist the urge to start supplementing until it is proven that you will need to.
If you do decide to offer supplements in the first few days or weeks of life rely on the research that you have done and try supplement in a way that will not effect your milk supply or risk nipple confusion. (Deciding if and when to supplement with donated human milk or infant formula is where having an experienced IBCLC on your team comes in really handy)
5) Trust your body and your baby
Finding faith and trust in your body to work as it is supposed to after it has been medically altered is a bit of a conundrum. It is hard to believe that your body will work as nature intended when it is no longer in its ‘natural state’.
In some cases it is possible to breastfeed exclusively after breast surgery. If this turns out to be your case (sending milky vibes and prayers your way) your body will eventually earn back the trust that you may be lacking now.
But aside from the actual milk making it is important to trust your body to nourish your baby in other ways. Trust the closeness of your body to bring him warmth and comfort. Trust your skin to give him your scent, trust your breath and heartbeat to calm him, trust your arms to keep him safe, and trust your body to give him as much milk as it can. Above all, trust that any amount of breast milk, however small, is valuable, each drop is a very special gift from you to your baby.
After that, trust your baby. Trust that he will tell you in his own way if there is something wrong, trust that he will breathe your scent, learn the rhythm of your breath and heart, trust that he will feel safe in your arms and find warmth and comfort at your breast. Trust that he will bond with you and love you regardless of how much or little milk you make for him.
Then trust that the decision you made to undergo breast surgery was the right decision for you, and that there will be many other chances to nurture and love your child if BFAR does not work out for you.
[1] I honestly don’t know where that 50/50 number came from, nearly every BFAR mother I know was told by her surgeon that her chances of BFAR were 50/50 and yet I can find no sources stating this as fact!
Do you have a BFAR experience you would like to share? What were the biggest challenges for you? How did you overcome them?
Are you preparing to BFAR? Have questions you would like to ask or concerns you would like to share? Feel free to post them in the comments here, or head over to the BFAR forums to connect with other moms who have breastfed after breast or nipple surgery.
